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Isn’t it better to incorporate HbA1c concentration variations reported in UK prospective diabetes study in the model rather than using the first 10 years average values?
- Arya K Kumarasena, none (1 May 2008)
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Using the FINDRISK tool lowers the cost
- James A Dunbar, Prasuna Reddy, Edward Janus, Brian Oldenburg, Rob Carter (6 May 2008)
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fantastic progress in diabetes care
- david j kinshuck (24 May 2008)
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Target women with gestational diabetes
- Mark Sillender (26 May 2008)
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Low compliance lowers cost effectiveness
- Olov Rolandsson (3 June 2008)
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Arya K Kumarasena, Director/consultant 85 ,Braybrroke ,place colombo2,Sri Lanka, none
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The paper indicates that HbA1c concentrations are likely to increase over time but it was not incorporated in the model due to unavailability of sufficient data. Actually what is more important is the difference between the HbA1c values of two groups and data available from UKPDS post monitoring period indicated that HbA1c values of intensive control group and the conventional group became similar just in 12-13 years [1]. Therefore predictions based on the average difference existed in first 10 years to predict 50 years result can have a reasonable error. In fact the trend of narrowing the difference in HbA1c concentrations was quite apparent even during the first 10 years [2]. 1. UKPROSPECTIVE DIABETES STUDY/Post study monitoring 2. UK Prospective Diabetes Study (UKPDS) Group. Intensive blood- glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 1998;352:837-53.[CrossRef][ISI][Medline] Competing interests: None declared |
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James A Dunbar, Director Greater Green Triangle UDRH, Flinders and Deakin Universities, Warrnambool, Vic 3280 Australia., Prasuna Reddy, Edward Janus, Brian Oldenburg, Rob Carter
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We note that Gillies et al in their paper on ‘Different strategies for screening and prevention of type 2 diabetes in adults: cost effectiveness analysis’ did not refer to the use the FINDRISK tool to predict the risk of type 2 diabetes. This diabetes risk test has eight questions and a score of >15 indicates a one-in-three chance of developing type 2 diabetes within 10 years. Assessed against two population cohorts, the test has shown sensitivity of 0.78 and 0.81, specificity of 0.77 and 0.76, and positive predicted value of 0.13 and 0.05. The test can be self-administered via the website or handed out by health service providers as demonstrated in two real-world implementation trials in Finland and Australia. , In our experience this diabetes risk test is simple to use, and substantially reduces the number of people who need to be screened by subsequent fasting glucose or oral glucose tolerance tests, thereby reducing the cost of public health prevention programs for diabetes. Our recent studies showed that half of those identified at risk using this test were willing to join a group lifestyle intervention that reduced the risk of diabetes by 40%, the prevalence of metabolic syndrome from 60% to 45%, and all CVD risks by 16%.4 The health economic calculations indicate a cost of approximately A$2,000 per disability adjusted life year, which makes this an inexpensive public health intervention. Work is underway to calibrate the FINDRISK test for culturally and linguistically diverse groups in Australia. Clare L Gillies, Paul C Lambert, Keith R Abrams, Alex J Sutton, Nicola J Cooper, Ron T Hsu, Melanie J Davies, Kamlesh Khunti. Different strategies for screening and prevention of type 2 diabetes in adults: cost effectiveness analysis. BMJ. doi:10.1136/bmj.39545.585259.25. Lindstrom J, Tuomilehto J. The Diabetes Risk Score: A practical tool to predict type 2 diabetes risk. Diabetes Care. 2003; 26:725-731. Absetz Pilviki, Valve Raisa, Oldenburg Brian, Heinonen Heikki, Nissinen Aulikki, Fogelholm Mikael, Ilvesmaki Vesa, Talja Martti, Uutela Antti. Type 2 diabetes prevention in the “Real World”. One-year results of the GOAL Implementation Trual. Diabetes Care. 2007; 30:2465-2470. LaatikainenT, Dunbar JA, Chapman A, Kilkkinen A, Vartiainen E, Heistaro S, Philpot B, Absetz P, Bunker S, O’Neil A, Reddy P, Best JD, Janus ED. Prevention of Type 2 Diabetes by lifestyle intervention in an Australian primary health care setting: Greater Green Triangle (GGT) Diabetes Prevention Project. BMC Public Health 2007; 7 (147):249 Competing interests: None declared |
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david j kinshuck, associate specialist in ophthalmology Good Hope Hospital, B75 7RR
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I welcome Gillies (BMJ, 2008;336:1180-1185, 24 May) analysis of the cost savings screening for diabetes. As an editor of a diabetic retinopathy website (www.diabeticretinopathy.org.uk) and as an ophthalmologist treating retinopathy I hear and see of the tragic consequences of late diagnosis. It seems to me that Al-Zuabi H, (Med Princ Pract. 2005 Sep-Oct;14(5):293-6) findings that 7% of patents’ just diagnosed as diabetic have retinopathy at time of diagnosis is still the situation across the UK. In this respect I agree with Goyder’s analysis (BMJ, 2008;336:1140- 1141, 24 May) that the new Dept of Health plan to screen everyone over 40 for blood pressure etc has to be a fantastic step forward. As Goyder points out simple steps then will not only help detect retinopathy but allow at risk patients to prevent or delay diabetes itself. However, reports of self testing not aiding control are disappointing. (O’Kane, BMJ, 2008;336:1174-1177, 24 May). But this is recognised…and the way forward is to teach self-control as part of an education package such as DAFNE, XPERT and DESMOND (Pediatr Diabetes. 2006 Dec;7(6):322-8.). Locally our first patients to have completed DAFNE report all the known benefits…they have come to terms with their diabetes and are happier taking control of it, and their HbA1c drops. We know that the average HbA1c of children in a clinic in Yale can be 2% lower than the equivalent UK clinic (data presented at the Diabetic Retinopathy meeting in Liverpool 2007)….we know what it is possible to achieve. We need our patients to complete such programs, before they get retinopathy. Only then with the new screening programs for diabetes and for retinopathy itself will we really reduce the incidence of retinopathy and other diabetic complications. Competing interests: None declared |
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Mark Sillender, Consultant Obstetrician & Gynaecologist Kaleeya Hospital, Fremantle, WA 6158, Australia
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One way to reduce type 2 diabetes would be to target women with gestational diabetes (GDM). Maternity services are increasingly screening women & treating GDM, following the demonstration of significant perinatal benefits (1). 35-60% of women with GDM will develop type 2 diabetes within 10 years (2). These women are an already-identified high-risk group. Their children are also more likely to be obese and share a genetic propensity to type 2 diabetes (3). Following up women with GDM allows the targeting of two high-risk individuals without additional screening. Many health service contacts are made in the first year of a child's life, therefore interventions may be easily delivered. Also, many women are receptive to health advice around the time of a birth when new lifestyle patterns are being established. Improved follow up of these women with promotion of diet, exercise and pharmacology, together with prolongation of breast feeding and subsequent healthy infant feeding is likely to be effective for mother, child, and the health service. References 1. Crowther CA, Hiller FE et al, for the Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS) Trial Group: Effect of treatment of gestational diabetes mellitus on pregnancy outcomes. N Engl J Med 352:2477–2486, 2005 2. National Institute of Diabetes and Digestive and Kidney Diseases: National diabetes statistics fact sheet: general information and national estimates on diabetes in the United States, 2005. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, 2005 3. Schaefer-Graf UM, Hartmann R, Pawliczak J, Passow D, Abou-Dakin M, Vetter K, Kordonouri O: Association of breast-feeding and early childhood overweight in children from mothers with gestational diabetes. Diabetes Care 29:1105–1107, 2006 Competing interests: None declared |
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Olov Rolandsson, Senior lecturer in family medicine Family Medicine, Umeå University, 901 85, Sweden
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In the article by Gillies et al they assumed a 100% compliance to both screening and intervention in their sensitivity analyses.1 They also found that even with compliance rates as low as 50% the screening strategy would be cost effective. Unfortunately, the compliance rate could be much lower than 50%. We found in a pilot study that only 16% of those identified with abnormal glucose tolerance accepted to participate in an intervention study.2 When scrutinizing the inclusion to the large preventive studies it could be estimated that only a very small proportion of the subjects at risk agreed to participate.3, 4 So, one should be cautious in extrapolating positive results from such trials to the overall population with abnormal glucose tolerance. It would be interesting to know what really would be the lowest compliance rate for the screening and intervention to be cost effective. 1. Gillies CL, Lambert PC, Abrams KR, Sutton AJ, Cooper NJ, Hsu RT, et al. Different strategies for screening and prevention of type 2 diabetes in adults: cost effectiveness analysis. Bmj 2008;336:1180-5. 2. Ruge T, Nystrom L, Lindahl B, Hallmans G, Norberg M, Weinehall L, et al. Recruiting high-risk individuals to a diabetes prevention program: how hard can it be? Diabetes Care 2007;30:e61. 3. Eriksson J, Lindstrom J, Valle T, Aunola S, Hamalainen H, Ilanne- Parikka P, et al. Prevention of Type II diabetes in subjects with impaired glucose tolerance: the Diabetes Prevention Study (DPS) in Finland. Study design and 1-year interim report on the feasibility of the lifestyle intervention programme. Diabetologia 1999;42:793-801. 4. The Diabetes Prevention Program (DPP): description of lifestyle intervention. Diabetes Care 2002;25:2165-71. Competing interests: None declared |
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