screening

Abstract: Introduction Although rates of invasive cervical cancer have declined precipitously over the past 50 years, nearly 10,000 new cases and 3700 deaths result from this cancer annually. Given the efficacy of early detection, invasive cervical cancer should no longer constitute a health threat; however, national studies reveal that many women, especially older women, do not receive Papanicolaou (Pap) tests. Methods In this complementary study, we examined data from the National Health Interview Survey focusing on the correlates of screening for women aged 55 years or older, an age group in which invasive cervical cancer rates escalate and rates of obtaining Pap tests decline. To more richly understand grounded perspectives, we queried 25 women who were rarely or never screened about factors and circumstances underlying their decision not to obtain a Pap test. Results Quantitative data indicate an association between Pap test use and demographic factors (being married, being younger, and having suburban or urban residence) and access to preventive care (obtaining mammograms, having a regular source of health care, and having contact with an obstetrician/gynecologist). Participants who provided qualitative data echoed this theme of inadequate use of preventive services, particularly among women with weak social ties, who were older, and who lived in rural areas. Shortages of health care professionals and a lack of continuity of care and privacy contribute to suboptimal prevention. Conclusion A vicious cycle emerges: many women decline to pursue preventive care because of competing health and financial demands and insufficient resources to seek care. When such women do go to the doctor’s office, they feel chastised by providers, which alienates them and thwarts future preventive care.

 cancer;  health;  screening;  cervical;  poverty;  

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Abstract: Microalbuminuria is an early sign of progressive cardiovascular and renal disease in individuals with and without diabetes. Despite compelling data, at present only a minority of patients with diabetes and rarely individuals without diabetes are screened for albuminuria in a systematic way. All of the criteria to implement systematic albuminuria screening are fulfilled in diabetes, and most are nearly fulfilled for microalbuminuria screening in individuals without diabetes. Because of the growing evidence that treatment of microalbuminuria in individuals without diabetes may offer a cost-effective benefit to prevent cardiovascular disease, nephrologists and other health care providers should pay more attention to the early detection and subsequent treatment of individuals with microalbuminuria.

 prevention;  diabetes;  nephropathy;  screening;  MICROALBUMINURIA;  review;  

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Abstract: OBJECTIVE: We examined factors associated with screening for albuminuria and initiation of ACE inhibitor or angiotensin receptor blocker (ARB) treatment in diabetic patients. RESEARCH DESIGN AND METHODS: We conducted surveys and medical record reviews for 5,378 patients participating in a study of diabetes care in managed care at baseline (2000-2001) and follow-up (2002-2003). Factors associated with testing for albuminuria were examined in cross-sectional analysis at baseline. Factors associated with initiating ACE inhibitor/ARB therapy were determined prospectively. RESULTS: At baseline, 52% of patients not receiving ACE inhibitor/ARB therapy and without known diabetic kidney disease (DKD) were screened for albuminuria. Patients > or =65 years of age, those with higher HbA(1c), those with cardiovascular disease (CVD), and those without hyperlipidemia were less likely to be screened. Of the patients with positive screening tests, 47% began ACE inhibitor/ARB therapy. Initiation of therapy was associated with positive screening test results, BMI > or =25 kg/m(2), treatment with insulin or oral antidiabetic agents, peripheral neuropathy, systolic blood pressure > or =140 mmHg, and CVD. Of the patients receiving ACE inhibitor/ARB therapy or with known DKD, 63% were tested for albuminuria. CONCLUSIONS: Screening for albuminuria was inadequate, especially in older patients or those with competing medical concerns. The value of screening could be increased if more patients with positive screening tests initiated ACE inhibitor/ARB therapy. The efficiency of screening could be improved by limiting screening to diabetic patients not receiving ACE inhibitor/ARB therapy and without known DKD.

 diabetes;  ACEI;  arb;  screening;  MICROALBUMINURIA;  health quality assessment;  

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Abstract: AIM: Forty percent of hypertensive type 2 diabetes patients develop nephropathy (microalbuminuria/overt nephropathy), indicating end organ damage, increased risk of cardiovascular disease (CVD), and death. In France, screening rates and nephropathy treatment are suboptimal. We assessed the health economic impact of nephropathy screening in hypertensive patients with type 2 diabetes followed by optimal antihypertensive/nephroprotective therapy in those who have nephropathy in France. METHODS: A Markov/Monte Carlo model simulated lifetime impacts of screening for albuminuria (microalbuminuria/overt nephropathy) using semi-quantitative urine dipsticks in a primary care setting, and subsequent addition of irbesartan 300 mg to conventional therapy in hypertensive type 2 diabetes patients identified as having nephropathy. Progression from no renal disease to end-stage renal disease (ESRD) was simulated. Probabilities, utilities and costs of CVD events, medications and ESRD treatment came from published sources. Cumulative incidence of ESRD, life expectancy, quality-adjusted life years (QALYs) and direct costs were projected. Second-order Monte Carlo simulation accounted for uncertainty in multiple parameters. Costs and QALYs were discounted at 3% annually. RESULTS: Screening and optimized treatment led to a 42% reduction in the cumulative incidence of ESRD from 10.1 +/- 9.9% without screening to 5.8 +/- 5.7%, improvements in life expectancy of 0.38 +/- 0.59 years, improvements of 0.29 +/- 0.32 QALYs, and decreased costs of Euro 4,812 +/- 7,882/patient over 25 years. Sensitivity analysis showed that the results were robust. Screening was most beneficial when performed in younger patients. CONCLUSION: In hypertensive patients with type 2 diabetes, screening for albuminuria followed by optimal antihypertensive/nephroprotective treatment improves patient outcomes and leads to cost savings in France.

 prevention;  diabetes;  arb;  nephropathy;  screening;  MICROALBUMINURIA;  irbesartan;  economic evaluation;  IDNT;  IRMA;  BENEDICT;  

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Abstract: THE ISSUE: Diabetes has become the main cause of end-stage renal disease. The costs for the treatment of diabetic patients with end-stage renal disease have increased in the last years and have become a relevant economic topic of the health service. The first unspecific predictor of a diabetic nephropathy is an albuminuria. The screening for diabetic nephropathy uses microalbuminuria as a proof. OBJECTIVES: - What significance does the determination of albuminuria have on the precaution and course-control of the diabetic nephropathy? a) in type 1 diabetic patients b) in type 2 diabetic patients ? - Which is an appropriate time to determine the albuminuria for the purpose of precaution and course-control of the diabetic nephropathy? a) in type 1 diabetic patients b) in type 2 diabetic patients ? Which method of testing is most effective concerning economic and medical aspects? METHODS: Published literature from 1998 up to 2004 was identified by searching in the most important databases. Most of the guidelines were found by hand searching in the internet. RESULTS: Of 2,792 citation titles and abstracts examined, 274 articles were retrieved for full-text review. Five metaanalyses and reviews, one review about clearing of guidelines (regarding 18 international guidelines) and four guidelines met the inclusion criteria for screening for microalbuminuria and type 1 diabetes. Seven metaanalyses, one HTA report, one review about clearing of guidelines (regarding 17 international guidelines), and seven guidelines met the inclusion criteria for screening for microalbuminuria and type 2 diabetes. At the moment, the determination of albuminuria still has a great significance because it is recommended in most published literature and guidelines. The time to determine the albuminuria depends on the age of the patients and their type of diabetes. Type 2 diabetic patients should start the determination when the diabetes is diagnosed whereas the determination is recommended five years later when type 1 diabetic patients are concerned. Most guidelines recommend a screening for microalbuminuria every year.DISCUSSION AND CONCLUSION: All guidelines an d most of the literature recommend this screening. However, these recommendations are only based on expert consensus. The specificity of this screening is rather low. False positive tests in type 2 diabetic patients will cause psychological problems. A positive test leads to the recommendation to achieve “normal blood pressure” and “normoglycaemia” – but this applies to each diabetic patient. Based on these facts, the screening for albuminuria in type 1 or type 2 diabetes patients cannot be recommended as long as benefit has not been demonstrated by large, clinical, controlled trials. Without an evidence of the benefit, this screening cannot be economic.

 prevention;  diabetes;  nephropathy;  screening;  MICROALBUMINURIA;  economic review;  

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Abstract: Introduction Public health organizations in the United States emphasize the importance of providing routine screening for breast cancer, cervical cancer, and colorectal cancer, as well as vaccinations against influenza and pneumococcal disease among older adults. We report a composite measure of adults aged 50 years and older who receive recommended cancer screening services and vaccinations. Methods We analyzed state data from the 2002 Behavioral Risk Factor Surveillance System, which included 105,860 respondents aged 50 and older. We created a composite measure that included colonoscopy or sigmoidoscopy within 10 years or a fecal occult blood test in the past year, an influenza vaccination in the past year, a Papanicolaou test within 3 years for women with an intact cervix, a mammogram, and for adults aged 65 and older, a pneumonia vaccination during their lifetime. We performed separate analyses for four age and sex groups: men aged 50 to 64, women aged 50 to 64, men aged 65 and older, and women aged 65 and older. Results The percentage of each age and sex group that was up-to-date according to our composite measure ranged from 21.1% of women aged 50 to 64 (four tests) to 39.6% of men aged 65 and older (three tests). For each group, results varied by income, education, race/ethnicity, insurance status, and whether the respondent had a personal physician. Conclusion These results suggest the need to improve the delivery of cancer screenings and vaccinations among adults aged 50 and older. We propose continued efforts to measure use of clinical preventive services.

 cancer;  screening;  

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Abstract: Aims. To evaluate the structured PROSIT(R) disease management programme for high-risk diabetic patients in primary care with respect to the cardio-vascular risk profile and mortality. Subjects and Methods. Retrospectively 55 albuminuric Type 2 diabetic patients included into the PROSIT(R) programme from 1994 to 1999 (intervention group: age 66.6 +/- 10.5 years, known duration of diabetes 8.9 +/- 6.5 years) were compared with 58 albuminuric patients not participating in the PROSIT(R) programme (control group: age 68.5 +/- 10.4 years, known duration of diabetes 8.5 +/- 6.7 years). Within PROSIT(R) a structured multifactorial intervention programme was applied. The main characteristics of this intervention were strict follow-ups of the patients risk profile every three months and the use of quality management methods (definition of target values, structured documentation, central data feedback with diagnostic and therapeutic recommendations based on European guidelines). The cardio-vascular risk profile, therapeutic intervention, and secondary diabetic complications were compared between both groups in 1994 and 1999. Results. In the period from 1994 to 1999 the intervention group showed a significant improvement in the vascular risk profile, while the control group did not. In 1999 the mean arterial blood pressure was significantly lower compared to the control group (115 +/- 13 mm Hg vs. 125 +/- 16 mm Hg, p < 0.05). The HbA1c improved only in the intervention group and in 1999 it was significantly lower than in the control group (7.0 +/- 1.3 \% vs. 8.4 +/- 1.8 \%, p < 0.01). Moreover, the occurrence of clinical endpoints in the intervention group could be reduced: Both the mortalitly rate (14.5 \% vs. 34.5 \%, p < 0.05) and the rate of new myocardial infarctions (6 \% vs. 20 \%, p < 0.05) of the intervention group were significantly lower. Conclusions. Participation of albuminuric Type 2 diabetic patients and their physicians in a structured intervention programme showed positive effects on the cardio-vascular risk profile and endpoints compared with a group of non-participating patients and physicians.

 diabetes;  screening;  MICROALBUMINURIA;  clinical trial;  PROSIT;  

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Abstract: CONTEXT: Chronic kidney disease is a growing public health problem. Screening for early identification could improve health but could also lead to unnecessary harms and excess costs. OBJECTIVE: To assess the value of periodic, population-based dipstick screening for early detection of urine protein in adults with neither hypertension nor diabetes and in adults with hypertension. DESIGN, SETTING, AND POPULATION: Cost-effectiveness analysis using a Markov decision analytic model to compare a strategy of annual screening with no screening (usual care) for proteinuria at age 50 years followed by treatment with an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin II-receptor blocker (ARB). MAIN OUTCOME MEASURE: Cost per quality-adjusted life-year (QALY). RESULTS: For persons with neither hypertension nor diabetes, the cost-effectiveness ratio for screening vs no screening (usual care) was unfavorable (282 818 dollars per QALY; incremental cost of 616 dollars and a gain of 0.0022 QALYs per person). However, screening such persons beginning at age 60 years yielded a more favorable ratio (53 372 dollars per QALY). For persons with hypertension, the ratio was highly favorable (18 621 dollars per QALY; incremental cost of 476 dollars and a gain of 0.03 QALYs per person). Cost-effectiveness was mediated by both chronic kidney disease progression and death prevention benefits of ACE inhibitor and ARB therapy. Influential parameters that might make screening for the general population more cost-effective include a greater incidence of proteinuria, age at screening (53 372 dollars per QALY for persons beginning screening at age 60 years), or lower frequency of screening (every 10 years: 80 700 dollars per QALY at age 50 years; 6195 dollars per QALY at age 60 years; and 5486 dollars per QALY at age 70 years). CONCLUSIONS: Early detection of urine protein to slow progression of chronic kidney disease and decrease mortality is not cost-effective unless selectively directed toward high-risk groups (older persons and persons with hypertension) or conducted at an infrequent interval of 10 years.

 prevention;  diabetes;  nephropathy;  screening;  MICROALBUMINURIA;  economic evaluation;  

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Abstract: BACKGROUND AND OBJECTIVE: Even though there are simple and cost-effective means for the early diagnosis of diabetic nephropathy, only a small proportion of diabetics in Germany is regularly tests for microalbuminuria. On the basis of evidence-based knowledge and of international guidelines the PROSIT project (proteinuria screening and intervention) aims to make good this deficiency in the German Federal Republic by introducing nephropathy screening and a structured intervention to improve blood sugar and blood pressure regulation, optimizing lipid metabolism and nutritional intake. It was the aim of this study to assess with a computer-aided diabetes model the clinical value and cost-effectiveness of such an intervention. PATIENTS AND METHODS: From data collected for 589 diabetics who participated in the PROSIT project, the short-time effects after one year on HbA1c, systolic blood pressure and lipid levels were obtained and cost-effectiveness compared with that of standard care. Life expectancy, life-time costs to be met by health insurance and event frequency of the diabetic nephropathy stages were calculated with a Markov model for type 2 diabetics. RESULTS: PROSIT improved individual life expectancy by 0.23 years with reduction of life-time costs by DM 9,772 (ca. \$4,900). The cumulative incidence of microalbuminuria was lowered by 30.5\%, that of terminal renal failure by 55.9\%. Even after discounting the results (i.e. the inclusion of time preference for cost and benefit) and stepwise changes of all variables by +/- 10\%, PROSIT remained the more cost-effective variant. CONCLUSION: From a health economy viewpoint PROSIT is superior to standard management. Early recognition of albuminuria and the introduction of a multifactorial treatment strategy make it possible to delay progression to terminal renal failure. In addition to its clinical benefits, prevention of dialysis and transplantation would reduce the annual savings of the health care system by several billion DM.

 prevention;  diabetes;  ACEI;  nephropathy;  screening;  MICROALBUMINURIA;  economic evaluation;  PROSIT;  

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Abstract: The PROSIT (Proteinuria Screening and Intervention) Project started in 1993 in order to obtain data on the prevalence of micro- and macroalbuminuria in diabetic patients treated in primary care, to establish an easy screening programme for microalbuminuria, in which also diabetic patients can participate in self-responsibility, and to implement a specific intervention programme for incipient nephropathy. In 58 representative doctors offices 647 diabetic patients were included, who performed at home self-tests for microalbuminuria on three days within one week using the early morning urine and a newly developed qualitative immunologic test-strip for microalbuminuria. After storage they returned the same urine samples to their doctors offices for semiquantitative retesting with the immunologic test-strip Micral-Test II. In case of positive results the proteinuria dipstick Combur-9-Test was applied in order to exclude other causes of positive microalbuminuria (e.g. urinary tract infection). Data of 569 patients (6\% Type 1, 88\% Type 2 and 6\% secondary diabetes) could be analysed. Both qualitative self-testing for microalbuminuria at home and semiquantitative retesting in doctors offices were found to be feasible. Based on semiquantitative retesting the prevalences of microalbuminuria (macroalbuminuria) were 19.6\% (0\%) in Type 1 diabetes, 17.2\% (10.8\%) in Type 2 diabetes and 11.7\% (7.8\%) in secondary diabetes. Type 2 diabetic patients showed a clear correlation between albuminuria and diabetes duration, HbA1c, serum creatinine, triglycerides as well as micro- and macrovascular complications. 227 patients with micro- or macroalbuminuria were included into the ongoing PROSIT intervention programme.

 epidemiology;  diabetes;  screening;  MICROALBUMINURIA;  PROSIT;  

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Abstract: OBJECTIVE: To examine the conditions necessary to make screening for microalbuminuria in patients with insulin dependent diabetes mellitus cost effective. DESIGN: This economic evaluation compared two strategies designed to prevent the development of end stage renal disease in patients with insulin dependent diabetes with disease for five years. Strategy A, screening for microalbuminuria as currently recommended, was compared with strategy B, a protocol in which patients were screened for hypertension and macroproteinuria. INTERVENTION: Patients identified in both strategies were treated with an angiotensin converting enzyme inhibitor. SETTING: Computer simulation. MAIN OUTCOME MEASURES: Strategy costs and quality adjusted life years (QALYs). RESULTS: The model predicted that strategy A would produce an additional 0.00967 QALYs at a present value cost of $261.53 (1990 US$) per patient (or an incremental cost/QALY of $27,041.69) over strategy B. The incremental cost/QALY for strategy A over B was sensitive to several variables. If the positive predictive value of screening for microalbuminuria (impact of false label and unnecessary treatment) is < 0.72, the effect of treatment to delay progression from microalbuminuria to macroproteinuria is < 1.6 years, the cumulative incidence of diabetic nephropathy falls to < 20\%, or > 64\% of patients demonstrate hypertension at the onset of microalbuminuria, then the incremental costs/QALY will exceed $75,000. CONCLUSION: Whether microalbuminuria surveillance in this population is cost effective requires more information. Being aware of the costs, recommendation pitfalls, and gaps in our knowledge should help focus our efforts to provide cost effective care to this population.

 prevention;  diabetes;  nephropathy;  screening;  MICROALBUMINURIA;  economic evaluation;  

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Abstract: Studies have demonstrated that antihypertensive treatment with angiotensin-converting enzyme inhibitors (ACEI) may retard the progress of nephropathy in patients with insulin-dependent diabetes mellitus. To obtain an indication of the potential effect of ACEI treatment and as a guide to future research, the effects of screening and early ACEI treatment programs were estimated using cost-effectiveness models. The preliminary analysis suggests that the early treatment of insulin-dependent diabetes mellitus patients with ACEI is likely to be a very cost-effective use of health care resources. The cost-effectiveness ratio for screening and treatment at the stage of microalbuminuria ($7,900 to $16,500 per year of life saved) compares favorably with those of other medical life-saving interventions. Less-aggressive programs (screening followed by treatment at the stage of proteinuria) would improve life expectancy to a lesser extent but could save net health care costs as well as years of life. Although more exact and comprehensive cost-effectiveness analysis must await clinical trials, these illustrative results demonstrate the range of cost-effectiveness that can be expected from these programs and identify data needed for more decisive policy conclusions.

 prevention;  diabetes;  nephropathy;  screening;  MICROALBUMINURIA;  economic evaluation;  

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