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Cited by 4Diabetes Management and EducationDiabetes Management and ResearchHealth Systems, Economic Evaluations, Quality of Life

Economic costs of implementing group interventions to reduce diabetes distress in adults with type 1 diabetes mellitus in the T1-REDEEM trial

Open access
Shumway, Martha, Fisher, Lawrence, Hessler, Danielle, Bowyer, Vicky, Polonsky, William H., Masharani, Umesh·2019·Journal of Diabetes and its Complications
DOI 10.1016/j.jdiacomp.2019.107416PMC PMC6823162
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Abstract

Aims: This study evaluated the implementation costs of two group interventions, one focused on diabetes education (KnowIt) and one focused directly on diabetes distress (OnTrack), that reduced diabetes distress and HbA1C in adults with poorly controlled type 1 diabetes (T1DM) in the T1-REDEEM trial. Methods: Resources used to provide interventions were enumerated using activity-based micro-costing methods. Costs were assigned to resources in 2017 US dollars. US median wage and benefit rates were used to calculate costs of staff time. Cost per unit change was calculated for diabetes distress and HbA1C. Results: For both interventions, per participant implementation costs were approximately $250 and cost per 1.0 percentage point (11 mmol/mol) change in HbA1C was $1400. Cost per unit change in diabetes distress was $364 for KnowIt and $335 for OnTrack. No statistically significant differences in costs were observed. Conclusions: This is the first study to examine the costs of implementing interventions targeting diabetes distress in the context of T1DM. Both interventions had per participant implementation costs in the lower end of the range of previously examined diabetes self-management interventions ($219 to $5390). These inventions and their costs merit further attention because reducing diabetes distress may impact long term T1DM outcomes. Clinical Trials Registration: ClinicalTrials.gov NCT02175732 © 2019

Integrity signals

Registry

Crossref · 10.1016/j.jdiacomp.2019.107416

Cites

24 of 24 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

10 of 29 cited sources checked · 4 supported · 0 flagged · accuracy not yet measured

  • Interpretationcitation

    The approximately $1,400 cost of a 1.0 percentage point (11 mmol/mol) reduction in HbA1C in T1-REDEEM falls near the lower range of costs reported in these studies, which in 2017 dollars ranged from $605 for the telephone intervention delivered by lay interviewers to $9,539 for the intensive, in-person intervention.

    “The approximately $1,400 cost of a 1.0 percentage point (11 mmol/mol) reduction in HbA1C observed in T1-REDEEM falls near the lower range of costs reported in these studies which, in 2017 dollars, ranged from $605 in the telephone intervention delivered by lay interviewers25 to $9,539 in the intensive, in-person intervention.26”
    Quote in the paperSubstantial claim2 of 2 sources checked
    • cites [25] source

      Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

      Experimental — accuracy not yet measured
    • cites [26] source

      Split into 2 atoms — 0 confirmed, 2 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

      Experimental — accuracy not yet measured
  • Premisecitation

    Per participant costs ranged from $219 for a telephone intervention delivered by lay health educators to $5,390 for an intensive intervention that included a residential retreat and 6 months of weekly, 4-hour, in-person meetings.

    “Per participant costs ranged from $219, for a telephone intervention delivered by lay health educators,25 to $5,390, for an intensive intervention that included a residential retreat, and 6 months of weekly, 4-hour, in-person meetings.26”
    Quote in the paperSubstantial claim2 of 2 sources checked
    • cites [25] source

      The Methods (Recruitment and intervention resources) describe weekly four-hour meetings after a retreat, and the Results (Participant costs) report a 2½-day retreat and 23 meetings. The passages retrieved from our copy do not state the cited $5,390 per-participant figure. The $219 telephone-intervention figure is attached to a different citation in the citing sentence, so it is not assessed against this paper. (LLM, conf=0.82)

      Experimental — accuracy not yet measured
    • cites [26] source

      Methods §2.1 describes a telephone intervention delivered by trained health educators. But Results §3.3 reports a cost specific to that intervention of $187.61 per person, not $219. The $5,390 retreat intervention is attached to a different citation in the citing sentence and is not assessed here. (LLM, conf=0.90)

      Experimental — accuracy not yet measured
  • Findingown data

    Changing OnTrack leadership from a psychologist to a social worker would reduce the per participant cost for OnTrack from $256.5 to $192.4, a 24% reduction.

    “Sensitivity analyses showed that changing leadership from a psychologist to a social worker would reduce the per participant cost for OnTrack from $256.5 to $192.4, a 24% reduction in cost.”
    Quote in the paperSubstantial claim
  • Findingown data

    Training a social worker to deliver OnTrack would cost $954.

    “Training a social worker to deliver the OnTrack intervention would cost $954.”
    Quote in the paperNot a substantial claim
  • Findingown data

    In both interventions, the four online meetings made up the largest share of resources and costs (42%−45%).

    “In both interventions, the four online meetings accounted for the largest percentage of resources and costs (42%−45%).”
    Quote in the paperNot a substantial claim
  • Classified as probably not a substantial claim. 13
  • May combine two claims. 18

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Diabetes distress has been linked to worse glycemic control and problematic self-care in both cross-sectional and longitudinal studies.

    “Diabetes distress is a significant clinical problem; it has been associated with poor glycemic control and problematic self-care behavior in both cross-sectional and longitudinal studies.5–9”
    Quote in the paperNot a substantial claim2 of 5 sources checked
    • cites [5] source
    • cites [6] source
    • cites [7] source
    • cites [8] source
    • cites [9] source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    About 42% of adults with type 1 diabetes have elevated diabetes distress.

    “Approximately 42% of adults with T1DM manifest elevated diabetes distress.4”
    Quote in the paperNot a substantial claim1 of 1 sources checked

  • May combine two claims.

    Premisecitation

    Recent intervention studies indicate that diabetes distress can be changed, with the largest effects from group programs that address emotional aspects of diabetes directly rather than focusing only on behavior change or education.

    “Recent intervention studies demonstrate that diabetes distress is malleable, with the strongest effects coming from group programs that target emotional aspects of diabetes directly, rather than focusing exclusively on behavior change or education.10–12”
    Quote in the paperSubstantial claim1 of 3 sources checked
    • cites [10] source

      The Discussion (p. 10) reports that psycho-education combining diabetes with mood or motivation content reduced distress, supporting the claim that distress can change and that emotional content matters. But the Meta-analysis (p. 9) says group versus individual format did not affect outcomes, so this source does not support the claim that group programs had the strongest effects. (LLM, conf=0.90)

      Experimental — accuracy not yet measured
    • cites [11] source
    • cites [12] source

  • Classified as probably not a substantial claim.

    Premisecitation

    A targeted cost analysis approach focused specifically on implementation costs has been promoted as a useful way to meet these information needs.

    “A targeted approach to cost analysis, that focuses specifically on implementation costs, has been promoted as a useful way to meet these information needs.16–18”
    Quote in the paperSubstantial claim1 of 3 sources checked
    • cites [16] source
    • cites [17] source
    • cites [18] source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation

    The Type 1-Diabetes Distress Scale (T1-DDS) is a 28-item measure with an alpha of .84.

    “Diabetes distress was assessed via online surveys at study entry and at 3 and 9 months after the workshop using the Type 1-Diabetes Distress Scale (T1-DDS), a 28-item scale (alpha = .84).20”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [20] source

      Results §3.1 identifies the T1-DDS as a 28-item scale, supporting the item count. The same section reports an alpha of .91 for the total scale, not .84; its subscale alphas range from .76 to .88. Page numbers are unavailable in our copy. (LLM, conf=0.92)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Findingown data

    In that sensitivity analysis, the associated cost of a unit change in diabetes distress was $256.5 and in HbA1C was $1,068.9.

    “The associated costs of a unit change in diabetes distress would be $256.5 and in HbA1C was $1,068.9.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    KnowIt participants were slightly older (mean age 47.3) than OnTrack participants (mean age 42.8) (t299=2.63, p=0.009).

    “KnowIt participants were slightly older (mean age 47.3) than OnTrack participants (mean age 42.8) (t299=2.63, p=0.009)”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The total cost of training a group leader was $1,535, comprising $682 in leader time and $853 in supervisor time.

    “The total cost of training a group leader was $1,535, which included $682 in leader time and $853 in supervisor time.”
    • Also stated in: § DISCUSSION · plain
      “Training a single group leader in either intervention cost $1,535.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    In both interventions, group leader effort accounted for less than half of the resources used and two-thirds of the costs incurred.

    “In both interventions, group leader effort accounted for less than one half of the resources used and two-thirds of the costs incurred.”
    • Also stated in: § DISCUSSION · plain
      “Group leader time accounts for two-thirds of intervention costs.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Total intervention cost per participant was $251.4 for KnowIt and $251.5 for OnTrack, with no between-group difference in cost (t=1.71, ns).

    “Total intervention cost per participant was $251.4 for KnowIt and $251.5 for OnTrack, with no between-group differences in cost (t=1.71, ns) (Table 2).”
    • Also stated in: § DISCUSSION · hedged
      “The per participant cost for both interventions was about $250.”
    • Also stated in: § Results · hedged
      “For both interventions, per participant implementation costs were approximately $250”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    There were no baseline differences between groups in diabetes distress or HbA1C.

    “but there were no between-group baseline differences in diabetes distress or HbA1C.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The cost of a 1.0 percentage point decrease in HbA1C (11 mmol/mol) was $1,396.7 for KnowIt and $1,397.2 for OnTrack.

    “The cost of a 1.0 percentage point decrease in HbA1C (11 mmol/mol) was $1,396.7 for KnowIt ($251.4/(8.77–8.6)) and $1,397.2 for OnTrack ($251.5/(8.8–8.7)).”
    • Also stated in: § DISCUSSION · hedged
      “The cost of a 1.0 percentage point (11 mmol/mol) decrease in HbA1C was about $1,400 for both interventions.”
    • Also stated in: § Results · plain
      “cost per 1.0 percentage point (11 mmol/mol ) change in HbA1C was $1,400”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    In sensitivity analysis, with a social worker as OnTrack leader and a CDE as KnowIt leader, the per participant cost of OnTrack fell to $192.4, which was statistically significantly lower than the cost of KnowIt (t=32.88, p<0.0001).

    “With a social worker as OnTrack leader and a CDE as KnowIt leader, the per participant cost of OnTrack was reduced to $192.4, a cost statistically significantly lower than the cost of KnowIt (t=32.88, p<0.0001).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The total cost of training an assistant was $329, comprising $232 in assistant time and $97 in supervisor time.

    “The total cost of training an assistant was $329 which included $232 in assistant time and $97 in supervisor time.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    No statistically or practically significant differences were observed between KnowIt and OnTrack in per-participant costs or in cost per unit change in diabetes distress or HbA1C.

    “No statistically or practically significant differences in per-participant costs or cost per unit change in diabetes distress or HbA1C were observed between the KnowIt and OnTrack interventions.”
    • Also stated in: § Results · plain
      “No statistically significant differences in costs were observed.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingreasoning

    The cost of a one-unit decrease in diabetes distress (one point on the T1-DDS) was $364.4 for KnowIt and $335.3 for OnTrack.

    “The cost of a one unit decrease in diabetes distress (one point on the T1-DDS) was $364.4 for KnowIt ($251.4/(2.87–2.2)) and $335.3 ($251.5/(2.9–2.2)) for OnTrack.”
    • Also stated in: § DISCUSSION · plain
      “The mean cost of a unit decrease in diabetes distress was $364.4 for KnowIt and $335.3 for OnTrack.”
    • Also stated in: § Results · plain
      “Cost per unit change in diabetes distress was $364 for KnowIt and $335 for OnTrack.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    The T1-REDEEM trial compared two group interventions, KnowIt and OnTrack, intended to lower diabetes distress and HbA1C in highly distressed adults with poorly controlled type 1 diabetes.

    “The recent T1-REDEEM (Reducing Distress and Enhancing Effective Management) trial12 compared two group interventions designed to reduce diabetes distress and HbA1C among highly distressed adults with poorly controlled T1DM.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [12] source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    Areas with lower or higher salary costs would experience somewhat different implementation costs.

    “As a result, areas with lower or higher salary costs would experience somewhat different implementation costs.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    As delivered in T1-REDEEM, with KnowIt led by a certified diabetes educator and OnTrack led by a psychologist, both interventions provide similar effectiveness at a similar cost.

    “As delivered in the T1-REDEEM study, with KnowIt groups led by a certified diabetes educator and OnTrack groups led by a psychologist, both interventions offer similar effectiveness at a similar cost.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductown data

    The T1-REDEEM study did not examine medical outcomes or medical utilization, so the associated costs cannot be considered.

    “The T1-REDEEM study did not examine medical outcomes or medical utilization, thus the associated costs cannot be considered.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    Sensitivity analyses were performed to examine intervention costs under plausible alternative scenarios.

    “As has been recommended16 sensitivity analyses were conducted to examine intervention costs under plausible alternative intervention scenarios.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [16] source

  • May combine two claims.

    Premiseown data

    Two group interventions significantly reduce diabetes distress and HbA1C in distressed adults with poorly controlled type 1 diabetes.

    “In conclusion, results show that two group interventions significantly reduce diabetes distress and HbA1C in distressed adults with poorly controlled T1DM”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [12] source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationnone given

    The use of online group meetings likely limits patient costs.

    “The use of online group meetings, however, likely limits patient costs.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductreasoning

    To maximize generalizability, national salary costs were used in the calculations.

    “To maximize generalizability, we used national salary costs in our calculations.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    The focus on implementation costs prevented examination of costs incurred by patients to participate, such as time and transportation.

    “Also, the focus on implementation costs precluded the examination of costs incurred by patients to participate in the interventions, e.g., time and transportation.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Per participant costs for effective diabetes self-management interventions ranged from $219 to $5,390 in 2017 dollars.

    “A recent systematic review found that per participant costs for effective self-management costs ranged from $219 to $5,390 in 2017 dollars.13”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [13] source

  • May combine two claims.

    Premisecitation

    In the T1-REDEEM trial, both interventions produced statistically significant reductions in diabetes distress and HbA1C, with a combined effect size of d = 1.06 for diabetes distress change, and no differences between groups in outcomes.

    “Statistically significant reductions in diabetes distress and HbA1C were observed with both interventions (d = 1.06 combined effect size for change in diabetes distress) and no between-group differences in outcomes were observed.12”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [12] source

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductnone given

    The analyses used an intent-to-treat perspective and included all participants who attended the initial workshop.

    “Analyses were conducted from an intent-to-treat perspective and included all participants who attended the initial workshop.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    Staff training costs were not included on a per-participant basis because they are not easily generalizable to different clinical settings where the number of staff trained and the number of patients they serve can vary considerably.

    “Additionally, we did not include staff training costs on a per-participant basis because they are not easily generalizable to different clinical settings where the number of staff trained, and the number of patients they serve, can vary considerably.”
    Quote in the paperNot a substantial claim
29 of 29

  • The paper relies on this without support.

    No prior study has examined the costs of implementing interventions that directly target diabetes distress in adults with type 1 diabetes mellitus.

    “This is the first study to examine the costs of implementing interventions targeting diabetes distress in the context of T1DM.”
    “This study is the first to examine the costs associated with implementing interventions directly targeting diabetes distress among adults with T1DM.”

  • The paper relies on this without support.

    Web meeting system resources are available from multiple sources at no cost.

    “Costs associated with the web meeting system were collected but were not included in analyses because these resources are now available from multiple sources at no cost.”

  • The paper relies on this without support.

    The resource use and costs observed in the T1-REDEEM trial, after excluding research activities and using standard values, represent real-world implementation costs.

    “To best approximate real-world implementation conditions, standard values for workshop size (8 participants) workshop set-up time (30 minutes) were used in all analyses.”

  • The paper relies on this without support.

    Social workers have training and expertise similar to psychologists for delivering the OnTrack intervention.

    “Many social workers receive training in delivering group interventions that are similar to the training psychologists receive.”
4 of 4

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Percentage reduction from social-worker OnTrack cost is inconsistent

    Minor

    The text says reducing OnTrack cost from $256.5 to $192.4 is a 24% reduction. The difference is $64.1, which is about 25.0% of $256.5.

    Reported 24 · recomputed 64.1

  • Discussion gives the wrong starting cost for OnTrack

    Minor

    The discussion says OnTrack's per-participant cost fell from $256.5, but the results report its original per-participant cost as $251.5. The $256.5 figure is reported elsewhere as a cost per unit change in diabetes distress under the social-worker scenario, not as the original per-participant cost.

2 of 2

Cites

Flagged first, then by citations

Research works printed but not linked: 1

  1. Hargreaves WA, Shumway M, Hu Teh-wei, Cuffel B. Cost-Outcome Methods for Mental Health. San Diego: Academic Press, 1998.

Cited by

Sorted by citations

Related

Authors
Shumway, M., Fisher, L., Hessler, D., Bowyer, V., Polonsky, W. H., & Masharani, U.
Affiliations
  • University of California, San Francisco (US)
  • University of California San Diego (US)
Corresponding author
Shumway, Martha
ORCID
Venue
Journal of Diabetes and its Complications
Publisher
Elsevier BV
Published
2019-11
Volume
33
Issue
11
Pages
107416
ISSN
  • 0891-6632 (ISSN-L)
  • 1056-8727
DOI
10.1016/j.jdiacomp.2019.107416
PMC
PMC6823162
OpenAlex
W2968641056
Semantic Scholar
a982ae7a9ea8d37973c1bf39c9ed0c5d5a90846a
Cited by
4
References
24
Citations by year
2024: 1 · 2022: 1 · 2021: 2
FWCI
0.61
Type
journal article
Language
en
Open access
Licence
Locations
  • Journal of Diabetes and its Complications (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
  • eScholarship (California Digital Library) (submittedVersion)
Funders
National Institute of Diabetes and Digestive and Kidney Diseases
Topics
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Education
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
  • Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Health Systems, Economic Evaluations, Quality of Life
Keywords
type 1 diabetes, diabetes distress, group intervention, implementation costs, diabetes education, HbA1c, cost per participant, diabetes self-management
MeSH terms
Implementation Science, Psychological Distress, Adult, Anxiety, Cost-Benefit Analysis, Depression, Diabetes Mellitus, Type 1, Group Processes, Humans, Middle Aged, Patient Acceptance of Health Care, Patient Education as Topic, Psychotherapy, Group, Self Care, Stress, Psychological, Health Care Costs

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