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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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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.
CKD

Progression of CKD can be slowed when it is detected in the early stages.42-44 Early identification, intervention, and referral to a nephrologist are essential to slow progression of CKD and avoid complications of ESRD.5,42 Typically, a multifactorial treatment approach is advocated to treat the causes and consequences of CKD, slow CKD progression, and avoid ESRD.43 As hypertension and type 2 diabetes are the major causes of CKD and are important treatment targets, it is possible to attenuate disease progression and slow reductions in eGFR with proactive treatment.44 Progression rates of CKD vary with annual reductions in kidney function ranging from 2 mL/min/1.73 m2 to 12 mL/min/1.73 m2 per year depending on the stage of CKD and comorbidities, such as diabetes.44,45 Rates of decline may be as high as 10 mL/min/1.73 m2 to 14 mL/min/1.73 m2 in individuals with diabetes who are not receiving early antihypertensive treatment.46 Although individuals in stage 3 typically do not have symptoms,44 progression to stages 4 and 5 is associated with such complications as hypertension, anemia, bone disease, metabolic acidosis, and increased risk of CVD.47 Prior research44,48 has supported the value of screening for and initiating intervention at stage 3a with eGFR less than 60 mL/min/1.73 m2 to generate the most quality-adjusted life-years.48 The decline in renal function may be slowed from an annual eGFR decline of 12.0 mL/min/1.73 m2 to a decline of 3.4 mL/min/1.73 m2 with early detection and care.48 With a baseline screening eGFR value of 58 mL/min/1.73 m2, this may represent a difference of 9 years (12.6 years vs 3.6 years) until eGFR declines to less than 15 mL/min/1.73 m2 (ESRD) with screening and nephrology care.

CKD is an increasingly prevalent healthcare burden, affecting approximately 13% of the US population.49 From an economic perspective, costs attributable to the disease increase by $9200 per person per year from stage 3 ($3500) to stage 4 ($12,700).50 Individuals with CKD incur medical costs due to comorbidities that are substantially greater in advanced stages of CKD (stages 4 and 5).3 Considering all-cause costs, progression between stage 3a ($27,000/year) and stages 4 and 5 ($77,000/year) equates to a roughly $50,000 difference (vs $122,000 for ESRD without dialysis) in commercial health plans, mostly due to inpatient costs.3 The estimated costs of hemodialysis (direct cost of treating CKD) for those who progress to ESRD among patients with newly identified CKD are expected to be greater than $300,000 in the first year and balloon to more than $7 million over 5 years based on the cost of hemodialysis treatment.6

Colorectal Cancer

Screening for colorectal cancer has been shown to reduce both incidence and mortality.4,51,52 Earlier-stage detection of colorectal cancer toward localized disease, more commonly treated with surgery, results in substantial cost savings spanning the continuum of cancer care, from the year of diagnosis (stage I, $30,000; stage IV, $67,000) through continuing years (stage I, $2500; stage IV, $11,000) to the last year of life (stage I, $54,000; stage IV, $76,000).53 Generally, adherence to colorectal cancer screening is more important than which strategy is used, with higher rates of screening being associated with a 25.5% reduction in annual colorectal cancer incidence.54 Despite these findings, more than one-third of eligible adults remain nonadherent to current colorectal cancer screening recommendations.55 Noninvasive stool testing improves compliance, with adherence nearly double that for colonoscopy.56 In addition, 97% of patients refusing colonoscopy accept a noninvasive screening test.12 Accordingly, the US Preventive Services Task Force recommends annual screening with a sensitive noninvasive stool test as part of a screening strategy for colorectal cancer.57 Although other screening modalities are considered effective,58 annual FIT screening for colorectal cancer is deemed more effective and less costly compared with other options.52 Moreover, newer FIT tests offer greater simplicity and sensitivity relative to historical fecal occult guaiac-based blood tests while remaining relatively inexpensive compared with other diagnostic screening modalities at $20 to $50 per kit.59

Limitations

A few limitations to the study should be considered when interpreting the study findings. First, although the study reflects data from a large workforce, the study population may not necessarily represent the demographics of all employers. Second, because participation in the annual health screening program was voluntary, participation reflected about 65% of the entire pool of employees and spouses eligible to participate and might include those more likely to be engaged in their healthcare; however, this population is likely to reflect other employee wellness program populations. Third, the study is based on laboratory evidence of chronic disease and self-reported physician diagnosis, but physician diagnoses from health records were not available for study; thus, definite diagnoses cannot be made. However, those identified based on laboratory evidence and self-reported diagnoses should provide a good indication of the fraction of participants who would benefit from additional follow-up. Despite these limitations, knowledge of previously unrecognized disease may enable health engagement and more positive health outcomes for individuals in a large population.

CONCLUSIONS

Population health screening identifies early evidence of unrecognized prediabetes, diabetes, CKD, and colorectal cancer in large populations to improve health trajectories. Early identification enables prompt treatment that can prevent disease progression and yield positive value on investment. This study provides quantification of unknown health risk for conditions that are not always screened for in employee populations9 and extrapolates the health impact and opportunity for an employee population. Provided data and insights may facilitate the delivery of population health programs to targeted employee segments—a strategy required to drive results.10 Driven by data, care pathways may narrow gaps in care and improve patient understanding, clinical outcomes, quality of life, and productivity, which may further benefit population health. As chronic diseases present a substantial and growing economic burden to large employers in regard to both healthcare costs and productivity, employer-sponsored annual health screenings may facilitate the delivery of population health.

Author Affiliations: Quest Diagnostics, Secaucus, NJ (MSF), and San Juan Capistrano, CA (DS, CEB).

Source of Funding: Sponsorship for this analysis was provided by Quest Diagnostics.

Author Disclosures: Drs Fragala, Shiffman, and Birse are employees of and own stock in Quest Diagnostics, which provides laboratory testing services.

Authorship Information: Concept and design (MSF, DS, CEB); acquisition of data (MSF, DS, CEB); analysis and interpretation of data (MSF, DS, CEB); drafting of the manuscript (MSF); critical revision of the manuscript for important intellectual content (MSF, DS, CEB); statistical analysis (MSF); and provision of patients or study materials (MSF).

Address Correspondence to: Maren S. Fragala, PhD, Quest Diagnostics, 500 Plaza Dr, Secaucus, NJ 07094. Email: maren.s.fragala@questdiagnostics.com.
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