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Table of contents
1. Screening for Diabetes: Can We Afford Not To Screen?.............................................................................

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Screening for Diabetes: Can We Afford Not To Screen?

Author: Nathan, David M; Herman, William H
Publication info: Annals of Internal Medicine 140.9 (May 4, 2004): 756-8.
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Abstract: Type 2 diabetes represents the archetype of a chronic degenerative disease. Screening is appropriate
when a disease represents an important health problem, its natural history is unknown, diagnosis of the
preclinical stage is feasible, and early treatment improves clinical outcomes. The rationale for any screening
program is that earlier identification results in interventions that will provide greater benefit than waiting for
symptoms or complications to reveal the diagnosis.
Full text: Chronic degenerative diseases represent the major challenge to public health in the 21st century.
Having largely conquered epidemic infectious diseases, we face a future in which such diseases as diabetes
and cardiovascular disease, and their underlying risk factors, predominate. Chronic degenerative diseases
already cause 70% of deaths worldwide (1). Our medical care system has largely been attuned to the diagnosis
and care of acute diseases, which generally cause symptoms and therefore do not require screening. On the
other hand, the early stages of chronic degenerative diseases and the risk factors that presage these diseases
are often clinically silent and would go undetected without screening.
Type 2 diabetes represents the archetype of a chronic degenerative disease. It has become epidemic, with
fewer than 50 million cases worldwide in 1985 and more than 170 million cases today (2). Diabetes is
associated with substantial morbidity and mortality because it damages the eyes, kidneys, and nerves and
accelerates disease of the cardiovascular system (3). Moreover, the onset of type 2 diabetes is often insidious,
without symptoms that would alert the patient or clinician. The estimated 9- to 12-year delay in diagnosis (4) is
of particular concern because patients lose the opportunity to control hyperglycemia, dyslipidemia, and
hypertension, which would reduce the complications of diabetes (5-7). Approximately 20% of patients with
"newly" diagnosed type 2 diabetes have eye, nerve, or kidney disease at the time of diagnosis (8). In addition,
cardiovascular disease, which is the cause of death in 75% of the diabetic population (9), begins to develop
during the "prediabetic phase" (10). Because diabetes screening is not standard practice, these asymptomatic
at-risk individuals cannot benefit from intensified treatment of blood pressure and dyslipidemia until symptoms
or other circumstances lead to a diagnosis of diabetes (11). Thus, the large population with undiagnosed type 2
diabetes (estimated at 5 million people in the United States) and the failure to identify prediabetic persons (an
estimated 20 million people in the United States) expose many people to the pernicious effects of
hyperglycemia and associated conditions.
Screening is appropriate when a disease represents an important health problem, its natural history is known,
diagnosis of the preclinical stage is feasible, and early treatment improves clinical outcomes. Unfortunately,
although the evidence from clinical trials supporting early interventions in persons with diagnosed diabetes is
increasingly persuasive, clinical trials that compare the benefit of screening for diabetes with the current state of
practice do not exist. Cost-effectiveness analyses tell us how well dollars spent on screening for diabetes
translate into improved outcomes relative to other health interventions. When clinical trial data on the long-term
effect of screening on costs, quality of life, and health outcomes are not available, researchers use models that
integrate evidence from diverse sources to make inferences about future economic, quality-of-life, and health
outcomes and to provide data for decision making (12).
The study by Hoerger and colleagues in this issue (13) uses a computer simulation to estimate the lifetime costs
and benefits of one-time screening for type 2 diabetes. A previous study using the model reported that the costeffectiveness of screening for type 2 diabetes among people 25 years of age and older was approximately $57
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000 per quality-adjusted life-year (QALY) gained (14). In that analysis, screening was more cost-effective in
younger people ($13 000 per QALY gained in people 25 to 34 years of age) than in older people ($575 000 per
QALY gained in people 65 years of age or older). Screening was also more cost-effective in people at greater
risk for microvascular and neuropathic complications. In the current report, the cost-effectiveness of screening
for diabetes improves from $126 000 per QALY gained in people screened at 35 years of age to $48 000 per
QALY in people screened at 75 years of age. The cost-effectiveness of screening for diabetes in persons with
hypertension improved from $87 000 in those screened at 35 years of age to $31 000 per QALY gained in those
screened at 75 years of age. In contrast to the earlier report, screening is more cost-effective in older people.
What explains the different results in the 2 reports? In the earlier report, the authors modeled the progression of
diabetes and its complications as a function of glycemic control (14). According to the model, screening and
earlier diagnosis of diabetes led to earlier interventions to improve glycemic control. In the short term, these
interventions slowed the development of microvascular and neuropathic complications and, in the long term,
improved quality of life by delaying or preventing blindness, end-stage renal disease, and lower-extremity
amputations. The model assumed no association between glycemic control and cardiovascular complications
because a causal relation remains unproved. In addition, the study did not take into account the effect of
hypertension and antihypertensive therapy on cardiovascular complications. In contrast, in the current report,
the authors use clinical trial data to model the progression of diabetes and its complications as a function of
glycemic and hypertension control (6, 7, 15). They used the results of the Hypertension Optimal Treatment
(HOT) trial to model the effect of antihypertensive therapy. The HOT trial shows that in persons with diabetes,
intensive control of blood pressure (achieving a diastolic blood pressure of 81.1 mm Hg vs. 85.2 mm Hg) was
associated with a 51% relative and a 12.5% absolute risk reduction in major cardiovascular events over 4 years
(15). The larger, more quickly realized benefit of intensive blood pressure control on cardiovascular outcomes
accounts for the improved cost-effectiveness of screening for diabetes in people with hypertension compared
with the general population. Moreover, the greater prevalence of hypertension in older people (19% in people
25 to 44 years of age, 37% in people 45 to 64 years of age, and 60% in people 65 to 74 years of age) and the
greater absolute risk for cardiovascular disease in older people resulted in more cost-effective screening in
older than younger people.
Models are only as good as the elements included, and the current study has several limitations. The sensitivity
and specificity of the screening test seem unrealistically high on the basis of other published reports. The
authors also assume that health utility scores are the same (1.0) for persons of all ages, both sexes, with and
without diabetes and hypertension, and with or without microvascular and neuropathic complications; this
assumption is unrealistic (16). Using only one criterion for diagnosing diabetes (a fasting glucose level of >or
=126 mg/dL) is also problematic; the more sensitive oral glucose tolerance test would identify a greater
proportion of otherwise undetected diabetic patients, albeit at a higher cost (17). Screening with an oral glucose
tolerance test would also identify prediabetic persons, an outcome that the author's model did not include. The
Diabetes Prevention Program, which prevented prediabetic persons from developing frank diabetes, was costeffective (18). The authors' failure to include the costs and additional benefits of aggressive lipid therapy is
another shortcoming of the model. Aggressive lipid lowering reduces macrovascular disease in persons with
diabetes, as shown by such studies as the Heart Protection Study (19). Finally, the investigators do not account
for the progressive character of type 2 diabetes, which worsens over time, with increasing insulin resistance and
diminished insulin secretion. Earlier identification and treatment will probably provide better diabetes control with
simpler and potentially less costly interventions.
Despite its limitations, the current analysis helps to quantify the benefit of diagnosing diabetes in people with
and without hypertension and intensifying their glycemic and antihypertensive management at an earlier time
than would have occurred in the absence of screening. The rationale for any screening program is that earlier
identification results in interventions that will provide greater benefit than waiting for symptoms or complications
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to reveal the diagnosis. Unfortunately, the current state of delivery of care to persons with diagnosed diabetes in
the United States does not bode well for the treatment of patients identified through screening. Many published
"report cards" of diabetes care have shown that the treatment of glycemia, hypertension, and dyslipidemia and
surveillance of foot and eye complications occur at far below recommended levels (20). Unless we optimize
care after we diagnose diabetes, screening cannot be effective or cost-effective.
References
References
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Burden of Disease. Geneva: World Health Organization; 2003.
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4. Harris MI, Klein R, Welborn TA, Knuiman MW. Onset of NIDDM occurs at least 4-7 yr before clinical
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13. Hoerger TJ, Harris R, Hicks KA, Donahue K, Sorensen S, Engelgau M. Screening for type 2 diabetes
melitus: a cost-effectiveness analysis. Ann Intern Med. 2004;140:689-99.
14. The cost-effectiveness of screening for type 2 diabetes. CDC Diabetes Cost-Effectiveness Study Group,
Centers for Disease Control and Prevention. JAMA. 1998;280:1757-63. [PMID: 9842951]
15. Hansson L, Zanchetti A, Carruthers SG, Dahlof B, Elmfeldt D, Julius S, et al. Effects of intensive bloodpressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension
Optimal Treatment (HOT) randomised trial. HOT Study Group. Lancet. 1998;351:1755-62. [PMID: 9635947]
16. Coffey JT, Brandle M, Zhou H, Marriott D, Burke R, Tabaei BP, et al. Valuing health-related quality of life in
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18. Herman WH, Brandle M, Zhang P, Williamson DF, Matulik MJ, Ratner RE, et al. Costs associated with the
primary prevention of type 2 diabetes mellitus in the diabetes prevention program. Diabetes Care. 2003;26:3647. [PMID: 12502656]
19. Collins R, Armitage J, Parish S, Sleigh P, Peto R. MRC/BHF Heart Protection Study of cholesterol-lowering
with simvastatin in 5963 people with diabetes: a randomised placebo-controlled trial. Lancet. 2003;361:2005-16.
[PMID: 12814710]
20. Saaddine JB, Engelgau MM, Beckles GL, Gregg EW, Thompson TJ, Narayan KM. A diabetes report card
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2004 American College of Physicians
AuthorAffiliation
David M. Nathan, MD
Massachusetts General Hospital
Harvard Medical School
Boston, MA 02114
William H. Herman, MD, MPH
University of Michigan
Ann Arbor, MI 48109
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: David M. Nathan, MD, Massachusetts General Hospital Diabetes Center, 50
Staniford Street, Boston, MA 02114; Dnathan@Partners.org.
Ann Intern Med. 2004;140:756-758.
Current author addresses are available at www.annals.org.
Subject: Diabetes; Medical screening; Medical diagnosis; Clinical outcomes; Chronic illnesses;
MeSH: Cost-Benefit Analysis, Diabetes Mellitus, Type 2 -- complications, Diabetes Mellitus, Type 2 -- diagnosis,
Diabetic Angiopathies -- complications, Humans, Hypertension -- complications, Mass Screening -- economics
Publication title: Annals of Internal Medicine
Volume: 140
Issue: 9
Pages: 756-8
Number of pages: 3
Publication year: 2004
Publication date: May 4, 2004
Year: 2004
Section: EDITORIAL
Publisher: American College of Physicians
Place of publication: Philadelphia
Country of publication: United States
Publication subject: Medical Sciences
ISSN: 00034819
Source type: Scholarly Journals

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Language of publication: English

Document type: Editorial, Comment
Document feature: References
Accession number: 15126261
ProQuest document ID: 222196959
Document URL: http://search.proquest.com/docview/222196959?accountid=25704
Copyright: Copyright American College of Physicians May 4, 2004
Last updated: 2013-04-25
Database: ProQuest Health Management,ProQuest Public Health,ProQuest Research Library

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