Screening: Australia

Type 2 diabetes is a costly yet preventable chronic disease. An approach to stabilise or even lower the prevalence and its associated economic burden is to screen for undiagnosed diabetes and future risk of developing diabetes follow by lifestyle intervention to prevent diabetes or early treatment to prevent its associated complications. In Australia, the annual excess direct cost associated with diabetes was $4.5 million in 2005.[1] Although universal health care applies in Australia, half of all diabetes cases in 2000 were undiagnosed.[2]

Government recommendations

Figure 1: Recommended testing for and diagnosing type 2 diabetes. Adapted from Colagiuri et al. 2009[3]
Figure 1: Recommended testing for and diagnosing type 2 diabetes. Adapted from Colagiuri et al. 2009[3]
In 2009, the National Health and Medical Research Council published an evidence based guideline for case detection and diagnosis of type 2 diabetes. The guideline recommended diabetes risk assessment should be performed on people from aged 40 years and Aboriginal and Torres Strait Islander people from aged 18 years.[3] A three-step procedure for detecting undiagnosed type 2 diabetes was also recommended. It includes an initial risk assessment using the Australian type 2 diabetes risk assessment tool (AUSDRISK)[4] or risk factors commonly associated with undiagnosed diabetes, a fasting plasma glucose measurement, and an oral glucose tolerance test for those with an equivocal result (Figure 1). People with impaired fasting glucose or impaired glucose tolerance, history of gestational diabetes, polycystic ovary syndrome or a cardiovascular disease event, and those on antipsychotic medication should bypass the initial risk assessment step. Capillary blood testing can be used for the screening step and the use of random plasma glucose or bypassing the fasting plasma glucose step may be performed if it is considered impractical to collect a fasting sample. Re-testing for undiagnosed type 2 diabetes was recommended annually for people with impaired fasting glucose or impaired glucose tolerance and once every three years for everyone else.

In 2012, a national guideline for the management of absolute cardiovascular disease risk recommended the use of the Framingham Risk Equation in the assessment of cardiovascular risk.[5] It also recommended that risk assessment should be performed on people aged 45-74 years, Aboriginal and Torres Strait Islander people aged 35-74 years, adults with diabetes aged ≤60 years, and adults who are overweight or obese, but are not known to have cardiovascular disease or to be at clinically determined high risk.[5] People with both diabetes and microalbuminuria, moderate or severe chronic kidney disease, a previous diagnosis of familial hypercholesterolaemia, severely elevated blood pressure (systolic blood pressure ≥ 180 mmHg or diastolic blood pressure ≥ 110 mmHg), high total cholesterol (serum total cholesterol >7.5 mmol/L), aged >60 years with diabetes, and Aboriginal and Torres Strait Islander people aged >74 years are considered at high cardiovascular risk, hence, do not require a cardiovascular disease risk assessment. Reassessment of cardiovascular disease risk was recommended once every six to twelve months for people with moderate risk and once every two years for those with low risk.

Clinical practice

Australia has no national screening program for diabetes or cardiovascular disease and its universal health insurance scheme, Medicare, does not subsidise health screening service. However, targeted screening in the form of health assessment by medical practitioners for diabetes and cardiovascular disease are subsidised by the Government through Medicare. Rebates are available for a one-off health assessment for people aged 45-49 years who are at risk of developing chronic disease, health assessment for Aboriginal and Torres Strait Islander people aged 15-54 years once every nine months, and health assessment provided as a type 2 diabetes risk evaluation for people aged 40-49 years with a high AUSDRISK score once every three years.[6] The type 2 diabetes risk evaluation must include an evaluation of the patient’s high risk score, an update of the patient’s history including physical examination and clinical investigations according to national guidelines, initiation of interventions, and provide advice and information.[6] People who have been identified, using AUSDRISK, as having a high risk of type 2 diabetes at the health assessment may be referred by their medical practitioner to a subsidised lifestyle modification program.

Treatments

There are no treatment recommendations specifically for people with screen-detected diabetes. People with screen-detected diabetes receive the same diabetes advice and treatment as those with newly diagnosed diabetes. The national guideline for blood glucose control in type 2 diabetes recommended a trial of lifestyle modification for people with newly diagnosed type 2 diabetes.[7] Moreover, those with significant hyperglycaemia at diagnosis may also require pharmacotherapy. Medicare subsidies are available for people with diabetes and referral from medical practitioners to attend group allied health services provided by diabetes educators, dietitians and exercise physiologists.[6] Culturally appropriate and clinically effective diabetes management service is available for Aboriginal and Torres Strait Islander people through the Government funded Quality Assurance for Aboriginal and Torres Strait Islander Medical Services.[8] For people with established diabetes, Medicare rebate is available for the annual Diabetes Cycle of Care, which offers incentives for medical practitioners to provide effective diabetes management.[9]

References

  1. ^ Lee CM, Colagiuri R, Magliano DJ, Cameron AJ, Shaw J, Zimmet P, Colagiuri S. The cost of diabetes in adults in Australia. Diabetes Res Clin Pract 2013; 99:385-390.

  2. ^ Dunstan D, Zimmet P, Welborn T, Sicree R, Armstrong T, Atkins R, Cameron A, Shaw J, Chadban S; AusDiab Steering Committee. Diabesity and associated disorders in Australia – 2000: the accelerating epidemic. The Australian Diabetes, Obesity and Lifestyle Study (AusDiab). International Diabetes Institute, Melbourne 2001.

  3. ^ Colagiuri S, Davies D, Girgis S, Colagiuri R. National evidence based guideline for case detection and diagnosis of type 2 diabetes. Diabetes Australia and the NHMRC, Canberra 2009.

  4. ^ Chen L, Magliano DJ, Balkau B, Colagiuri S, Zimmet PZ, Tonkin AM, Mitchell P, Philips PJ, Shaw JE. AUSDRISK: an Australian type 2 diabetes risk assessment tool based on demographic, lifestyle and simple anthropometric measures. Med J Aust 2010; 192:197-202.

  5. ^ National Vascular Disease Prevention Alliance. Guidelines for the management of absolute cardiovascular disease risk. 2012.

  6. ^ Commonwealth of Australia. MBS Online Medicare benefits schedule. URL http://www.mbsonline.gov.au. (Accessed on 24 April 2014).

  7. ^ Colagiuri S, Dickinson S, Girgis S, Colagiuri R. National evidence based guideline for blood glucose control in type 2 diabetes. Diabetes Australia and the NHMRC, Canberra 2009.

  8. ^ Quality assurance for Aboriginal and Torres Strait Islander medical services. URL http://www.qaams.org.au. (Accessed on 24 April 2014).

  9. ^ Department of Human Services. Practice incentives program. Diabetes incentive guidelines 2013. URL http://www.medicareaustralia.gov.au/provider/incentives/pip/files/9520.1308.pdf. (Accessed on 24 April 2014).

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