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Christoffersen NB, Nilou FE, Thilsing T, Larsen LB, Østergaard JN, Broholm-Jørgensen M. Exploring targeted preventive health check interventions - a realist synthesis. BMC Public Health 2023; 23:1928. [PMID: 37798691 PMCID: PMC10557298 DOI: 10.1186/s12889-023-16861-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 09/29/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND Preventive health checks are assumed to reduce the risk of the development of cardio-metabolic disease in the long term. Although no solid evidence of effect is shown on health checks targeting the general population, studies suggest positive effects if health checks target people or groups identified at risk of disease. The aim of this study is to explore why and how targeted preventive health checks work, for whom they work, and under which circumstances they can be expected to work. METHODS The study is designed as a realist synthesis that consists of four phases, each including collection and analysis of empirical data: 1) Literature search of systematic reviews and meta-analysis, 2) Interviews with key-stakeholders, 3) Literature search of qualitative studies and grey literature, and 4) Workshops with key stakeholders and end-users. Through the iterative analysis we identified the interrelationship between contexts, mechanisms, and outcomes to develop a program theory encompassing hypotheses about targeted preventive health checks. RESULTS Based on an iterative analysis of the data material, we developed a final program theory consisting of seven themes; Target group; Recruitment and participation; The encounter between professional and participants; Follow-up activities; Implementation and operation; Shared understanding of the intervention; and Unintended side effects. Overall, the data material showed that targeted preventive health checks need to be accessible, recognizable, and relevant for the participants' everyday lives as well as meaningful to the professionals involved. The results showed that identifying a target group, that both benefit from attending and have the resources to participate pose a challenge for targeted preventive health check interventions. This challenge illustrates the importance of designing the recruitment and intervention activities according to the target groups particular life situation. CONCLUSION The results indicate that a one-size-fits-all model of targeted preventive health checks should be abandoned, and that intervention activities and implementation depend on for whom and under which circumstances the intervention is initiated. Based on the results we suggest that future initiatives conduct thorough needs assessment as the basis for decisions about where and how the preventive health checks are implemented.
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Affiliation(s)
- Nanna Bjørnbak Christoffersen
- Research Program On Health and Social Conditions, National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Freja Ekstrøm Nilou
- Research Program On Health and Social Conditions, National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Trine Thilsing
- Research Unit of General Practice, University of Southern, Odense, Denmark
| | - Lars Bruun Larsen
- Research Unit of General Practice, University of Southern, Odense, Denmark
- Steno Diabetes Center Zealand, Holbæk, Denmark
| | | | - Marie Broholm-Jørgensen
- Research Program On Health and Social Conditions, National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark.
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Stol DM, Over EAB, Badenbroek IF, Hollander M, Nielen MMJ, Kraaijenhagen RA, Schellevis FG, de Wit NJ, de Wit GA. Cost-effectiveness of a stepwise cardiometabolic disease prevention program: results of a randomized controlled trial in primary care. BMC Med 2021; 19:57. [PMID: 33691699 PMCID: PMC7948329 DOI: 10.1186/s12916-021-01933-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 02/01/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Cardiometabolic diseases (CMD) are the major cause of death worldwide and are associated with a lower quality of life and high healthcare costs. To prevent a further rise in CMD and related healthcare costs, early detection and adequate management of individuals at risk could be an effective preventive strategy. The objective of this study was to determine long-term cost-effectiveness of stepwise CMD risk assessment followed by individualized treatment if indicated compared to care as usual. A computer-based simulation model was used to project long-term health benefits and cost-effectiveness, assuming the prevention program was implemented in Dutch primary care. METHODS A randomized controlled trial in a primary care setting in which 1934 participants aged 45-70 years without recorded CMD or CMD risk factors participated. The intervention group was invited for stepwise CMD risk assessment through a risk score (step 1), additional risk assessment at the practice in case of increased risk (step 2) and individualized follow-up treatment if indicated (step 3). The control group was not invited for risk assessment, but completed a health questionnaire. Results of the effectiveness analysis on systolic blood pressure (- 2.26 mmHg; 95% CI - 4.01: - 0.51) and total cholesterol (- 0.15 mmol/l; 95% CI - 0.23: - 0.07) were used in this analysis. Outcome measures were the costs and benefits after 1-year follow-up and long-term (60 years) cost-effectiveness of stepwise CMD risk assessment compared to no assessment. A computer-based simulation model was used that included data on disability weights associated with age and disease outcomes related to CMD. Analyses were performed taking a healthcare perspective. RESULTS After 1 year, the average costs in the intervention group were 260 Euro higher than in the control group and differences were mainly driven by healthcare costs. No meaningful change was found in EQ 5D-based quality of life between the intervention and control groups after 1-year follow-up (- 0.0154; 95% CI - 0.029: 0.004). After 60 years, cumulative costs of the intervention were 41.4 million Euro and 135 quality-adjusted life years (QALY) were gained. Despite improvements in blood pressure and cholesterol, the intervention was not cost-effective (ICER of 306,000 Euro/QALY after 60 years). Scenario analyses did not allow for a change in conclusions with regard to cost-effectiveness of the intervention. CONCLUSIONS Implementation of this primary care-based CMD prevention program is not cost-effective in the long term. Implementation of this program in primary care cannot be recommended. TRIAL REGISTRATION Dutch Trial Register NTR4277 , registered on 26 November 2013.
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Affiliation(s)
- Daphne M. Stol
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
| | - Eelco A. B. Over
- National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Ilse F. Badenbroek
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
| | - Monika Hollander
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mark M. J. Nielen
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
| | - Roderik A. Kraaijenhagen
- Netherlands Institute for Prevention and E-health Development (NIPED), Amsterdam, The Netherlands
| | - François G. Schellevis
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
- Department of General Practice and Elderly Care Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers (location VUmc), Amsterdam, The Netherlands
| | - Niek J. de Wit
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - G. Ardine de Wit
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
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Abstract
BACKGROUND Diabetes mellitus, a metabolic disorder characterised by hyperglycaemia and associated with a heavy burden of microvascular and macrovascular complications, frequently remains undiagnosed. Screening of apparently healthy individuals may lead to early detection and treatment of type 2 diabetes mellitus and may prevent or delay the development of related complications. OBJECTIVES To assess the effects of screening for type 2 diabetes mellitus. SEARCH METHODS We searched CENTRAL, MEDLINE, LILACS, the WHO ICTRP, and ClinicalTrials.gov from inception. The date of the last search was May 2019 for all databases. We applied no language restrictions. SELECTION CRITERIA We included randomised controlled trials involving adults and children without known diabetes mellitus, conducted over at least three months, that assessed the effect of diabetes screening (mass, targeted, or opportunistic) compared to no diabetes screening. DATA COLLECTION AND ANALYSIS Two review authors independently screened titles and abstracts for potential relevance and reviewed the full-texts of potentially relevant studies, extracted data, and carried out 'Risk of bias' assessment using the Cochrane 'Risk of bias' tool. We assessed the overall certainty of the evidence using the GRADE approach. MAIN RESULTS We screened 4651 titles and abstracts identified by the search and assessed 92 full-texts/records for inclusion. We included one cluster-randomised trial, the ADDITION-Cambridge study, which involved 20,184 participants from 33 general practices in Eastern England and assessed the effects of inviting versus not inviting high-risk individuals to screening for diabetes. The diabetes risk score was used to identify high-risk individuals; it comprised variables relating to age, sex, body mass index, and the use of prescribed steroid and anti-hypertensive medication. Twenty-seven practices were randomised to the screening group (11,737 participants actually attending screening) and 5 practices to the no-screening group (4137 participants). In both groups, 36% of participants were women; the average age of participants was 58.2 years in the screening group and 57.9 years in the no-screening group. Almost half of participants in both groups were on antihypertensive medication. The findings from the first phase of this study indicate that screening compared to no screening for type 2 diabetes did not show a clear difference in all-cause mortality (hazard ratio (HR) 1.06, 95% confidence interval (CI) 0.90 to 1.25, low-certainty evidence). Screening compared to no screening for type 2 diabetes mellitus showed an HR of 1.26, 95% CI 0.75 to 2.12 (low-certainty evidence) for diabetes-related mortality (based on whether diabetes was reported as a cause of death on the death certificate). Diabetes-related morbidity and health-related quality of life were only reported in a subsample and did not show a substantial difference between the screening intervention and control. The included study did not report on adverse events, incidence of type 2 diabetes, glycosylated haemoglobin A1c (HbA1c), and socioeconomic effects. AUTHORS' CONCLUSIONS We are uncertain about the effects of screening for type 2 diabetes on all-cause mortality and diabetes-related mortality. Evidence was available from one study only. We are therefore unable to draw any firm conclusions relating to the health outcomes of early type 2 diabetes mellitus screening. Furthermore, the included study did not assess all of the outcomes prespecified in the review (diabetes-related morbidity, incidence of type 2 diabetes, health-related quality of life, adverse events, socioeconomic effects).
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Affiliation(s)
- Nasheeta Peer
- Non-communicable Diseases Research Unit, South African Medical Research Council, Durban, South Africa
| | - Yusentha Balakrishna
- Biostatistics Unit, South African Medical Research Council, Durban, South Africa
| | - Solange Durao
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
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Hiligsmann M, Wyers CE, Mayer S, Evers SM, Ruwaard D. A systematic review of economic evaluations of screening programmes for cardiometabolic diseases. Eur J Public Health 2018; 27:621-631. [PMID: 28040737 DOI: 10.1093/eurpub/ckw237] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Background The early detection and adequate management of cardiometabolic diseases (CMD) is becoming a priority to prevent future health problems and related healthcare costs. Aim This study systematically reviewed the economic evaluations of screening programmes for the early detection of persons at risk for CMD. Methods A systematic review was conducted using MEDLINE, Web of Science, NHSEED and the CEA registry to identify relevant articles published between 1 January 2005 and 1 May 2015. Two reviewers independently selected articles, systematically extracted data and critically appraised the study quality using the Extended Consensus on Health Economic Criteria (CHEC) List. Results From the initial 2820 studies identified, 17 were included. Six studies assessed whether screening would be cost-effective, seven aimed to determine the most efficient screening programme and four assessed the cost-effectiveness of existing programmes. There were 11 cost-utility analyses using quality-adjusted life years (QALYs) or disability-adjusted life years. Decision-analytic modelling (e.g. Markov model) was most frequently used (n = 10), followed by simulation models (n = 4), observational (n = 2) and trial-based (n = 1) studies. All studies assessing the cost per QALY gained of screening for cardiovascular diseases and diabetes mellitus (n = 8) were below a threshold of £30 000, while those assessing chronic kidney diseases (n = 2) were above the threshold. Conclusions: In view of the heterogeneity in study objectives, country setting, screening programmes, comparators, methodology and outcomes, it is not possible to make clear recommendations about the economic value of screening programmes for CMD. Developing further screening programmes and conducting thorough economic analysis, including usual care, is needed.
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Affiliation(s)
- Mickael Hiligsmann
- Department of Health Services Research, School for Public Health and Primary Care (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Caroline E Wyers
- Department of Internal Medicine, VieCuri Medical Centre, Venlo, The Netherlands.,Department of Internal Medicine, NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Susanne Mayer
- Department of Health Services Research, School for Public Health and Primary Care (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.,Department of Health Economics, Centre for Public Health, Medical University of Vienna, Vienna, Austria
| | - Silvia M Evers
- Department of Health Services Research, School for Public Health and Primary Care (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Dirk Ruwaard
- Department of Health Services Research, School for Public Health and Primary Care (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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Sortsø C, Komkova A, Sandbæk A, Griffin SJ, Emneus M, Lauritzen T, Simmons RK. Effect of screening for type 2 diabetes on healthcare costs: a register-based study among 139,075 individuals diagnosed with diabetes in Denmark between 2001 and 2009. Diabetologia 2018; 61:1306-1314. [PMID: 29549417 DOI: 10.1007/s00125-018-4594-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Accepted: 02/05/2018] [Indexed: 02/07/2023]
Abstract
AIMS/HYPOTHESIS Trials have not demonstrated benefits to the population of screening for type 2 diabetes. However, there may be cost savings for those found to have diabetes. We therefore aimed to compare healthcare costs among individuals with incident type 2 diabetes in a screened group with those in an unscreened group. METHODS In this register-based, non-randomised controlled trial, eligible individuals were men and women aged 40-69 years without known diabetes who were registered with a general practice in Denmark (n = 1,912,392). Between 2001 and 2006, 153,107 individuals registered with 181 practices participating in the Anglo-Danish-Dutch Study of Intensive Treatment in People with Screen Detected Diabetes in Primary Care (ADDITION)-Denmark study were sent a diabetes risk-score questionnaire. Individuals with a moderate-to-high risk were invited to visit their family doctor for assessment of diabetes status and cardiovascular risk (screening group). The 1,759,285 individuals registered with all other practices in Denmark constituted the retrospectively constructed no-screening (control) group. In this post hoc analysis, we identified individuals from the screening and no-screening groups who were diagnosed with diabetes between 2001 and 2009 (n = 139,075). Using national registry data, we quantified the cost of healthcare services in these two groups between 2001 and 2012. From a healthcare sector perspective, we estimated the potential healthcare cost savings for individuals with diabetes that were attributable to the screening programme. RESULTS In the screening group, 27,177 of 153,107 individuals (18% of those sent a risk-score questionnaire) attended for screening, 1533 of whom were diagnosed with diabetes. Between 2001 and 2009, 13,992 people were newly diagnosed with diabetes in the screening group (including those diagnosed by screening) and 125,083 in the no-screening group. Healthcare costs were significantly lower in the screening group compared with the no-screening group (difference in mean total annual healthcare costs -€889 per individual with incident diabetes; 95% CI -€1196, -€581). The screening programme was associated with a cost saving per person with incident diabetes over a 5-year period of €2688 (95% CI €1421, €3995). CONCLUSIONS/INTERPRETATION Healthcare costs were lower among individuals with incident type 2 diabetes in the screened group compared with the unscreened group. The relatively modest cost of screening per person discovered to have developed diabetes was offset within 2 years by savings in the healthcare system.
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Affiliation(s)
- Camilla Sortsø
- Applied Economics and Health Research Aps, Ewaldsgade 3, 2200, Copenhagen N, Denmark.
| | - Anastasija Komkova
- Applied Economics and Health Research Aps, Ewaldsgade 3, 2200, Copenhagen N, Denmark
| | - Annelli Sandbæk
- Department of Public Health, Section of General Practice, Aarhus, Denmark
| | - Simon J Griffin
- Department of Public Health, Section of General Practice, Aarhus, Denmark
- Primary Care Unit, Institute of Public Health, Cambridge, UK
| | - Martha Emneus
- Applied Economics and Health Research Aps, Ewaldsgade 3, 2200, Copenhagen N, Denmark
| | - Torsten Lauritzen
- Department of Public Health, Section of General Practice, Aarhus, Denmark
| | - Rebecca K Simmons
- Department of Public Health, Section of General Practice, Aarhus, Denmark.
- Danish Diabetes Academy, Odense University Hospital, Odense, Denmark.
- Aarhus Institute of Advanced Studies, Aarhus, Denmark.
- The Healthcare Improvement Studies (THIS) Institute, University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, CB2 0AH, UK.
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Heltberg A, Andersen JS, Sandholdt H, Siersma V, Kragstrup J, Ellervik C. Predictors of undiagnosed prevalent type 2 diabetes - The Danish General Suburban Population Study. Prim Care Diabetes 2018; 12:13-22. [PMID: 28964672 DOI: 10.1016/j.pcd.2017.08.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 08/26/2017] [Accepted: 08/29/2017] [Indexed: 02/01/2023]
Abstract
AIMS To investigate how self-reported risk factors (including socioeconomic status) predict undiagnosed, prevalent type 2 diabetes mellitus (T2DM). To externally validate Leicester Risk Assessment Score (LRAS), Finnish Diabetes Risk Score (FINDRISC) and Danish Diabetes Risk Score (DDRS), and to investigate how these predict a European Heart SCORE≥5% in a Danish population study. METHODS We included 21,205 adults from the Danish General Suburban Population Study. We used relative importance calculations of self-reported variables in prediction of undiagnosed T2DM. We externally validated established prediction models reporting ROC-curves for undiagnosed T2DM, pre-diabetes and SCORE. RESULTS More than 20% of people with T2DM were undiagnosed. The 7 most important self-rated predictors in sequential order were high BMI, antihypertensive-therapy, age, cardiovascular disease, waist-circumference, fitness compared to peers and family disposition for T2DM. The Area Under the Curve for prediction of undiagnosed T2DM was 77.1 for LRAS; 75.4 for DDRS and 67.9 for FINDRISC. AUCs for SCORE was 75.1 for LRAS; 62.3 for DDRS and 54.3 for FINDRISC. CONCLUSIONS BMI and self-reported cardiovascular disease are important risk factors for undiagnosed T2DM. LRAS performed better than DDRS and FINDRISC in prediction of undiagnosed T2DM and SCORE≥5%. SCORE performed best in predicting pre-diabetes.
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Affiliation(s)
- Andreas Heltberg
- Section of General Practice, Department of Public Health and Research Unit for General Practice, University of Copenhagen, Denmark.
| | - John Sahl Andersen
- Section of General Practice, Department of Public Health and Research Unit for General Practice, University of Copenhagen, Denmark
| | - Håkon Sandholdt
- Section of General Practice, Department of Public Health and Research Unit for General Practice, University of Copenhagen, Denmark
| | - Volkert Siersma
- Section of General Practice, Department of Public Health and Research Unit for General Practice, University of Copenhagen, Denmark
| | - Jakob Kragstrup
- Section of General Practice, Department of Public Health and Research Unit for General Practice, University of Copenhagen, Denmark
| | - Christina Ellervik
- Department of Production, Research, and Innovation, Region Zealand, Sorø, Denmark; Department of Laboratory Medicine, Boston Children's Hospital & Harvard Medical School, Boston, MA, USA; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
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Einarson TR, Bereza BG, Acs A, Jensen R. Systematic literature review of the health economic implications of early detection by screening populations at risk for type 2 diabetes. Curr Med Res Opin 2017; 33:331-358. [PMID: 27819150 DOI: 10.1080/03007995.2016.1257977] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Undetected/uncontrolled diabetes is associated with substantial morbidity and mortality and consequent costs. Early detection through screening identifies patients at risk, allowing for earlier treatment initiation. OBJECTIVES To determine the economic impact of screening for type 2 diabetes (T2DM). DATA SOURCES We systematically reviewed health economic analyses of screening programs for T2DM/pre-diabetes. STUDY ELIGIBILITY CRITERIA Published between 2000 and 2015 in any language. Articles must have reported costs of screening, test/patient outcomes and cost-effectiveness. PARTICIPANTS AND INTERVENTIONS Any type of screening (universal, targeted, opportunistic) was accepted. METHODS Data were extracted from Scopus/Medline/Embase, then tabulated. RESULTS There were 137 studies identified, 108 rejected; 29 were analyzed. Screening types included 18 universal, 8 targeted and 8 opportunistic. One study screened for pre-diabetes, 16 for T2DM and 12 examined both. Fourteen (48%) reported costs of screening only, 9 (31%) costs of screening combined with interventions and 6 (21%) presented all costs separately. Screening was compared to no screening in 13 studies (45%); screening was cost-effective in 8 (62%), not cost-effective in 4 (31%) and neither in 1 (8%). When comparing different screening methods, 6 found targeted screening was cost-effective compared with universal screening (none found the opposite), 2 found opportunistic superior to universal. Sensitivity analyses generally confirmed primary findings. Cost drivers included prevalence of T2DM/pre-diabetes, type of blood test used and uptake of testing. For optimal cost-effectiveness, screening for both T2DM and pre-diabetes should be initiated around age 45-50, with repeated testing every 5 years. CONCLUSIONS/IMPLICATIONS Targeted screening appears to be cost-effective compared to universal screening.
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Affiliation(s)
| | - Basil G Bereza
- a Leslie Dan Faculty of Pharmacy , University of Toronto , Canada
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Simmons RK, Borch-Johnsen K, Lauritzen T, Rutten GE, Sandbæk A, van den Donk M, Black JA, Tao L, Wilson EC, Davies MJ, Khunti K, Sharp SJ, Wareham NJ, Griffin SJ. A randomised trial of the effect and cost-effectiveness of early intensive multifactorial therapy on 5-year cardiovascular outcomes in individuals with screen-detected type 2 diabetes: the Anglo-Danish-Dutch Study of Intensive Treatment in People with Screen-Detected Diabetes in Primary Care (ADDITION-Europe) study. Health Technol Assess 2016; 20:1-86. [PMID: 27583404 PMCID: PMC5018687 DOI: 10.3310/hta20640] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Intensive treatment (IT) of cardiovascular risk factors can halve mortality among people with established type 2 diabetes but the effects of treatment earlier in the disease trajectory are uncertain. OBJECTIVE To quantify the cost-effectiveness of intensive multifactorial treatment of screen-detected diabetes. DESIGN Pragmatic, multicentre, cluster-randomised, parallel-group trial. SETTING Three hundred and forty-three general practices in Denmark, the Netherlands, and Cambridge and Leicester, UK. PARTICIPANTS Individuals aged 40-69 years with screen-detected diabetes. INTERVENTIONS Screening plus routine care (RC) according to national guidelines or IT comprising screening and promotion of target-driven intensive management (medication and promotion of healthy lifestyles) of hyperglycaemia, blood pressure and cholesterol. MAIN OUTCOME MEASURES The primary end point was a composite of first cardiovascular event (cardiovascular mortality/morbidity, revascularisation and non-traumatic amputation) during a mean [standard deviation (SD)] follow-up of 5.3 (1.6) years. Secondary end points were (1) all-cause mortality; (2) microvascular outcomes (kidney function, retinopathy and peripheral neuropathy); and (3) patient-reported outcomes (health status, well-being, quality of life, treatment satisfaction). Economic analyses estimated mean costs (UK 2009/10 prices) and quality-adjusted life-years from an NHS perspective. We extrapolated data to 30 years using the UK Prospective Diabetes Study outcomes model [version 1.3; (©) Isis Innovation Ltd 2010; see www.dtu.ox.ac.uk/outcomesmodel (accessed 27 January 2016)]. RESULTS We included 3055 (RC, n = 1377; IT, n = 1678) of the 3057 recruited patients [mean (SD) age 60.3 (6.9) years] in intention-to-treat analyses. Prescription of glucose-lowering, antihypertensive and lipid-lowering medication increased in both groups, more so in the IT group than in the RC group. There were clinically important improvements in cardiovascular risk factors in both study groups. Modest but statistically significant differences between groups in reduction in glycated haemoglobin (HbA1c) levels, blood pressure and cholesterol favoured the IT group. The incidence of first cardiovascular event [IT 7.2%, 13.5 per 1000 person-years; RC 8.5%, 15.9 per 1000 person-years; hazard ratio 0.83, 95% confidence interval (CI) 0.65 to 1.05] and all-cause mortality (IT 6.2%, 11.6 per 1000 person-years; RC 6.7%, 12.5 per 1000 person-years; hazard ratio 0.91, 95% CI 0.69 to 1.21) did not differ between groups. At 5 years, albuminuria was present in 22.7% and 24.4% of participants in the IT and RC groups, respectively [odds ratio (OR) 0.87, 95% CI 0.72 to 1.07), retinopathy in 10.2% and 12.1%, respectively (OR 0.84, 95% CI 0.64 to 1.10), and neuropathy in 4.9% and 5.9% (OR 0.95, 95% CI 0.68 to 1.34), respectively. The estimated glomerular filtration rate increased between baseline and follow-up in both groups (IT 4.31 ml/minute; RC 6.44 ml/minute). Health status, well-being, diabetes-specific quality of life and treatment satisfaction did not differ between the groups. The intervention cost £981 per patient and was not cost-effective at costs ≥ £631 per patient. CONCLUSIONS Compared with RC, IT was associated with modest increases in prescribed treatment, reduced levels of risk factors and non-significant reductions in cardiovascular events, microvascular complications and death over 5 years. IT did not adversely affect patient-reported outcomes. IT was not cost-effective but might be if delivered at a reduced cost. The lower than expected event rate, heterogeneity of intervention delivery between centres and improvements in general practice diabetes care limited the achievable differences in treatment between groups. Further follow-up to assess the legacy effects of early IT is warranted. TRIAL REGISTRATION ClinicalTrials.gov NCT00237549. FUNDING DETAILS This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 64. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Rebecca K Simmons
- Medical Research Council Epidemiology Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Knut Borch-Johnsen
- Holbæk Hospital, Holbæk, Denmark
- School of Public Health, Department of General Practice, University of Aarhus, Aarhus, Denmark
| | - Torsten Lauritzen
- School of Public Health, Department of General Practice, University of Aarhus, Aarhus, Denmark
| | - Guy Ehm Rutten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Annelli Sandbæk
- School of Public Health, Department of General Practice, University of Aarhus, Aarhus, Denmark
| | - Maureen van den Donk
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - James A Black
- Medical Research Council Epidemiology Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Libo Tao
- Medical Research Council Epidemiology Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Edward Cf Wilson
- Department of Public Health and Primary Care, Cambridge Centre for Health Services Research, University of Cambridge, School of Clinical Medicine, Cambridge, UK
| | - Melanie J Davies
- Diabetes Research Centre, Leicester Diabetes Centre, University of Leicester, Leicester General Hospital, Leicester, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, Leicester Diabetes Centre, University of Leicester, Leicester General Hospital, Leicester, UK
| | - Stephen J Sharp
- Medical Research Council Epidemiology Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Nicholas J Wareham
- Medical Research Council Epidemiology Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Simon J Griffin
- Medical Research Council Epidemiology Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
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Systematic Review and Meta-Analysis of Response Rates and Diagnostic Yield of Screening for Type 2 Diabetes and Those at High Risk of Diabetes. PLoS One 2015; 10:e0135702. [PMID: 26325182 PMCID: PMC4556656 DOI: 10.1371/journal.pone.0135702] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 07/25/2015] [Indexed: 12/16/2022] Open
Abstract
Background Screening for type 2 diabetes (T2DM) and individuals at risk of diabetes has been advocated, yet information on the response rate and diagnostic yield of different screening strategies are lacking. Methods Studies (from 1998 to March/2015) were identified through Medline, Embase and the Cochrane library and included if they used oral glucose tolerance test (OGTT) and WHO-1998 diagnostic criteria for screening in a community setting. Studies were one-step strategy if participants were invited directly for OGTT and two, three/four step if participants were screened at one or more levels prior to invitation to OGTT. The response rate and diagnostic yield were pooled using Bayesian random-effect meta-analyses. Findings 47 studies (422754 participants); 29 one-step, 11 two-step and seven three/four-step were identified. Pooled response rate (95% Credible Interval) for invitation to OGTT was 65.5% (53.7, 75.6), 63.1% (44.0, 76.8), and 85.4% (76.4, 93.3) in one, two and three/four-step studies respectively. T2DM yield was 6.6% (5.3, 7.8), 13.1% (4.3, 30.9) and 27.9% (8.6, 66.3) for one, two and three/four-step strategies respectively. The number needed to invite to the OGTT to detect one case of T2DM was 15, 7.6 and 3.6 in one, two, and three/four-step strategies. In two step strategies, there was no difference between the response or yield rates whether the first step was blood test or risk-score. There was evidence of substantial heterogeneity in rates across study populations but this was not explained by the method of invitation, study location (rural versus urban) and developmental index of the country in which the study was performed. Conclusions Irrespective of the invitation method, developmental status of the countries and or rural/urban location, using a multi-step strategy increases the initial response rate to the invitation to screening for diabetes and reduces the number needed to have the final diagnostic test (OGTT in this study) for a definite diagnosis.
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Dhippayom T, Chaiyakunapruk N, Krass I. How diabetes risk assessment tools are implemented in practice: a systematic review. Diabetes Res Clin Pract 2014; 104:329-42. [PMID: 24485859 DOI: 10.1016/j.diabres.2014.01.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Revised: 10/08/2013] [Accepted: 01/02/2014] [Indexed: 02/02/2023]
Abstract
This review aimed to explore the extent of the use of diabetes risk assessment tools and to determine influential variables associated with the implementation of these tools. CINAHL, Google Scholar, ISI Citation Indexes, PubMed, and Scopus were searched from inception to January 2013. Studies that reported the use of diabetes risk assessment tools to identify individuals at risk of diabetes were included. Of the 1719 articles identified, 24 were included. Follow-up of high risk individuals for diagnosis of diabetes was conducted in 5 studies. Barriers to the uptake of diabetes risk assessment tools by healthcare practitioners included (1) attitudes toward the tools; (2) impracticality of using the tools and (3) lack of reimbursement and regulatory support. Individuals were reluctant to undertake self-assessment of diabetes risk due to (1) lack of perceived severity of type 2 diabetes; (2) impracticality of the tools; and (3) concerns related to finding out the results. The current use of non-invasive diabetes risk assessment scores as screening tools appears to be limited. Practical follow up systems as well as strategies to address other barriers to the implementation of diabetes risk assessment tools are essential and need to be developed.
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Affiliation(s)
- Teerapon Dhippayom
- Pharmaceutical Care Research Unit, Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok 65000, Thailand; Faculty of Pharmacy, The University of Sydney, Sydney, NSW, Australia.
| | - Nathorn Chaiyakunapruk
- Discipline of Pharmacy, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia; Center of Pharmaceutical Outcomes Research, Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand; School of Population Health, University of Queensland, Brisbane, Australia; School of Pharmacy, University of Wisconsin-Madison, Madison, WI, USA
| | - Ines Krass
- Faculty of Pharmacy, The University of Sydney, Sydney, NSW, Australia
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Perreault L, Færch K. Approaching pre-diabetes. J Diabetes Complications 2014; 28:226-33. [PMID: 24342268 DOI: 10.1016/j.jdiacomp.2013.10.008] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Revised: 10/18/2013] [Accepted: 10/19/2013] [Indexed: 01/06/2023]
Abstract
As the global epidemic of type 2 diabetes continues to rise, the time has come to revisit our approach to pre-diabetes. Recently, much ado has been made about screening, diagnosis, pathophysiology and clinical interventions in pre-diabetes, and all for good reason as the key to reversing the diabetes epidemic likely lies therein. The somewhat controversial term "pre-diabetes" represents collective dysglycemic states intermediate between normal glucose regulation (NGR) and diabetes. Not all people with pre-diabetes will develop diabetes, but the majority will. In fact, up to 70% of those with pre-diabetes may acquire the disease over their lifetime. Furthermore, even when overt diabetes is delayed or prevented, both micro- and macrovascular disease appears more prevalent in those with pre-diabetes compared to their normoglycemic peers. Hence, there is growing consensus that NGR should be the goal for people with pre-diabetes. Nevertheless, there is much to consider in that pursuit. Herein, we provide an update on the global burden of pre-diabetes, its underlying pathophysiology and discuss clinical considerations in these individuals at high risk of developing diabetes.
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Affiliation(s)
- Leigh Perreault
- University of Colorado Anschutz Medical Center, Aurora, CO, USA.
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Lauritzen T, Borch-Johnsen K, Davies MJ, Khunti K, Rutten GEHM, Sandbæk A, Simmons RK, van den Donk M, Wareham NJ, Griffin SJ. Screening for diabetes: what do the results of the ADDITION trial mean for clinical practice? ACTA ACUST UNITED AC 2013. [DOI: 10.2217/dmt.13.40] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Johansen NB, Hansen ALS, Jensen TM, Philipsen A, Rasmussen SS, Jørgensen ME, Simmons RK, Lauritzen T, Sandbæk A, Witte DR. Protocol for ADDITION-PRO: a longitudinal cohort study of the cardiovascular experience of individuals at high risk for diabetes recruited from Danish primary care. BMC Public Health 2012; 12:1078. [PMID: 23241242 PMCID: PMC3583712 DOI: 10.1186/1471-2458-12-1078] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Accepted: 12/06/2012] [Indexed: 11/26/2022] Open
Abstract
Background Screening programmes for type 2 diabetes inevitably find more individuals at high risk for diabetes than people with undiagnosed prevalent disease. While well established guidelines for the treatment of diabetes exist, less is known about treatment or prevention strategies for individuals found at high risk following screening. In order to make better use of the opportunities for primary prevention of diabetes and its complications among this high risk group, it is important to quantify diabetes progression rates and to examine the development of early markers of cardiovascular disease and microvascular diabetic complications. We also require a better understanding of the mechanisms that underlie and drive early changes in cardiometabolic physiology. The ADDITION-PRO study was designed to address these issues among individuals at different levels of diabetes risk recruited from Danish primary care. Methods/Design ADDITION-PRO is a population-based, longitudinal cohort study of individuals at high risk for diabetes. 16,136 eligible individuals were identified at high risk following participation in a stepwise screening programme in Danish general practice between 2001 and 2006. All individuals with impaired glucose regulation at screening, those who developed diabetes following screening, and a random sub-sample of those at lower levels of diabetes risk were invited to attend a follow-up health assessment in 2009–2011 (n = 4,188), of whom 2,082 (50%) attended. The health assessment included detailed measurement of anthropometry, body composition, biochemistry, physical activity and cardiovascular risk factors including aortic stiffness and central blood pressure. All ADDITION-PRO participants are being followed for incident cardiovascular disease and death. Discussion The ADDITION-PRO study is designed to increase understanding of cardiovascular risk and its underlying mechanisms among individuals at high risk of diabetes. Key features of this study include (i) a carefully characterised cohort at different levels of diabetes risk; (ii) detailed measurement of cardiovascular and metabolic risk factors; (iii) objective measurement of physical activity behaviour; and (iv) long-term follow-up of hard clinical outcomes including mortality and cardiovascular disease. Results will inform policy recommendations concerning cardiovascular risk reduction and treatment among individuals at high risk for diabetes. The detailed phenotyping of this cohort will also allow a number of research questions concerning early changes in cardiometabolic physiology to be addressed.
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Pereira Gray DJ, Evans PH, Wright C, Langley P. The cost of diagnosing Type 2 diabetes mellitus by clinical opportunistic screening in general practice. Diabet Med 2012; 29:863-8. [PMID: 22313143 DOI: 10.1111/j.1464-5491.2012.03607.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
AIMS Type 2 diabetes is associated with serious complications and shortens life. Its prevalence is increasing rapidly worldwide and no cure is available. One logical response is to diagnose the condition as early as possible. Clinical opportunistic screening is one mechanism for making the diagnosis before symptoms are reported. This paper reports the cost of using this technique in UK general practice. METHODS In one UK general practice, the electronic medical records were searched to determine the number of blood glucose and oral glucose tolerance tests undertaken for non-pregnant adults without known diabetes over three consecutive years. The laboratory, staff and administrative costs associated with these screening tests were calculated. The records of all patients newly diagnosed with Type 2 diabetes during the same period were reviewed to identify diagnoses made by clinical opportunistic screening. Total costs were divided by the number of diagnoses to determine a cost per diagnosis detected by opportunistic screening. RESULTS During the study period, 5720 screening tests were conducted for 2763 patients. Over the 3 years, 86 patients were diagnosed with Type 2 diabetes, 54 (63%) via screening (yield 2.0%; number needed to screen 51.2). The screening costs totalled £ 20,372. The average cost per new screen-detected diagnosis was £ 377. CONCLUSIONS Almost two-thirds of new cases of Type 2 diabetes can be detected before symptoms are reported, at reasonable cost by opportunistic screening in general practice, without the use of extra resources. As an affordable alternative to population screening, clinical opportunistic screening merits further consideration.
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Fisher BG, Ang YLE, Goodhart C, Simmons RK. Record-based, stepwise screening for type 2 diabetes integrated into an annual cardiovascular care review system: Findings from a UK general practice. Prim Care Diabetes 2011; 5:265-269. [PMID: 21968319 DOI: 10.1016/j.pcd.2011.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2011] [Revised: 08/08/2011] [Accepted: 09/01/2011] [Indexed: 11/28/2022]
Abstract
AIMS Screening high-risk individuals for type 2 diabetes (T2DM) is recommended by many organisations. We report results from a pragmatic stepwise T2DM screening programme integrated into an annual review system in a UK general practice. METHODS Patients with hypertension, cardiovascular disease or chronic kidney disease attending an annual review were screened for dysglycaemia by random blood glucose (RBG) measurement. At the discretion of the usual doctor, individuals with an RBG≥6.1 mmol/l were invited to return for fasting blood glucose (FBG) or HbA(1C) measurement, allowing diagnosis of T2DM. RESULTS 786 eligible patients were invited for T2DM screening as part of their annual review. 544 attended screening, of whom 120 had an RBG≥6.1 mmol/l. 40 individuals attended FBG measurement and 8 individuals attended HbA(1C) measurement, leading to 9 T2DM diagnoses. The positive predictive value of the test for T2DM was 19% and the laboratory cost was £91 per patient diagnosed with T2DM. CONCLUSIONS It is feasible to integrate a simple T2DM screening programme within an annual review system in a UK general practice. Different strategies may be required to increase initial attendance and ensure completion of the screening programme.
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