Return on investment of health intervention among diabetic patient: A systematic review

. A strategy for reducing healthcare costs of diabetic mellitus (DM) is by reducing body weight and blood glucose through lifestyle-modification programs such as intensive lifestyle interventions, meal-replacement programs, and physical activity. A return on investment (ROI) analysis needs to be done to see a program's effectiveness, which aims to make this program provide benefits, especially in the long term. In this systematic review, the authors describe ROI, the program, the program's cost, adoption, and implementation. The authors searched the Science Direct, Pubmed, and SAGE databases using the following search terms: ‘Return on Investment’ AND ‘Diabetic Mellitus’ and Programs”. Moreover, hand searching identifies further studies. This review includes eight articles, and most articles on lifestyle modification intervention have great ROI; several articles with public health workers have great ROI. The findings show that long-term and program intensity in a long time horizon plays a major role in outcomes and more significant ROI. Programs with lifestyle intervention fellow health workers or CHWs that helped deliver physical activity, education, and dietary had a good impact in lowering diabetes risk.


Introduction
The incidence of diabetes mellitus worldwide has increased, which is a global threat [1][2][3].The most recent estimate of the number of people with diabetes ranges from 20-79 years of age and is expected to increase to 642 million in 2040, which means that 1 in 10 adults will have diabetes.In addition, in middle and low-income countries, 3 out of 4 adults have diabetes.Diabetes is the cause of 6.7 million deaths worldwide which means that 1 death every 5 seconds.From an economic burden standpoint, diabetes spends 966 billion USD on health costs, and this increase is 315% from the last 15 years [4].
Lifestyle change interventions in improving physical activity and diet can increase the incidence of type 2 diabetes mellitus by 58% within three years; this has been done in the Diabetes Prevention Program (DPP) clinical trial program.This intervention's benefits were also shown for the next 10 to 15 years [5,6].The results of the DPP issued a recommendation that overweight or obese adults with at least one risk factor for cardiovascular disease receive behavioral counseling to minimize the severity of complications [3,[7][8][9].This intervention also was a strategy to reduce the cost of treating DM, which showed that modifying lifestyle with intensive intervention through a diet program reduces the health cost of DM [10,11].Weight loss in DM patients has been shown to provide benefits in terms of health costs, both hospitalization costs and medical expenses in DM patients.Diabetic patients with excess weight incur higher medical costs than diabetic patients with normal weight [12,13].The government's agenda and making a national plan for managing the prevalence of DM, providing a budget for the DM program will be more beneficial in the long term when viewed from the value of the cost of health costs caused by DM disease [40].The results of the NDPP and the Diabetes Prevention Program Observation Study confirm that lifestyle interventions and metformin are equally cost-effective [14].
Evaluation of DM disease prevention programs has been affordable, only limited to its implementation and effectiveness in financing and the health of DM sufferers.Economic effectiveness can be assessed by ROI analysis by assessing the benefits of program interventions to obtain a return on investment (ROI) value from the health system perspective [15].In this systematic review, the authors explain the types of interventions implemented, the costs, and the value of the ROI resulting from the interventions.A review of ROI will be beneficial in making diabetes-related policies.This review will provide priority recommendations that are most effective and profitable long-term so that therapy in diabetes patients will be more cost-effective.

Search Strategy
The authors systematically reviewed the completed ROI values from program interventions aimed at prediabetic patients or diabetics.This systematic review is part of a research study ROI analysis in health programs in Indonesia with a code of ethics number KE/FK/1652/EC/2022.The disbursement database, Pubmed, Science Direct, and SAGE, uses the following search keywords 'Return on Investment' AND 'Diabetic Mellitus' AND 'Intervention'.A hand search was performed to identify further studies.The limit in this particular payment is the last ten years of articles and articles in English.

Study Selection an Inclusion Criteria
The studies included in this systematic are each ROI study with an intervention design for diabetes patients in the community.These included articles from the past ten years.The authors search for program interventions related to the science and art of promoting and protecting health and well-being to prevent ill health and prolong life through community-organized efforts for diabetes prevention and diabetes in high-income countries.The program is then assessed economically by return on investment analysis.This systematic review is based on items in the Systematic Review and Meta-Analysis (PRISMA) [16].The authors screen original articles with full text related to interventions in diabetes patients and are in English.The exclusion criteria in this study did not count the variable return on investment, and the article was incomplete.

Selection Article and Data Extraction
The first investigator (KI) initially screened the article titles.Investigators (KI) independently review the relevance of titles and abstracts of articles that are fit for purpose.The results of the articles were then discussed by (SA) and (DE) by reading the entire manuscript.The investigator (TM) then independently extracted and assessed the quality of the articles.Next, the reviewer (SA) decides on the assessment results and the article's qualit.

Study Selection
An article search was conducted on Pubmed, ScienceDirect, and SAGE, and the article was found (Figure 1).n = 428 journals from PubMed, n = 120 journals from ScienceDirect, and n = 83 from SAGE Journals.Article screening was carried out by reading article titles and abstracts relevant to the inclusion criteria and identifying 89 potentially relevant titles.At Positioning this stage, 89 articles were read thoroughly to assess their suitability with the desired outcome in a systematic review.From this process, articles will be decided according to the objectives of the systematic review, and some articles were excluded for the following reasons, complete articles were not found (n=34), duplicates (n=9), and excluded for other reasons (n=30).In-depth review of the full text was excluded because the results did not meet the inclusion criteria and study protocol.Therefore, eight articles are relevant Place the figure as close as possible after the point where it is first referenced in the text.If there is a large number of figures and tables it might be necessary to place some before their text citation.

Study Characteristic
Table 1 describes the characteristics.The eight studies were conducted in the UK, USA, and around.The duration of this study ranged from 1 years-10 years.Two perspectives appear in the article: the perspective of the payer and the provider payer perspective is used in articles [15,17], and the payer perspective is used in articles [15,16,[18][19][20][21].Studies with a payer perspective are the perspectives of companies such as insurance, private companies, or the government, which will pay for costs related to health services provided to participants.The costs considered in this perspective are direct costs, but the analysis can consider indirect costs such as lost productivity or lost workdays [22].Lifestyle intervention was a health plan with a healthy diet and physical activity for obese, diabetes, and prediabetes patients [17-19, 23, 24].Counseling-based programs are carried out in various ways, starting from providing material, medical journals given to the patient, digital intervention, and education face-to-face with patients facilitated by health workers [15,20,21].There was also research on counseling interventions and therapy for DM patients with foot ulcers [20].A health service provider's perspective is the actual value of the product or health service provided by the health service.These include direct costs, namely professional service fees, hospitalization costs, medical expenses, laboratory examination fees, and consumables [22].

Counseling health public and health workers' intervention.
There were three articles on counseling, public health, and health workers' intervention.The value of the cost of intervention from these articles ranges from 115-500 USD.The ROI value range is 7.4-9.01. Figure 2 shows that the highest ROI value is 9.01, with a time horizon of 3 years.2 shows that cost of lifestyle interventions ranges from 248.2-1487 USD.Several articles do not include the value of the cost of intervention but still display the ROI value.ROI values in lifestyle intervention range from 0.42-16.9.The highest value is 16.9, with an estimated intervention if it is carried out for ten years.

Discussion
ROI can be used in calculating a program's intervention or several interventions if the company has a large-scale scope and can also be one of the measuring indicators to be compared with other interventions [28].Assessing the ROI ratio is seen from how much the ratio is.ROI is greater than or equal to 1, then the program has a practical value because it has value equal to or more than the cost of implementation.In this case, the ROI value is considered positive.For example, an ROI of 1.8 indicates that for every 1 rupiah invested in the program, the agency will earn a of 1.80 rupiah.ROI is less than 1, then the intervention suffers a loss.In this case, ROI is considered negative.For example, ROI-1.5 shows that for every 1 dollar invested, the agency suffers a loss of 1.50 rupiah.If the ROI value is 0.8, then for every 1 dollar invested, 0.8 dollars will be obtained by the agency, while the agency will lose 0.2 dollars for every 1 dollar spent on the program [29].Most of the articles do interventions in lifestyle modifications.These lifestyle modifications include physical activity and diet.In the articles, interventions are different; this is also related to the results to be achieved.Several articles measure effectiveness in comparison with a control group.In comparison with the control group, the value of cost saving can also be seen from the comparison with the reduction of the two groups [17,24].The article provides an intervention in which participants are asked to complete household tasks, including selfmonitoring of eating and physical activity.The physical activities will be in the form of safety training, stretching, basic strength training, and increasing activity levels with each predetermined schedule [17-19, 23, 24] There are two interesting findings in a systematic review regarding ROI in interventions in DM patients.
First, even with the most basic economic evaluation, it is clear that most public health interventions include with monitoring and lifestyle intervention are substantial cost savings.It confirms our theory that public health interventions generally offer a sizable ROI.Overall, the results of our systematic review clearly show that public health interventions save costs for health services and the wider economy.Besides, some very rapid: preventive interventions report substantial results within one year.Greater return on investment seen over the ten years horizon.It has significant implications for policymakers, who often work with shorter time horizons (usually 3-5 years).It is in line with previous research that the intervention of physical activity and diet positively affects weight loss and blood sugar [2,21,30].
Second, health worker-based interventions provide a relatively high ROI value compared to physical activity and diet alone.Intervention with physical activity and diet provides high effectiveness if given in the long term.This positive result from [15] is driven by the large difference in HbA1c results achieved in the DIMM versus the PCP group, as well as the relatively low cost of pharmacist interventions designed as a limited series of visits to treat patients.Interventions with health workers have many benefits and effectiveness, especially in patient health, and can avoid long-term complications and a better quality of life [31,32].Education intervention for diabetic programs in adults showed a good impact on cost saving if given in the long term, at least with 1 year duration [33,34].One article is about diabetic foot care, and that showed good ROI.The positive results of providing regular foot wound care to DM patients with foot wounds indicate that cost savings can be obtained if the patient receives regular and longterm care [20].
Cost saving is a benefit variable to measure the success of a program by assessing the cost saving.ROI analysis is obtained by dividing the net benefit value by the intervention cost.In other words, the net benefit here is significant, obtained from the cost saving minus the intervention cost value.The benefit value in the net benefit has the same concept as the net profit value [35].The current study shows that the impact of an effective program for diabetes in adult patients correlates with cost savings, savings from complications, and also comorbidities [33,23,25].This finding is similar to estimates of cost savings reported in previous studies.For example, 12-month pre-and post-education cost data were examined for diabetes program participants, with $815 direct cost savings through the program and $1504 indirect cost savings through changes in comorbid disease burden [36].There is a correlation between clinical outcomes and cost-effectiveness in providing usual care and lifestyle interventions for DM patients.Bringing patients, providers, and the healthcare system together and integrating public health workers as liaisons between patients is an excellent approach to effective diabetes management [37].Other studies that showed cost saving of diabetes intervention showed good member health workers to manage diabetes can reduce comorbid condition, cost, and HbA1C [4,36,38].

Return on Investment
Studies find it important to consider the long-term impact to capture the full ROI and find positive ROI values [20].Programs designed for cost-saving can be looked at in the short-term, medium-term, and longterm.To see good and effective service quality requires an affordable intervention program so that it can be carried out in the long term.Identification of good ROI can be seen from how well the profit is given in the long term [39].The authors recommend that advisory bodies regularly emphasize that public health interventions can offer rapid results, which can increase further in the long term.The limitations of this review are that several articles did not mention the value of the discount rate and cost of intervention.Some articles did not explain in detail the interventions carried out.Very little has been done regarding research conducted by research authors regarding ROI.Many studies on ROI have been conducted in developed countries, but only a few focused on diabetes and public health.

Conclusion
The findings show that long-term and program intensity in a long time horizon plays a major role in outcomes and more significant ROI.Programs with fellow lifestyle intervention deliver physical activity, education, and dietary had a good impact in lowering diabetes risk.The authors recommend that advisory bodies regularly emphasize that public health interventions can offer rapid results, which can increase further in the long term.

Fig. 2 .
Fig. 2. The graph gender of (a) Return on Investment and (b) Time Horizon

Table 1 .
Summary Study Characteristics There were five articles with lifestyle interventions.Table