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Fornari E, Barbetti F, Iafusco D, Lombardo F, Miraglia Del Giudice E, Rabbone I, Mozzillo E. Type 2 diabetes in pediatrics. Minerva Pediatr (Torino) 2021; 73:549-562. [PMID: 34286947 DOI: 10.23736/s2724-5276.21.06530-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Type 2 diabetes (T2D) in adolescents has become an increasing health concern throughout the world and its prevention and screening should be implemented in pediatric care. As clinical features at presentation, in some cases can be similar to type 1 diabetes and family history can be in favour of a monogenic form of diabetes, it is pivotal for physicians to be aware of youth-onset T2D specificities to ensure an accurate diagnosis. The global increase of overweight and obesity can complicate the diagnostic process and makes it essential to apply a systematic approach to each new diagnosis. Microvascular complications may be present at the time of diagnosis and chronic complications are frequent and need to be screened regularly. Regular screening of comorbidities should also be performed. Childhood T2D should be followed up by pediatric diabetes units to avoid diagnostic errors and delay in care. A multidisciplinary approach, by an experienced team, is pivotal to provide treatment options targeting the unique needs of pediatric patients. Treatment programs must include the whole family and address all the aspects of the care (lifestyle, pharmacological therapy, psychological aspects, complications and comorbidities). An organized process of transition to adult care is essential.
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Affiliation(s)
- Elena Fornari
- Section of Pediatric Diabetes and Metabolism, Department of Surgery, Dentistry, Pediatrics and Gynecology, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Fabrizio Barbetti
- Department of Experimental Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Dario Iafusco
- Department of Pediatrics, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Fortunato Lombardo
- Department of Human Pathology in Adult and Developmental Age, University of Messina, Messina, Italy
| | - Emanuele Miraglia Del Giudice
- Department of the Woman, of the Child, of General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Ivana Rabbone
- Division of Paediatrics, Department of Health Sciences, University of Piemonte Orientale, Novara, Italy
| | - Enza Mozzillo
- Regional Center of Pediatric Diabetes, Department of Translational Medical Science, Section of Pediatrics, University of Naples Federico II, Naples, Italy -
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Olchanski N, van Klaveren D, Cohen JT, Wong JB, Ruthazer R, Kent DM. Targeting of the diabetes prevention program leads to substantial benefits when capacity is constrained. Acta Diabetol 2021; 58:707-722. [PMID: 33517494 PMCID: PMC8276501 DOI: 10.1007/s00592-021-01672-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 01/04/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Approximately 84 million people in the USA have pre-diabetes, but only a fraction of them receive proven effective therapies to prevent type 2 diabetes. We estimated the value of prioritizing individuals at highest risk of progression to diabetes for treatment, compared to non-targeted treatment of individuals meeting inclusion criteria for the Diabetes Prevention Program (DPP). METHODS Using microsimulation to project outcomes in the DPP trial population, we compared two interventions to usual care: (1) lifestyle modification and (2) metformin administration. For each intervention, we compared targeted and non-targeted strategies, assuming either limited or unlimited program capacity. We modeled the individualized risk of developing diabetes and projected diabetic outcomes to yield lifetime costs and quality-adjusted life expectancy, from which we estimated net monetary benefits (NMB) for both lifestyle and metformin versus usual care. RESULTS Compared to usual care, lifestyle modification conferred positive benefits and reduced lifetime costs for all eligible individuals. Metformin's NMB was negative for the lowest population risk quintile. By avoiding use when costs outweighed benefits, targeted administration of metformin conferred a benefit of $500 per person. If only 20% of the population could receive treatment, when prioritizing individuals based on diabetes risk, rather than treating a 20% random sample, the difference in NMB ranged from $14,000 to $20,000 per person. CONCLUSIONS Targeting active diabetes prevention to patients at highest risk could improve health outcomes and reduce costs compared to providing the same intervention to a similar number of patients with pre-diabetes without targeted selection.
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Affiliation(s)
- Natalia Olchanski
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington Street #63, Boston, MA, 02111, USA.
| | - David van Klaveren
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington Street #63, Boston, MA, 02111, USA
| | - Joshua T Cohen
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington Street #63, Boston, MA, 02111, USA
| | - John B Wong
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington Street #63, Boston, MA, 02111, USA
- Division of Clinical Decision Making, Tufts Medical Center, Boston, MA, USA
| | - Robin Ruthazer
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington Street #63, Boston, MA, 02111, USA
| | - David M Kent
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington Street #63, Boston, MA, 02111, USA
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Mühlenbruch K, Zhuo X, Bardenheier B, Shao H, Laxy M, Icks A, Zhang P, Gregg EW, Schulze MB. Selecting the optimal risk threshold of diabetes risk scores to identify high-risk individuals for diabetes prevention: a cost-effectiveness analysis. Acta Diabetol 2020; 57:447-454. [PMID: 31745647 PMCID: PMC7093341 DOI: 10.1007/s00592-019-01451-1] [Citation(s) in RCA: 5] [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: 09/18/2019] [Accepted: 10/31/2019] [Indexed: 01/21/2023]
Abstract
AIMS Although risk scores to predict type 2 diabetes exist, cost-effectiveness of risk thresholds to target prevention interventions are unknown. We applied cost-effectiveness analysis to identify optimal thresholds of predicted risk to target a low-cost community-based intervention in the USA. METHODS We used a validated Markov-based type 2 diabetes simulation model to evaluate the lifetime cost-effectiveness of alternative thresholds of diabetes risk. Population characteristics for the model were obtained from NHANES 2001-2004 and incidence rates and performance of two noninvasive diabetes risk scores (German diabetes risk score, GDRS, and ARIC 2009 score) were determined in the ARIC and Cardiovascular Health Study (CHS). Incremental cost-effectiveness ratios (ICERs) were calculated for increasing risk score thresholds. Two scenarios were assumed: 1-stage (risk score only) and 2-stage (risk score plus fasting plasma glucose (FPG) test (threshold 100 mg/dl) in the high-risk group). RESULTS In ARIC and CHS combined, the area under the receiver operating characteristic curve for the GDRS and the ARIC 2009 score were 0.691 (0.677-0.704) and 0.720 (0.707-0.732), respectively. The optimal threshold of predicted diabetes risk (ICER < $50,000/QALY gained in case of intervention in those above the threshold) was 7% for the GDRS and 9% for the ARIC 2009 score. In the 2-stage scenario, ICERs for all cutoffs ≥ 5% were below $50,000/QALY gained. CONCLUSIONS Intervening in those with ≥ 7% diabetes risk based on the GDRS or ≥ 9% on the ARIC 2009 score would be cost-effective. A risk score threshold ≥ 5% together with elevated FPG would also allow targeting interventions cost-effectively.
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Affiliation(s)
- Kristin Mühlenbruch
- Department of Molecular Epidemiology, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
- German Center for Diabetes Research (DZD), Neuherberg, Germany
| | - Xiaohui Zhuo
- Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Barbara Bardenheier
- Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Hui Shao
- Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Michael Laxy
- German Center for Diabetes Research (DZD), Neuherberg, Germany
- Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Institute of Health Economics and Health Care Management, Neuherberg, Germany
| | - Andrea Icks
- German Center for Diabetes Research (DZD), Neuherberg, Germany
- Institute of Health Services Research and Health Economics, German Diabetes Centre, Leibniz-Centre for Diabetes Research, Düsseldorf, Germany
- Institute of Health Services Research and Health Economics, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Ping Zhang
- Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Edward W Gregg
- Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Matthias B Schulze
- Department of Molecular Epidemiology, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany.
- German Center for Diabetes Research (DZD), Neuherberg, Germany.
- Institute of Nutritional Sciences, University of Potsdam, Potsdam, Germany.
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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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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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Sturgiss EA, van Weel C, Ball L, Jansen S, Douglas K. Obesity management in Australian primary care: where has the general practitioner gone? Aust J Prim Health 2016; 22:473-476. [DOI: 10.1071/py16074] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 09/24/2016] [Indexed: 11/23/2022]
Abstract
Obesity is a chronic condition with significant health and economic consequences that requires more effective management in Australia. General practitioners (GPs) currently act as care co-ordinators in line with national guidelines for overweight and obesity. Australian patients indicate that they would appreciate more involvement from their GP in the management of obesity, and this is in line with international findings. Not all patients have access to specialist obesity services or affordable allied health care because of location, cost and time, particularly in rural and remote areas where there is a greater prevalence of obesity. Empowering GPs to use their skills as expert generalists to manage obesity is an option that should be explored to improve access for all individuals. GPs will require evidence-based tools to assist them in structuring obesity management within their own general practice environment.
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Memish ZA, Chang JL, Saeedi MY, Al Hamid MA, Abid O, Ali MK. Screening for Type 2 Diabetes and Dysglycemia in Saudi Arabia: Development and Validation of Risk Scores. Diabetes Technol Ther 2015; 17:693-700. [PMID: 26154413 DOI: 10.1089/dia.2014.0267] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The prevalence of type 2 diabetes in Saudi Arabia is the highest worldwide after excluding small island nations. We developed and validated a noninvasive screening test based on demographic and clinical data for identifying adults with undiagnosed diabetes and dysglycemia in Saudi Arabia. RESEARCH DESIGN AND METHODS Data from 1,485 nonpregnant Saudi adults ≥20 years of age without a current diagnosis of diabetes were obtained from urban and rural primary healthcare centers in 2009. Clinical and demographic data were obtained through physician-administered interviews. Oral glucose tolerance test data were used to define diabetes (fasting plasma glucose ≥7.0 mmol/L or 2-h post-load glucose ≥11.1 mmol/L) and dysglycemia (fasting plasma glucose ≥5.6 mmol/L or 2-h post-load glucose ≥7.8 mmol/L). Predictive models were developed using data from 1,435 individuals. Multivariable logistic regression and receiver operating characteristic curves were used to develop and evaluate a separate risk score for both diabetes and dysglycemia. Scores were validated on a hold-out sample of 50 individuals. RESULTS The risk score for undiagnosed diabetes contained age, history of gestational diabetes, smoking, family history of diabetes, and central obesity with a sensitivity of 76.6% and a specificity of 52.1%. The dysglycemia risk score contained age, gestational diabetes, hypertension, and central obesity with a sensitivity of 71.2% and a specificity of 54.0%. All performed equally well, if not better, in the hold-out sample. CONCLUSIONS These risk scores can identify Saudi adults with undiagnosed diabetes or dysglycemia and should be validated in prospective studies.
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Affiliation(s)
- Ziad A Memish
- 1 Ministry of Health , Riyadh, Kingdom of Saudi Arabia
| | | | | | | | - Omer Abid
- 1 Ministry of Health , Riyadh, Kingdom of Saudi Arabia
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Ng TW, Khan AA, Meikle PJ. Investigating the pathogenesis and risk of Type 2 diabetes: clinical applications of metabolomics. ACTA ACUST UNITED AC 2012. [DOI: 10.2217/clp.12.75] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Abstract
The prevalence of type 2 diabetes is rapidly increasing. A strong rationale exists for identifying asymptomatic individuals who are at high risk or are likely to have diabetes. Screening programs may provide a conduit through which diabetes intervention may be targeted towards those who might benefit most. Diabetes screening could lessen disease burden in two ways. Firstly, by identifying people with undiagnosed diabetes, the burden of diabetes complications could be lessened through appropriate management of the condition. Secondly, by indentifying people at high risk of developing diabetes, and entering these people into diabetes prevention programs, the number of people with diabetes could be reduced. Screening for diabetes should ideally involve a non-invasive risk assessment followed by blood testing for those found to be at high risk. It should be noted that conclusive randomised controlled trial data to support the long-term health and economic impact of screening programs is lacking. The answers surrounding who and how we should screen for diabetes and the associated long term benefits will continue to evolve as the evidence base builds. As the use of screening for diabetes builds in popularity, it is essential that health care systems are sufficiently equipped to effectively manage the newly identified high risk and prevalent cases of type 2 diabetes.
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Chen L, Magliano DJ, Zimmet PZ. The worldwide epidemiology of type 2 diabetes mellitus--present and future perspectives. Nat Rev Endocrinol 2011; 8:228-36. [PMID: 22064493 DOI: 10.1038/nrendo.2011.183] [Citation(s) in RCA: 1373] [Impact Index Per Article: 105.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Over the past three decades, the number of people with diabetes mellitus has more than doubled globally, making it one of the most important public health challenges to all nations. Type 2 diabetes mellitus (T2DM) and prediabetes are increasingly observed among children, adolescents and younger adults. The causes of the epidemic of T2DM are embedded in a very complex group of genetic and epigenetic systems interacting within an equally complex societal framework that determines behavior and environmental influences. This complexity is reflected in the diverse topics discussed in this Review. In the past few years considerable emphasis has been placed on the effect of the intrauterine environment in the epidemic of T2DM, particularly in the early onset of T2DM and obesity. Prevention of T2DM is a 'whole-of-life' task and requires an integrated approach operating from the origin of the disease. Future research is necessary to better understand the potential role of remaining factors, such as genetic predisposition and maternal environment, to help shape prevention programs. The potential effect on global diabetes surveillance of using HbA(1c) rather than glucose values in the diagnosis of T2DM is also discussed.
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Affiliation(s)
- Lei Chen
- Baker IDI Heart and Diabetes Institute, 99 Commercial Road, Melbourne, VIC 3004, Australia
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