Health economic evaluation alongside randomised clinical trial of a health behaviour intervention to manage type 2 diabetes in Nepal

Background: Prevention of type 2 diabetes is becoming an urgent public health concern in low and middle-income countries (LMICs). However, there is currently no evidence of a cost-effective approach of health behaviour interventions from community settings in low-income countries like Nepal. Therefore, this study aimed to assess the within-trial economic evaluation of a health behaviour intervention compared with usual care for managing type 2 diabetes in a community setting in Nepal.

Methods: We randomly assigned 30 clusters comprising 481 patients with type 2 diabetes of which 15 to a health behaviour intervention (n = 238 patients) and 15 to the usual care (n = 243 patients). Patients in the intervention group received community health workers-led intensive training for diabetes self-management along with regular phone calls and ongoing support from peer supporters. Costs, quality-adjusted life years (QALYs) and incremental cost-effectiveness ratio (ICER) as costs per QALYs gained were assessed after 6-month from a healthcare system perspective. Probabilistic sensitivity analysis was conducted using 10,000 Monte Carlo simulations to assess the impact of uncertainty of cost-effectiveness analysis under the threshold of three times gross domestic product (GDP) per capita for Nepal (i.e., US $4,140).

Results: Over the 6-month, the intervention yielded an incremental cost of US $28.55 (95% CI = US $21.26 to US $35.84) per person and an incremental QALYs of 0.0085 (95% CI = -0.0106 to 0.0275) per person. The ICER associated with the health behaviour intervention was US $3,358.82 (95% CI = US $-2005.66 to US $3,974.54) per QALY gained, which was below the estimated threshold, indicating a cost-effective approach with a net monetary benefit of US $6.64 (95% CI = US $-22.62 to US $78.01). Furthermore, the probabilistic sensitivity analysis consisting of 10,000 Monte Carlo simulations indicates that the intervention being cost-effective at the given threshold was 89.63%.

Conclusions: Health behaviour interventions in community settings are a cost-effective approach to manage type 2 diabetes, offering good value for money. However, more studies focused on long-term follow-up across diverse setting of LMICs should be warranted to assess the maximum impact of such interventions.

Trial registration: Australia and New Zealand Clinical Trial Registry (ACTRN12621000531819) Registered on 6^th May 2021.