BACKGROUND Rural Americans have higher prevalence of obesity and type 2 diabetes (T2D) than urban populations and more limited access to behavioral programs to promote healthy lifestyle habits. Descriptive evidence from the Rural Lifestyle Intervention Treatment Effectiveness trial delivered through local cooperative extension service offices in rural areas previously identified that behavioral modification with both nutrition education and coaching resulted in a lower program delivery cost per kilogram of weight loss maintained at 2-years compared with an education-only comparator intervention. OBJECTIVE This analysis extended earlier Rural Lifestyle Intervention Treatment Effectiveness trial research regarding weight loss outcomes to assess whether nutrition education with behavioral coaching delivered through cooperative extension service offices is cost-effective relative to nutrition education only in reducing T2D cases in rural areas. DESIGN A cost-utility analysis was conducted. PARTICIPANTS/SETTING Trial participants (n=317) from June 2008 through June 2014 were adults residing in rural Florida counties with a baseline body mass index between 30 and 45, but otherwise identified as healthy. INTERVENTION Trial participants were randomly assigned to low, moderate, or high doses of behavioral coaching with nutrition education (ie, 16, 32, or 48 sessions over 24 months) or a comparator intervention that included 16 sessions of nutrition education without coaching. Participant glycated hemoglobin level was measured at baseline and the end of the trial to assess T2D status. MAIN OUTCOME MEASURES T2D categories by treatment arm were used to estimate participants' expected annual health care expenditures and expected health-related utility measured as quality adjusted life years (ie, QALYs) over a 5-year time horizon. Discounted incremental costs and QALYs were used to calculate incremental cost-effectiveness ratios for each behavioral coaching intervention dose relative to the education-only comparator. STATISTICAL ANALYSES PERFORMED Using a third-party payer perspective, Markov transition matrices were used to model participant transitions between T2D states. Replications of the individual participant behavior were conducted using Monte Carlo simulation. RESULTS All three doses of the behavioral coaching intervention had lower expected total costs and higher estimated QALYs than the education-only comparator. The moderate dose behavioral coaching intervention was associated with higher estimated QALYs but was costlier than the low dose; the moderate dose was favored over the low dose with willingness to pay thresholds over $107,895/QALY. The low dose behavioral coaching intervention was otherwise favored. CONCLUSIONS Because most rural Americans live in counties with cooperative extension service offices, nutrition education with behavioral coaching programs similar to those delivered through this trial may be effective and efficient in preventing or delaying T2D-associated consequences of obesity for rural adults.

中文翻译：

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三剂行为干预在农村地区预防或延缓 2 型糖尿病的成本效益

背景与城市人口相比，美国农村人口的肥胖症和 2 型糖尿病 (T2D) 患病率更高，并且获得促进健康生活方式习惯的行为计划的机会更有限。通过农村地区当地合作推广服务办公室提供的农村生活方式干预治疗效果试验的描述性证据先前表明，与营养教育和辅导相结合的行为改变导致每公斤体重减轻的计划实施成本较低，与 2 年相比仅教育比较干预。目标本分析扩展了早期关于减肥结果的农村生活方式干预治疗有效性试验研究，以评估通过合作推广服务办公室提供的行为指导营养教育是否比仅在减少农村地区的 T2D 病例方面的营养教育更具成本效益。设计 进行了成本效用分析。参与者/设置 2008 年 6 月至 2014 年 6 月的试验参与者 (n=317) 是居住在佛罗里达州农村县的成年人，其基线体重指数在 30 到 45 之间，但在其他方面被确定为健康。干预 试验参与者被随机分配到低、中或高剂量的行为指导和营养教育（即，16、32、或 24 个月内的 48 次会议）或比较干预措施，其中包括 16 次没有辅导的营养教育。在基线和试验结束时测量参与者的糖化血红蛋白水平以评估 T2D 状态。主要结果测量按治疗组划分的 T2D 类别用于估计参与者的预期年度医疗保健支出和预期健康相关效用，以 5 年时间范围内的质量调整生命年（即 QALYs）衡量。折扣增量成本和 QALYs 用于计算每个行为指导干预剂量相对于仅教育比较器的增量成本效益比。执行的统计分析 使用第三方付款人的角度，马尔可夫转换矩阵用于模拟参与者在 T2D 状态之间的转换。使用蒙特卡罗模拟进行个体参与者行为的复制。结果 与仅接受教育的对照相比，所有三种剂量的行为指导干预均具有更低的预期总成本和更高的估计 QALY。中等剂量的行为指导干预与较高的估计 QALYs 相关，但比低剂量的成本更高；中等剂量比低剂量更受青睐，愿意支付超过 107,895 美元/QALY 的门槛。低剂量行为指导干预在其他方面受到青睐。结论 因为大多数农村美国人生活在有合作推广服务办公室的县，