1. Is Screening and Integrated Care for GDM Cost Effective?
Anil Kapur

2. Hyperglycemia in Pregnancy – Why it is relevant?
High risk of maternal and perinatal morbidity and mortality and poor pregnancy outcome
Identifies women at high future risk of diabetes, CVD offers opportunity of primary prevention
Offspring of GDM pregnancy at high risk of metabolic problems including type 2 diabetes

3. Pregnancy Outcomes are linked to maternal hyperglycemia
HAPO study,NEJM 2008
Increasing complications with rising maternal glucose
Atlantic DIP Study
Diabetologia 2011

4. Hyperglycemia impacts pregnancy outcomes
These complications probably contributed to the excessive adverse maternal and perinatal outcomes shown in the study
In 23 developing countries maternal diabetes and obesity increased the risk of macrosomia 2 to 3 fold
Increased risk of birth trauma, asphyxia, and meconium aspiration
Emergency caesarean section due to obstructed labour
High risk of abnormal haemorrhage, uterine atony, and prolonged labour.
The Lancet 2013; 381:

5. Treating GDM lowers risk of perinatal complications

6. GDM Assiciated with High Risk of Maternal Diabetes Post GDM
Women with gestational diabetes had a 7 fold increased risk of developing type 2 diabetes (RR 7·43, 95% CI 4·79–11·51).
Within 5 years of a pregnancy complicated by gestational diabetes women had a relative risk of 4.69, which more than doubled to 9.34 in those examined more than 5 years post partum
Leanne Bellamy, Juan-Pablo Casas, Aroon D Hingorani, David Williams
Lancet 2009; 373: 1773–79

7. Women with GDM at high risk of premature CVD
Retnakaran R, Shah BR. Mild glucose intolerance in pregnancy and risk of cardiovascular disease: a population-based cohort study. CMAJ 2009;181:371e6.],
Over a median 12 y follow-up, women with GDM have a higher risk of CVD (adjusted hazard ratio 1.66 (95% CI 1.30, 2.13), p < 0.001)
Kessous R, Shoham-Vardi I, Pariente G, et al. An association between gestational diabetes mellitus and long-term maternal cardiovascular morbidity. Heart 2013;99:1118e21
Over 10 y women with GDM had more non-invasive cardiac diagnostic procedures (OR 1.8 (95% CI )), simple cardiovascular events (OR 2.7 (95% CI )) and total cardiovascular hospitalizations (OR 2.3 (95% CI )) after adjusting for age, ethnicity and co-morbidities such as pre-eclampsia and obesity

8. Post Partum Lifestyle intervention prevents Type 2 DM (and perhaps CVD) in women with GDM
Ratner RE, Christophi CA, Metzger BE et al. Diabetes Prevention Program Research Group. Prevention of diabetes in women with a history of gestational diabetes: effects of metformin and lifestyle interventions. J Clin Endocrinol Metab :
Both intensive lifestyle and metformin have been shown to be highly effective in delaying or preventing diabetes in women with IGT and a history of GDM
Aroda VR et al. The Effect of Lifestyle Intervention and Metformin on Preventing or Delaying Diabetes Among Women With and Without Gestational Diabetes: The Diabetes Prevention Program Outcomes Study 10-Year Follow-Up. J Clin Endocrinol Metab Feb 23:jc
In the Diabetes Prevention Program Outcomes Study (DPPOS) over 10 y follow up in women with GDM, intensive lifestyle (ILS) and metformin reduced progression to diabetes compared with placebo by 35% and 40%, respectively.
Bao W, Tobias DK, Bowers K, et al. Physical activity and sedentary behaviors associated with risk of progression from gestational diabetes mellitus to type 2 diabetes mellitus: a prospective cohort study. JAMA Intern Med. 2014;174:
In a cohort of over 4500 women with GDM from the Nurses health study followed for 10 y, moderately intense physical activity (150 minutes/week) reduced the risk of type 2 diabetes 47% (RR, 0.53; 95% CI, ); the association remained significant after additional adjustment for BMI

9. Diabetes Begets Diabetes.
Evidence that treating GDM prevents Type 2 diabetes in Offspring is lacking

10. The Challenge ~127 Million Pregnancies/Year
~21 million /year complicated by hyperglycaemia
~3 to 4 million detected and treated
? Receive Post partum follow up and lifestyle advice

11. The evidence – what works?

12. Is it cost effective to screen, detect and treat GDM?
The Question that is often asked
Is it cost effective to screen, detect and treat GDM?

13. Cost Effectiveness Analysis
Measures the benefits associated with an intervention relative to its cost
Average Cost-effectiveness ratio (CE ratio):
Benefit of intervention maybe measured as quality adjusted life year (QALY) gained or disability adjusted life year (DALY) prevented

14. Comparing More than One Intervention
Incremental cost-effectiveness is the difference in costs between two interventions divided by the difference in QALYs gained or DALYs averted

15. According to the WHO CHOISE analysis any intervention in a given country is considered
highly cost-effective if its cost is less than its annual GDP per capita;
cost-effective when it is between one and three times GDP per capita;
not cost-effective when it is more than three times GDP per capita.

16. Perspective (in economic evaluation)
The viewpoint from which an economic evaluation is conducted. The viewpoint may be that of the patient, hospital/clinic, healthcare system or society.
Perspective (in economic evaluation)
Costs and benefits incurred today are usually valued more highly than costs and benefits occurring in the future. Discounting health benefits reflects society's preference for benefits to be experienced in the present rather than the future. Discounting costs reflects society's preference for costs to be experienced in the future rather than the present.
Discounting
An economic evaluation that expresses both costs and outcomes of an intervention in monetary terms. Benefits are valued in monetary terms using valuations of people's observed or stated preferences, such as the willingness-to-pay approach.
Cost–benefit analysis or Cost-utility analysis

17. The opportunity cost of investing in a healthcare intervention is the other healthcare programs that are displaced by its introduction. This may be best measured by the health benefits that could have been achieved had the money been spent on the next best alternative healthcare intervention.
Opportunity cost
An intervention is dominated if it has higher costs and worse outcomes than an alternative intervention.
Dominance
The incremental cost-effectiveness ratio (ICER) for a given treatment alternative is higher than that of the next, more effective, alternative (that is, it is dominated by the combination of 2 alternatives and should not be used to calculate appropriate ICERs)
Extended dominance

18. The Cost Effective Plane
Extended Dominance
Dominant

19. Health System Perspective
Screen
&
Diagnose
Costs depend on
Technology
Criteria used
Cut off values
Prevalence
Savings depend on
Efficacy of Rx
Type & severity of complications averted
Immediate
Long Term (Discounted)
Costs depend on type & efficacy of interventions
Cost of Rx DM, CVD and their complications in future
MCH Perspective
NCD Perspective
Health System Perspective
GDM
T2D/NCDs in offspring
T2D in mother
Postpartum Lifestyle
Treat
Perinatal complications
CVD in mother

20. GDM Cost Effectiveness Model
Societal Perspective

21. Studies on Cost Effectiveness of GDM Screening and Treatment

22. Cost-Effectiveness of Interventions to Prevent and Control Diabetes Mellitus: A Systematic Review, Diabetes Care 33:1872–1894, 2010
Based on supportive evidence, screening for GDM is cost saving and Intensive post partum diet and education in women with GDM to prevent type 2 diabetes is cost effective

23. Conclusions
GDM testing – when associated with good GDM care and post-partum interventions for T2D prevention - is highly cost-effective in both high-income (US, Israel) and low-income (India) countries according to WHO standards
GDM screening could be cost-effective in some settings, even if only perinatal events are counted

24. Life Course Approach to Prevention
There is increasing acceptance that intrauterine period and two years of early life - the so called 1000 golden days offer us a huge opportunity to address prevention of NCDs in the next generations due to the plasticity this period provides. Interventions done later are not only more difficult to implement due to established behaviors but are perhaps less effective because of reduced functional capacity and inadequate response to new challenges due to reduced plasticity.
While general public health measures to improve next generation health should begin as early in life as possible, the outcomes are a little difficult to measure, concrete results likely to be visible only after many years and hence sustaining long term interest difficult. Targeting health during pregnancy offers a good opportunity because of its emotional appeal and readiness to take action, some intermediate outcomes can be visible quickly and thus provide enthusiasm to carry forward the initiatives in the high risk mother child pair with even more measurable outcomes becoming visible within five to ten years providing further encouragement for continuing action. Thus pregnancy offers the most optimal time to initiate future health initiatives which can then be carried forward through life course and intergenerational prevention approach.

25. Window of Opportunity
Pregnancy offers a cost effective window of opportunity to provide maternal care services to
Reduce traditional maternal and perinatal morbidity and mortality indicators
Cost Effectively address intergenerational prevention of NCDs, such as diabetes, hypertension, cardiovascular disease, and stroke.