The Health System and Population Health Implications of Large-Scale Diabetes Screening in India

A Microsimulation Model of Alternative Approaches

Citation: Basu S, Millett C, Vijan S, Hayward RA, Kinra S, Ahuja R, et al. (2015) The Health System and Population Health Implications of Large-Scale Diabetes Screening in India: A Microsimulation Model of Alternative Approaches. PLoS Med 12(5): e1001827. doi:10.1371/journal.pmed.1001827
Published: May 19, 2015

Abstract
Background: Like a growing number of rapidly developing countries, India has begun to develop a system for large-scale community-based screening for diabetes. We sought to identify the implications of using alternative screening instruments to detect people with undiagnosed type 2 diabetes among diverse populations across India.
Methods and Findings: We developed and validated a microsimulation model that incorporated data from 58 studies from across the country into a nationally representative sample of Indians aged 25–65 y old. We estimated the diagnostic and health system implications of three major survey-based screening instruments and random glucometer-based screening. Of the 567 million Indians eligible for screening, depending on which of four screening approaches is utilized, between 158 and 306 million would be expected to screen as “high risk” for type 2 diabetes, and be referred for confirmatory testing. Between 26 million and 37 million of these people would be expected to meet international diagnostic criteria for diabetes, but between 126 million and 273 million would be “false positives.” The ratio of false positives to true positives varied from 3.9 (when using random glucose screening) to 8.2 (when using a survey-based screening instrument) in our model. The cost per case found would be expected to be from US$5.28 (when using random glucose screening) to US$17.06 (when using a survey-based screening instrument), presenting a total cost of between US$169 and US$567 million. The major limitation of our analysis is its dependence on published cohort studies that are unlikely fully to capture the poorest and most rural areas of the country. Because these areas are thought to have the lowest diabetes prevalence, this may result in overestimation of the efficacy and health benefits of screening.
Conclusions: Large-scale community-based screening is anticipated to produce a large number of false-positive results, particularly if using currently available survey-based screening instruments. Resource allocators should consider the health system burden of screening and confirmatory testing when instituting large-scale community-based screening for diabetes.

Editors' Summary
Background: Worldwide, 387 million people have diabetes, a chronic condition characterized by high levels of glucose (sugar) in the blood. Blood sugar levels are usually controlled by insulin, a hormone released by the pancreas after meals. In people with type 2 diabetes (the most common type of diabetes), blood sugar control fails because the fat and muscle cells that normally respond to insulin by removing excess sugar from the blood become less responsive to insulin. Risk factors for diabetes include being overweight, having a large waist, being physically inactive, and having a family history of diabetes. The symptoms of diabetes, which develop slowly, include excessive urination at night and unexplained weight loss. Type 2 diabetes can usually be controlled initially with diet and exercise and with antidiabetic drugs such as metformin and sulfonylureas, but many patients eventually need insulin injections. Long-term complications of diabetes, which include an increased risk of heart disease and stroke, reduce the life expectancy of people with diabetes by about 10 years compared to people without diabetes.

Why Was This Study Done?
Diabetes is becoming increasing common, particularly in rapidly developing countries, but most people with diabetes in these countries are unaware that they have the condition. Because the risk of developing diabetic complications is reduced by careful blood sugar control, it is important to identify and treat anyone who has diabetes as early as possible. Some rapidly developing countries are therefore beginning to develop systems for large-scale community-based screening for diabetes (even though the UK has recently decided against such screening). In India, for example, more than 53 million adults living in rural and urban communities have already been screened using either questionnaires designed to provide a risk score (survey-based screening) or random blood glucose testing (glucometer-based screening). People who are identified as “high risk” using these approaches are referred for fasting blood glucose tests to confirm the diagnosis. Although the Indian government plans to expand this screening program, no data have been collected to track its performance. Here, the researchers develop a microsimulation model (a computer model that operates at the level of individuals) to investigate the implications of using alternative screening instruments to identify people with undetected diabetes across diverse populations in India.

What Did the Researchers Do and Find?
The researchers constructed a synthetic nationally representative population of Indians aged 25–65 years using data from 58 sub-national studies. They then used their microsimulation model to estimate the diagnostic and health system implications of using three survey-based screening instruments and glucometer-based screening to identify individuals in this population with diabetes. Depending on which approach was used for screening, between 158 million and 306 million of the 567 million Indians eligible for screening would be classified as high risk for diabetes and would be referred for confirmatory testing, according to the model. However, between 126 million and 273 million of these high-risk individuals would be false positives; only between 26 million and 37 million of these individuals would meet the international diagnostic criteria for diabetes (true positives). The researchers estimate that the cost per case found would vary from US$5.28 (when using random glucose screening) to US$17.06 (when using a survey-based screening instrument). Finally, they estimate that the total cost for screening the eligible population would be between US$169 and US$567 million.

What Do These Findings Mean?
Established criteria for implementing screening programs specify that such programs should use reliable instruments that detect a large proportion of true cases (high sensitivity) and that have a low rate of false positives (high specificity). Screening programs should also offer significant therapeutic benefits to individuals diagnosed through screening. The findings of this study suggest that large-scale community-based screening for diabetes in India using the currently available screening instruments is unlikely to meet these criteria. Indeed, because the data used to construct the synthetic population came from published studies that did not capture the situation in the poorest, most rural areas of India, where the proportion of the population with diabetes is thought to be lowest, these findings may overestimate the efficacy and health benefits of screening. The researchers suggest, therefore, that an approach that focuses on symptom-based screening and on improvements in the treatment of already diagnosed individuals might be a more sensible path for India to take to deal with its burgeoning diabetes epidemic than community-based mass screening.

Additional Information.
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1​001827.

  • The US National Diabetes Information Clearinghouse provides information about diabetes for patients, healthcare professionals, and the general public (in English and Spanish)
  • The UK National Health Service Choices website provides information for patients and caregivers about type 2 diabetes and about living with diabetes; it also provides people’s stories about diabetes
  • The charity Diabetes UK provides detailed information for patients and caregivers in several languages
  • The UK-based non-profit organization HealthTalkOnline has interviews with people about their experiences of diabetes
  • MedlinePlus provides links to further resources and advice about diabetes (in English and Spanish)
  • A statement from the UK National Screening Committee on diabetes screening in adults is available

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