USPSTF research and findings for screening and managing Diabetes in adults
Type of Intervention recommended
Intensive lifestyle and pharmacotherapeutic interventions reduce the progression of prediabetes to diabetes.
Health risks identified with diabetes and prediabetes
The risk for death among persons with diabetes is about twice that of persons without diabetes, and cardiovascular events account for more than three fourths of these deaths 4. Type 2 diabetes often goes undiagnosed for many years because hyperglycemia develops gradually and may not produce symptoms 3,5. Persons with diabetes are at increased risk for microvascular and macrovascular complications, and duration of diabetes and degree of hyperglycemia are associated with an increased risk for microvascular complications 6-9. The prevalence of macrovascular complications is elevated in persons with prediabetes (defined as impaired fasting glucose, impaired glucose tolerance, or both) and in persons with newly diagnosed diabetes 10-18. A substantial proportion of persons presenting with a new cardiovascular event have undiagnosed diabetes or prediabetes 10,19-23. Several recent observational studies and a meta-analysis suggest an association between chronic hyperglycemia and cardiovascular disease and stroke 24-27.
Cost-effectivness of early detection
Two recent high-quality studies suggested that targeted screening for type 2 diabetes among persons with hypertension may be relatively cost-effective when macrovascular benefits of optimal blood pressure control are considered 35,47, older persons benefited more than younger persons 35,47, and screening obese persons was more cost-effective than mass screening 35.
Screening and Treatment of Pre-Diabetes
Modeling studies have been used to examine the treatment of prediabetes 35,87-94. The health technology assessment by Waugh and colleagues 35 recommended screening for glucose intolerance because strategies for reducing cholesterol and blood pressure are effective and because type 2 diabetes can be prevented. Waugh and colleagues seem to assume that the effects of treating persons with screening-detected diabetes are the same as those of treating persons with clinically detected diabetes and that there are proven linkages between treating dysglycemia and final health outcomes.
Delaying the onset of diabetes would substantially reduce the incidence of vascular complications, improve quality of life, and avoid future medical costs. They concluded that if a screening program was implemented to target persons at risk for diabetes, subsequent treatment for persons with impaired glucose tolerance with lifestyle or pharmacologic interventions was a good use of resources.
Early Intervention: Improving Health While Reducing Health Care Cost
Herman and associates 90 examined the lifetime utility and cost-effectiveness of the DPP lifestyle intervention 36 and found the intervention to be relatively cost-effective (cost per quality-adjusted life-year, $8800
Eddy and colleagues 87,88 examined the DPP interventions and also predicted large absolute reductions in the proportion of persons developing type 2 diabetes and a delay of 7 to 8 years in onset of diabetes, as well as that the DPP lifestyle intervention will lead to fewer complications and improved quality-adjusted life-years 95. They, however, estimated much higher marginal cost-effectiveness ratios than did Herman and associates 96.
Several other models recently evaluated primary prevention of type 2 diabetes among persons with impaired glucose tolerance 91,92,94,97, and all demonstrated relative cost-effectiveness of lifestyle interventions. Two models examined metformin and found it to be cost-saving under many conditions 92,97.
Observed Long Term Benefits and Ongoing Research for Clinical Pathways
We must learn whether early, aggressive glycemic control in persons with diabetes produces improvements in clinical outcomes after many years of follow-up 151. An extension of the largest study of an initial strategy of sustained tight glycemic control in type 1 diabetes 152 suggested that participants originally randomly assigned to tight glycemic control had a significant reduction in cardiovascular events at long-term follow-up despite similar glycemic control in the control group during the post randomization period 153. To date, similar data are unavailable for type 2 diabetes. We also need studies to define the duration of the prediabetes phase and identify measurable risk factors for progression to diabetes and its complications, particularly cardiovascular disease.
Focus on Long-Term Cost-effectiveness of diabetes treatment programs
The cost-effectiveness of diabetes screening programs is considered to be mainly determined by the long-term health benefits rather than the cost of detection and treatment of diabetes 154. Thus, intervention research needs to continue focusing on long-term, sustainable interventions that affect health outcomes in real-world settings.