Engelgau M M, Narayan K M, Herman W H
Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia 30341, USA.
Diabetes Care. 2000 Oct;23(10):1563-80. doi: 10.2337/diacare.23.10.1563.
Definitive studies of the effectiveness of screening for type 2 diabetes are currently not available. RCTs would be the best means to assess effectiveness, but several barriers prevent these studies from being conducted. Prospective observational studies may characterize some of the benefits of screening by creating screened and unscreened groups for comparison. The availability of better data systems and health services research techniques will facilitate such comparisons. Unfortunately, the interpretation of the results of such studies is extremely problematic. Several screening tests have been evaluated. Risk assessment questionnaires have generally performed poorly as stand-alone tests. Screening with biochemical tests performs better. Venous and capillary glucose measurements may perform more favorably than urinary glucose or HbA(1c) measurements, and measuring postprandial glucose levels may have advantages over measuring fasting levels. However, performance of all screening tests is dependent on the cutoff point selected. Unfortunately, there are no well-defined and validated cutoff points to define positive tests. A two-stage screening test strategy may assist with a more efficient use of resources, although such approaches have not been rigorously tested. The optimal interval for screening is unknown. Even though periodic, targeted, and opportunistic screening within the existing health care system seems to offer the greatest yield and likelihood of appropriate follow-up and treatment, much of the reported experience with screening appears to be episodic poorly targeted community screening outside of the existing health care system. Statistical models have helped to answer some of the key questions concerning areas in which there is lack of empirical data. Current models need to be refined with new clinical and epidemiological information, such as the UKPDS results (200). In addition, future models need to include better information on the natural history of the preclinical phase of diabetes. Data from ongoing clinical trials of screening and treatment of impaired glucose tolerance, such as the Diabetes Prevention Program, may eventually offer more direct evidence for early detection and treatment of asymptomatic hyperglycemia (201). It will be important to use comprehensive cardiovascular disease modules that assess the conjoint influence of glucose and cardiovascular risk factor reduction, information on QOL, and refined economic evaluations using common outcome measures (cost per life-year or QALY gained) (11,178,202-204). Such studies should consider all of the costs associated with a comprehensive screening program, including, at a minimum, the direct costs of screening, diagnostic testing, and care for patients with diabetes detected through screening. Finally, combinations of screening tests and different screening intervals should be evaluated within economic studies to allow selection of the optimal approach within the financial and resource limitations of the health care system.
目前尚无关于2型糖尿病筛查有效性的确定性研究。随机对照试验是评估有效性的最佳方法，但存在一些障碍阻碍了这些研究的开展。前瞻性观察性研究可以通过设立筛查组和未筛查组进行比较，从而描述筛查的一些益处。更好的数据系统和卫生服务研究技术的可用性将有助于此类比较。不幸的是，对此类研究结果的解释极具问题。已经评估了几种筛查测试。风险评估问卷作为独立测试通常表现不佳。生化测试筛查表现更好。静脉和毛细血管血糖测量可能比尿糖或糖化血红蛋白（HbA1c）测量表现更优，测量餐后血糖水平可能比测量空腹水平更具优势。然而，所有筛查测试的表现都取决于所选的临界值。不幸的是，尚无明确且经过验证的临界值来定义阳性测试。两阶段筛查测试策略可能有助于更有效地利用资源，尽管此类方法尚未经过严格测试。最佳筛查间隔尚不清楚。尽管在现有医疗保健系统内进行定期、有针对性和机会性筛查似乎能带来最大收益以及进行适当随访和治疗的可能性，但所报道的许多筛查经验似乎都是在现有医疗保健系统之外进行的偶发性、针对性差的社区筛查。统计模型有助于回答一些缺乏实证数据领域的关键问题。当前模型需要用新的临床和流行病学信息进行完善，比如英国前瞻性糖尿病研究（UKPDS）的结果（200）。此外，未来模型需要纳入关于糖尿病临床前期自然史的更好信息。正在进行的糖耐量受损筛查和治疗临床试验（如糖尿病预防计划）的数据，最终可能为无症状高血糖的早期检测和治疗提供更直接的证据（201）。使用综合心血管疾病模块很重要，该模块可评估血糖和心血管危险因素降低的联合影响、生活质量信息以及使用常见结局指标（每生命年成本或获得的质量调整生命年）进行的精细经济评估（11,178,202 - 204）。此类研究应考虑与全面筛查计划相关的所有成本，至少包括筛查、诊断测试以及对通过筛查发现的糖尿病患者进行护理的直接成本。最后，应在经济研究中评估筛查测试组合和不同的筛查间隔，以便在医疗保健系统的财务和资源限制范围内选择最佳方法。
