Cost-effectiveness of screening strategies for identifying pediatric diabetes mellitus and dysglycemia

Abstract

Objective: To conduct a cost-effectiveness analysis of screening strategies for identifying children with type 2 diabetes mellitus and dysglycemia (prediabetes/diabetes).

Design: Cost simulation study.

Setting: A one-time US screening program.

Study participants: A total of 2.5 million children aged 10 to 17 years.

Intervention: Screening strategies for identifying diabetes and dysglycemia.

Main outcome measures: Effectiveness (proportion of cases identified), total costs (direct and indirect), and efficiency (cost per case identified) of each screening strategy based on test performance data from a pediatric cohort and cost data from Medicare and the US Bureau of Labor Statistics.

Results: In the base-case model, 500 and 400 000 US adolescents had diabetes and dysglycemia, respectively. For diabetes, the cost per case was extremely high ($312 000-$831 000 per case identified) because of the low prevalence of disease. For dysglycemia, the cost per case was in a more reasonable range. For dysglycemia, preferred strategies were the 2-hour oral glucose tolerance test (100% effectiveness; $390 per case), 1-hour glucose challenge test (63% effectiveness; $571), random glucose test (55% effectiveness; $498), or a hemoglobin A1c threshold of 5.5% (45% effectiveness; $763). Hemoglobin A1c thresholds of 5.7% and 6.5% were the least effective and least efficient (ranges, 7%-32% and $938-$3370) of all strategies evaluated. Sensitivity analyses for diabetes revealed that disease prevalence was a major driver of cost-effectiveness. Sensitivity analyses for dysglycemia did not lead to appreciable changes in overall rankings among tests.

Conclusions: For diabetes, the cost per case is extremely high because of the low prevalence of the disease in the pediatric population. Screening for diabetes could become more cost-effective if dysglycemia is explicitly considered as a screening outcome.

Figure 1

Screening effectiveness for diabetes (percentage of cases identified) plotted against screening efficiency (costs per case identified) from a societal perspective. A, Base-case analysis; B, alternative estimates of hemoglobin A_lc (HbA_lc) test performance. OGTT indicates oral glucose tolerance test.

Figure 2

Screening effectiveness for dysglycemia (percentage of cases identified) plotted against screening efficiency (costs per case identified) from a societal perspective. A, Base-case analysis; B, alternative estimates of hemoglobin A_1c (HbA_1c) test performance. GCT indicates glucose challenge test; and OGTT, oral glucose tolerance test.