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Different strategies for screening and prevention of type 2 diabetes in adults: cost effectiveness analysis

BMJ 2008; 336 doi: (Published 22 May 2008) Cite this as: BMJ 2008;336:1180
  1. Clare L Gillies, lecturer in medical statistics 1,
  2. Paul C Lambert, senior lecturer in medical statistics1,
  3. Keith R Abrams, professor of medical statistics1,
  4. Alex J Sutton, reader in medical statistics1,
  5. Nicola J Cooper, MRC training fellow in health services research1,
  6. Ron T Hsu, senior clinical teaching fellow in epidemiology and public health1,
  7. Melanie J Davies, professor of diabetes medicine2,
  8. Kamlesh Khunti, professor of primary care diabetes and vascular medicine3
  1. 1Centre for Biostatistics and Genetic Epidemiology, Department of Health Sciences, University of Leicester, Leicester LE1 7RH
  2. 2Department of Cardiovascular Sciences, University of Leicester
  3. 3Division of General Practice and Primary Health Care, Department of Health Sciences, University of Leicester
  1. Correspondence to: C L Gillies clg13{at}
  • Accepted 25 March 2008


Objective To compare four potential screening strategies, and subsequent interventions, for the prevention and treatment of type 2 diabetes: (a) screening for type 2 diabetes to enable early detection and treatment, (b) screening for type 2 diabetes and impaired glucose tolerance, intervening with lifestyle interventions in those with a diagnosis of impaired glucose tolerance to delay or prevent diabetes, (c) as for (b) but with pharmacological interventions, and (d) no screening.

Design Cost effectiveness analysis based on development and evaluation of probabilistic, comprehensive economic decision analytic model, from screening to death.

Setting A hypothetical population, aged 45 at time of screening, with above average risk of diabetes.

Data sources Published clinical trials and epidemiological studies retrieved from electronic bibliographic databases; supplementary data obtained from the Department of Health statistics for England and Wales, the screening those at risk (STAR) study, and the Leicester division of the ADDITION study.

Methods A hybrid decision tree/Markov model was developed to simulate the long term effects of each screening strategy, in terms of both clinical and cost effectiveness outcomes. The base case model assumed a 50 year time horizon with discounting of both costs and benefits at 3.5%. Sensitivity analyses were carried out to investigate assumptions of the model and to identify which model inputs had most impact on the results.

Results Estimated costs for each quality adjusted life year (QALY) gained (discounted at 3.5% a year for both costs and benefits) were £14 150 (€17 560; $27 860) for screening for type 2 diabetes, £6242 for screening for diabetes and impaired glucose tolerance followed by lifestyle interventions, and £7023 for screening for diabetes and impaired glucose tolerance followed by pharmacological interventions, all compared with no screening. At a willingness-to-pay threshold of £20 000 the probability of the intervention being cost effective was 49%, 93%, and 85% for each of the active screening strategies respectively.

Conclusions Screening for type 2 diabetes and impaired glucose tolerance, with appropriate intervention for those with impaired glucose tolerance, in an above average risk population aged 45, seems to be cost effective. The cost effectiveness of a policy of screening for diabetes alone, which offered no intervention to those with impaired glucose tolerance, is still uncertain.


  • We thank the STAR study, in particular Jenny Tringham, and the Leicester arm of the ADDITION study, for providing the data on individual patients that were used for the analyses. We also thank Philip Clarke for advice on the UKPDS outcomes model.

  • Contributors: CLG performed the data extraction and analyses, wrote the first draft of the article, and is guarantor. KRA and PCL gave detailed advice at all stages of the analyses. All authors contributed to the writing of the paper and gave substantial advice and input into the study. KRA and KK had the initial idea for this project.

  • Funding: CLG is funded jointly by the UK Medical Research Council and the Economic and Social Research Council, under an interdisciplinary postgraduate research studentship in the social and medical sciences. NJC is funded by a Medical Research Council training fellowship in health services research.

  • Competing interests: MJD and KK have received sponsorship for attending conferences and small honorariums and funding for research from pharmaceutical companies that manufacture hypoglycaemic and anti-obesity drugs. KRA has also received funding for research from pharmaceutical companies that manufacture hypoglycaemic and anti-obesity drugs and has acted as a paid consultant to consultancy companies who undertake work for the healthcare industry generally.

  • Ethical approval: Not required.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

  • Accepted 25 March 2008
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