OBJECTIVES: To estimate the cost-effectiveness of diabetes prevention programs in individuals with pre-diabetes and assess whether targeting treatment using individual cost-effectiveness information may increase population net monetary benefit (NMB).

METHODS: Using a micro-simulation model, we estimated total lifetime costs and quality-adjusted life expectancy (QALE) for individuals receiving: (1) lifestyle intervention involving an intensive program focused on healthy diet and exercise, (2) metformin administration, or (3) no intervention. The model combines several components. First a Cox proportional hazards model predicted onset of diabetes from baseline characteristics for each pre-diabetic individual and yielded a probability distribution for each alternative. We derived this risk model from the Diabetes Prevention Program (DPP) clinical trial data and the follow-up study DPP-OS. The Michigan Diabetes Research Center Model for Diabetes then estimated costs and outcomes for individuals after diabetes diagnosis using standard of care diabetes treatment. Based on individual costs and QALE, we evaluated NMB of the two interventions at population and individual levels, stratified by risk quintiles for diabetes onset at 3 years.

RESULTS: The DPP trial followed 3234 adults with impaired glucose tolerance for 3 years and had a 7-year open-label follow-up study with 2766 participants. Our model found both interventions to be cost-effective on average, with NMB of $26000 for lifestyle intervention and $16000 for metformin. Individual NMB were positive for lifestyle intervention. The NMB for metformin increased with increasing 3-year risk of diabetes, but the lowest risk quintile had a negative average NMB.

CONCLUSIONS: Individual NMB analysis suggests that lifestyle intervention is favorable in all patients. Metformin therapy appears cost-effective in higher risk individuals, but not in those at lowest risk of developing diabetes. Considering individual risk for developing diabetes to target the type of preventive treatment should be worthwhile.