Markov Decision Process-Based Personalized Follow-Up Planning for Type 2 Diabetes: Retrospective Cohort Study

Personalized follow-up for type 2 diabetes may improve the alignment between monitoring intensity and patient needs, but operational approaches that jointly consider follow-up timing, modality, expected health benefits, and resource use remain limited.

This study develops a Markov decision process (MDP) framework for personalized follow-up planning, externally validates complementary risk-prediction models, and estimates the projected 12-month cost-effectiveness of model-generated follow-up strategies.

We retrospectively analyzed longitudinal data from 41,398 patients with type 2 diabetes managed in 10 community health centers in Nanjing, China, over the 2015-2024 calendar period. An independent Shanghai cohort included 25,506 patients from 10 communities. We developed least absolute shrinkage and selection operator (LASSO)-Cox models to predict 1-year incident complication and mortality risk and evaluated discrimination in Shanghai. Separately, a 12-cycle finite-horizon MDP used observed action-conditional state transitions with prespecified utility, cost, access, and willingness-to-pay parameters to generate personalized follow-up policies.

For an example patient initially without recorded complications (S0), the personalized policy increased annual effectiveness by 0.48 quality-adjusted life days (QALDs; 0.0013 quality-adjusted life years [QALYs]) and cost by 33.46 CNY (1 CNY=US $0.15), yielding an incremental cost-effectiveness ratio (ICER) of 25,499 CNY/QALY. In a heterogeneous simulated cohort of 1000 patients initialized in S0, mean annual effectiveness increased from 313.52 to 314.05 QALDs (0.85896 to 0.86041 QALYs), and mean annual cost increased by 24.67 CNY, yielding an ICER of 17,016 CNY/QALY. External C-indices were 0.778 for incident complications and 0.812 for mortality. Deterministic sensitivity analyses did not materially alter the cost-effectiveness conclusion.

The MDP framework generated individualized 12-month follow-up policies with small projected QALY gains at modest incremental program cost, while the complementary risk models demonstrated external discrimination in an independent cohort. As action-conditional transitions were estimated from observational records and several economic parameters were prespecified, the modeled differences represent projections rather than causal treatment effects and require prospective implementation and economic validation before clinical adoption.