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Screening Everyone 35 and Older Makes a Difference

The cost would be only marginally greater, new findings show…. 

Dr. Sukyung Chung of the Palo Alto Medical Foundation Research Institute and her colleagues note in their report that one in five people with diabetes in the U.S. have not been diagnosed.

Guidelines on screening for diabetes are inconsistent with one another, the researchers add, and complex for physicians to use.

For example, the U.S. Preventive Services Task Force (USPSTF) recommends routine screening of asymptomatic adults only if they have a blood pressure above 135/80 mmHg. The American Diabetes Association (ADA) recommends screening for asymptomatic adults under 45 with a body mass index (BMI) of 25 or higher and at least one of 12 different diabetes risk factors, and everyone 45 and older regardless of their risk factors.

To investigate whether universal screening based on age might be a more effective way to identify patients with diabetes, the researchers used data from the National Health and Nutrition Examination Survey 2007-2010, comparing the number needed to screen (NNS) to identify one person with diabetes using age cutoffs, the USPSTF guidelines, and the ADA guidelines. They based their cost estimates on the 2010 Medicare fee schedule.

Just over 80% of non-pregnant, diabetes-free adults met the ADA screening criteria, the researchers found, while 28.2% would be screened based on the USPSTF guidelines. The NNS was 17% with the ADA criteria and 14% with the USPSTF criteria. The NNS would be 15% with opportunistic universal screening of people 35 and older.

Strict application of the ADA guidelines would miss undiagnosed diabetes in nearly 15% of people 35 to 44 years old, Dr. Chung and her colleagues found. The USPSTF guidelines would miss 61% of positive tests of people 35 and older.

The cost per positive test would be $66 with universal screening of people 35 and older, versus $62 with the ADA guidelines and $57 with the USPSTF guidelines.

Universal screening for people 35 and older would be cost effective, and it would also simplify physicians’ lives, Dr. Chung said. Clinicians who want to be more cautious could limit testing to people with BMIs indicating that they are overweight or obese, but further assessment of risk factors is unnecessary, she added.

Dr. Chung and her team concluded that, "Given the substantial benefit of early detection with small incremental costs for extending diabetes screening, and evidence that nearly universal screening is already practiced, it may be time to harmonize guidelines and recognize universal screening for diabetes in adults aged 35 years (and older) as formal policy."

Practice Pearls:

  • One in five people with diabetes in the U.S. have not been diagnosed
  • Strict application of the ADA guidelines would miss undiagnosed diabetes in nearly 15% of people 35 to 44 years old,
  • USPSTF guidelines would miss 61% of positive tests of people 35 and older.

Am J Prev Med 2014.