• Health reform
• EMRs
• Medicare
• Liability
• AMA House
• » More

• Contract Language
• Ethics Forum
• In the Courts
• Practice Management
• Technically Speaking
• » More

• Issue dates
• Regions
• Health plans
• Sections
• News briefs
• Columns
• Editorials
• Letters
• Series
• Writers
• Other years

• Search tips
• Email alert
• RSS
• Mobile
• Subscribe
• Institutions
• Staff directory
• Advertising
• Permissions
• Reprints
• News media
• Site guide
• Useful links
• About
• Premium
• Contact

• AMA Wire
• CPT
• DMPHP
• JAMA
• JAMA&Archives
• news@JAMA
• Virtual Mentor
• Physician jobs

Researchers call for more diabetes testing

But experts do not agree on who should be screened, and many patients fail to get the test when it's recommended.

By Victoria Stagg Elliott, amednews staff. Sept. 22/29, 2003.

• PRINT|
• E-MAIL|
• RESPOND|
• REPRINTS|
• SHARE
•  

Screening all adults older than 45 and those with certain risk factors such as obesity or a family history of the disease is an effective way to find all diabetes cases and deal with the more than one-third of diabetics who are believed to be undiagnosed, according to a paper published in the September Proceedings of the National Academy of Sciences.

"We could be detecting these patients and we're not. And we could be bringing them into treatment," said Susan C. Weller, PhD, lead author and professor of preventive medicine and community health at the University of Texas Medical Branch in Galveston.

Many specialists agree that the more screening the better, because they see the downstream effects of late diagnosis -- the heart attacks, the kidney disease, the blindness, the loss of limbs.

"It's not uncommon to diagnose diabetes at the time of renal failure or the time of the first MI," said Francine Kaufman, MD, past president of the American Diabetes Assn. "The earlier we get them, we could theoretically get rid of all of that."

Costs and benefits

Still, some physicians aren't quite so convinced that the benefits of wider screening outweigh the drawbacks. Many suspect there are benefits from earlier diagnosis, but science has yet to offer definitive proof.

"The criteria are so far-reaching that it's a small step between the current criteria and just saying 'do a fasting glucose on every adult,'" said Ken Bertka, MD, a family physician in Toledo, Ohio. "Yes, diabetes is very important but there's all sorts of other things out there, and when you're trying to make good public health policy, it's important to make sure that you're really spending the money and the effort wisely."

For instance, there is actually very little agreement on who should be screened.

The NAS study relied on the 1997 guidelines developed by the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus, which was convened by the American Diabetes Assn. The study authors found the guidelines effective, although they also suggested they could be simplified to target Caucasian patients older than 40 and nonwhites older than 30. Such a step, the authors concluded, would result in fewer tests but an equal number of diagnosed cases.

Other researchers have questioned the validity of the expert committee's risk factors. The U.S. Preventive Services Task Force concluded that there is not enough evidence to recommend for or against screening those who are asymptomatic. The task force does, however, recommend screening people with high blood pressure or high cholesterol within the context of a cardiac risk management program.

There is also significant concern about several other related issues.

First, the price tag, both for the test and the follow-up care, is a part of the cost-benefit formula that cannot be overlooked. The fasting plasma glucose screening test recommended by the expert committee is one of the less expensive tests, costing most patients between $20 and $50 if paid out of pocket, and less if covered at least in part by insurance. But doctors worry about the burden on the health care system if recommendations were widely expanded.

A 2001 study in Effective Clinical Practice, for example, screened people who had high blood pressure and high cholesterol. It found that each new case cost $4,064. If the current expert committee recommendations were followed to the letter, 83% of the population would be screened.

"What do you do with the barely symptomatic people?" said Dr. Kaufman, who is also a pediatric endocrinologist at Children's Hospital Los Angeles. "You've got to give them nutrition counseling and lifestyle counseling and maybe they need some medication for a while. They need more doctor's visits. Who's going to pay for it all?"

Compliance issues

The test can also be less than convenient for patients. The Northwest Ohio Primary Care Research Network conducted a diabetes screening pilot project using the ADA guidelines and found that about a quarter of those who should have been screened weren't. For more than half of that group, the doctor ordered the test but the patient never followed through. A frequent reason for the lack of compliance: The test requires a blood draw and at least an 8-hour fast, which is less than appealing for many patients.

"One of my hypotheses is that you could get better compliance if you could do this with the equipment that is generally available in most doctors' offices versus having to send them out for blood," said Dr. Bertka, chair of NOPCRN's steering committee.

The preventive services task force also expressed concern that the risks of labeling someone as diabetic or pre-diabetic might outweigh the benefits. Such a diagnosis could lead to anxiety and problems being insured. First-line treatments, especially for pre-diabetes, are things such as diet and exercise. Patients should be taking these steps anyway. And once drug therapy is initiated, the task force questioned whether there might be some harm caused by people being on the drugs longer because of earlier diagnosis.

"The ADA guidelines would label a huge number of apparently healthy people either pre-diabetic or diabetic, and you've got to wonder whether that's a good idea," said Alfred O. Berg, MD, MPH, task force chair.

Back to top

 ADDITIONAL INFORMATION: