INTRODUCCIÓN
La inadecuada calidad de atención brindada a personas con diabetes tipo 2, genera un gran impacto socioeconómico y un grave problema de salud pública. La educación de estas personas a través de pares con diabetes mellitus es una alternativa, a la brindada por equipos profesionales (educación tradicional), que logra resultados no inferiores a esta última. Sin embargo, hay escasa evidencia de costo-efectividad de la educación a través de pares respecto de la tradicional.

OBJETIVO
Evaluar la relación costo-efectividad de la educación de personas con diabetes tipo 2, durante un año por un equipo profesional (educación tradicional), versus educación y apoyo impartida por un par con diabetes mellitus (educación de pares).

MÉTODOS
Análisis de costo-efectividad basado en un estudio clínico prospectivo aleatorizado, desarrollado en la ciudad de La Plata sobre 199 personas con diabetes tipo 2, organizados en dos grupos: uno que recibió educación tradicional y otro educación a través de pares con diabetes mellitus. Como indicador primario de efectividad se consideró el cambio en la hemoglobina glicosilada y como secundarios otros como índice de masa corporal, presión arterial sistólica, presión arterial diastólica, glucemia en ayunas, colesterol total y triglicéridos. Se estimó el costo directo de cada estrategia basándose en recursos utilizados en el estudio clínico y evaluándose tres escenarios de costos para la educación de pares. La robustez de los resultados se evaluó mediante análisis de sensibilidad univariado.

RESULTADOS
El costo por unidad de descenso (%) de hemoglobina glicosilada con educación tradicional fue de $2621 pesos argentinos; y con educación a través de pares fue de $1508, $1779 y $2071 pesos argentinos, para cada uno de los tres escenarios considerados (escenario 1, escenario 2 y escenario 3), respectivamente. Por cada $100 pesos argentinos invertidos se logró descender 0,04% de hemoglobina glicosilada con la educación tradicional. Con la educación a través de pares los resultados fueron 0,07% en escenario 1; 0,06% en escenario 2 y 0,05% en escenario 3. El análisis de sensibilidad demostró la robustez de los resultados obtenidos.

CONCLUSIÓN
La educación de personas con diabetes tipo 2 a través de pares, complementaria al control y tratamiento de la enfermedad, es costo efectiva respecto a la educación tradicional.

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

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

E-mail: lgonzalez@cenexa.org

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

Citation: 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

Submission date: 25/8/2015

Acceptance date: 14/12/2015

Publication date: 29/12/2015

Origin: not requested

Type of review: reviewed by three external peer reviewers, double-blind

PubMed record

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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,