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Medwave 2015 Dic;15(11):e6348 doi: 10.5867/medwave.2015.11.6348
Educación de personas con diabetes tipo 2: ¿es costo-efectiva su implementación a través de pares con diabetes?
Education of people with type 2 diabetes through peers with diabetes: is it cost effective?
Lorena González, Jorge Federico Elgart, Juan José Gagliardino
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Palabras clave: cost-effectiveness analysis, education, diabetes mellitus type 2

Abstract

INTRODUCTION
Inadequate quality of care provided to people with type 2 diabetes mellitus, generates a significant socioeconomic burden and a serious public health problem. Diabetes education through peers with diabetes is an alternative to that provided by professional educators (traditional education) which achieves non-inferior results. However, there is little evidence of cost-effectiveness of education trough peers over traditional education.

OBJECTIVE
To evaluate cost-effectiveness of education of people with type 2 diabetes mellitus, during a year, by a team of professional educators (traditional education) versus education and support delivered by trained peers with diabetes.

METHODS
Cost-effectiveness analysis based on a randomized prospective clinical study conducted in the city of La Plata, including 199 people with type 2 diabetes mellitus, divided in two groups:, one receiving traditional education and another receiving the same education but delivered by peer educators with type 2 diabetes mellitus. Change in glycosylated hemoglobin (HbA1c) was considered as a primary indicator of effectiveness and secondary indicators were others, such as body mass index, systolic blood pressure, diastolic blood pressure, fasting blood glucose, total cholesterol and triglyceride levels. The direct cost of each strategy was estimated based on resources used in the trial, evaluating three cost scenarios for peer education. The strength of the results was assessed by univariate sensitivity analysis.

RESULTS
Cost per unit decrease (%) in HbA1c: traditional education: $2 621; peer education: $1 508, $1 779 y $2 071 for each of the three scenarios considered (scenario 1, scenario 2, scenario 3), respectively. For each $100 invested a decrease of 0.04% in the HbA1c with traditional education was achieved; and 0.07% in scenario 1; 0.06% in scenario 2 and 0.05% in scenario 3, with education delivered by peer educators. Sensitivity analysis showed the strength of the results.

CONCLUSION
Education of type 2 diabetes mellitus patients through peers as a complement to control and treatment of the disease, is cost-effective compared to traditional education.


 

This article does not have an English version.

 

Licencia Creative Commons Esta obra de Medwave está bajo una licencia Creative Commons Atribución-NoComercial 3.0 Unported. Esta licencia permite el uso, distribución y reproducción del artículo en cualquier medio, siempre y cuando se otorgue el crédito correspondiente al autor del artículo y al medio en que se publica, en este caso, Medwave.

 

INTRODUCTION
Inadequate quality of care provided to people with type 2 diabetes mellitus, generates a significant socioeconomic burden and a serious public health problem. Diabetes education through peers with diabetes is an alternative to that provided by professional educators (traditional education) which achieves non-inferior results. However, there is little evidence of cost-effectiveness of education trough peers over traditional education.

OBJECTIVE
To evaluate cost-effectiveness of education of people with type 2 diabetes mellitus, during a year, by a team of professional educators (traditional education) versus education and support delivered by trained peers with diabetes.

METHODS
Cost-effectiveness analysis based on a randomized prospective clinical study conducted in the city of La Plata, including 199 people with type 2 diabetes mellitus, divided in two groups:, one receiving traditional education and another receiving the same education but delivered by peer educators with type 2 diabetes mellitus. Change in glycosylated hemoglobin (HbA1c) was considered as a primary indicator of effectiveness and secondary indicators were others, such as body mass index, systolic blood pressure, diastolic blood pressure, fasting blood glucose, total cholesterol and triglyceride levels. The direct cost of each strategy was estimated based on resources used in the trial, evaluating three cost scenarios for peer education. The strength of the results was assessed by univariate sensitivity analysis.

RESULTS
Cost per unit decrease (%) in HbA1c: traditional education: $2 621; peer education: $1 508, $1 779 y $2 071 for each of the three scenarios considered (scenario 1, scenario 2, scenario 3), respectively. For each $100 invested a decrease of 0.04% in the HbA1c with traditional education was achieved; and 0.07% in scenario 1; 0.06% in scenario 2 and 0.05% in scenario 3, with education delivered by peer educators. Sensitivity analysis showed the strength of the results.

CONCLUSION
Education of type 2 diabetes mellitus patients through peers as a complement to control and treatment of the disease, is cost-effective compared to traditional education.

Autores: Lorena González[1], Jorge Federico Elgart[1], Juan José Gagliardino[1]

Filiación:
[1] Centro de Endocrinología Experimental y Aplicada, Facultad de Ciencias Médicas Universidad Nacional de La Plata, La Plata, Argentina

E-mail: lgonzalez@cenexa.org

Correspondencia a:
[1] Facultad de Ciencias Médicas
Universidad Nacional de La Plata
Avenida 60 Sin Número
La Plata
Argentina

Citación: González L, Elgart JE, Gagliardino JJ. Education of people with type 2 diabetes through peers with diabetes: is it cost effective?. Medwave 2015 Dic;15(11):e6348 doi: 10.5867/medwave.2015.11.6348

Fecha de envío: 25/8/2015

Fecha de aceptación: 14/12/2015

Fecha de publicación: 29/12/2015

Origen: no solicitado

Tipo de revisión: con revisión por tres pares revisores externos, a doble ciego

Ficha PubMed

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  1. Gruber W, Lander T, Leese B, Songer T, Williams R. The Economics of DM and DM Care. A Report of the DM Health Economics Study Group. IDF: WHO; 1998
  2. [No authors listed]. Glucose tolerance and mortality: comparison of WHO and American Diabetes Association diagnostic criteria. The DECODE study group. European Diabetes Epidemiology Group. Diabetes Epidemiology: Collaborative analysis Of Diagnostic criteria in Europe. Lancet. 1999 Aug 21;354(9179):617-21. | PubMed |
  3. Ringborg A, Cropet C, Jönsson B, Gagliardino JJ, Ramachandran A, Lindgren P. Resource use associated with type 2 diabetes in Asia, Latin America, the Middle East and Africa: results from the International Diabetes Management Practices Study (IDMPS). Int J Clin Pract. 2009 Jul;63(7):997-1007. | CrossRef | PubMed |
  4. Elgart JF, Asteazarán S, De La Fuente JL, Camillucci C, Brown JB, Gagliardino JJ. Direct and indirect costs associated to type 2 diabetes and its complications measured in a social security institution of Argentina. Int J Public Health. 2014 Oct;59(5):851-7. | CrossRef | PubMed |
  5. Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Report of the expert committee on the diagnosis and classification of diabetes mellitus. Diabetes Care. 2003 Jan;26 Suppl 1:S5-20. | PubMed |
  6. Stamler J, Vaccaro O, Neaton JD, Wentworth D. Diabetes, other risk factors, and 12-yr cardiovascular mortality for men screened in the Multiple Risk Factor Intervention Trial. Diabetes Care. 1993 Feb;16(2):434-44. | PubMed |
  7. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. The Diabetes Control and Complications Trial Research Group. N Engl J Med. 1993 Sep 30;329(14):977-86. | PubMed |
  8. Ferrante D, Linetzky B, Konfino J, King A, Virgolini M, Laspiur S. Encuesta Nacional de Factores de Riesgo 2009: evolución de la epidemia de enfermedades crónicas no transmisibles en Argentina. Estudio de corte transversal. Rev Argent Salud Pública, 2011; 2(6), 34-41. | Link |
  9. Dirección de Promoción de la Salud y Control de Enfermedades no trasmisibles. 3º Encuesta Nacional de Factores de Riesgo. Presentación de los principales resultados para Enfermedades No Transmisibles. Ministerio de Salud de la Nación; 2014. [on line] | Link |
  10. Laing W, Williams DRR. Diabetes: A Model for Health Care Management. London: Offce of Health Economics; 1989.
  11. International Diabetes Federation. IDF Diabetes Atlas, 6th edn. Brussels, Belgium: International Diabetes Federation, 2013. [on line]. | Link |
  12. Williams R, Van Gaal L, Lucioni C; CODE-2 Advisory Board. Assessing the impact of complications on the costs of Type II diabetes. Diabetologia. 2002 Jul;45(7):S13-7. Epub 2002 Jun 12. | PubMed |
  13. Morsanutto A, Berto P, Lopatriello S, Gelisio R, Voinovich D, Cippo PP, et al. Major complications have an impact on total annual medical cost of diabetes: results of a database analysis. J Diabetes Complications. 2006 May-Jun;20(3):163-9. | PubMed |
  14. Vivian EM. Type 2 diabetes in children and adolescents--the next epidemic? Curr Med Res Opin. 2006 Feb;22(2):297-306. | PubMed |
  15. Gaede P, Lund-Andersen H, Parving HH, Pedersen O. Effect of a multifactorial intervention on mortality in type 2 diabetes. N Engl J Med. 2008 Feb 7;358(6):580-91. | CrossRef | PubMed |
  16. [No authors listed]. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. The Diabetes Control and Complications Trial Research Group. N Engl J Med. 1993 Sep 30;329(14):977-86. 8366922 | PubMed |
  17. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet. 1998 Sep 12;352(9131):837-53. | PubMed |
  18. Gagliardino JJ, Olivera EM, Etchegoyen GS, Guidi ML; Martella A, Caporale, JE; De La Hera M, Siri F, Bonelli Pl. Control y prevención secundaria para personas con diabetes: impacto de la implementación de un programa de atención (PROPAT). [Control and secondary prevention for people with diabetes: impact of the implementation of a healthcare program (PROPAT)]. Rev Soc Argent Diabetes. 2001;35(2): 77–86.
  19. Gagliardino JJ, Lapertosa S, Villagra M, Caporale JE, Oliver P, Gonzalez C, et al. PRODIACOR: a patient-centered treatment program for type 2 diabetes and associated cardiovascular risk factors in the city of Corrientes, Argentina: study design and baseline data. Contemp Clin Trials. 2007 Jul;28(4):548-56. Epub 2007 Jan 12. | PubMed |
  20. Evaluation of the quality of care for diabetic patients in Latin America. Gagliardino JJ, de la Hera M, Siri F; Grupo de Investigación de la Red QUALIDIAB. Rev Panam Salud Publica. 2001 Nov;10(5):309-17.
  21. Beckles GL, Engelgau MM, Narayan KM, Herman WH, Aubert RE, Williamson DF. Population-based assessment of the level of care among dults with diabetes in the U.S. Diabetes Care. 1998 Sep;21(9):1432-8. | PubMed |
  22. Chan JC, Gagliardino JJ, Baik SH, Chantelot JM, Ferreira SR, Hancu N, et al. Multifaceted determinants for achieving glycemic control: the International Diabetes Management Practice Study (IDMPS). Diabetes Care. 2009 Feb;32(2):227-33. | CrossRef | PubMed |
  23. Commendatore V, Dieuzeide G, Faingold C, Fuente G, Luján D, Aschner P, et al. Registry of people with diabetes in three Latin American countries: a suitable approach to evaluate the quality of health care provided to people with type 2 diabetes. Int J Clin Pract. 2013 Dec;67(12):1261-6. | CrossRef | PubMed |
  24. American Diabetes Association: clinical practice recommendations 1999. Diabetes Care. 1999 Jan;22 Suppl 1:S1-114. | PubMed |
  25. Latin American DM Association. Guias ALAD 2001 para el diagnostico y manejo de la DM mellitus tipo 2 con medicina basada en evidencia. Boletín de la Asociación Latino Americana de DM 2001.
  26. Faingold C, Lapertosa S, Fuente G, Perez Manghi F, Gonzalez J, et al. Calidad de atención de personas con diabetes tipo 2 en argentina (QUALIDIAB): ¿Prescribimos y logramos metas terapéuticas recomendadas en nuestros pacientes?. XIX Congreso Argentino de Diabetes, Sociedad Argentina de Diabetes (SAD). Rev Soc Arg Diabetes. Noviembre 2014; 48: 92.
  27. Norris SL, Engelgau MM, Narayan KM. Effectiveness of self-management training in type 2 diabetes: a systematic review of randomized controlled trials. Diabetes Care. 2001 Mar;24(3):561-87. | PubMed |
  28. Gagliardino JJ, Olivera E, Etchegoyen GS, Guidi ML, Caporale JE, Martella A, et al. PROPAT: a study to improve the quality and reduce the cost of diabetes care. Diabetes Res Clin Pract. 2006 Jun;72(3):284-91. | PubMed |
  29. Eddy DM, Schlessinger L, Kahn R. Clinical outcomes and cost-effectiveness of strategies for managing people at high risk for diabetes. Ann Intern Med. 2005 Aug 16;143(4):251-64. | PubMed |
  30. Trento M, Gamba S, Gentile L, Grassi G, Miselli V, Morone G, et al. Rethink Organization to iMprove Education and Outcomes (ROMEO): a multicenter randomized trial of lifestyle intervention by group care to manage type 2 diabetes. Diabetes Care. 2010 Apr;33(4):745-7. | CrossRef | PubMed |
  31. Gagliardino JJ, Aschner P, Baik SH, Chan J, Chantelot JM, Ilkova H, et al. Patients' education, and its impact on care outcomes, resource consumption and working conditions: data from the International Diabetes Management Practices Study (IDMPS). Diabetes Metab. 2012 Apr;38(2):128-34. | CrossRef | PubMed |
  32. Thom DH, Ghorob A, Hessler D, De Vore D, Chen E, Bodenheimer TA. Impact of peer health coaching on glycemic control in low-income patients with diabetes: a randomized controlled trial. Ann Fam Med. 2013 Mar-Apr;11(2):137-44. | CrossRef | PubMed |
  33. Gagliardino JJ, Arrechea V, Assad D, Gagliardino GG, González L, Lucero S, et al. Type 2 diabetes patients educated by other patients perform at least as well as patients trained by professionals. Diabetes Metab Res Rev. 2013 Feb;29(2):152-60. | CrossRef | PubMed |
  34. Moskowitz D, Thom DH, Hessler D, Ghorob A, Bodenheimer T. Peer coaching to improve diabetes self-management: which patients benefit most? J Gen Intern Med. 2013 Jul;28(7):938-42. | CrossRef | PubMed |
  35. van der Wulp I, de Leeuw JR, Gorter KJ, Rutten GE. Effectiveness of peer-led self-management coaching for patients recently diagnosed with Type 2 diabetes mellitus in primary care: a randomized controlled trial. Diabet Med. 2012 Oct;29(10):e390-7. | CrossRef | PubMed |
  36. Dale JR, Williams SM, Bowyer V. What is the effect of peer support on diabetes outcomes in adults? A systematic review. Diabet Med. 2012 Nov;29(11):1361-77.
  37. Simmons D, Voyle J, Rush E, Dear M. The New Zealand experience in peer support interventions among people with diabetes. Fam Pract. 2010 Jun;27 Suppl 1:i53-61. | CrossRef | PubMed |
  38. Heisler M. Overview of peer support models to improve diabetes self-management and clinical outcomes. Diabetes Spectr 2007;20: 214–221.
  39. Dennis CL. Peer support within a health care context: a concept analysis. Int J Nurs Stud. 2003 Mar;40(3):321-32. | PubMed |
  40. Boren SA, Fitzner KA, Panhalkar PS, Specker JE.. Costs and benefits associated with diabetes education: a review of the literature Diabetes Educ. 2009 Jan-Feb;35(1):72-96. | CrossRef | PubMed |
  41. Gobierno de chile, Ministerio de Salud, Subsecretaría de Salud Pública. Departamento de Economía de la Salud. Guía metodológica para la evaluación económica de intervenciones en salud en Chile. Santiago, Chile: MINSAL; 2013. [on line] | Link |
  42. Gagliardino JJ, Etchegoyen G; PENDID-LA Research Group. A model educational program for people with type 2 diabetes: a cooperative Latin American implementation study (PEDNID-LA). Diabetes Care. 2001 Jun;24(6):1001-7. | PubMed |
  43. Fisher L, Glasgow RE, Mullan JT, Skaff MM, Polonsky WH. Development of a brief diabetes distress screening instrument. Ann Fam Med. 2008 May-Jun;6(3):246-52. | CrossRef | PubMed |
  44. Brock, D. Ethical issues in the use of cost effectiveness analysis for the prioritization of health care resources. En: WHO Guide to Cost Effectiveness Analysis. Geneva: WHO; 2003:289-312. | Link |
  45. Gillespie P, O'Shea E, Paul G, O'Dowd T, Smith SM. Cost effectiveness of peer support for type 2 diabetes. Int J Technol Assess Health Care. 2012 Jan;28(1):3-11. | CrossRef | PubMed |
  46. Pichon-Riviere A, et al. HTA in Latin-America and the Caribbean (LAC), facilitators and barriers for international collaboration: a survey. V Annual Meeting, 9 de Julio, Montréal Canadá; 2008,
Gruber W, Lander T, Leese B, Songer T, Williams R. The Economics of DM and DM Care. A Report of the DM Health Economics Study Group. IDF: WHO; 1998

[No authors listed]. Glucose tolerance and mortality: comparison of WHO and American Diabetes Association diagnostic criteria. The DECODE study group. European Diabetes Epidemiology Group. Diabetes Epidemiology: Collaborative analysis Of Diagnostic criteria in Europe. Lancet. 1999 Aug 21;354(9179):617-21. | PubMed |

Ringborg A, Cropet C, Jönsson B, Gagliardino JJ, Ramachandran A, Lindgren P. Resource use associated with type 2 diabetes in Asia, Latin America, the Middle East and Africa: results from the International Diabetes Management Practices Study (IDMPS). Int J Clin Pract. 2009 Jul;63(7):997-1007. | CrossRef | PubMed |

Elgart JF, Asteazarán S, De La Fuente JL, Camillucci C, Brown JB, Gagliardino JJ. Direct and indirect costs associated to type 2 diabetes and its complications measured in a social security institution of Argentina. Int J Public Health. 2014 Oct;59(5):851-7. | CrossRef | PubMed |

Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Report of the expert committee on the diagnosis and classification of diabetes mellitus. Diabetes Care. 2003 Jan;26 Suppl 1:S5-20. | PubMed |

Stamler J, Vaccaro O, Neaton JD, Wentworth D. Diabetes, other risk factors, and 12-yr cardiovascular mortality for men screened in the Multiple Risk Factor Intervention Trial. Diabetes Care. 1993 Feb;16(2):434-44. | PubMed |

The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. The Diabetes Control and Complications Trial Research Group. N Engl J Med. 1993 Sep 30;329(14):977-86. | PubMed |

Ferrante D, Linetzky B, Konfino J, King A, Virgolini M, Laspiur S. Encuesta Nacional de Factores de Riesgo 2009: evolución de la epidemia de enfermedades crónicas no transmisibles en Argentina. Estudio de corte transversal. Rev Argent Salud Pública, 2011; 2(6), 34-41. | Link |

Dirección de Promoción de la Salud y Control de Enfermedades no trasmisibles. 3º Encuesta Nacional de Factores de Riesgo. Presentación de los principales resultados para Enfermedades No Transmisibles. Ministerio de Salud de la Nación; 2014. [on line] | Link |

Laing W, Williams DRR. Diabetes: A Model for Health Care Management. London: Offce of Health Economics; 1989.

International Diabetes Federation. IDF Diabetes Atlas, 6th edn. Brussels, Belgium: International Diabetes Federation, 2013. [on line]. | Link |

Williams R, Van Gaal L, Lucioni C; CODE-2 Advisory Board. Assessing the impact of complications on the costs of Type II diabetes. Diabetologia. 2002 Jul;45(7):S13-7. Epub 2002 Jun 12. | PubMed |

Morsanutto A, Berto P, Lopatriello S, Gelisio R, Voinovich D, Cippo PP, et al. Major complications have an impact on total annual medical cost of diabetes: results of a database analysis. J Diabetes Complications. 2006 May-Jun;20(3):163-9. | PubMed |

Vivian EM. Type 2 diabetes in children and adolescents--the next epidemic? Curr Med Res Opin. 2006 Feb;22(2):297-306. | PubMed |

Gaede P, Lund-Andersen H, Parving HH, Pedersen O. Effect of a multifactorial intervention on mortality in type 2 diabetes. N Engl J Med. 2008 Feb 7;358(6):580-91. | CrossRef | PubMed |

[No authors listed]. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. The Diabetes Control and Complications Trial Research Group. N Engl J Med. 1993 Sep 30;329(14):977-86. 8366922 | PubMed |

Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet. 1998 Sep 12;352(9131):837-53. | PubMed |

Gagliardino JJ, Olivera EM, Etchegoyen GS, Guidi ML; Martella A, Caporale, JE; De La Hera M, Siri F, Bonelli Pl. Control y prevención secundaria para personas con diabetes: impacto de la implementación de un programa de atención (PROPAT). [Control and secondary prevention for people with diabetes: impact of the implementation of a healthcare program (PROPAT)]. Rev Soc Argent Diabetes. 2001;35(2): 77–86.

Gagliardino JJ, Lapertosa S, Villagra M, Caporale JE, Oliver P, Gonzalez C, et al. PRODIACOR: a patient-centered treatment program for type 2 diabetes and associated cardiovascular risk factors in the city of Corrientes, Argentina: study design and baseline data. Contemp Clin Trials. 2007 Jul;28(4):548-56. Epub 2007 Jan 12. | PubMed |

Evaluation of the quality of care for diabetic patients in Latin America. Gagliardino JJ, de la Hera M, Siri F; Grupo de Investigación de la Red QUALIDIAB. Rev Panam Salud Publica. 2001 Nov;10(5):309-17.

Beckles GL, Engelgau MM, Narayan KM, Herman WH, Aubert RE, Williamson DF. Population-based assessment of the level of care among dults with diabetes in the U.S. Diabetes Care. 1998 Sep;21(9):1432-8. | PubMed |

Chan JC, Gagliardino JJ, Baik SH, Chantelot JM, Ferreira SR, Hancu N, et al. Multifaceted determinants for achieving glycemic control: the International Diabetes Management Practice Study (IDMPS). Diabetes Care. 2009 Feb;32(2):227-33. | CrossRef | PubMed |

Commendatore V, Dieuzeide G, Faingold C, Fuente G, Luján D, Aschner P, et al. Registry of people with diabetes in three Latin American countries: a suitable approach to evaluate the quality of health care provided to people with type 2 diabetes. Int J Clin Pract. 2013 Dec;67(12):1261-6. | CrossRef | PubMed |

American Diabetes Association: clinical practice recommendations 1999. Diabetes Care. 1999 Jan;22 Suppl 1:S1-114. | PubMed |

Latin American DM Association. Guias ALAD 2001 para el diagnostico y manejo de la DM mellitus tipo 2 con medicina basada en evidencia. Boletín de la Asociación Latino Americana de DM 2001.

Faingold C, Lapertosa S, Fuente G, Perez Manghi F, Gonzalez J, et al. Calidad de atención de personas con diabetes tipo 2 en argentina (QUALIDIAB): ¿Prescribimos y logramos metas terapéuticas recomendadas en nuestros pacientes?. XIX Congreso Argentino de Diabetes, Sociedad Argentina de Diabetes (SAD). Rev Soc Arg Diabetes. Noviembre 2014; 48: 92.

Norris SL, Engelgau MM, Narayan KM. Effectiveness of self-management training in type 2 diabetes: a systematic review of randomized controlled trials. Diabetes Care. 2001 Mar;24(3):561-87. | PubMed |

Gagliardino JJ, Olivera E, Etchegoyen GS, Guidi ML, Caporale JE, Martella A, et al. PROPAT: a study to improve the quality and reduce the cost of diabetes care. Diabetes Res Clin Pract. 2006 Jun;72(3):284-91. | PubMed |

Eddy DM, Schlessinger L, Kahn R. Clinical outcomes and cost-effectiveness of strategies for managing people at high risk for diabetes. Ann Intern Med. 2005 Aug 16;143(4):251-64. | PubMed |

Trento M, Gamba S, Gentile L, Grassi G, Miselli V, Morone G, et al. Rethink Organization to iMprove Education and Outcomes (ROMEO): a multicenter randomized trial of lifestyle intervention by group care to manage type 2 diabetes. Diabetes Care. 2010 Apr;33(4):745-7. | CrossRef | PubMed |

Gagliardino JJ, Aschner P, Baik SH, Chan J, Chantelot JM, Ilkova H, et al. Patients' education, and its impact on care outcomes, resource consumption and working conditions: data from the International Diabetes Management Practices Study (IDMPS). Diabetes Metab. 2012 Apr;38(2):128-34. | CrossRef | PubMed |

Thom DH, Ghorob A, Hessler D, De Vore D, Chen E, Bodenheimer TA. Impact of peer health coaching on glycemic control in low-income patients with diabetes: a randomized controlled trial. Ann Fam Med. 2013 Mar-Apr;11(2):137-44. | CrossRef | PubMed |

Gagliardino JJ, Arrechea V, Assad D, Gagliardino GG, González L, Lucero S, et al. Type 2 diabetes patients educated by other patients perform at least as well as patients trained by professionals. Diabetes Metab Res Rev. 2013 Feb;29(2):152-60. | CrossRef | PubMed |

Moskowitz D, Thom DH, Hessler D, Ghorob A, Bodenheimer T. Peer coaching to improve diabetes self-management: which patients benefit most? J Gen Intern Med. 2013 Jul;28(7):938-42. | CrossRef | PubMed |

van der Wulp I, de Leeuw JR, Gorter KJ, Rutten GE. Effectiveness of peer-led self-management coaching for patients recently diagnosed with Type 2 diabetes mellitus in primary care: a randomized controlled trial. Diabet Med. 2012 Oct;29(10):e390-7. | CrossRef | PubMed |

Dale JR, Williams SM, Bowyer V. What is the effect of peer support on diabetes outcomes in adults? A systematic review. Diabet Med. 2012 Nov;29(11):1361-77.

Simmons D, Voyle J, Rush E, Dear M. The New Zealand experience in peer support interventions among people with diabetes. Fam Pract. 2010 Jun;27 Suppl 1:i53-61. | CrossRef | PubMed |

Heisler M. Overview of peer support models to improve diabetes self-management and clinical outcomes. Diabetes Spectr 2007;20: 214–221.

Dennis CL. Peer support within a health care context: a concept analysis. Int J Nurs Stud. 2003 Mar;40(3):321-32. | PubMed |

Boren SA, Fitzner KA, Panhalkar PS, Specker JE.. Costs and benefits associated with diabetes education: a review of the literature Diabetes Educ. 2009 Jan-Feb;35(1):72-96. | CrossRef | PubMed |

Gobierno de chile, Ministerio de Salud, Subsecretaría de Salud Pública. Departamento de Economía de la Salud. Guía metodológica para la evaluación económica de intervenciones en salud en Chile. Santiago, Chile: MINSAL; 2013. [on line] | Link |

Gagliardino JJ, Etchegoyen G; PENDID-LA Research Group. A model educational program for people with type 2 diabetes: a cooperative Latin American implementation study (PEDNID-LA). Diabetes Care. 2001 Jun;24(6):1001-7. | PubMed |

Fisher L, Glasgow RE, Mullan JT, Skaff MM, Polonsky WH. Development of a brief diabetes distress screening instrument. Ann Fam Med. 2008 May-Jun;6(3):246-52. | CrossRef | PubMed |

Brock, D. Ethical issues in the use of cost effectiveness analysis for the prioritization of health care resources. En: WHO Guide to Cost Effectiveness Analysis. Geneva: WHO; 2003:289-312. | Link |

Gillespie P, O'Shea E, Paul G, O'Dowd T, Smith SM. Cost effectiveness of peer support for type 2 diabetes. Int J Technol Assess Health Care. 2012 Jan;28(1):3-11. | CrossRef | PubMed |

Pichon-Riviere A, et al. HTA in Latin-America and the Caribbean (LAC), facilitators and barriers for international collaboration: a survey. V Annual Meeting, 9 de Julio, Montréal Canadá; 2008,