How should developing countries manage diabetes?
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Cost of Illness↗
Biomedical subjects
Michael Engelgau
Publications and source records attributed to Michael Engelgau.
A national progress report on diabetes: successes and challenges.
Over the last few decades, numerous public health agencies and other private and public organizations have sought to prevent and delay the disabling complications of diabetes by increasing the use of preventive care practices and reducing risk factors for complications among people with diabetes. Now, federal diabetes surveillance activities are yielding encouraging reports that progress is being made in increasing the use of preventive care practices, reducing risk factors for complications, and preventing or delaying diabetes complications. However, although several gains have been noted, levels of preventive care practices remain suboptimal, risk factors for diabetes complications are too prevalent, and diabetes complications are too pervasive. Furthermore, with compelling evidence that the onset of diabetes can be prevented or delayed among adults at high risk, prevention of diabetes has become a major new challenge. Additional efforts are needed to address the growing problems of obesity and physical inactivity, to identify the most efficacious and cost-effective prevention strategies and interventions, and to implement surveillance activities that allow us to gauge our success. Although progress has been made against diabetes complications, the current epidemic of diabetes increases the urgency of primary prevention efforts.
Aged↗
Screening for type 2 diabetes mellitus: a cost-effectiveness analysis.
BACKGROUND: No randomized, controlled trial of screening for diabetes has been conducted. In the absence of direct evidence, cost-effectiveness models may provide guidance about preferred screening strategies. OBJECTIVE: To estimate the incremental cost-effectiveness of 2 diabetes screening strategies: screening targeted to people with hypertension and universal screening. DESIGN: Markov model. DATA SOURCES: United Kingdom Prospective Diabetes Study, Hypertension Optimal Treatment trial, and recent cost data. TARGET POPULATION: General primary care population in the United States. TIME HORIZON: Lifetime. PERSPECTIVE: Health care system. INTERVENTIONS: Diabetes screening targeted to people with hypertension and universal screening. OUTCOME MEASURES: Cost per quality-adjusted life-year (QALY) gained. Costs (in 1997 U.S. dollars) and QALYs discounted at a 3% annual rate. RESULTS OF BASE-CASE ANALYSIS: At all ages, incremental cost-effectiveness ratios were more favorable for screening targeted to people with hypertension than for universal screening. For example, at age 55 years, the cost per QALY for targeted screening compared with no screening was 34,375 dollars, whereas the cost per QALY for universal screening compared with targeted screening was 360,966 dollars. Screening was more cost-effective for ages 55 to 75 years than for younger ages. RESULTS OF SENSITIVITY ANALYSIS: In single-way and probabilistic sensitivity analyses, findings were robust to therapy costs, screening costs, screening lead time, reduced effectiveness of intensive antihypertensive therapy, and increased relative risk reduction for stroke attributable to intensive hypertension control. LIMITATIONS: We did not consider screening targeted to persons with dyslipidemia, and we used studies of people whose diabetes was detected clinically to estimate screening benefits. CONCLUSIONS: Diabetes screening targeted to people with hypertension is more cost-effective than universal screening. The most cost-effective strategy is targeted screening at age 55 to 75 years.
Adult↗
Review of the performance of methods to identify diabetes cases among vital statistics, administrative, and survey data.
PURPOSE: The ability to identify prevalent cases of diagnosed diabetes is crucial to monitoring preventative care practices and health outcomes among persons with diagnosed diabetes. METHODS: We conducted a comprehensive literature review to assess and summarize the validity of various strategies for identifying individuals with diagnosed diabetes and to examine the factors influencing the validity of these strategies. RESULTS: We found that studies using either administrative data or survey data were both adequately sensitive (i.e., identified the majority of cases of diagnosed diabetes) and highly specific (i.e., did not identify the individuals as having diabetes if they did not). In contrast, studies based on cause-of-death data from death certificates were not sensitive, failing to identify about 60% of decedents with diabetes and in most of these studies, researchers did not report specificity or positive predictive value. CONCLUSIONS: Surveillance is critical for tracking trends in diabetes and targeting diabetes prevention efforts. Several approaches can provide valuable data, although each has limitations. By understanding the limitations of the data, investigators will be able to estimate diabetes prevalence and improve surveillance of diabetes in the population.
Databases, Factual↗
Prevalence of lower-extremity disease in the US adult population >=40 years of age with and without diabetes: 1999-2000 national health and nutrition examination survey.
OBJECTIVE: Although lower-extremity disease (LED), which includes lower-extremity peripheral arterial disease (PAD) and peripheral neuropathy (PN), is disabling and costly, no nationally representative estimates of its prevalence exist. The aim of this study was to examine the prevalence of lower-extremity PAD, PN, and overall LED in the overall U.S. population and among those with and without diagnosed diabetes. RESEARCH DESIGN AND METHODS: The analysis consisted of data for 2873 men and women aged >or=40 years, including 419 with diagnosed diabetes, from the 1999-2000 National Health and Nutrition Examination Survey. The main outcome measures consisted of the prevalence of lower-extremity PAD (defined as ankle-brachial index <0.9), PN (defined as >or=1 insensate area based on monofilament testing), and of any LED (defined as either PAD, PN, or history of foot ulcer or lower-extremity amputations). RESULTS: Of the U.S. population aged >or=40 years, 4.5% (95% CI 3.4-5.6) have lower-extremity PAD, 14.8% (12.8-16.8) have PN, and 18.7% (15.9-21.4) have any LED. Prevalence of PAD, PN, and overall LED increases steeply with age and is higher (P < 0.05) in non-Hispanic blacks and Mexican Americans than non-Hispanic whites. The prevalence of LEDs is approximately twice as high for individuals with diagnosed diabetes (PAD 9.5% [5.5-13.4]; PN 28.5% [22.0-35.1]; any LED 30.2% [22.1-38.3]) as the overall population. CONCLUSIONS: LED is common in the U.S. and twice as high among individuals with diagnosed diabetes. These conditions disproportionately affect the elderly, non-Hispanic blacks, and Mexican Americans.
Adult↗
Screening for diabetes in an African-American community: the Project DIRECT experience.
AIM: To report the results of a community-based screening program associated with Project DIRECT, a multiyear diabetes mellitus prevention and control project targeting African-American residents of southeast Raleigh, NC. METHODS: Between December 1996 and June 1999, 183 screening events took place in community settings. Screening was by capillary glucose concentration. Participants with a positive screen were referred for confirmatory testing and physician follow-up. MAIN RESULTS: Risk factors for diabetes were prevalent, including ethnic minority race (88.2%), obesity (45.6%), and family history of diabetes (41.7%). In all, 197 personshad an elevated screening result; the prevalence of diabetes in the screened population that underwent follow-up testiing was 1.7%. Despite persistent tracking efforts, 28% of the persons with a high screening test received no final diagnosis CONCLUSIONS: In this community-based screening program targeted to high-risk African Americans, risk factors for diabetes were common, but new cases of undiagnosed diabetes among participants were uncommon. Intensive follow-up for persons with high screening values is necessary but difficult to achieve. Our results support national recommendations against community-based screening; opportunistic screening for diabetes in clinical settings is likely a more effective use of resources.
Adult↗
Microalbuminuria in the US population: third National Health and Nutrition Examination Survey.
Microalbuminuria (MA) is associated with adverse health outcomes in diabetic and hypertensive adults. The prevalence and clinical significance of MA in nondiabetic populations is less clear. The purpose of this study was to generate national estimates of the prevalence of MA in the US population. Untimed urinary albumin concentrations (UACs) and creatinine concentrations were evaluated in a nationally representative sample of 22,244 participants aged 6 years and older. Persons with hematuria and menstruating or pregnant women were excluded from analysis. The percent prevalence of clinical proteinuria (UAC > or = 300 mg/L) was similar for males and females. However, the prevalence of MA (urinary albumin-creatinine ratio [ACR], 30 to 299 mg/g) was significantly lower in males (6.1%) compared with females (9.7%). MA prevalence was greater in children than young adults and increased continuously starting at 40 years of age. MA prevalence was greater in non-Hispanic blacks and Mexican Americans aged 40 to 79 years compared with similar-aged non-Hispanic whites. MA prevalence was 28.8% in persons with previously diagnosed diabetes, 16.0% in those with hypertension, and 5.1% in those without diabetes, hypertension, cardiovascular disease, or elevated serum creatinine levels. In adults aged 40+ years, after excluding persons with clinical proteinuria, albuminuria (defined as ACR > or = 30 mg/g) was independently associated with older age, non-Hispanic black and Mexican American ethnicity, diabetes, hypertension, and elevated serum creatinine concentration. MA is common, even among persons without diabetes or hypertension. Age, sex, race/ethnicity, and concomitant disease contribute to the variability of MA prevalence estimates.
Adolescent↗
Optimal allocation of resources across four interventions for type 2 diabetes.
BACKGROUND: Several interventions can be applied to prevent complications of type 2 diabetes. This article examines the optimal allocation of resources across 4 interventions to treat patients newly diagnosed with type 2 diabetes. The interventions are intensive glycemic control, intensified hypertension control, cholesterol reduction, and smoking cessation. METHODS: A linear programming model was designed to select sets of interventions to maximize quality-adjusted life years (QALYs), subject to varied budget and equity constraints. RESULTS: For no additional cost, approximately 211,000 QALYs can be gained over the lifetimes of all persons newly diagnosed with diabetes by implementing interventions rather than standard care. With increased availability of funds, additional health benefits can be gained but with diminishing marginal returns. The impact of equity constraints is extensive compared to the solution with the same intervention costs and no equity constraint. Under the conditions modeled, intensified hypertension control and smoking cessation interventions were provided most often, and intensive glycemic control and cholesterol reduction interventions were provided less often. CONCLUSIONS: A resource allocation model identifies trade-offs involved when imposing budget and equity constraints on care for individuals with newly diagnosed diabetes.
Adult↗