Design of stepwise screening for prediabetes and type 2 diabetes based on costs and cases detected

Objectives: To provide insight into the trade-off between cost per case detected (CPCD) and the detection rate in questionnaire-based stepwise screening for impaired fasting glucose and undiagnosed type 2 diabetes.Study Design and Setting: We considered a stepwise screening in which individuals whose risk score exceeds a predetermined cutoff value arc invited for further blood glucose testing. Using individual patient data to determine questionnaire sensitivity and specificity and external sources to determine screening costs and patient response rates, we rolled back a decision tree to estimate the CPCD and the detection rate for all possible cutoffs on the questionnaire.Results: We found a U-shaped relation between CPCD and detection rate, with high costs per case detected at very low and very high detection rates. Changes in patient response rates had a large impact on both the detection rate and the CPCD, whereas screening costs and questionnaire accuracy mainly impacted the CPCD.Conclusion: Our applied method makes it possible to identify a range of efficient cutoffs where higher detection rates can be achieved at an additional cost per detected patient. This enables decision makers to choose an optimal cutoff based on their willingness to pay for additional detected patients. (C) 2015 Elsevier Inc. All rights reserved.