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Harris RP, Lux LJ, Bunton AJ, et al. Screening for Type 2 Diabetes Mellitus [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2003 Feb. (Systematic Evidence Reviews, No. 19.)

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

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Screening for Type 2 Diabetes Mellitus [Internet].

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Analytic Framework and Key Questions

To complete this systematic evidence review (SER) for the US Preventive Services Task Force (USPSTF), we developed an analytic framework (Figure 2) and 6 key questions (Table 1) to quantify the benefits, harms, and costs of screening for type 2 diabetes mellitus (DM-2). The analytic framework describes the relationship between screening a population at risk for asymptomatic diabetes and 4 critical health outcomes: severe visual impairment, chronic renal failure (ie, end-stage renal disease), lower extremity amputations, and macrovascular endpoints (cardiovascular disease [CVD] events). Early treatments and intermediate or health outcomes that they affect include: laser photocoagulation for retinopathy; tight glycemic control for retinopathy, albuminuria, foot ulcers, and macrovascular endpoints; tight blood pressure control for retinopathy, hypertension, and macrovascular endpoints; angiotension-converting enzyme (ACE) inhibitors and angiotension receptor blockers (ARBs) for albuminuria and macrovascular endpoints; foot care programs for foot ulcers; and lipid control for dyslipidemia. In this logic model, tight glycemic control and tight blood pressure control relate to all 4 health outcomes; laser photocoagulation to severe visual impairment, foot care programs to lower extremity amputations, and lipid control to cardiovascular events. Finally, prevention (below the screening arrow) concerns the question of early detection and treatment of impaired fasting glucose or impaired glucose tolerance and, in theory, primary prevention of the complications shown as the 4 major health outcomes. The arrows in the analytic framework thus represent steps in the chain of logic connecting screening with these 4 outcomes; the numbers in parentheses are key questions in Table 1.

Figure 2. Screening for Type 2 Diabetes: Analytic Framework.


Figure 2. Screening for Type 2 Diabetes: Analytic Framework.

Table 1. Screening for Type 2 Diabetes: Key Questions.


Table 1. Screening for Type 2 Diabetes: Key Questions.

Search Strategy

We identified studies in the English language by searching the MEDLINE database from 1966 through November 7, 2001. Apart from formal searches, we examined reference lists of textbooks, monographs, and review articles, and we queried experts in the field.

All MEDLINE searches included the term "NIDDM" and a wide range of additional terms: risk retinopathy, nephropathy, neuropathy, cardiovascular disease, stroke, visual impairment, chronic renal failure, lower extremity amputation, mass screening, glucose tolerance, costs and cost-effectiveness, harms (psychological, drug related), primary prevention, cataracts, and quality of life. Searches for the key questions on treatment efficacy added terms for the specific treatments; these included, for example, angiotension-converting-enzyme inhibitors, calcium channel blockers, diet, and glycemic control (with either insulin or oral agents), HMG co-A reductase inhibitors, photocoagulation, and physical activity, as well as terms for "randomized controlled trial."

Our search strategy involved 2 phases. The first used broad search terms and review criteria to maximize the probability of identifying all potentially relevant articles. The second applied more stringent criteria to focus on those studies directly applicable to the key questions.

The first author and at least 1 other author or physician consultant independently reviewed the titles and abstracts of the 4,983 articles and selected 1,557 as most relevant to the key questions. Of these, we retained and abstracted data from 44 that met the stringent inclusion criteria and most directly addressed the key questions. Data describing studies (trials, observational studies, and meta-analyses) and their results were recorded in the evidence tables.

Production of the Systematic Evidence Review

The project team included representatives from the Research Triangle Institute-University of North Carolina at Chapel Hill Evidence-based Practice Center and 3 representatives from the US Preventive Services Task Force. The entire Task Force discussed the SER's work plan, evidence tables, and preliminary text at several meetings and provided overall guidance. A draft SER was subjected to extensive external peer review (see Acknowledgments, Appendix A) and we revised the SER accordingly. A shorter version of the work 37 accompanies the USPSTF Recommendations and Rationale statement on this topic.

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