Publications and Products
The Economics of Diabetes Mellitus:
An Annotated Bibliography
TYPES
OF INTERVENTION
Diabetes
in Pregnancy
Gestational
Diabetes
120
TITLE:
Capillary Blood Glucose Screening for Gestational Diabetes: A Preliminary
Investigation. Landon, M.B.; Cembrowski, G.S.; Gabbe, S.G. American
Journal of Obstetrics and Gynecology. 155(4): 717-721. October 1986.
OBJECTIVE:
To evaluate the utility of capillary blood glucose measurement using a
reflectance meter as an outpatient screening tool for gestational diabetes.
CATEGORY:
Diabetes in pregnancy.
Type of
Study: Patient screening.
Methodology: Cost analysis.
Perspective: Health care system.
CONCLUSION:
Capillary blood glucose evaluation using a reflectance meter can provide
accurate outpatient screening for gestational diabetes with significant
cost savings over laboratory plasma assays.
RECOMMENDATION:
None.
ABSTRACT:
The authors screened 125 consecutive pregnant women in a high-risk practice
in a university hospital in Philadelphia, Pennsylvania. All the women
underwent a standard 50 g glucose challenge at 26 to 28 gestational weeks.
Capillary glucose values obtained with the use of a reflectance meter
were highly correlated with plasma venous values obtained by the central
laboratory, but mean capillary values were significantly higher (136.35
versus 111.74 mg/dL, p < 0.001) with the reflectance meter. The authors
found that a capillary value of 160 mg/dL was the optimal reference point;
its sensitivity and specificity were 93 percent and 96 percent, respectively,
for an abnormal test of venous plasma ($ 135 mg/dL). Costs of screening
1,000 patients were estimated to be $5,900 for the laboratory plasma study
and $1,034 for the capillary reflectance meter assay, with the latter
costs including 32 additional glucose tolerance tests at $12 each because
of a 3.2 percent false-positive rate. The potential cost savings associated
with capillary blood glucose screening combined with its high efficiency
make it an economically viable alternative to laboratory plasma assays
for the detection of gestational diabetes. 2 figures, 2 tables, 16 references.
121
TITLE:
Capillary Glucose Determination in the Screening of Gestational Diabetes.
Meriggi, E.; Trossarelli, G.F.; Carta, Q.; Menato, G.; Porta, M.A.; Bordon,
R.; Gagliardi, L. Diabetes Research and Clinical Practice. 5(1):
55-61. May 19, 1988.
OBJECTIVE:
To determine a threshold for glucose challenge test positivity using capillary
blood to facilitate use of a reflectance meter in gestational diabetes
screening; to verify a plasma glucose threshold for glucose challenge
test positivity; and to determine the differences and correlations between
glucose values obtained from plasma and capillary blood with a reflectance
meter during a glucose challenge test.
CATEGORY:
Diabetes in pregnancy.
Type of
Study: Patient screening.
Methodology: Statistical analysis.
Perspective: Health care system.
CONCLUSION:
A plasma glucose value of 135 mg/dL and a capillary value of 155 mg/dL
represent optimal cutoff points for recommending a diagnostic glucose
tolerance test.
RECOMMENDATION:
The simplicity, precision, and high efficiency of the reflectance meter
make it suitable for screening for gestational diabetes in all pregnant
women.
ABSTRACT:
Paired capillary-venous blood samples were obtained from 418 pregnant
women, aged 25 years or older with or without risk factors, who underwent
an oral glucose challenge test (GCT) to screen for gestational diabetes.
Plasma glucose was measured by the glucose oxidase method; capillary glucose,
by a Reflocheck glucose strip and a Reflocheck reflectance meter (both
from Boehringer Mannheim Diagnostic, Inc.). The relationship between capillary
and plasma glucose concentrations was investigated to establish a capillary
GCT threshold. The receiver operator characteristic curve technique provided
a quantitative method for determining cutoff points and the level of efficacy
to be expected in detecting gestational diabetes. A plasma glucose value
of 135 mg/dL and a capillary value of 155 mg/dL were found to represent
optimal cutoff points for recommending the oral glucose tolerance test.
Values of various plasma thresholds and those of corresponding capillary
thresholds (20 mg/dL higher) were similar in sensitivity, specificity,
and predictive values. The differences between mean values of plasma and
capillary glucose determinations fasting and 1 hour after glucose load
were 10-12 mg/dL and 22-24 mg/dL, respectively. The authors recommend
early screening (at 12-16 weeks) in cases with risk factors because one-third
of glucose tolerance test positive cases can be diagnosed and treated.
These investigators believe the reflectance meter has advantages over
laboratory enzymatic techniques in the screening of gestational diabetes.
3 figures, 3 tables, 20 references.
122
TITLE:
Clinical Experience with a Screening Program for Gestational Diabetes.
Lavin, J.; Barden, T.; Miodovnik, M. American Journal of Obstetrics
and Gynecology. 141(5): 491-494. November 1981.
OBJECTIVE:
To evaluate the cost and effects of a screening program for gestational
diabetes in a large population of women attending a prenatal clinic at
a university hospital.
CATEGORY:
Diabetes in pregnancy.
Type of
Study: Patient screening.
Methodology: Cost analysis.
Perspective: Health care system.
CONCLUSION:
The cost per case of gestational diabetes detected was $328.96.
RECOMMENDATION:
Cost-benefit analyses should be included in determinations of the sensitivity
and specificity of screening tests for gestational diabetes and comparisons
of perinatal morbidity and mortality in screened and unscreened populations.
ABSTRACT:
The authors determined the cost of screening for gestational diabetes
in 2,077 pregnant women without diabetes attending a university prenatal
clinic in Cincinnati over a 2-year period. Participants were divided into
group 1 (959 women who presented with historical or clinical risk factors
for gestational diabetes) and group 2 (1,118 patients without risk factors).
Patients in group 1 underwent a glucose challenge test at their initial
visit; an oral glucose tolerance test was performed if the glucose challenge
test was abnormal. Glucose challenge and glucose tolerance tests were
repeated at 28 weeks if the patient had an initially normal glucose challenge
test. Group 2 patients underwent a glucose challenge test at 28 to 32
weeks; a glucose tolerance test was performed if the glucose challenge
test was abnormal. Direct costs of the screening program were estimated
by proration of component costs. The incidence of abnormal glucose challenge
test and abnormal glucose tolerance test results was not statistically
different for the two groups. Of the total population, 137 participants
(6.6 percent) had an abnormal glucose challenge test and 30 participants
(1.4 percent) had an abnormal glucose tolerance test. The total estimated
cost for the screening program was $9,900, including $5,700 for serum
glucose determination, $1,300 for glucose challenge test and glucose tolerance
test solutions, and $2,900 for the phlebotomist's salary. The cost per
patient screened was $4.75 and the cost per case of gestational diabetes
detected was $328.96. These costs are marginally understated. The study
confirms the feasibility of routine screening for abnormal carbohydrate
metabolism in pregnancy in large populations. 4 tables, 16 references.
123
TITLE:
Cost Efficacy of Routine Screening for Diabetes in Pregnancy: 1-h versus
2-h Specimen. Weiner, C.P.; Fraser, M.M.; Burns, J.M.; Schnoor, D.; Herrig,
J.; Whitaker, L.A. Diabetes Care. 9(3): 255-259. May-June 1986.
OBJECTIVE:
To compare the specificity and costs of 1-hour and 2-hour oral glucose
challenge testing to screen patients for gestational diabetes mellitus.
CATEGORY:
Diabetes in pregnancy.
Type of
Study: Patient screening.
Methodology: Cost analysis.
Perspective: Health care system.
CONCLUSION:
The 2-hour glucose challenge testing was more sensitive and cost effective
than the 1-hour screening test.
RECOMMENDATION:
Screening for gestational diabetes on the basis of past medical history
should be abandoned, and all pregnant women should undergo oral glucose
challenge screening.
ABSTRACT:
This study at the University of Iowa Hospitals and Clinics sought to determine
whether the specificity of the glucose challenge test for diabetes screening
during pregnancy could be increased by using a 2-hour rather than a 1-hour
glucose challenge. Plasma glucose concentrations were measured in 790
women 1 hour after challenge (Trutol, Monoject Scientific, 50 g): all
the women were asked to give a 2-hour blood sample; 342 complied. Abnormal
1-hour glucose challenge tests (above 139 mg/dL) prompted standard
oral glucose tolerance tests. Costs per glucose challenge test and oral
glucose tolerance test were $7.25 and $64.00, respectively. Of 1-hour
glucose challenge tests, 24.3 percent were elevated; 2-hour glucose
challenge tests exceeded 115 and 117 mg/dL in 20.5 and 16.3 percent of
women, respectively. Oral glucose tolerance tests were positive in 10.8
percent of women with an elevated 1-hour glucose challenge test, in 13.0
percent of those with a 2-hour glucose challenge test above 115 mg/dL,
and in 16.4 percent of women in which the latter test exceeded 117 mg/dL.
All women with abnormal 1-hour glucose challenge tests and positive
oral glucose tolerance tests had abnormal ($ 118 mg/dL) 2-hour glucose
challenge tests; 28 women had abnormal 2-hour but normal 1-hour glucose
challenge tests. Thirty-four percent fewer oral glucose tolerance tests
were needed based on 2-hour (versus 1-hour) glucose challenge tests (p
< .05), and the cost of identifying a case of gestational diabetes
mellitus would have dropped 24 percent (from $866 to $662) if the 2-hour
test were used. With risk-factor screening, 77 percent of gestational
diabetes mellitus cases would have been missed, and the cost per case
would have been $1,805. In a second group (n = 190), the cost per case
of gestational diabetes mellitus would have declined by 32 percent if
the 2-hour screen had been used. 6 tables, 9 references.
124
TITLE:
Cost of Non-Insulin-Dependent Diabetes in Women with a History of Gestational
Diabetes: Implications for Prevention. Gregory, K.D.; Kjos, S.L.; Peters,
R.K. Obstetrics and Gynecology. 81(5 Pt 1): 782-786. May 1993.
OBJECTIVE:
To estimate the potential savings in health care costs that would result
from primary prevention programs targeted at women with gestational diabetes.
CATEGORY:
Diabetes in pregnancy.
Type of
Study: Epidemiological cohort model.
Methodology: Cost-benefit analysis.
Perspective: Health care system.
CONCLUSION:
Preventive therapy may result in a net savings over 10 years of $32 million
to $331 million, depending on the assumed percentage reduction in diabetes
incidence.
RECOMMENDATION:
A prospective prevention trial should be conducted to evaluate the potential
health and cost benefits of ongoing postpartum education and cognitive
reinforcement of lifestyle changes adopted during pregnancy in women with
gestational diabetes.
ABSTRACT:
The authors estimated potential health care cost savings over 10 years
from a hypothetical primary prevention program aimed at women with gestational
diabetes. An economic model was developed based on a series of assumptions
about a national cohort: 3 percent of all live births in 1990 were complicated
by gestational diabetes (resulting in 125,370 cases of gestational diabetes);
50 percent of the women with gestational diabetes (62,685) would develop
type 2 diabetes; and the rate of progression to diabetes would be constant
(6.7 percent) over a 10-year period. Average annual health care costs
per case for women with diabetes were estimated at $2,834 (in 1990 dollars),
cumulative net costs for caring for all women who developed diabetes over
10 years were estimated at $818 million. Calculations discounted future
dollars by 5 percent per year. New costs incurred for preventive counseling
and evaluation were estimated at $39.8 million (in 1990 dollars) for the
entire cohort over 10 years (these costs included serum glucose determinations
and dietary consultations). Net potential savings began to accrue if the
prevention program reduced the incidence of diabetes by 5 percent. Estimated
net savings for reductions in the incidence of gestational diabetes of
5, 10, 25, and 50 percent were $500,000, $31.9 million, $139.5 million,
and $331.4 million, respectively, over 10 years. Various limitations of
the analysis are discussed; for example, evidence suggests that conversion
to diabetes is not linear, occurring more often in the first 5 years after
pregnancy than the second 5 years. For another example, the Latina population
has a 6 percent rate of gestational diabetes and a higher rate of disease
progression. 3 tables, 17 references.
125
TITLE:
Cost-Effective Approach to Office Screening for Gestational Diabetes.
Teplick, F.B.; Lindenbaum, C.R.; Cohen, A.W. Journal of Perinatology.
10(3): 301-303. September 1990.
OBJECTIVE:
To examine the cost-effectiveness of outpatient office screening for gestational
diabetes using capillary blood measurements with a reflectance meter.
CATEGORY:
Diabetes in pregnancy.
Type of
Study: Patient screening.
Methodology: Cost-effectiveness analysis.
Perspective: Health care system.
CONCLUSION:
Use of a glucose reflectance meter offers an accurate, quick, cost-effective
approach to glucose screening for gestational diabetes.
RECOMMENDATION:
Providers of prenatal care should use screening programs like glucose
reflectance meters more readily for gestational diabetes, with the understanding
that cutoff values for each meter must be established for each facility.
ABSTRACT:
Over a 6-month period, 50 patients were screened for gestational diabetes
with a standard 50 g oral glucose load (Glucola) in the nonfasting state
at 27 to 28 weeks gestation. One hour later, a capillary blood specimen
was evaluated by means of an Accu-Check II (Boehringer-Mannheim, Indianapolis,
IN) reflectance meter; a venous sample was evaluated in a hospital laboratory.
Any patient with a serum glucose value greater than 130 mg/dL was scheduled
for a 3-hour glucose tolerance test. The authors found a significant correlation
between capillary blood glucose concentration and laboratory serum values
(r = 0.59). Using a reflectance meter cutoff value of greater than 160
mg/dL, the authors did not miss any patients who would have required a
3-hour glucose tolerance test via serum screening. The sensitivity and
specificity of this testing method were very good, and its negative predictive
value was 100 percent. The authors' findings suggest that by using the
glucose reflectance meter, 90 percent of patients can be screened without
laboratory studies, resulting in significant savings. In addition to the
cost savings, the immediate results (within 2 minutes) obtained by a reflectance
meter allow for prompt identification of an abnormal screen and timely
scheduling of the 3-hour glucose tolerance test. 1 figure, 1 table, 11
references.
126
TITLE:
Cost-Effective Criteria for Glucose Screening. Marquette, G.P.; Klein,V.R.;
Repke, J.T.; Niebyl, J.T. Obstetrics and Gynecology. 66(2): 181-184.
August 1985.
OBJECTIVE:
To identify a cost-effective method of screening for gestational diabetes
without decreasing sensitivity to a level substantially below that of
universal screening.
CATEGORY:
Diabetes in pregnancy.
Type of
Study: Patient screening.
Methodology: Cost-effectiveness analysis.
Perspective: Health care system.
CONCLUSION:
The cost of screening for gestational diabetes can be reduced without
substantially compromising sensitivity by restricting screening to patients
aged 24 years or older and using a glucose screening threshold of 150
mg/dL.
RECOMMENDATION:
Studies are needed to analyze the cost of additional days in the hospital
caused by maternal or neonatal morbidity secondary to undiagnosed gestational
diabetes.
ABSTRACT:
The authors conducted a cost-effectiveness analysis of screening criteria
for gestational diabetes on 1,012 unselected pregnant women registered
at Johns Hopkins Hospital who were between 26 and 30 weeks of gestation.
Direct medical costs included glucose tolerance tests and glucose screening.
Fasting patients were given a 50 g oral glucose load, followed by a 1-hour
plasma glucose test. If the glucose concentration was 130 mg/dL or greater,
a 3-hour oral glucose tolerance test was performed. A total of 24 women
(2.4 percent) were identified as having gestational diabetes; 21 of the
24 women were aged 24 or older with glucose concentrations of 150 mg/dL
or greater on screening. Increasing the glucose screen threshold from
130 to 150 mg/dL with universal screening caused the positive predictive
value to increase from 10 percent (24 of 235 patients) to 24 percent (23
of 96). Screening only patients aged 24 years or older and using the 130
mg/dL threshold had a positive predictive value of 14 percent (22 of 153).
Increasing the threshold to 150 mg/dL while still screening only women
aged 24 or older caused the positive predictive value to increase to 30
percent, with 21 of 24 cases of gestational diabetes identified. The cost
of the diagnosis in these latter patients was 40 percent of the cost of
diagnosis of universal screening using a 130 mg/dL threshold. 2 figures,
3 tables, 10 references.
127
TITLE:
First Prenatal Visit Glucose Screening. Hong, P.L.; Benjamin, F.; Deutsch,
S. American Journal of Perinatology. 6(4): 433-436. October 1989.
OBJECTIVE:
To determine the benefit of early glucose screening for gestational diabetes.
CATEGORY:
Diabetes in pregnancy.
Type of
Study: Patient management.
Methodology: Cost analysis.
Perspective: Health care system.
CONCLUSION:
Universal screening for gestational diabetes at first prenatal visit detected
a significant number of cases that would have been missed if current screening
recommendations were followed.
RECOMMENDATION:
Universal glucose screening for gestational diabetes at first prenatal
visit is recommended; minor increases in cost associated with universal
screening may be offset by potential savings from more timely initiation
of appropriate antepartum management.
ABSTRACT:
The authors evaluated the benefit of glucose screening at first prenatal
visit. Nine hundred and ninety-nine new obstetric patients at a New York
City hospital who had not been previously diagnosed with diabetes underwent
a glucose challenge test at their first prenatal visit, regardless of
gestational age. A total of 228 patients had a gestational age (in weeks)
of less than 14; 354, 14 to 23; 122, 24 to 28; and 295, greater than 28.
Follow-up oral glucose tolerance tests were performed for results of 130
mg/dL or higher. Data were subdivided by patient age in years (under 24,
24 and over, 25 and over, and 30 and over) to allow comparison with other
studies and current screening recommendations. Patients under 24 years
of age had a lower mean glucose screening value than older patients (106.1
mg/dL versus 117.4 mg/dL, p < 0.05), but 13 percent of cases of diagnosed
gestational diabetes occurred in this youngest group. One-third of the
diagnoses of gestational diabetes were for women screened in week 32 or
earlier. Total screening program costs were $7,130 for universal screening,
$4,041 for screening patients 25 years and over, and $2,286 for screening
patients 30 years and over; costs per diagnosed case of gestational diabetes
were $184 (universal), $122 (25 plus), and $120 (30 plus). The slightly
greater cost of universal screening for gestational diabetes would be
offset by potential savings from more timely initiation of appropriate
antepartum management. When the criterion for an abnormal glucose challenge
test was changed to $ 140 mg/dL, costs per diagnosed case dropped to $115,
$106, and $102. 8 tables, 16 references.
128
TITLE:
Screening for Gestational Diabetes. Zoller, D.P.; Jurica, J.V.; Gould,
S.H.; Weinstein-Mayer, S. The Journal of the American Board of Family
Practice. 1(2): 98100. April-June 1988.
OBJECTIVE:
To determine the validity of screening all pregnant women for gestational
diabetes mellitus (GDM); to determine the Cost-effectiveness of such a
program.
CATEGORY:
Diabetes in pregnancy.
Type of
Study: Patient screening.
Methodology: Cost analysis.
Perspective: Health care system.
CONCLUSION:
Universal screening of pregnant women for GDM was found to be simple and
cost effective. There was no difference between women with risk factors
and those without in rate of abnormal glucose tolerance.
RECOMMENDATION:
Because a history of risk factors for diabetes is an insensitive predictor
of GDM, it is necessary to screen all pregnant patients; a plasma glucose
concentration of 140 mg/dL on the glucose challenge test should be a minimum
criterion for proceeding to the glucose tolerance test.
ABSTRACT:
Three hundred sixty-three consecutive pregnant patients attending obstetrical
clinics at teaching hospitals of the University of Illinois College of
Medicine at Rockford underwent screening for GDM by a glucose challenge
test that measured plasma glucose 1 hour after they were fed 50 g of glucose.
Most of the women were between 24 and 28 weeks of gestation; their average
age was 21.3 years; and 41.9 percent were nulliparous. Those patients
with a plasma glucose greater than 140 mg/dL were given a standard 3hour
glucose tolerance test using 100 g of oral glucose to confirm GDM. Fifty-two
(14.3 percent) of the patients had abnormal glucose challenge tests. The
average cost per patient screened was $14.30, and the cost per case of
GDM diagnosed was $519. Patients with one or more risk factors (e.g.,
obesity, family history of diabetes, previous delivery of a macrosomic
infant) were compared with those without risk factors; there was no significant
difference between the two groups in percentage of abnormal glucose tolerance
tests (2.9 percent in the risk factor group; 2.7 percent in the other).
The authors concluded that all pregnant patients must be screened in order
to identify GDM. They noted that the risks associated with screening are
very low and that patients would not be inappropriately treated because
of false-positive tests, as all positive glucose challenge tests are followed
by a 3hour glucose tolerance test. 1 table, 26 references.
129
TITLE:
Screening for Gestational Diabetes: Analysis by Screening Criteria. Reed,
B. Journal of Family Practice. 19(6): 751-755. December 1984.
OBJECTIVE:
To review the appropriateness and cost-effectiveness of a 1-hour, 50 g
glucose screening test for gestational diabetes.
CATEGORY:
Diabetes in pregnancy.
Type of
Study: Patient screening.
Methodology: Cost-effectiveness analysis.
Perspective: Health care system.
CONCLUSION:
Screening for gestational diabetes is sensitive and cost effective.
RECOMMENDATION:
All pregnant women over age 25 years should be screened for gestational
diabetes with a 1-hour, 50 g glucose test.
ABSTRACT:
The author examined the cost-effectiveness of various approaches to screening
for gestational diabetes. The initial test consisted of measuring the
serum glucose level in a pregnant patient 1 hour after ingestion of 50
grams of glucose solution. Five protocol strategies were evaluated: (1)
glucose screening test for all patients, with an oral glucose tolerance
test for positive results; (2) glucose screening test only for patients
with risk factors, with oral glucose tolerance test for positive results;
(3) oral glucose tolerance test for patients with risk factors; (4) oral
glucose tolerance test for all patients; and (5) glucose screening test
for all patients over age 25 years, followed by an oral glucose tolerance
test if the result is positive. The costs for utilization of the screening
test were calculated using data from O'Sullivan et al. (1973) and current
local hospital charges. Costs for the glucose screening test and the oral
glucose tolerance test were assumed to be $10.15 and $24.40, respectively.
Cost per case of detected gestational diabetes ranged from $386.11 for
screening of all patients over age 25 to $976.00 for an oral glucose tolerance
test for all patients. Screening only patients with risk factors for gestational
diabetes was not cost effective, costing $683.18 per detected case and
missing many cases (60 percent rate of false negatives). Performing an
oral glucose tolerance test on all patients was the most accurate means
of detecting gestational diabetes (no false negatives) but also the most
costly. Screening with the glucose screening test for all pregnant women
over age 25 years followed by the oral glucose tolerance test when indicated
is the most cost-effective strategy; its false-negative rate in this analysis
was 24 percent. 2 tables, 17 references.
130
TITLE:
Screening for Gestational Diabetes: An Analysis of Health Benefits and
Costs. Everett, W.D. American Journal of Preventive Medicine. 5(1):
38-43. January-February 1989.
OBJECTIVE:
To determine the health benefits and costs of screening all pregnant women
for diabetes at 28 weeks of gestation.
CATEGORY:
Diabetes in pregnancy.
Type of
Study: Patient screening.
Methodology: Cost-benefit analysis.
Perspective: Health care system.
CONCLUSION:
The most cost-benefit outcome of screening all pregnant women for gestational
diabetes would be a decrease in perinatal mortality rates. The cost of
preventing cesarean section, death from macrosomia, and certain other
outcomes would be so great that a decision to screen should not be based
on trying to prevent these events.
RECOMMENDATION:
Further research that focuses on decreasing the cost of screening pregnant
women for gestational diabetes is needed because available data do not
clearly demonstrate a favorable cost-benefit ratio for universal screening.
ABSTRACT:
The current recommendation to screen all pregnant mothers for diabetes
at 28 weeks of gestation is examined, using known epidemiologic evidence
presented in the literature, to determine the cost benefit of averting
infant death, macrosomia, cesarean section, birth injury, shoulder dystocia,
and maternal death from cesarean section. The author concludes that screening
for and treating gestational diabetes may be beneficial, but data are
not sufficient to determine the full cost and benefits of universal screening.
Most of the benefit would come from a hoped-for decrease in the perinatal
mortality rate. Additional benefits such as a decrease in cesarean sections,
shoulder dystocia, or birth trauma would have a high cost per case presented.
Because of ethical considerations, a study of appropriate size to clarify
the issue of decreased perinatal mortality in treated compared with untreated
gestational diabetes is unlikely. The Centers for Disease Control recommends
that where cost and inconvenience make universal screening impractical,
women with any of the following risk factors should be screened: age 25
years or older, obesity, history of diabetes in a first-degree relative,
history of pregnancy with stillbirth or infant weighing over 9 pounds,
and history of congenital malformation in a previous child. 1 figure,
4 tables, 21 references.
131
TITLE:
Screening for Gestational Diabetes in a High-Risk Population. Massion,
C.; O'Connor, P.J.; Gorab, R.; Crabtree, B.F.; Nakamura, R.M.; Coulehan,
J.L. The Journal of Family Practice. 25(6): 569575. December 1987.
OBJECTIVE:
To evaluate the use of the glucose screening test in a well-defined primary
care population at high risk for gestational diabetes.
CATEGORY:
Diabetes in pregnancy.
Type of
Study: Patient screening.
Methodology: Cost-effectiveness analysis.
Perspective: Health care system.
CONCLUSION:
When several variables, including historical factors and the glucose screening
test result, were analyzed, only the test result was associated with the
risk of gestational diabetes.
RECOMMENDATION:
Universal screening for gestational diabetes should be conducted and oral
glucose tolerance tests should be performed when 1-hour blood glucose
concentrations are $ 130 mg/dL.
ABSTRACT:
A 50 g glucose load was administered to 181 pregnant, nonfasting Navajo
women during routine prenatal care between 28 and 32 weeks of gestation;
plasma glucose concentrations were determined 1 hour later. Patients with
a plasma glucose concentration of 130 mg/dL or greater were asked to return
for a 3hour oral glucose tolerance test to confirm a diagnosis of gestational
diabetes. The incidence of gestational diabetes in the study population
was 6.1 percent. Incidence of gestational diabetes was 10 percent (2 of
21) in patients whose screening result was 130 to 149 mg/dL; 39 percent
(9 of 23) in patients whose screening result was 150 mg/dL or greater.
The marginal cost for each case of gestational diabetes detected was $114
for universal screening with the 130 mg/dL as the test cutoff point (181
screening tests and 44 glucose tolerance tests to detect 11 cases of gestational
diabetes); for this approach, sensitivity approached 1.00, specificity
was 0.80, and positive predictive value was 0.25. For universal screening
with a threshold of 150 mg/dL, the marginal cost per case detected was
$106 (181 screening tests and 23 glucose tolerance tests to detect 9 cases
of gestational diabetes). Sensitivity decreased to 0.81, specificity was
0.58, and positive predictive value was 0.39. The small differences in
cost per case of gestational diabetes detected and the increased sensitivity
of the universal screening test with the 130 mg/dL threshold suggests
this approach is preferable to universal screening with a 150mg/dL threshold
or selective screening based on risk factors. This conclusion depends
on cost of screening and diagnostic tests, however. By logistic regression
analysis, the glucose test results were associated with risk of gestational
diabetes (p = 0.0004), but historical risk factors were not. 3 tables,
26 references.
132
TITLE:
Screening of High-Risk and General Populations for Gestational Diabetes:
Clinical Application and Cost Analysis. Lavin, J.P. Diabetes. 34
(Supplement 2): 24-27. June 1985.
OBJECTIVE:
To determine the feasibility and investigate the costs of universal screening
for abnormal carbohydrate metabolism in pregnancy in a prenatal clinic;
to detect the relative prevalence of gestational diabetes among populations
defined as high and low risk based on historic and clinical factors.
CATEGORY:
Diabetes in pregnancy.
Type of
Study: Patient screening.
Methodology: Cost analysis.
Perspective: Health care system.
CONCLUSION:
A significant number of women with gestational diabetes and their offspring
will be denied the benefits of improved care if screening is limited to
those with a high risk for gestational diabetes. Universal screening costs
compare favorably with those incurred for other screening tests for other
diseases during pregnancy.
RECOMMENDATION:
Greater standardization in protocols, presentation, and interpretation
of data will facilitate selection of an optimal protocol for screening
for gestational diabetes.
ABSTRACT:
Costs and outcomes of screening 2,077 pregnant women for gestational diabetes
were analyzed. The women were placed in either high- or low-risk groups,
depending on whether they had historic or clinical risk factors (Group
1) or none of these factors (Group 2). Group 1 included 959 women; Group
2 included 1,118 women. All women in Group 2 underwent an initial glucose
challenge test between 28 and 32 weeks of gestation, followed by an oral
glucose tolerance test if the glucose challenge test was abnormal. Those
with an abnormal glucose tolerance test were referred to the Pregnancy
Special Care Clinic. Group 1 women underwent a glucose challenge test
at their first antepartum visit; those with a normal result or a normal
glucose tolerance test after an abnormal glucose challenge test received
routine prenatal care until 28 weeks of gestation, when the testing sequence
was repeated. Fifty-seven women in Group 1 (5.9 percent) tested positive
on the initial glucose challenge test; 14 of these women (25 percent,
or 1.5 percent of the total group) also tested positive on the glucose
tolerance test. At week 28, 7.2 percent of these women tested positive
on the glucose challenge test, but none tested positive on the glucose
tolerance test. In Group 2, 6.1 percent of the women had a positive glucose
challenge test; 23 percent of these women (1.4 percent of the total group)
also tested positive on the glucose tolerance test. Differences between
the groups were not statistically significant. In all, 46.7 percent of
the cases of gestational diabetes were identified in women with risk factors,
and 53.3 percent were identified in women with no risk factors. The total
estimated direct cost for this screening program was $9,869. The cost
per patient screening was $4.75 and per case of gestational diabetes detected,
$328.96. Results support the concept of greater cost efficiency in universal
screening compared with screening only high-risk populations. 3 tables,
25 references.
133
TITLE:
Weight Excess Before Pregnancy: Complications and Cost. Galtier-Dereure,
F.; Montpeyroux, F.; Boulot, P.; Bringer, J.; Jaffiol, C. International
Journal of Obesity. 19(7): 443448. July 1995.
OBJECTIVE:
To study maternal and fetal complications, course of labor, and overall
cost of pregnancy care in relation to prepregnancy weight.
CATEGORY:
Diabetes in pregnancy.
Type of
Study: Patient management.
Methodology: Statistical analysis.
Perspective: Health care system.
CONCLUSION:
Hypertension, toxemia, gestational diabetes, insulin treatment, urinary
tract infections, and macrosomia were positively correlated with maternal
excess weight prior to pregnancy. Women who were overweight had longer
hospital stays and higher costs than normal-weight women.
RECOMMENDATION:
Because even moderate excess weight is a significant risk factor for obstetrical
complications, multidisciplinary management before birth is needed to
prevent maternal or fetal complications.
ABSTRACT:
Data concerning 112 deliveries at a hospital in Montpellier, France, among
89 overweight patients from 1980 to 1993 were reviewed and compared with
a control group of 54 normal-weight pregnant patients during the same
period. Exclusion criteria were hepatic, cardiac, or renal failure; previous
diabetes mellitus; height below 145 cm; and age under 18 years. Patients
were placed into four groups according to their pregravid body mass index
(BMI = kg/m2): normal weight (control group), 18 to 24.9; moderately overweight,
25 to 29.9; obese, 30 to 34.9; massively obese, 35 or higher. The authors
measured the incidence of maternal complications (e.g., hypertension,
gestational diabetes), complications of labor (e.g., macrosomia), and
duration of hospitalization. Dysfunctional uterine bleeding was more common
among obese patients. Hypertensive diseases and glucose tolerance abnormalities
were strongly correlated with overweight. The incidence of hypertension
increased even in moderately overweight patients (p = 0.018). The frequency
of gestational diabetes mellitus, insulin-treated gestational diabetes,
and toxemic syndrome was higher in the three overweight groups, but it
reached statistical significance only for the obese and massively obese.
Labor complications among obese women included cephalopelvic disproportion
(25 percent), fetal distress (21 percent), and stagnation of induced labor
(17 percent). There was a higher frequency of overall cesarean sections
(43 percent versus 9 percent, p = 0.002) and first cesarean sections (33
percent versus 7 percent, p = 0.006) in the massively obese. The mean
total duration of hospitalization was correlated with prepregnancy weight.
Overall cost (including the postpartum period) was more than three times
higher in massively obese than in normal weight patients (p = 0.0001).
In the normal-weight group, 9 percent of patients were hospitalized in
the antepartum period, versus 33 percent of overweight, 36 percent of
obese, and 66 percent of massively obese patients. 1 figure, 4 tables,
22 references.
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