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Direct evidence of the benefits of early detection of type 2 diabetes by screening are lacking and are now unlikely to be obtained. However, the ADDITION study, the recent robust modelling studies, and a move to using non-invasive tests followed by haemoglobin A as a diagnostic test for diabetes suggest that screening and intensive risk factor control of people with diabetes is feasible in primary care and is likely to be cost effective.
Spending limited health service resources on a diabetes risk assessment and prevention programme reduces resources available for specialist management of these serious preventable diabetes complications. While, in the short term, the theoretical cost savings from reduced complication rates generated by screening programmes can rarely be realised in practice, the real savings generated by not screening could immediately be spent on diabetes patients’ care.
COMMENT: In one sense these two articles reflex the maxim: “Where you stand depends on where you sit.” If you are focused on the individual sitting in your clinic as in the YES essay, then you would screen when there is sufficient risk. And there are certainly data that would allow a clinician to make a cost effective decision based upon clinical and epidemiologic characteristics of the person across from you. If you are focused on the health care system as is the NO essay, however, then you want to spend your preventative funds in the most cost effective way. That decision would then rest with population statistics and evidence of the cost effectiveness of life style cardiovascular prevention programs. My own view is that each perspective has merits. Whereas we probably should not go back to universal screening at malls and train stations, careful screening of persons at risk when they encounter the health care system seems reasonable. Meanwhile we will need to design, evaluate, implement and expand population-based cardiovascular disease prevention programs focused primarily on obesity prevention and increased physical activity.