A comparison of cost per case detected of screening strategies for Type 2 diabetes and impaired glucose regulation: Modelling study
Introduction
Vascular disease which includes Type 2 diabetes mellitus, cardiovascular disease and chronic kidney disease accounts for 36% of all deaths in developed countries [1]. Type 2 diabetes and its associated long term complications can cost developed nations up to 10% of its financial budget, as well decreasing quality of life and length of life by up to ten years [2]. An estimated 30–50% of people with diabetes are currently undiagnosed [3], and at presentation some 20–30% already has developed complications [4]. Therefore there is emphasis on detecting Type 2 diabetes early in its disease course, especially as the average delay between developing this condition and its eventual diagnosis can be up to seven years [5].
Early detection of diabetes will identify individuals who can be targeted for lifestyle and therapeutic intervention to delay the onset of complications. Furthermore, screening for Type 2 diabetes is feasible and identifies people with a large burden of modifiable cardiovascular risk factors [6]. A strategy of screening for diabetes together with its hyperglycaemic precursor, impaired glucose regulation is suggested to be more cost effective in the long term [7] and is recommended in some national guidelines, as it subsequently facilitates the prevention of diabetes strategies [8], [9], [10]. A recent report suggested the best age to start screening from is 30 years old [11]. However, there is still some debate over the most sensitive and cost-effective method for screening for diabetes.
There are a number of tests available for screening and diagnosing Type 2 diabetes and impaired glucose regulation (also termed prediabetes: impaired fasting glucose and/or impaired glucose tolerance using World Health Organisation, WHO, 1999 diagnostic criteria). These include the oral glucose tolerance test, the fasting plasma glucose test, glycated haemoglobin (HbA1c) and a number of specifically developed risk scores, such as the FINDRISC [12], [13], [14]. These tests can be used individually or in combination as part of a multi-stage strategy. Recently, the WHO recommended HbA1c as a diagnostic tool for Type 2 diabetes but not for impaired glucose regulation [14]. Although there is no consensus on the most accurate screening test for detection of diabetes, the oral glucose tolerance test is often considered the standard diagnostic test for comparison of clinical outcome measures including sensitivity and specificity. However, the oral glucose tolerance test is considered more expensive, inconvenient and cumbersome to both patients and clinical staff in comparison to some of the other available options [15]. Therefore to determine the best screening strategies to implement in clinical practice, other factors including cost-effectiveness, practicality and acceptability to patients should be considered.
This study focuses on the screening options available for Type 2 diabetes alone and in combination with impaired glucose regulation and associated costs. Screening for impaired glucose regulation allows for preventative strategies such as lifestyle or pharmacological interventions to be implemented, which have been shown to be cost-effective in reducing progression rates to diabetes [16]. Our aim is to determine a cost comparison of available and feasible screening strategies to identify the best approaches for identifying people with Type 2 Diabetes and impaired glucose regulation in a community setting.
Section snippets
Population description
This study analysed cross-sectional data from ADDITION-Leicester, a population based systematic diabetes screening study [17]. The study contributed to the multi-centre ADDITION-Europe, consisting of a screening phase followed by five-year cluster randomised controlled trial [6]. Here we consider data from the screening phase of the UK based Leicester arm, a stand-alone study of a large multi-ethnic population. Study methods have been described in detail previously [17]. Briefly, a random
Baseline demographics
Of the 5794 participants screened, there were 4487 (77.4%) white Europeans and 1307 (22.6%) south Asians. The relatively high number of south Asians screened is representative of the Leicester City region [28]; individuals of other ethnic groups were excluded from the analysis due to low numbers. The mean age was 57.1 years (standard deviation 9.4) and there were 2759 (47.6%) males. There were 188 (3.2%) individuals detected as having Type 2 diabetes, 825 (14.2%) with impaired glucose
Discussion
The incidence of undiagnosed Type 2 diabetes and impaired glucose regulation is set to increase; consequently there will be increased costs for health care providers to screen for these conditions on a population level [29], [30]. There are a number of methods of screening for Type 2 diabetes alone or with impaired glucose regulation. Choosing the appropriate multi-staged screening strategy will be driven by economic factors, resources available, patient convenience and diagnostic accuracy of
Financial disclosure
ADDITION-Leicester study was funded by Department of Health (Trial Registration number: NCT00318032). The views expressed in this publication are those of the authors and and not necessarily those of the Department of Health. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Contributors
KK and MJD conceived and designed the study. NT and CG had access to the databases and conducted the statistical analysis and modelling, with support from KA. The script was written by SM, CG and SH. All authors contributed to results interpretation and drafting of the manuscript. KK and MJD obtained funding for ADDITION-Leicester and provided administrative, technical and material support.
Conflict of interest
The authors have a competing interest to declare. KK (Chair) and MJD are members of the National Institute for Health and Clinical Excellence Public Health Guidance on prevention of Type 2 diabetes among people with prediabetes. MJD and KK are advisors to the UK Department Health for the NHS Health Checks Programme. MJD has received funds for research, honoraria for speaking at meetings and has served on Advisory Boards for Lilly, Sanofi Aventis, MSD, Novo Nordisk, BMS, BI and Roche. KK has
Acknowledgments
We would like to acknowledge the following people: Professor John Thompson, David Webb, Bala Srinivasan, Joe Henson, Janette Barnett, Laura Gray and all other members of the ADDITION-Leicester team and the participants for their contributions, as well as support from NIHR LNR CLAHRC and NIHR Leicester Diet, Lifestyle and Physical Activity Biomedical Research Unit.
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