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Introducing management efforts to prediabetic patients will result in
benefits to patients and the health system
Our model cannot fully capture the full scale of economic, health, and individual benefits that
would be accrued by the implementation of the Scheme. The model maintains a conservative
estimate of the benefits gained by patients and the health system while simultaneously over-
estimating the costs demanded in implementation. This is especially notable in the Scheme’s
additional management efforts for individuals diagnosed with prediabetes.

Recent research has explored the prediabetes diagnostic state for its possible cost
implications within the short- and long-term. Patients with prediabetes or with no DM
diagnosis may help prevent future costs when they improve their baseline state of health
and are prevented from likely comorbidities.

According to a consensus by the American College of Endocrinology and the American
Association of Clinical Endocrinologists released in 2008, prediabetes alone can raise the
short-term absolute risk of DM by 3- to 10-fold (Garber et al., 2008). Patients with prediabetes
are already at risk of complication development, with evidence showing associations
between pre-diabetes and early forms of nephropathy, chronic kidney disease, small fibre
neuropathy, diabetic retinopathy, and increased risk of macrovascular disease (Garber et al.,
2008; Tabák et al., 2012). As such, addressing pre-diabetic patients may be crucial in
preventing future complications of DM, such as related microvascular disease and CVD
(Chiasson et al., 2003; DREAM Trial Investigators, 2008; Ghody et al., 2015; Ratner et al., 2005).

Literature also shows that regression toward normo-glycaemia is beneficial for both patients
and the health system. Incorporating prediabetic management would likely contribute to
lower costs to the health system, including GOPC-based care costs and complications
costs, with the impact of interventions potentially leading to effects lasting up to 20 years
after the time of intervention (Kerrison et al., 2017; Nah et al., 2019; Perreault et al., 2012;
Zhuo et al., 2014).

Proposal to attain more accurate screening results

The most notable instance of change in prevention is in relation to screening services.
Recommendations for DM screening within the Hong Kong Reference Framework for
Diabetes currently entail using either a HbA1c test or a FPG test to conduct screening
for DM (PHO, 2018). Individuals who do not meet the threshold for not having DM will receive
additional screening services to confirm their diagnosis.

Our model and screening methodology instead employ a more aggressive approach to
obtain a diagnosis. We propose that to ensure accuracy of diagnosis for modelling purposes,
screening should consist of two rounds of testing, with each round consisting of different
tests to ensure a higher likelihood of providing a correct diagnosis. In the first round, we
propose that all eligible individuals should receive both the HbA1c test and FPG test.
Individuals who do not meet the threshold for either DM or prediabetes can be diagnosed as
“healthy without DM” and will not require a second round of testing. Individuals who fall into
the prediabetic range of either HbA1c and FPG tests will retake the HbA1c and FPG tests in
addition to an OGTT test. Individuals who initially fall into the diabetic range will retake the
HbA1c and FPG tests to confirm their DM diagnosis. In doing so, we hope to minimise the
false negative rate of these tests, which would provide an incorrect “healthy” diagnosis, and
to minimise the false positive rate, which would provide an incorrect DM diagnosis.

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