J Kruger , A Brennan , P Thokala , S
Heller on behalf of the DAFNE
1 School of Health and Related Research (ScHARR), University
of Sheffield, Sheffield
2 Academic Unit of Diabetes, Endocrinology and Metabolism,
School of Medicine and Biomedical Sciences, University of
The cost-effectiveness of providing a DAFNE
follow-up intervention to predicted nonresponders
The Dose Adjustment for Normal Eating (DAFNE) course is a structured education programme for adults with Type 1 diabetes. DAFNE has been
found to improve glycosylated haemoglobin (HbA 1c) levels in UK Type 1 diabetes patients 1 and a cost-effectiveness modelling analysis concluded
that DAFNE was cost-effective2. This analysis assumed that HbA 1c benefit experienced by patients receiving DAFNE was homogeneous, however
it has been found that HbA1c response to DAFNE is highly variable between patients. Although some patients do experience significant HbA 1c
reductions after DAFNE, other patients experience a worsening of HbA 1c1,3 and some find it difficult to maintain initial HbA 1c improvements4.
Offering an early follow-up intervention to those patients predicted from their initial change in psychosocial characteristics not to respond to
DAFNE in the long term may be cost-effective if additional HbA 1c benefit can be gained.
This study aims to explore statistical modelling methodologies to predict individual clinical responses to DAFNE from psychosocial characteristics
and incorporate psychosocial predictors into an economic simulation model to investigate the cost-effectiveness of providing a follow-up
intervention to subgroups of predicted non-responders.
Data from the National Institute for Health Research (NIHR) DAFNE Research Programme were used to support all analyses*. In the psychosocial
sub-study of the NIHR DAFNE Research Programme demographic, psychosocial and clinical data were collected from 262 patients at baseline and
3-, 6-, and 12-months after DAFNE.
Two regression models were used to investigate the relationships between initial change (baseline to 3 months) in psychosocial characteristics
and 12-month HbA1c response to DAFNE:
Definition of treatment response
Statistical analysis method
Change in HbA1c from baseline to 12-months
Multiple linear regression
Probability of responding to DAFNE (reduction of at least 0.5% by 12
The regression prediction models were integrated with a patient level simulation model of Type 1 diabetes and What If? analyses were
conducted. The follow-up intervention was assumed to cost 359 (the cost of repeating the DAFNE intervention) and to provide a 12-month
HbA1c reduction of 0.25%, 0.5% or 1.0%. The integrated model was used to compare provision of a follow-up intervention to DAFNE with current
practice. The model estimated costs and quality-adjusted life-years (QALYs) over a 50-year time horizon from an NHS perspective. Costs and
Figure 1: The cost-effectiveness of providing a
QALYs were discounted at a rate of 3.5%.
intervention costing 359 vs. current
Initial change in fear of hypoglycaemia5 and initial change in diabetes
knowledge6 were found to be significantly predictive (p<0.05) of 12-month
HbA1c change after DAFNE. The adjusted R2 of prediction model A was 0.064.
Prediction model B correctly categorised 85.2% of non-responders and 50.7%
The results suggest that providing a follow-up intervention to predicted
DAFNE non-responders may be cost-effective. The results provide a useful
starting point for consideration of the required benefit of a DAFNE follow-up
intervention targeted at HbA1c reduction to demonstrate cost-effectiveness.
The adapted economic model offers the opportunity to investigate research
questions about the cost-effectiveness of DAFNE that could not be assessed
using previously published cost-effectiveness models of Type 1 diabetes.
Average discounted incremental costs
The results suggest that providing a follow-up intervention costing 359 to
predicted DAFNE non-responders would be cost-effective at the National
Institute for Health and Clinical Excellence (NICE) threshold of 20,000 per
QALY7 if it provided a 12-month HbA1c reduction of between 0.5% and 1.0%.
This result was sensitive to the treatment response prediction model used,
and in some scenarios providing a follow-up intervention dominated current
DAFNE Study Group. Training in flexible, intensive insulin management to enable dietary freedom in people with type 1
diabetes: dose adjustment for normal eating (DAFNE) randomised controlled trial. British Medical Journal 2002;325:746-749.
Shearer A, Bagust A, Sanderson D, Heller S, Roberts S. Effectiveness of flexible intensive insulin management to enable
dietary freedom in people with type1 diabetes in the UK. Diabetic Medicine 2004;21:460467.
DAFNE NIHR Research Group. Personal communication: Unpublished data. 2006.
Speight J, Amiel S, Bradley C, Heller S, Oliver L, Roberts S, et al. Long-term biomedical and psychosocial outcomes following
DAFNE (Dose Adjustment For Normal Eating) structured education to promote intensive insulin therapy in adults with suboptimally controlled Type 1 diabetes. Diabetes Research and Clinical Practice 2010;89:22-9.
Cox D, Irvine A, Gonder-Frederick L, Nowacek G, Butterfield J. Fear of hypoglycemia: quantification, validation, and utilization.
Diabetes Care 1987;10(5):617-21.
Fitzgerald J, Funnell M, Hess G, Barr P, Anderson R, Hiss R. The Reliability and Validity of a Brief Diabetes Knowledge Test.
Diabetes Care 1998;21(5):706-10.
National Institute for Health and Clinical Excellence. Guide to the Methods of Technology Appraisal. 2008.
Average discounted incremental QALYs
We would like to thank our collaborators Dr Debbie Cooke and Dr Marie Clark at
University College London and Dr Rod Bond at University of Sussex for sharing
data and preliminary research findings from the psychosocial sub-study of the
NIHR DAFNE Research Programme.
* This study was funded by the NIHR. This poster presents independent research commissioned by the NIHR under Improving management of Type 1 diabetes in the UK: the DAFNE programme as a research test-bed. The views
expressed in this poster are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.
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