Early glucose screening means early diagnosis
ADA says it’s a good idea for those at risk
Researchers at the Centers for Disease Control and Prevention (CDC) speculate that someday soon a blood glucose screening will become as much a part of the routine doctor’s office visit as taking blood pressure and weight measurements.
A recent study from the CDC in Atlanta shows that early opportunistic screening for Type II diabetes will not only permit early diagnosis but can be cost-effective as well.
The study published in the Nov. 25 Journal of the American Medical Association shows that early screening can be most helpful in ferreting out the earliest symptoms of the disease in young African-Americans, who are at high risk, as well as among other patients at risk, including those who are obese or who have a family history of the disease.
The CDC study states that early opportunistic screening for younger at-risk Americans "may be an appropriate public health strategy." This targets that nebulous group, estimated at 3.2% of the American population between the ages of 20 and 74, who are unaware they have diabetes and who may have the disease for nine to 12 years before it is diagnosed, resulting in an increased rate of complications. Early screening would result in a diagnosis of diabetes an average of 5.5 years earlier than under current practice, the study shows.
Early detection improves quality of life
The complex computerized projections of the lifetime cost effectiveness (in 1995 dollars) for one-time screening between the ages of 25 and 34 show modest savings in actual cost and almost no increase in longevity, but an enormous improvement in quality of life for those diagnosed early.
"The study is unique in that it gives us solid information on costing," says Michael M. Engelgau, MD, a medical epidemiologist in the CDC’s Division of Diabetes Translation in Atlanta and lead author of the study. "And the cost effectiveness is more favorable among younger people and higher-risk populations."
A cheap and simple finger stick to measure fasting blood glucose with a standard monitor during a routine visit to a doctor’s office could save money and pain in the long term.
Using a range of epidemiological and clinical research studies to simulate the natural progression of the disease from onset to death, Engelgau followed a hypothetical group of 10,000 patients. He measured lifetime health care costs per patient after early screening during a routine visit to a health care provider and compared the costs if the same group was screened according to current practices that recommend screening beginning at age 45. A cutoff value of 110 mg/dl fasting blood glucose was used as an indicator of diabetes, and an oral glucose tolerance test was used to provide a positive diagnosis.
Engelgau found the average person’s life would be extended only about one week through early diagnosis, and early screening would save $1,275 in health care costs over the lifetime of the average patient — but $5,539 per African-American patient diagnosed early.
Engelgau discovered, however, early screening can postpone or even prevent the deterioration in quality of life due to diabetic complications like kidney failure, neuropathy, and blindness. In addition, it can potentially save enormous costs associated with those complications.
Those who were diagnosed early, Engelgau’s study shows, have a 26% reduction in the development of end-stage renal disease, a 35% reduction in the incidence of blindness, and a 22% lesser chance of a lower extremity amputation over their lifetimes.
In addition, they would live longer free of these complications:
- .27 years longer without blindness;
- .15 years without lower-extremity amputation;
- .08 years without end-stage renal disease.
"What we’re gaining from early screening is improvement to the quality of life, not in length of life," Engelgau says.
Quite simply, this means that for every year a diabetic patient lives free of amputation, blindness, or other painful and debilitating complication, life is better, he explains.
Data for African-Americans were used in the minority component of the study because they were readily available from other studies, Engelgau says, but researchers estimate the effect would be similar in other at-risk populations, including Hispanics and Native Americans.
He writes: "Opportunistic screening of all adults aged 25 years or older for Type II diabetes would cost $236,449 per life-year gained and $56,649 per QALY [quality-adjusted life-year] gained. In comparison, screening mammography for women aged 50 years or older costs from $3,400 to $83,830 per life-year gained, annual screening screening for cervical cancer for women aged 21 years or older costs $50,000 per life-year gained, and hypertension screening for asymptomatic men and women 20 years old costs $48,000 and $87,000 respectively."
Engelgau acknowledges that the American Diabetes Association (ADA) recommendations for routine screening begin at age 45, but says, "These results suggest that screening is more cost-effective at younger ages."
The ADA is not ready to revise its recommendation for routine screenings beginning at the age of 45, according to Richard Kahn, PhD, the ADA’s chief scientific and medical officer in Alexandria, VA, but says, he sees "no conflict whatsoever with the recommendation for early screening for high-risk individuals." He also says the finger stick and glucose monitoring in a doctor’s office is "our preferred way to go. It’s simple and cheap."
"It’s an interesting and useful piece of information," Kahn says while he raises a question not answered by the Engelgau study: "What is the frequency with which they should be measured?"
An ADA statement on Engelgau’s findings states, "This study underscores the association’s general recommendations that screening for diabetes as part of routine medical care may be appropriate if patients, including a young adult, have one or more risk factors. . . . However, it may be too soon to assess if this single study will have any impact on the American Diabetes Association’s overall guidelines to begin testing for diabetes at age 45, and, if normal, to be repeated at three-year intervals."
For further information, contact Michael Engelgau, MD, Medical Epidemiologist, Centers for Disease Control and Prevention, Atlanta. Telephone: (770) 488-5842.
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