USPSTF Diabetes Screening Recommendations Are Cost-effective

Alicia Ault

June 20, 2016

NEW ORLEANS — The US Preventive Services Task Force (USPSTF) recommendation that overweight and obese adults aged 40 to 70 be screened for abnormal glucose levels is cost-effective, relative to no screening or the previous USPSTF guideline, according to a study presented here at the American Diabetes Association (ADA) 2016 Scientific Sessions.

The USPTF made the latest recommendation in October 2015, giving it a grade B for moderate evidence of benefit. Patients with abnormal glucose levels should be referred to programs that promote a healthy diet and physical activity, said the panel, which had previously advised in 2008 that only asymptomatic individuals with hypertension (blood pressure > 135/80 mm Hg) should be screened for abnormal blood glucose levels.

The new recommendation has policy implications "because under the Affordable Care Act, any preventive service that gets a grade A or B by the task force is then going to be covered by most health insurance plans, and most health insurance plans are going to cover it with no cost sharing," said Thomas J Hoerger, PhD, senior fellow in health economics and financing at RTI International, in Research Triangle Park, North Carolina, which conducts research for the US Centers for Disease Control and Prevention (CDC) and Center for Medicare and Medicaid Services.

Dr Hoerger found that screening overweight and obese individuals for abnormal glucose followed by lifestyle interventions or medical therapy is cost-effective but still involves a fairly high cost of about $29,000 per quality-adjusted life-year (QALY).

Screening will "have an effect on costs, but it looks to be of good value," he said.

Rozalina G McCoy, MD, an endocrinologist at the Mayo Clinic, Rochester, Minnesota, who chaired the session during which Dr Hoerger's analysis was presented, said that the USPSTF recommendation forces the question of whether, from a population perspective, it is worth "diagnosing diabetes earlier on in a large number of patients?"

Studies have shown that "informing patients that they have diabetes and sparking their lifestyle changes will reduce risk of progression to diabetes or progression of diabetes once they have it," she told Medscape Medical News.

Overall, 62% of Population Eligible to Be Screened

Dr Hoerger and colleagues used the diabetes cost-effectiveness model of the CDC to estimate costs and cost-effectiveness of the newest screening recommendation.

Researchers assumed that screening will detect previously undiagnosed individuals, that people with diabetes will advance along five disease pathways (nephropathy, neuropathy, retinopathy, coronary heart disease, and stroke), that those with prediabetes will progress to diabetes, that patients with diabetes will be offered standard treatment and those with prediabetes will be offered lifestyle intervention.

Under the old USPSTF guideline, about 36% of those aged 35 to 74 years were eligible for screening. Following the new recommendation, 62% of that age group are eligible. Researchers said that under the old guideline, 6.2% of patients with prediabetes would transition to diabetes, while 5.3% will under the new guideline. A little over 5% of those with normal glucose levels will transition to prediabetes under the new recommendation, compared with 6% under the old guideline.

Researchers assumed that people would receive an annual HbA1c test, at a cost of $13.75 for the test plus $33.70 for physician time, and people would also receive a follow-up fasting plasma glucose test, at a cost of $5.56 for the test plus $3.00 for the blood draw.

The USPSTF recommends that individuals found to have impaired fasting glucose or impaired glucose tolerance should be referred for intensive behavioral-counseling interventions to promote a healthy diet and physical activity.

Dr Hoerger and colleagues assumed that about one-quarter of those screened would participate in such an intervention and patients would achieve an average weight loss of 4%. The risk of diabetes in these patients would be reduced by 32%, said Dr Hoerger.

The incremental cost-effectiveness ratio ― the difference in cost between two interventions divided by the difference in effect ― of screening was $29,337 per QALY for all ages under the new guideline, which was only slightly higher than the old guideline, which came to about $29,227 per QALY, Dr Hoerger noted.

More people would be screened under the new recommendation, which will cost more, but it will also increase the QALY for the population as a whole, he explained. And, assuming that the societal willingness to pay for QALYs is at least $50,000 per QALY, "the new recommendation is cost-effective relative to no screening or the old USPSTF recommendation," he explained.

Missed Opportunities

Dr McCoy said that the study was well designed but missed the opportunity to showcase the other positive effects lifestyle changes would have — for instance, lowering the risk of heart disease or stroke — that could make a stronger case for the cost-effectiveness of screening.

Even with trying to screen as many patients as possible, a large fraction of those with diabetes go undiagnosed, and only one in 10 of those with prediabetes are diagnosed, Dr McCoy told Medscape Medical News.

It may take a while for clinicians to adopt the USPSTF recommendation, but having new flags in health information systems could help speed that up, she concluded.

Dr Hoerger has reported no relevant financial relationships. Dr McCoy receives research support from the Mayo Clinic Kern Center for the Science of Health Care Delivery.

American Diabetes Association (ADA) 2016 Scientific Sessions; June 14, 2016; New Orleans, Louisiana. Abstract 353-OR

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