1. Cost-Effectiveness of a Diabetes Intervention in Rural India Kushan Shah, B.D.S.; Erin Carlson, DrPH; Sangeeta Shenoy, M.B.B.S.,MPH; Pankaj Shah M.B.B.S. INTRODUCTION METHODS CONCLUSION RESULTS Diabetes is a global epidemic. There is increasing concerns about the burden of this disease in developing countries. India is the second highest for number of people living with diabetics in the world, with the disease impacting impoverished rural residents at an alarming rate. Estimates show that India has five- times the number of undiagnosed diabetics and diabetes- related deaths compared to U.S. Sanjivani Health and Relief Committee, an Indian non profit organization, in partnership with a global project, Together on Diabetes, has established Project Diabetes to meet the devastating challenges of diabetes. They provide weekly diabetes screenings, education, and medication to impoverished residents in rural Gujarat villages. Project Diabetes has been successful in increasing awareness of diabetes, educating residents about diabetes management, and improving diabetic health outcomes in the villages served. Programs such as Project Diabetes and others are emerging to address the growing epidemic, but little is known about the long-term health outcomes cost- effectiveness of such programs. We seek to estimate the long-term health effects and cost-effectiveness of such interventions. We estimated the long-term health effects and cost- effectiveness of this and similar diabetes programs using the Archimedes mathematical simulation model of expected health outcomes and estimated costs. The Archimedes model simulates populations and clinical interventions, models the expected health outcomes of individual and estimates the expected health care costs associated with the outcomes. The Cardio-Metabolic Risk(CMR) data set derived from the Archimedes model provided simulated controlled trial data. Using these data, we analyzed the health outcomes and cost-effectiveness of implementing the Project Diabetes model of care to treat adults with poorly controlled diabetes.(HbA1c>9) The Archimedes model was based on 10,000 simulated adults similar in demographics and health characteristics to Project Diabetes participants. The cost for the program is estimated to be less than $1 per participant per day. To be conservative, we assumed the cost was $1 per participant per day, and a discount rate of 3%. Simulated Intervention Outcomes Over 20 years Trial ArmSubpopulation Size (People) Blind Events Foot Amputation Events Myocardial Infarction Events Stroke Events Death Events Cost per QALY added Control Group A A1c above 9 Receives usual care 100071340246116502N/A Intervention Group A A1c reduced to 9 100069261197116490$11,786 Control Group B A1c above 7 Receives usual care 100039179205111489N/A Intervention Group B A1c reduced to 7 100037121161110479$31,649 Control Group C Age 65 to 84 years among those with A1c above 9 100075310280193823N/A Intervention Group C A1c reduced to 9 in those with A1c above 9 who are 65 to 84 years 100075258233193814$19,276 Control Group D Age 65 to 84 years among those with A1c above 7 100047181236168815N/A Intervention Group D A1c reduced to 7 in those with A1c above 7 who are 65 to 84 years 100047132183169809$34,525 REFERENCES Preliminary results indicate the program is cost- effective compared to usual practices in reducing blood sugar levels below recommended thresholds. The success of Project Diabetes suggests that mobile health education and medical care programs providing disease management for rural Indians can potentially improve health outcomes for the population they serve in a cost- effective and thus, sustainable, manner. The control group includes participants with HbA1c>9 receiving usual care. The intervention group is intended to represent the population receiving the Project Diabetes intervention. The group assumes the HbA1c among participants in the intervention group is reduced to 9 in one simulation and reduced to 7 in another simulation Results are also presented for subpopulation aged 65 and over to allow for comparisons across different groups. 23% reduction in foot amputations resulted in the overall group when reducing HbA1c to 9 and maintaining that level for 20 years. 32% reduction in foot amputations resulted from reducing the HbA1c to 7 and maintaining that level for 20 years. The intervention also reduced myocardial infarction (MI) in all trial arms between 16% and 22% Deaths were reduced by the intervention in every trial group. The intervention was found to be cost-effective in every year, costing under $50,000* per quality- adjusted life year gained in every trial. *$50,000 per QALY is the threshold by which an intervention is considered cost-effective. The greatest improvements in health outcomes due to the intervention were a reduction in foot amputations. Guariguata, L., Whiting, D. R., Hambleton, I., Beagley, J., Linnenkamp, U., & Shaw, J. E. (2014). Global estimates of diabetes prevalence for 2013 and projections for 2035. Diabetes research and clinical practice, 103(2), 137-149. Ramachandran, A., Snehalatha, C., Yamuna, A., Mary, S., & Ping, Z. (2007). Cost-effectiveness of the interventions in the primary prevention of diabetes among asian indians within-trial results of the Indian Diabetes Prevention Programme (IDPP). Diabetes Care, 30(10), 2548-2552. Grosse, S. D. (2008). Assessing cost-effectiveness in healthcare: history of the $50,000 per QALY threshold. Ramachandran, A., Snehalatha, C., Mary, S., Mukesh, B., Bhaskar, A. D., & Vijay, V. (2006). The Indian Diabetes Prevention Programme shows that lifestyle modification and metformin prevent type 2 diabetes in Asian Indian subjects with impaired glucose tolerance (IDPP- 1). Diabetologia, 49(2), 289-297.