Initial impact and cost of a nationwide population screening campaign for diabetes in Brazil: a follow up study.

The Cnddm Working Group ,Cristiana M Toscano,Luciana B Nucci,Carísi Anne Polanczyk,Maria Inês Schmidt,Bruce B Duncan,Cláudio D Fonseca,Sotero S Mengue,Adriana Costa E Forti

doi:10.1186/1472-6963-8-189

Abstract

BackgroundIn 2001 Brazilian citizens aged 40 or older were invited to participate in a nationwide population screening program for diabetes. Capillary glucose screening tests and procedures for diagnostic confirmation were offered through the national healthcare system, diagnostic priority being given according to the severity of screening results. The objective of this study is to evaluate the initial impact of the program.MethodsPositive testing was defined by a fasting capillary glucose ≥ 100 mg/dL or casual glucose ≥ 140 mg/dL. All test results were tabulated locally and aggregate data by gender and clinical categories were sent to the Ministry of Health. To analyze individual characteristics of screening tests performed, a stratified random sample of 90,106 tests was drawn. To describe the actions taken for positive screenees, a random sub-sample of 4,906 positive screenees was actively followed up through home interviews.Main outcome measures considered were the number of diabetes cases diagnosed and cost per case detected and incorporated into healthcare.ResultsOf 22,069,905 screening tests performed, we estimate that 3,417,106 (95% CI 3.1 – 3.7 million) were positive and that 346,168 (290,454 – 401,852) new cases were diagnosed (10.1% of positives), 319,157 (92.2%) of these being incorporated into healthcare. The number of screening tests needed to detect one case of diabetes was 64. As many cases of untreated but previously known diabetes were also linked to healthcare providers during the Campaign, the estimated number needed screen to incorporate one case into the healthcare system was 58. Total screening and diagnostic costs were US$ 26.19 million, the cost per diabetes case diagnosed being US$ 76. Results were especially sensitive to proportion of individuals returning for diagnostic confirmation.ConclusionThis nationwide population-based screening program, conducted through primary healthcare services, demonstrates the feasibility, within the context of an organized national healthcare system, of screening campaigns for chronic diseases. Although overall costs were significant, cost per new case diagnosed was lower than previously reported. However, cost-effectiveness analysis based on more clinically significant outcomes needs to be conducted before this screening approach can be recommended in other settings.

Highlights

In 2001 Brazilian citizens aged 40 or older were invited to participate in a nationwide population screening program for diabetes
Population, nutrition and epidemiological changes in the last century have produced a health risk profile in which chronic diseases such as diabetes mellitus account for a growing proportion of the total disease burden [1]
To evaluate the initial impact of the screening program, a stratified sampling process was used to select first a random sample of 50 municipalities from all of Brazil's 5 regions, entrance probability being proportional to the number of screening tests reported, and second, in each municipality, one primary healthcare unit, again with probability proportional to the number of tests reported

Summary

Introduction

In 2001 Brazilian citizens aged 40 or older were invited to participate in a nationwide population screening program for diabetes. In 2000 an estimated 171 million people, or 2.8% of the world's population, were living with diabetes, Brazil being one of the 10 countries with the highest number [2]. Diabetes is associated with high morbidity and mortality, and substantial loss in quality of life. Associated direct medical costs vary from 2.5% to 15% of total national health expenditures, depending on prevalence and treatment availability [3]. Annual deaths caused by diabetes in Latin America and Caribbean have been estimated at 340,000 in 2000, representing a loss of 760,000 years of productive life and total costs of U$ 65 billion [4]. Diabetes figures among the 10 major causes of mortality in the country [5] and current best data suggests that the prevalence of undiagnosed diabetes is high [6]

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