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The American Journal of Managed Care November 2019
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Population Health Screenings for the Prevention of Chronic Disease Progression
Maren S. Fragala, PhD; Dov Shiffman, PhD; and Charles E. Birse, PhD
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Shaohui Zhai, PhD; Rebecca A. Malouin, PhD, MPH, MS; Jean M. Malouin, MD, MPH; Kathy Stiffler, MA; and Clare L. Tanner, PhD

Population Health Screenings for the Prevention of Chronic Disease Progression

Maren S. Fragala, PhD; Dov Shiffman, PhD; and Charles E. Birse, PhD
Identification of chronic diseases in their early stages enables prompt treatment that can slow or prevent disease development and debilitating and costly health outcomes.
Annual screening of employees and spouses found that for every 10,000 participants, 287 (2.9%) had previously unrecognized hyperglycemia (laboratory evidence of diabetes; A1C >6.4% or FG >125 mg/dL). Using previous reports of CVD incidence16 and microvascular complications (retinopathy, neuropathy, and nephropathy),15 we estimated that within 1 year, for every 1000 patients with confirmed diabetes, about 105 would experience complications (Table 215,16,25): 10 patients would have CVD, 14 patients would have retinopathy, 36 patients would have neuropathy, and 45 patients would have nephropathy. Within 5 years, about 489 would experience complications, including 50 patients with CVD, 68 patients with retinopathy, 168 patients with neuropathy, and 203 patients with nephropathy.

Annual screening for laboratory evidence of CKD found that for every 10,000 participants, 146 (1.46%) had previously unrecognized low eGFR (<60 mL/min/1.73 m2) (Table 33,6,17,20). Similar rates have been observed in patients screened in primary care settings.26 Prior research17 suggests that approximately 50% of initial low eGFR findings are confirmed as CKD upon follow-up. Considering the progression rate from CKD to ESRD observed in the Alberta Kidney Disease Network,20 we predicted that for every 1000 cases of confirmed CKD, about 7 patients would progress to ESRD within a year and about 34 within 5 years (Table 33,6,17,20). In addition, based on previous research,18,19 136 would be expected to progress to stage 4 or stage 5 (of 5 stages) over 5 years.

Annual screening for colorectal cancer resulted in a positive screening test rate of 6.7% (Table 421,22). For every 10,000 FIT tests evaluated, 669 had a positive result. Assuming that 78% of those with a positive test have a follow-up colonoscopy21 (n = 525), we estimate subsequent diagnosis of 263 adenomas (some considered precancerous) and 14 colorectal cancers. Assuming a similar stage distribution to profiles observed in other FIT-based screening studies,22 we estimate that the 14 colorectal cancers detected would be made up of 6 stage I , 4 stage II, and 4 stage III cases (of 4 stages). We also assume that the screen-dependent shift toward earlier-stage detection would result in 3 more stage I cancers and 1 fewer stage II cancer and 2 fewer stage IV cancers being diagnosed than would have been the case without screening.



Early detection of prediabetes is important because type 2 diabetes can be present for 9 to 12 years before being diagnosed and, as a result, complications are often present at the time of diagnosis.27 Without detection and early intervention, 4% to 19% of those with prediabetes develop diabetes each year, depending on the population and criteria.28,29 A1C and FG are accepted methods for prediabetes screening and diagnosis of diabetes. We recently reported that elevated A1C in working-age individuals with normal FG in an employee wellness program was associated with 2- to 8-fold greater odds of incident diabetes within 4 years.30

Fortunately, lifestyle interventions are effective in reducing incidence of diabetes.14,29 Lifestyle interventions may reduce incidence of diabetes by up to 58% over 3 years.14,29 Prior research has similarly shown the effectiveness of employer-based health screening for diabetes and prediabetes,31 but benefits depend on many factors. Benefits of diabetes prevention are greater when diabetes risk is detected early.32 Thus, in addition to disease prevention, prompt screening and intervention is associated with reduced absolute and relative risk and all-cause mortality at 5 years compared with a 3-year delay in diagnosis.32

Medical costs of prediabetes and undiagnosed diabetes are approximately $510 and $4030 per year per person, respectively.2 When prediabetes progresses to diabetes, people with diagnosed diabetes, on average, have medical expenditures approximately 2.3 times higher than they would be in the absence of diabetes.24 In addition, indirect costs associated with absence, productivity, and disability further exacerbate the costs of chronic health conditions.7,24 The American Diabetes Association quantified the estimated cost of diagnosed diabetes in the United States in 2017 as $327 billion, including $237 billion (72%) in direct medical costs and $90 billion (28%) in reduced productivity.24


Poor management of diabetes can be associated with disease-related complications such as CVD, nephropathy, retinopathy, and neuropathy, which can lead to chronic morbidities and mortality.33,34 More than 20% of diabetes in the United States is undiagnosed,35 and risk of complications is associated with diabetes duration.36 Detection and treatment that is delayed by 3 years has been shown to translate into 40% higher 5-year CVD risk (11.2% vs 7.9%) and 20% higher incidence of all-cause mortality (7.2% vs 6.0%).32 In addition, risk for cardiovascular events or vascular events is 11% to 16% higher with every 1% increase in A1C37,38 or 18 mg/dL (1 mmol/L) increase in FG greater than 100 mg/dL.39,40 Thus, detection and care may reduce CVD and microvascular complications, including retinopathy, neuropathy, and nephropathy. Average lifetime medical costs for an individual with diabetes have been estimated at $85,200, of which 53% is due to treating diabetic complications.41 Per-year medical costs for a person with diabetes are approximately $16,750, and about $9600 to $10,970 of these costs are attributed to diabetes.2,24

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