Screening for Type 2 Diabetes Mellitus: A Cost-Effectiveness Analysis

4 May 2004 | Volume 140 Issue 9 | Pages 689-699

Background: No randomized, controlled trial of screening for diabetes has been conducted. In the absence of direct evidence, cost-effectiveness models may provide guidance about preferred screening strategies.

Objective: To estimate the incremental cost-effectiveness of 2 diabetes screening strategies: screening targeted to people with hypertension and universal screening.

Design: Markov model.

Data Sources: United Kingdom Prospective Diabetes Study, Hypertension Optimal Treatment trial, and recent cost data.

Target Population: General primary care population in the United States.

Time Horizon: Lifetime.

Perspective: Health care system.

Interventions: Diabetes screening targeted to people with hypertension and universal screening.

Outcome Measures: Cost per quality-adjusted life-year (QALY) gained. Costs (in 1997 U.S. dollars) and QALYs discounted at a 3% annual rate.

Results of Base-Case Analysis: At all ages, incremental cost-effectiveness ratios were more favorable for screening targeted to people with hypertension than for universal screening. For example, at age 55 years, the cost per QALY for targeted screening compared with no screening was $34 375, whereas the cost per QALY for universal screening compared with targeted screening was $360 966. Screening was more cost-effective for ages 55 to 75 years than for younger ages.

Results of Sensitivity Analysis: In single-way and probabilistic sensitivity analyses, findings were robust to therapy costs, screening costs, screening lead time, reduced effectiveness of intensive antihypertensive therapy, and increased relative risk reduction for stroke attributable to intensive hypertension control.

Limitations: We did not consider screening targeted to persons with dyslipidemia, and we used studies of people whose diabetes was detected clinically to estimate screening benefits.

Conclusions: Diabetes screening targeted to people with hypertension is more cost-effective than universal screening. The most cost-effective strategy is targeted screening at age 55 to 75 years.

Editors' Notes Context In 2003, the U.S. Preventive Services Task Force recommended screening for type 2 diabetes in adults with hypertension or hyperlipidemia. The economic implications of this recommendation are unclear. Contribution Diabetes screening for 55-year-old hypertensive persons would cost the U.S. health care system $34 375 per quality-adjusted life-year gained. Expanding screening to all adults regardless of the presence of hypertension would cost an additional $360 966 per quality-adjusted life-year. Implications The cost-effectiveness of targeting diabetes screening to hypertensive adults older than 55 years of age is similar to the cost-effectiveness of many accepted health care interventions. Universal diabetes screening is far more costly. –The Editors

 

Author and Article Information

From RTI International, Research Triangle Park, North Carolina; University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and Centers for Disease Control and Prevention, Atlanta, Georgia.

Disclaimer: The authors of this article are responsible for its contents, including any clinical or treatment recommendations. No statement in this article should be construed as an official position from the Agency for Healthcare Research and Quality, the Centers for Disease Control and Prevention, or the U.S. Department of Health and Human Services.

Acknowledgments: The authors thank David Atkins, MD, MPH, and Jean Slutsky, PA, MSPH, at the Agency for Healthcare Research and Quality, who helped us obtain funding and provided useful feedback. Also at the Agency for Healthcare Research and Quality, Eve Shapiro, Amy Pfeiffer, and Margi Grady provided editing help and Nilam Patel provided general organizational assistance. At RTI International, Kathleen N. Lohr, PhD, Director of the RTI-UNC Evidence-based Practice Center, provided many suggestions and essential editorial help. Also at RTI, Sonya Sutton and Loraine Monroe developed the manuscript, managed the reference database, and created tables from our description. At the UNC Cecil G. Sheps Center for Health Services Research, Audrina Bunton assisted with manuscript and reference preparation. The Director of the Sheps Center, Timothy Carey, MD, MPH, created an environment in which this work could be conducted. The authors also thank the reviewers, including U.S. Preventive Services Task Force members Steven Teutsch, MD, MPH, Steven H. Woolf, MD, MPH, and Paul Frame, MD, who gave excellent suggestions.

Grant Support: By contract 290-97-0011 from the Agency for Healthcare Research and Quality. Development of the cost-effectiveness model was supported by the Centers for Disease Control and Prevention contract 200-97-0621.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Thomas J. Hoerger, PhD, RTI International, 3040 Cornwallis Road, PO Box 12194, Research Triangle Park, NC 27709; e-mail, tjh{at}rti.org.

Current Author Addresses: Dr. Hoerger and Ms. Hicks: RTI International, 3040 Cornwallis Road, PO Box 12194, Research Triangle Park, NC 27709.

Dr. Harris: Cecil G. Sheps Center for Health Services Research, CB# 7590, University of North Carolina School of Medicine, 725 Airport Road, Chapel Hill, NC 27599-7590.

Dr. Donahue: Department of Family Practice, University of North Carolina School of Medicine, CB# 7595, Manning Drive, Chapel Hill, NC 27599.

Drs. Sorensen and Engelgau: Centers for Diseases Control and Prevention, 4770 Buford Highway NE, Mailstop K-10, Atlanta, GA 30341.

Author Contributions: Conception and design: T.J. Hoerger, R. Harris, K.A. Hicks, K. Donahue, S.W. Sorensen, M.M. Engelgau.

Analysis and interpretation of the data: T.J. Hoerger, R. Harris, K.A. Hicks, K. Donahue, S.W. Sorensen, M.M. Engelgau.

Drafting of the article: T.J. Hoerger, R. Harris, K.A. Hicks, S.W. Sorensen, M.M. Engelgau.

Critical revision of the article for important intellectual content: T.J. Hoerger, R. Harris, K.A. Hicks, S.W. Sorensen, M.M. Engelgau.

Final approval of the article: T.J. Hoerger, R. Harris, K.A. Hicks, K. Donahue, S.W. Sorensen, M.M. Engelgau.

Statistical expertise: T.J. Hoerger.

Obtaining of funding: T.J. Hoerger, R. Harris.

Administrative, technical, or logistic support: T.J. Hoerger, K.A. Hicks.

Collection and assembly of data: T.J. Hoerger, K.A. Hicks.