By their analysis, treating all 14 million asymptomatic diabetics in the US with statins would prevent 84 000 events (30% of the expected total events) at a cost of $10.1 billion, gaining 1 092 000 life-years, for a cost-effectiveness ratio of $9249 per life-year. By contrast, the alternative strategy of screening all 14 million asymptomatic diabetic subjects using myocardial perfusion scintigraphy at an estimated cost of $809 per person would cost $11.3 billion and identify the 20% of subjects among whom 80% of events would occur. If these test-positive patients were then treated with statins, to the tune of an additional $2 billion, the life-years gained would be 873 600 and the cost-effectiveness ratio would be $15 224 per life-year. This number is likely an underestimation of costs, given that a positive perfusion imaging test would also like to lead to further tests, Diamond et al write.

"The belief among test advocates is that we should throw more technology at patients," states, Diamond.. "Fine-tuning these selection processes is not going to solve the problem fundamentally, because no test can save a life. Only treatments save lives, and testing excludes treatment."

But in a counterpoint article, Dr George Beller (University of Virginia, Charlottesville, VA) argues that the question is not whether or not diabetics should be universally screened to make decisions about statin treatment because all asymptomatic diabetics should have their LDL cholesterol below 100 mg/dL, and most would require statin therapy to reach this goal.
"The issue is really, what do you do to identify those type 2 diabetics who might require even more aggressive medical therapy and even further testing for silent extensive coronary disease?"

In response, Diamond stated, "That would be fine if there were evidence to support an outcomes benefit of aggressive management among diabetics. There isn't."

Diamond, however, insists that Beller and others who have argued for a strategy of screening high-risk asymptomatic diabetics need to first answer three "critical" questions: how much does it cost, how much is it going to benefit, and where is the money going to come from?

The screening debate, Diamond argues, detracts from the simple fact that diabetics are not getting the proven medical therapies they need. "There should be a global strategy to minimize their risk across the board, and that would include predominantly unrestricted use of proven medications like statins and ACE inhibitors. If we're not going to treat diabetics with all these medications, we better have a real good reason why we're not, and the reason shouldn't be, I gave a test and it wasn't positive."

Diamond GA, Kaul S, Shah PK, et al. Screen testing: Cardiovascular prevention in asymptomatic diabetic patients. J Am Coll Cardiol 2007; 49:1915-1917. Beller GA. Noninvasive screening for coronary atherosclerosis and silent ischemia in asymptomatic type 2 diabetic patients: Is it appropriate and cost-effective? J Am Coll Cardiol 2007; 49:1918-1923.

===============================

FACT: