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Publications and Products
The Economics of Diabetes Mellitus:
An Annotated Bibliography
TYPES
OF INTERVENTION
Primary
Intervention
Screening
for Impaired Glucose Tolerance (IGT)
1
TITLE:
Effectiveness of Screening for Diabetes. Gerken, K.L.; Van Lente, F. Archives
of Pathology and Laboratory Medicine. 114(2): 201-203. February 1990.
OBJECTIVE:
To evaluate the diagnostic yield from screening patients for diabetes
by measuring their fasting serum glucose and hemoglobin A1c levels during
routine health surveillance. To compare the oral glucose tolerance test
and repeat fasting glucose determination as a follow-up to screening.
CATEGORY:
Primary intervention.
Type of
Study: Retrospective.
Methodology: Cost-effectiveness analysis.
Perspective: Health care system.
CONCLUSION:
Oral glucose tolerance testing was as cost effective and more efficient
for diagnosing diabetes after an abnormal fasting serum glucose test than
were repeat fasting serum glucose determinations. Hemoglobin A1c did not
reliably predict impaired or diabetic glucose tolerance.
RECOMMENDATION:
If mass screening for diabetes is instituted, obligatory oral glucose
tolerance testing must be made part of the follow-up protocols for positive
findings on a fasting serum glucose test.
ABSTRACT:
The authors analyzed the effectiveness of screening for diabetes mellitus
in an executive health surveillance program by examining laboratory records
for 6,445 patient visits from 1985 to 1988. They retrospectively identified
336 persons with borderline high (6.6 to 7.6 mmol/L) or high (7.7 mmol/L
or higher) fasting serum glucose levels; 29 of these persons had no further
records, and 110 were known to have diabetes. Of the remainder, 61 had
a follow-up fasting serum glucose test and 33 had an oral glucose tolerance
test. Ninety-three persons had hemoglobin A1c (HbA1C) tested.
Among borderline high individuals, on repeat fasting serum glucose, 38
percent had levels of 6.1 mmol/L or less; 55 percent had 6.2 to 7.6 mmol/L;
and 7 percent had 7.7 mmol/L or greater. Comparable results for persons
with high initial fasting serum glucose were 14, 25, and 61 percent, respectively.
Follow-up oral glucose tolerance tests resulted in normal, impaired, and
diabetic glucose levels in 32, 40, and 28 percent of the borderline high
persons and 25, 0, and 75 percent of the persons with high values, respectively.
Significantly different levels of HbA1C (p < .01) were found
between the two groups of persons (borderline high and high), but only
3 percent of those with borderline high fasting serum glucose and only
64 percent of those with high fasting serum glucose had increased HbA1C.
From screening, 30 new cases of diabetes and 10 new cases of impaired
glucose tolerance were identified, a total of 40 (0.6 percent) of 6,445
patients screened. The overall rate of identification of abnormal serum
glucose was 0.6 percent. The cost per case found (based on Medicare reimbursement
rates) was $488.04 with repeat fasting serum glucose and an oral glucose
tolerance test and $484.54 with a follow-up oral glucose tolerance test
alone. The oral glucose tolerance test is as cost effective as repeat
fasting serum glucose with oral glucose tolerance testing as needed and
more diagnostically efficient than repeating that test Addition of HbA1C
increased cost to $522 and cannot be recommended. The oral glucose tolerance
test should be made obligatory to follow-up abnormal initial serum glucose
tests. 3 tables, 12 references.
2
TITLE:
Technical and Clinical Evaluation of Fructosamine Determination in Serum.
Desjarlais, F.; Comtois, R.; Beauregard, H.; Nguyen, M.; Letellier, G.
Clinical Biochemistry. 22(4): 329-335. August 1989.
OBJECTIVE:
To evaluate the effectiveness of a serum fructosamine (glycated serum
proteins) assay for diagnosis and follow-up of patients with diabetes;
to compare its effectiveness with a serum glycosylated hemoglobin measurement.
CATEGORY:
Primary intervention.
Type of
Study: Nonrandomized clinical trial.
Methodology: Cost-effectiveness analysis.
Perspective: Health care system.
CONCLUSION:
The serum fructosamine assay is simple, rapid, and cost efficient.
RECOMMENDATION:
The serum fructosamine assay should be a valuable addition to monitoring
glucose control in patients with diabetes.
ABSTRACT:
Researchers evaluated a serum fructosamine assay and compared the results
with those of glycosylated hemoglobin for diagnosing and managing diabetes.
Blood samples were drawn from 375 participants with or without diabetes
(total: 514 samples). The serum fructosamine assay was not significantly
affected by hemolysates, but high lipemia and addition of bilirubin decreased
and increased the values, respectively. In 48 normal participants, the
correlation between serum fructosamine and serum protein or serum albumin
was statistically significant, with a linear correlation of 0.809 and
0.746, respectively. Overall, the linear correlation between serum fructosamine
and glycosylated hemoglobin was 0.794; when fructosamine was corrected
for protein, the value was 0.838. Among 16 patients with diabetes hospitalized
to improve blood glucose control, the linear correlation of the percent
decrease for glycosylated hemoglobin and blood glucose was 0.28 (p >
0.05); for fructosamine and blood glucose, it was 0.64 (p < 0.01).
Using a fructosamine concentration cutoff of 2.70 mmol/L (the normal mean
plus two standard deviations), this test had a 96 percent specificity
and a 90 percent sensitivity for patients with overt diabetes but only
an 11 percent sensitivity for patients with diabetes by glucose tolerance
test but normal fasting glucose levels. When applied to gestational diabetes,
fructosamine had a specificity of 95 percent but a sensitivity of just
21 percent. Because the assay for fructosamine can be automated, it is
easy and fast to use and the average per-patient cost is $0.93, including
protein measurements. The glycosylated hemoglobin test is performed manually,
is difficult to interpret, and the per-patient cost is $6.15. The serum
fructosamine assay is simple, reliable, and economic for measuring ambient
glucose concentration in stable and unstable diabetes mellitus. It may
be useful in diagnosing diabetes when the fasting blood glucose exceeds
7.8 mmol/L (overt diabetes). In such cases, a concomitant fructosamine
evaluation might preclude the need for a second fasting glucose. 5 figures,
2 tables, 30 references.
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Page last modified: December 20, 2005
Content Source: National Center for Chronic Disease Prevention and Health Promotion
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