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The Cost of Type 2 Diabetes Screening in the USA

The Cost of Type 2 Diabetes Screening in the USA. Michael M. Engelgau Division of Diabetes Translation US Centers for Disease Control and Prevention (CDC). Symposium on Diabetes Economics São Paulo, Brazil, 27 September 2004.

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The Cost of Type 2 Diabetes Screening in the USA

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  1. The Cost of Type 2 Diabetes Screening in the USA Michael M. Engelgau Division of Diabetes Translation US Centers for Disease Control and Prevention (CDC) Symposium on Diabetes Economics São Paulo, Brazil, 27 September 2004

  2. Five Countries in the WHO Americas Region with the Largest Number of persons with Diabetes in 2000 USA Brazil Mexico Canada Argentina Number of persons with diabetes (millions) Source: WHO, 2004.

  3. Percent Increase in the Number of Persons with Diabetes from 2000 to 2030 among Five Countries with the Largest 2000 Diabetes Populations in the WHO Americas Region USA Brazil Mexico Canada Argentina Percent

  4. Criteria to Screen for Undiagnosed DM • Burden • Natural history • “Preclinical” detectable phase • Tests that can detect • Early treatment better • HC system can handle the cost and pt load • Integration into routine care *Engelgau et al., Diabetes Care 2000.

  5. So, how does screening fit into our control efforts … or does it?

  6. Does economic information help? • Rational for economic analyses • resources are limited • choices must be made

  7. What are the benefits of screening? • No RCT of benefit • Used disease models to study • Benefits • Costs • Determine cost effectiveness • Comparison groups • No screening • Universal opportunistic screening • Targeted at persons with HTN Hoerger TJ et al., Ann Intern Med 2004; 2004: 689-99.

  8. Cost-Effectiveness Study • Markov model • Primary-care population in US attending clinic • Assumptions • Onset to clinical diagnosis 10 years • Onset to screen diagnosis 5 years • After diagnosis • UKPDS benefits • Hypertension Optimal Treatment (HOT) trial • US costs 1997 dollars • Societal perspective • Lifetime horizon • Discount rate 3% Hoerger TJ et al., Ann Intern Med 2004; 140: 689-99.

  9. Assumptions for Screening Model Treatment of diabetes Screened and diagnosed Onset of diabetes Treatment of diabetes Clinical diagnosis t=0 t=5 t=10 Hoerger TJ et al., Ann Intern Med 2004; 140: 689-99.

  10. Macrovascular Complications Coronary Heart Disease Angina Normal CHD CA/MI Death History of CA/MI Stroke Within Year History of Stroke Normal Death Stroke

  11. What are the outcomes? • Life-years Number of addition years of survival • Quality-adjusted life years (QALYs) Number of additional years of survival adjusted by the quality of those extra years

  12. Results - Benefits • Example: 55-year-old (onset at age 50) per case detected • Comparison Lifetime cumulative Benefits • incidence (%) • ESRD CHD Life-yrs QALYs • Targeted 6.4 27.4 19.2 13.4 • None 6.5 29.9 18.9 13.2 • Effect -0.1 -2.5 0.3 0.2 • Universal 6.0 31.6 19.1 13.4 • None 6.2 32.7 18.9 13.3 • Effect -0.2 -1.1 0.2 0.1 Hoerger TJ et al., Ann Intern Med 2004;140: 689-99.

  13. Results - Costs • 55-year-old cohort (per person eligible for screening) • Comparison Lifetime time cost (US$) • Treatment Complications Total • Targeted 2408 1859 4267 • None 1799 1884 3683 • Effect 609 -25 584 • Universal 1796 1529 3351 • None 1320 1552 2872 • Effect 476 -23 479 Hoerger TJ et al., Ann Intern Med 2004;140:.689-99.

  14. What is cost effective? • Societal concept • Dependent on: Country Region Culture • Developed country perspective here

  15. What are the thresholds for good value? • Societal judgement and is not absolute • Expert panels in developed countries suggest: • <$20,000/QALY ready uptake • $20-100,000/QALY consider • >$100,000/QALY less attractive

  16. Cost/ QALY of Target and Universal Screening versus No Screening(55-year-old cohort) Strategy Hoerger TJ et al., Ann Intern Med 2004; 140: 689-99.

  17. Cost/ QALY of Targeted Screening versus No Screening (by age) Strategy Hoerger TJ et al., Ann Intern Med 2004; 140: 689-99.

  18. Cost/ QALY of Targeted versus Universal Screening (55-year-old cohort) Strategy Hoerger TJ et al., Ann Intern Med 2004; 140: 689-99.

  19. Results • Targeted screening in range to be considered • Universal compared to targeted not attractive • Screening was never cost-saving over lifetime • CE more favorable for older persons Hoerger TJ et al., Ann Intern Med 2004; 140: 689-99.

  20. Implications • Useful information to aid decision • Need to consider local setting and priorities • Other interventions for treating persons with known diabetes tend to be more favorable from a cost-effective perspective

  21. Cost/ QALY Lifetime Follow-Up(US cohort >=25 years) Glycemia Hypertension Lipid Intervention type CDC JAMA 2002

  22. Implications • Also consider • ASA treatment • Influenza and pneumococcal vaccines • Others

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