OBJECTIVE To synthesize updated evidence on the cost-effectiveness (CE) of interventions to manage diabetes, its complications, and comorbidities. RESEARCH DESIGN AND METHODS We conducted a systematic literature review of studies from high-income countries evaluating the CE of diabetes management interventions recommended by the American Diabetes Association (ADA) and published in English between June 2008 and July 2017. We also incorporated studies from a previous CE review from the period 1985–2008. We classified the interventions based on their strength of evidence (strong, supportive, or uncertain) and levels of CE: cost-saving (more health benefit at a lower cost), very cost-effective (≤$25,000 per life year gained [LYG] or quality-adjusted life year [QALY]), cost-effective ($25,001–$50,000 per LYG or QALY), marginally cost-effective ($50,001–$100,000 per LYG or QALY), or not cost-effective (>$100,000 per LYG or QALY). Costs were measured in 2017 U.S. dollars. RESULTS Seventy-three new studies met our inclusion criteria. These were combined with 49 studies from the previous review to yield 122 studies over the period 1985–2017. A large majority of the ADA-recommended interventions remain cost-effective. Specifically, we found strong evidence that the following ADA-recommended interventions are cost-saving or very cost-effective: In the cost-saving category are 1) ACE inhibitor (ACEI)/angiotensin receptor blocker (ARB) therapy for intensive hypertension management compared with standard hypertension management, 2) ACEI/ARB therapy to prevent chronic kidney disease and/or end-stage renal disease in people with albuminuria compared with no ACEI/ARB therapy, 3) comprehensive foot care and patient education to prevent and treat foot ulcers among those at moderate/high risk of developing foot ulcers, 4) telemedicine for diabetic retinopathy screening compared with office screening, and 5) bariatric surgery compared with no surgery for individuals with type 2 diabetes (T2D) and obesity (BMI ≥30 kg/m2). In the very cost-effective category are 1) intensive glycemic management (targeting A1C <7%) compared with conventional glycemic management (targeting an A1C level of 8–10%) for individuals with newly diagnosed T2D, 2) multicomponent interventions (involving behavior change/education and pharmacological therapy targeting hyperglycemia, hypertension, dyslipidemia, microalbuminuria, nephropathy/retinopathy, secondary prevention of cardiovascular disease with aspirin) compared with usual care, 3) statin therapy compared with no statin therapy for individuals with T2D and history of cardiovascular disease, 4) diabetes self-management education and support compared with usual care, 5) T2D screening every 3 years starting at age 45 years compared with no screening, 6) integrated, patient-centered care compared with usual care, 7) smoking cessation compared with no smoking cessation, 8) daily aspirin use as primary prevention for cardiovascular complications compared with usual care, 9) self-monitoring of blood glucose three times per day compared with once per day among those using insulin, 10) intensive glycemic management compared with conventional insulin therapy for T2D among adults aged ≥50 years, and 11) collaborative care for depression compared with usual care. CONCLUSIONS Complementing professional treatment recommendations, our systematic review provides an updated understanding of the potential value of interventions to manage diabetes and its complications and can assist clinicians and payers in prioritizing interventions and health care resources.

OBJECTIVE We conducted a systematic review of studies evaluating the cost-effectiveness (CE) of interventions to prevent type 2 diabetes (T2D) among high-risk individuals and whole populations. RESEARCH DESIGN AND METHODS Interventions targeting high-risk individuals are those that identify people at high risk of developing T2D and then treat them with either lifestyle or metformin interventions. Population-based prevention strategies are those that focus on the whole population regardless of the level of risk, creating public health impact through policy implementation, campaigns, and other environmental strategies. We systematically searched seven electronic databases for studies published in English between 2008 and 2017. We grouped lifestyle interventions targeting high-risk individuals by delivery method and personnel type. We used the median incremental cost-effectiveness ratio (ICER), measured in cost per quality-adjusted life year (QALY) or cost saved to measure the CE of interventions. We used the $50,000/QALY threshold to determine whether an intervention was cost-effective or not. ICERs are reported in 2017 U.S. dollars. RESULTS Our review included 39 studies: 28 on interventions targeting high-risk individuals and 11 targeting whole populations. Both lifestyle and metformin interventions in high-risk individuals were cost-effective from a health care system or a societal perspective, with median ICERs of $12,510/QALY and $17,089/QALY, respectively, compared with no intervention. Among lifestyle interventions, those that followed a Diabetes Prevention Program (DPP) curriculum had a median ICER of $6,212/QALY, while those that did not follow a DPP curriculum had a median ICER of $13,228/QALY. Compared with lifestyle interventions delivered one-on-one or by a health professional, those offered in a group setting or provided by a combination of health professionals and lay health workers had lower ICERs. Among population-based interventions, taxing sugar-sweetened beverages was cost-saving from both the health care system and governmental perspectives. Evaluations of other population-based interventions—including fruit and vegetable subsidies, community-based education programs, and modifications to the built environment—showed inconsistent results. CONCLUSIONS Most of the T2D prevention interventions included in our review were found to be either cost-effective or cost-saving. Our findings may help decision makers set priorities and allocate resources for T2D prevention in real-world settings.

To assess retention in the National Diabetes Prevention Program (DPP) lifestyle change program, which seeks to prevent type 2 diabetes in adults at high risk. RESEARCH DESIGN AND METHODS We analyzed retention among 41,203 individuals who enrolled in Centers for Disease Control and Prevention (CDC)-recognized in-person lifestyle change programs at organizations that submitted data to CDC's Diabetes Prevention Recognition Program during January 2012-February 2017. RESULTS Weekly attrition rates were typically <1-2% but were between 3.5% and 5% at week 2 and at weeks 17 and 18, where session frequency typically transitions from weekly to monthly. The percentage of participants retained through 18 weeks varied by age (45.9% for 18-29 year olds, 53.4% for 30-44 year olds, 60.2% for 45-54 year olds, 66.7% for 55-64 year olds, and 67.6% for ‡65 year olds), race/ethnicity (70.5% for non-Hispanic whites, 60.5% for non-Hispanic blacks, 52.6% for Hispanics, and 50.6% for other), mean weekly percentage of body weight lost (41.0% for £0% lost, 66.2% for >0% to <0.25% lost, 72.9% for 0.25% to <0.5% lost, and 73.9% for ‡0.5% lost), and mean weekly physical activity minutes (12.8% for 0 min, 56.1% for >0 to <60 min, 74.8% for 60 to <150 min, and 82.8% for ‡150 min) but not by sex (63.0% for men and 63.1% for women). CONCLUSIONS Our results demonstrate the need to identify strategies to improve retention, especially among individuals who are younger or are members of racial/ethnic minority populations and among those who report less physical activity or less early weight loss. Strategies that address retention after the first session and during the transition from weekly to monthly sessions offer the greatest opportunity for impact. An estimated 30.3 million people in the U.S. have diabetes (1). Diabetes is associated with millions of hospitalizations each year for major cardiovascular diseases; can lead to other serious outcomes such as chronic kidney disease, vision loss, and lowerextremity amputation; and is the seventh leading cause of death (1). Furthermore, individuals with diabetes incur increased medical expenditures (2,3), with direct and

What is already known on this topic?Factors associated with accessibility and use of telehealth have been reported for the adult population; however, little is known about factors associated with accessibility of telehealth among older adults.What is added by this report? Over 80% of Medicare beneficiaries in our study reported that their usual providers offered telehealth during the COVID-19 pandemic. Disparities in accessibility of telehealth services by sex, residing area, income, and census region were observed.What are the implications for public health practice? Educational outreach and training, such as improving digital literacy, can be considered for improving accessibility of telehealth during the COVID-19 pandemic and beyond.

The aim of the US Centers for Disease Control and Prevention’s (CDC) National Diabetes Prevention Program (National DPP) is to make an evidence-based lifestyle change program widely available to the more than 88 million American adults at risk for developing type 2 diabetes. The National DPP allows for program delivery using four delivery modes: in person, online, distance learning, and combination. The objective of this study was to analyze cumulative enrollment in the National DPP by delivery mode. We included all participants who enrolled in CDC-recognized organizations delivering the lifestyle change program between January 1, 2012, and December 31, 2019, and whose data were submitted to CDC’s Diabetes Prevention Recognition Program. During this time, the number of participants who enrolled was 455,954. Enrollment, by delivery mode, was 166,691 for in-person; 269,004 for online; 4,786 for distance-learning; and 15,473 for combination. In-person organizations enrolled the lowest proportion of men (19.4%) and the highest proportions of non-Hispanic Black/African American (16.1%) and older (65+ years) participants (28.2%). Online organizations enrolled the highest proportions of men (27.1%), younger (18-44 years) participants (41.5%), and non-Hispanic White participants (70.3%). Distance-learning organizations enrolled the lowest proportion of Hispanic/Latino participants (9.0%). Combination organizations enrolled the highest proportions of Hispanic/Latino participants (37.3%) and participants who had obesity (84.1%). Most in-person participants enrolled in organizations classified as community-centered entities (41.4%) or medical providers (31.2%). Online and distance-learning participants were primarily enrolled (93.3% and 70.2%, respectively) in organizations classified as for-profit businesses or insurers. Participants in combination programs were enrolled almost exclusively in organizations classified as medical providers (89%). The National DPP has reached nearly half a million participants since its inception in 2012, but continued expansion is critical to stem the tide of type 2 diabetes among the many Americans at high risk.

Objective: To synthesize updated evidence on the cost-effectiveness (CE) of interventions to manage diabetes, its complications, and comorbidities. <p>Research Design and Methods: We conducted a systematic literature review of studies from high-income countries evaluating the CE of diabetes management interventions recommended by the American Diabetes Association (ADA) and published in English between January 2008 and July 2017. We also incorporated studies from a previous CE review from 1985-2008. We classified the interventions based on their strength of evidence (strong, supportive, or uncertain) and levels of CE: cost-saving (more health benefit at a lower cost), very cost-effective (≤$25,000 per life year gained [LYG] or quality-adjusted life year [QALY]), cost-effective ($25,001 to $50,000 per LYG or QALY), marginally cost-effective ($50,001 to $100,000 per LYG or QALY), or not cost-effective (>$100,000 per LYG or QALY). Costs were measured in 2017 U.S. dollars.</p> <p>Results: Seventy-three new studies met our inclusion criteria. These were combined with 49 studies from the previous review to yield 122 studies over the period 1985-2017. A large majority of the ADA-recommended interventions remain cost-effective. Specifically, we found strong evidence that the following ADA-recommended interventions are cost-saving or very cost-effective: (I) Cost-saving: 1) Angiotensin-converting enzyme inhibitor (ACEI)/Angiotensin Receptor Blocker (ARB) therapy for intensive hypertension management compared with standard hypertension management; 2) ACEI/ARB therapy to prevent chronic kidney disease and/or end-stage renal disease in people with albuminuria compared with no ACEI/ARB therapy; 3) comprehensive foot care and patient education to prevent and treat foot ulcers among those at moderate/high risk of developing foot ulcers; 4) telemedicine for diabetic retinopathy screening compared with office screening; and 5) bariatric surgery compared with no surgery for individuals with T2D and obesity (BMI≥30 kg/m²). (II) Very cost-effective: 1) intensive glycemic management (targeting A1c <7%) compared with conventional glycemic management (targeting A1c level of 8-10%) for individuals with newly diagnosed type 2 diabetes (T2D); 2). multi-component interventions (involving behavior change/education and pharmacological therapy targeting hyperglycemia, hypertension, dyslipidemia, microalbuminuria, nephropathy/retinopathy, secondary prevention of CVD with aspirin) compared with usual care; 3) statin therapy compared with no statin therapy for individuals with T2D and history of cardiovascular disease; 4) diabetes self-management education and support compared with usual care; 5) T2D screening every 3 years starting at age 45 years compared with no screening; 6) integrated, patient-centered care compared with usual care; 7) smoking cessation compared with no smoking cessation; 8) daily aspirin use as primary prevention for cardiovascular complications compared with usual care; 9) self-monitoring of blood glucose three times per day compared with once per day among those using insulin; 10) intensive glycemic management compared with conventional insulin therapy for T2D among adults aged 50+ years; and 11) collaborative care for depression compared with usual care. </p> Conclusions: Complementing professional treatment recommendations, our systematic review provides an updated understanding of the potential value of interventions to manage diabetes and its complications and can assist clinicians and payers in prioritizing interventions and health care resources.

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The removal of regulatory and reimbursement barriers during the COVID-19 pandemic in the United States presented opportunities to explore the potential of telehealth to improve access to and use of healthcare among underserved populations.Therefore, we examined factors associated with accessibility and utilisation of telehealth among older adults during the COVID-19 pandemic. We analysed the nationally representative Medicare Current Beneficiary Survey COVID-19 Supplement File of community-dwelling Medicare beneficiaries aged ≥65 years (n = 5,189), administered from 5 October 2020, through 15 November 2020. Two survey-weighted multivariable logistic regression models were used to assess the association between factors (i.e., socio-demographics, co-morbidities and digital access/literacy) and whether (1) beneficiaries' regular providers offered telehealth during the COVID-19 pandemic, and (2) those being offered telehealth used it. Furthermore, subgroup analyses by residing area and income status were conducted. Of study beneficiaries, 83.6% reported their regular providers offered telehealth during COVID-19. Disparities in accessibility of telehealth by sociodemographic status were observed [e.g., those living in a non-metro area (versus metro) were 7.1% (marginal effect [ME] = −7.1%; p < 0.01) less likely to report accessibility of telehealth]. Beneficiaries who had no access to internet (ME = −8.2%; p < 0.001) and had not participated in video/voice calls/conferencing prior (versus participated) (ME = −6.6%; p < 0.001) were less likely to report having access to telehealth. Among those being offered telehealth services, 43.0% reported using telehealth services. Hispanic and Non-Hispanic Black beneficiaries (e.g., Black versus White; ME = 11.3%; p < 0.01) and those with co-morbidities (versus 0-1 condition) (e.g., 2-3 co-morbidities, ME = 7.3%; p < 0.01) were more likely to report using telehealth services when offered. Similar results were observed in the subgroup analyses regarding disparities in accessibility and utilisation of telehealth. The accessibility and utilisation of telehealth have increased amidst the pandemic; however, disparities in accessibility of telehealth were observed. A telehealth triage protocol is needed to ensure underserved patients continue to receive appropriate care.