Cost-Effectiveness of Three Doses of a Behavioral Intervention to Prevent or Delay Type 2 Diabetes in Rural Areas

Background Rural Americans have higher prevalence of obesity and type 2 diabetes (T2D) than urban populations and more limited access to behavioral programs to pro- mote healthy lifestyle habits. Descriptive evidence from the Rural Lifestyle Intervention Treatment Effectiveness trial delivered through local cooperative extension service of- fices in rural areas previously identi fied that behavioral modi fication with both nutri- tion education and coaching resulted in a lower program delivery cost per kilogram of weight loss maintained at 2 -years compared with an education -only comparator intervention. Objective This analysis extended earlier Rural Lifestyle Intervention Treatment Effec- tiveness trial research regarding weight loss outcomes to assess whether nutrition education with behavioral coaching delivered through cooperative extension service of fices is cost-effective relative to nutrition education only in reducing T2D cases in rural areas. Design A cost -utility analysis was conducted. Participants/setting Trial participants (n 1 / 4 317) from June 2008 through June 2014 were adults residing in rural Florida counties with a baseline body mass index between 30 and 45, but otherwise identi fied as healthy. Intervention Trial participants were randomly assigned to low, moderate, or high doses of behavioral coaching with nutrition education (ie, 16, 32, or 48 sessions over 24 months) or a comparator intervention that included 16 sessions of nutrition education without coaching. Participant glycated hemoglobin level was measured at baseline and the end of the trial to assess T2D status. Main outcome measures T2D categories by treatment arm were used to estimate participants ? expected annual health care expenditures and expected health -related utility measured as quality adjusted life years (ie, QALYs) over a 5 -year time horizon. Discounted incremental costs and QALYs were used to calculate incremental cost- effectiveness ratios for each behavioral coaching intervention dose relative to the education -only comparator. Statistical analyses performed Using a third -party payer perspective, Markov tran- sition matrices were used to model participant transitions between T2D states. Repli- cations of the individual participant behavior were conducted using Monte Carlo simulation. Results All three doses of the behavioral coaching intervention had lower expected total costs and higher estimated QALYs than the education -only comparator. The moderate dose behavioral coaching intervention was associated with higher estimated QALYs but was costlier than the low dose; the moderate dose was favored over the low dose with willingness to pay thresholds over $107,895/QALY. The low dose behavioral coaching intervention was otherwise favored. Conclusions Because most rural Americans live in counties with cooperative extension service of fices, nutrition education with behavioral coaching programs similar to those delivered through this trial may be effective and ef ficient in preventing or delaying T2D- associated consequences of obesity for rural adults.