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August 10, 2011

Exercise Interventions and Glycemic Control in Patients With Diabetes

Author Affiliations

Author Affiliation: Hubert Department of Global Health, Emory University, Atlanta, Georgia (dfwilli@sph.emory.edu).

JAMA. 2011;306(6):607-610. doi:10.1001/jama.2011.1106

To the Editor: Dr Pahor made a sound case for insurers to seriously consider reimbursing for physical activity and exercise programs delivered to patients with diabetes.1 Unfortunately, his assessment of the economic value of lifestyle intervention programs to prevent diabetes may be misleading.

Based on a mathematical modeling study by Eddy et al,2 Pahor suggested that from an insurer's perspective, the lifetime cost-effectiveness of the Diabetes Prevention Program (DPP) lifestyle intervention is $143 000 per quality-adjusted life-year. This estimate, however, used the very high annual cost of the lifestyle program ($1365 per participant) as implemented in the DPP research trial in which the intervention was delivered to individual participants in a 1:1 format. Pahor did not report the estimate by Eddy et al of lifetime cost-effectiveness when the annual cost of the intervention was reduced to $217 per participant by delivering the intervention to groups rather than individuals. In this case the cost-effectiveness is only $27 000 per quality-adjusted life-year.

Furthermore, Pahor failed to cite the economic modeling study by Herman et al3 of the DPP lifestyle intervention published just prior to Eddy et al. Herman et al estimated that the DPP lifestyle intervention delivered in group format would be cost-saving over participants' lifetimes.

A growing literature describes efforts to translate the DPP lifestyle program to real-world settings with limited resources. One of these studies, the DEPLOY study (Diabetes Education and Prevention with a Lifestyle Intervention Offered at the YMCA),4 found that weight losses approaching those obtained in the DPP clinical trial could be achieved and maintained at substantially reduced cost. This was accomplished using regular YMCA staff to deliver the 1-year lifestyle program to groups of 8 to 12 participants.

Based on the results of the DEPLOY and other translation studies, the US Centers for Disease Control and Prevention began urging health insurers to offer reimbursement for evidence-based lifestyle programs delivered to persons at high risk for diabetes. In response, the nation's largest health insurer, UnitedHealth Group, began fully covering a 1-year lifestyle program for diabetes prevention in 2010. This program, modeled on the DPP intervention, is delivered by YMCA staff to groups of participants with prediabetes.5

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Article Information

Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported that he is funded by an interagency agreement between the Centers for Disease Control and Prevention and Emory University to serve as a consultant to the Division of Diabetes Translation.

Pahor M. Consideration of insurance reimbursement for physical activity and exercise programs for patients with diabetes.  JAMA. 2011;305(17):1808-1809PubMedArticle
Eddy DM, Schlessinger L, Kahn R. Clinical outcomes and cost-effectiveness of strategies for managing people at high risk for diabetes.  Ann Intern Med. 2005;143(4):251-264PubMedArticle
Herman WH, Hoerger TJ, Brandle M,  et al; Diabetes Prevention Program Research Group.  The cost-effectiveness of lifestyle modification or metformin in preventing type 2 diabetes in adults with impaired glucose tolerance.  Ann Intern Med. 2005;142(5):323-332PubMedArticle
Ackermann RT, Finch EA, Brizendine E, Zhou H, Marrero DG. Translating the Diabetes Prevention Program into the community: the DEPLOY pilot study.  Am J Prev Med. 2008;35(4):357-363PubMedArticle
Abelson R. An insurer's new approach to diabetes. New York Times. April 14, 2010. http://www.theledger.com/article/20100414/ZNYT01/4143005/1001/BUSINESS?Title=An-Insurer-x2019-s-New-Approach-to-Diabetes. Accessed May 10, 2011