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GPs to take on millions with pre-diabetes under CVD screening plans

By Nigel Praities

GPs face having to manage diabetes and pre-diabetes in millions of new patients, under Government plans to add routine glucose tolerance testing to the cardiovascular screening programme.

The Department of Health is considering proposals for GPs to routinely test for impaired glucose tolerance as part of planned vascular checks, after a major evaluation showed it was more cost-effective than screening for diabetes alone.

The department is keen to involve GPs in lifestyle interventions for prevention of diabetes, insisting there is ‘increasing evidence' for their effectiveness.

But moves to screen for pre-diabetes would pile enormous pressure on practices. An estimated 20% of patients screened would be diagnosed with diabetes or impaired glucose tolerance, and would require continuous monitoring, lifestyle advice and treatment.

In March, health secretary Alan Johnson announced everyone at risk aged 40-75 would be offered a plasma glucose test for diabetes as part of a programme of vascular checks to be introduced next year.

Under the screening plans, a diagnosis of diabetes could be set at a fasting plasma glucose level of more than 6mmol/l.

But UK researchers now say that adding glucose tolerance tests for those with borderline fasting plasma glucose levels would make the screening more cost-effective.

Their evaluation, based on data from 15 practices in Leicestershire, showed the estimated cost for diabetes screening was £14,150 per quality-adjusted life year, compared with £6,242 for screening for IGT and diabetes. They also found introducing drug treatment for diabetes and IGT was cost-effective.

The study, published online by the BMJ, suggested all patients with a fasting plasma glucose of more than 5.7mmol/l should get an oral glucose tolerance test to identify those with IGT. About 4% of people aged 40-74 have undiagnosed diabetes, but a further 16% have IGT.

Study leader Professor Kamlesh Khunti, professor of primary care diabetes and vascular medicine at the University of Leicester, admitted IGT screening would be ‘very time-consuming' for GPs, but said the evidence supporting its inclusion was strong.

Professor Khunti, who helped collate the evidence supporting vascular screening for the National Screening Committee, said: ‘If you do a glucose tolerance test you will find people with IGT – and we know interventions are effective and can reduce the risk of developing diabetes by 50%.'

A Department of Health spokesperson said: ‘There is increasing evidence on the clinical benefits and cost-effectiveness of lifestyle interventions for people with impaired glucose regulation and we will be considering this, with stakeholders, in the coming months.'

But Dr Peter Stott, a GP in Tadworth, Surrey, and a GPSI in diabetes, warned managing patients with IGT as well as diabetes would be an ‘enormous' problem.

‘The rise in diabetes already has the potential to break the NHS and if we double the population needing treatment it has very significant cost and workload implications.'

Diabetes: screening set to lead to massive new workload Diabetes: screening set to lead to massive new workload Vascular screening programme

• The £250m vascular checks programme will be piloted from the end of this year and will be available for everyone aged
40-75 from next year
• Checks will include basic information such as height, weight, current medication,
age, family history of vascular diseases, smoking, blood pressure and cholesterol levels
• People at risk of diabetes will receive a glucose test within their initial visit and people with glucose levels just below those diagnostic for diabetes may receive a test for impaired glucose tolerance

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