Strategies for Identifying Diabetes in Adolescents
A study investigating the cost effectiveness of diabetes mellitus screening strategies for children found that the cost per case was extremely high for all screening options; however, researchers noted that screening could be more cost effective if dysglycemia was considered as a screening outcome. The findings from the cost simulation study were reported in JAMA Pediatrics [2013;167(1):32-39].
Childhood obesity is a growing concern in the United States and it has been estimated by the Centers for Disease Control and Prevention that as many as 2.5 million adolescents could quality for diabetes mellitus screening. While previous research has investigated the cost effectiveness of screening strategies for identifying adults with diabetes and dysglycemia, little research has been done on the cost effectiveness of screening options for children.
The American Diabetes Association recommends using the hemoglobin A1C (HbA1c) test to identify children or adults with diabetes or prediabetes; however, in this study, researchers examined the costs, effectiveness, and efficiency of multiple diabetes screening options for children 10 to 17 years of age using test performance from a pediatric cohort and cost data from Medicare and the US Bureau of Labor Statistics.
The study's base case was determined using national estimates and assumed a 16% prevalence of dysglycemia and a 0.02% prevalence of diabetes among a hypothetical cohort of 2.5 million obese or overweight children in the United States. This gave researchers a base case of 500 adolescents with diabetes and 400,000 adolescents with dysglycemia.
To identify diabetes, researchers evaluated the 2-hour oral glucose tolerance test (OGTT), which required no additional confirmation screening. They also evaluated the following 3 HbA1C thresholds: 6.5%, 5.7%, and 5.5%. These strategies were considered a 2-step process because researchers assumed those that had a positive result with an HbA1C screening would also have a 2-hour OGTT to confirm the results.
To identify prediabetes, researchers evaluated the 2-hour OGTT, again assuming this screening to be a 1-step process, along with the following 2-step screening methods: HbA1C at thresholds of 5.5%, 5.7%, and 6.5%; random glucose test results at thresholds of 100 mg/dL and 110 mg/dL; and a 1-hour glucose challenge test (GCT) at thresholds of 110 mg/dL and 120 mg/dL.
The primary outcome measures of the study were the effectiveness, total costs, and efficiency of each screening strategy.
The cost-per-case figures were significantly reduced when researchers assessed the cost effectiveness of the screening methods for identifying dysglycemia. Researchers found that the 2-hour OGTT had the lowest cost-per-case of $390. The screening strategies with the highest cost-per-case figures were the HbA1C strategies with thresholds at the 5.7% and 6.5% levels, where the cost-per-case amounts ranged from $938 to $3370. The other strategies, including the random glucose test with a threshold of
100 mg/dL, the 1-hour GCT with a threshold of 110 mg/dL, and the HbA1C strategy with a threshold of 5.5%, fell in the middle with cost-per-case values of $498, $571, and $763, respectively.
In terms of effectiveness, the 2-hour OGTT was once again found to be the most effective (100%), followed by the 1-hour GCT threshold of 110 mg/dL (63%) and the random glucose threshold of
100 mg/dL (55%). The HbA1C strategies at thresholds of 5.5%, 5.7%, and 6.5% had the lowest effectiveness with values of 45%, 32%, and 7%, respectively.
According to researchers, some of the limitations of the study included only assessing a one-time screening of the pediatric population, only using Medicare to determine costs, and not including costs associated with treatment of the disease.
