Screening for Prediabetes and Diabetes in a National Network of Federally Qualified Health Centers: An Observational Study.

BACKGROUND: In 2021, the U.S. Preventive Services Task Force (USPSTF) recommended screening for prediabetes and diabetes among adults aged 35-70 years with overweight or obesity. Studying dysglycemia screening in federally qualified health centers (FQHCs) that serve vulnerable patient populations is needed to understand health equity implications of this recommendation. OBJECTIVE: To investigate screening practices among FQHC patients who would be eligible according to the 2021 USPSTF recommendation. DESIGN: Retrospective cohort study analyzing electronic health records from a national network of 282 FQHC sites. PARTICIPANTS: We included 183,329 patients without prior evidence of prediabetes or diabetes, who had ≥ 1 office visit from 2018-2020. MAIN MEASURES: Screening eligibility was based on age and measured body mass index (BMI). The primary outcome, screening completion, was ascertained using hemoglobin A1c or fasting plasma glucose results from 2018-2020. KEY RESULTS: Among 89,543 patients who would be eligible according to the 2021 USPSTF recommendation, 53,263 (59.5%) were screened. Those who completed screening had higher BMI values than patients who did not (33.0 ± 6.7 kg/m2 vs. 31.9 ± 6.2 kg/m2, p < 0.001). Adults aged 50-64 years had greater odds of screening completion relative to younger patients (OR 1.13, 95% CI: 1.10-1.17). Patients from racial and ethnic minority groups, as well as those without health insurance, were more likely to complete screening than White patients and insured patients, respectively. Clinical risk factors for diabetes were also associated with dysglycemia screening. Among patients who completed screening, 23,588 (44.3%) had values consistent with prediabetes or diabetes. CONCLUSIONS: Over half of FQHC patients who would be eligible according to the 2021 USPSTF recommendation were screened. Screening completion was higher among middle-aged patients, those with greater BMI values, as well as vulnerable groups with a high risk of developing diabetes. Future research should examine adoption of the 2021 USPSTF screening recommendation and its impact on health equity.

A pilot randomized controlled trial comparing nutritious meal kits and no-prep meals to improve food security and diet quality among food pantry clients.

BACKGROUND: Food pantry clients have high rates of food insecurity and greater risk for and prevalence of diet-related diseases. Many clients face time, resource, and physical constraints that limit their ability to prepare healthy meals using foods typically provided by pantries. We compared two novel approaches to alleviate those barriers and encourage healthier eating: meal kits, which bundle ingredients with a recipe on how to prepare a healthy meal, and nutritious no-prep meals, which can be eaten after thawing or microwaving. METHODS: Participants were adult pantry clients from a large food pantry in the Southern sector of Dallas, Texas. We conducted a repeated measures between-subjects study with 70 clients randomized to receive 14-days of meal kits (n = 35) or no-prep meals (n = 35). Participants completed questionnaires at baseline and two-week follow-up on demographics, hedonic liking of study meals, perceived dietary quality, and food security. Two-way repeated measures analysis of variance was used to examine group and time effects, and group by time interactions. We also describe feasibility and satisfaction outcomes to inform future implementation. RESULTS: Sixty-six participants completed the study (94%). Participants were predominantly Hispanic or Latino(a) (63%) and African American or Black (31%) women (90%). There was a significant interaction on hedonic liking of study meals (ηp²=0.16, F(1,64) = 11.78, p < .001), such that participants that received meal kits had greater improvements in hedonic liking over time than participants in the no-prep group. We observed significant improvements in perceived dietary quality (ηp²=0.36, F(1,64) = 36.38, p < .001) and food security (ηp²=0.36, F(1,64) = 36.38, p < .001) across both groups over time, but no between group differences or significant interactions indicating one intervention was more effective than the other. Program satisfaction was high across both groups, but higher among the meal kit group (ηp²=0.09, F(1,64) = 6.28, p = .015). CONCLUSIONS: Results suggest nutritious meal kits and no-prep meals may be desirable nutrition intervention strategies for pantry clients and have potential to increase food security and perceived dietary quality in the short-term. Our findings are limited by a small sample and short follow-up. Future studies should continue to test both interventions, and include longer follow-up, objective measures of dietary quality, and relevant clinical outcomes. TRIAL REGISTRATION: This trial was registered on 25/10/2022 on ClinicalTrials.gov, identifier: NCT05593510.

Building Toward a Population-Based Approach to Diabetes Screening and Prevention for US Adults.

PURPOSE OF REVIEW: Evidence-based treatments for prediabetes can prevent and delay the development of type 2 diabetes in adults. In this review, we propose a framework for population-based diabetes prevention that links screening and prevention activities across key stakeholders. We also discuss gaps in current practice, while highlighting opportunities to improve diabetes screening and prevention efforts population-wide. RECENT FINDINGS: Awareness of diabetes risk is low, and many adults with prediabetes are not identified through existing screening efforts. Accumulating evidence and policies support expansion of the Diabetes Prevention Program (DPP) into clinical and community settings. However, the infrastructure to facilitate referrals and promote data exchange among patients, clinical settings, and community-based DPP programs is lacking. Development of evidence-driven, scalable processes for assessing diabetes risk, screening eligible adults, and delivering preventive treatments are needed to effectively improve the glycemic health of the US adult population.

A community health worker led diabetes self-management education program: Reducing patient and system burden.

AIMS: Conduct a secondary analysis of the TIME (Telehealth-supported, Integrated Community Health Workers (CHWs), Medication access, diabetes Education) made simple trial (SIMPLE) to evaluate healthcare utilization and explore variables that may have influenced HbA1c. METHODS: Participants (N = 134 [67/group]) were low-income, uninsured Hispanics with or at risk for type 2 diabetes mellitus. We included in-person and telehealth clinician visits, other visits, missed visits, orders placed, and guideline-adherence (e.g., vaccinations, quarterly HbA1c for uncontrolled diabetes). Using multivariable models, we explored for associations between HbA1c changes and these measures. RESULTS: The control arm had higher missed visits rates (intervention: 45 %; control: 56 %; p = 0.007) and missed telehealth appointments (intervention: 10 %; control: 27.4 %; p = 0.04). The intervention group received more COVID vaccinations than the control (p = 0.005). Other health measures were non-significant between groups. Intervention individuals' HbA1c improved with more missed visits (-0.60 %; p < 0.01) and worsened with improved guideline-adherent HbA1c measurements (HbA1c: 1.2 %; p = 0.057). The control group had non-significant HbA1c associations. CONCLUSIONS: Findings suggest that the SIMPLE trial's improved HbA1c levels stemmed from a CHW-driven intervention and not additional healthcare contact. Exploratory outcomes resulted in seemingly counterintuitive HbA1c associations with missed visits and guideline-adherent measurements; these may suggest that an intervention that enhances communication provides support to reduce the amount of follow-up needed by participants without sacrificing clinical improvements.

Predicting hospital readmission in Medicaid patients with diabetes using administrative and claims data.

OBJECTIVES: Readmission is common and costly for hospitalized Medicaid patients with diabetes. We aimed to develop a model predicting risk of 30-day readmission in Medicaid patients with diabetes hospitalized for any cause. STUDY DESIGN: Using 2016-2019 Medicaid claims from 7 US states, we identified patients who (1) had a diagnosis of diabetes or were prescribed any diabetes drug, (2) were hospitalized for any cause, and (3) were discharged to home or to a nonhospice facility. For each encounter, we assessed whether the patient was readmitted within 30 days of discharge. METHODS: Applying least absolute shrinkage and selection operator variable selection, we included demographic data and claims history in a logistic regression model to predict 30-day readmission. We evaluated model fit graphically and measured predictive accuracy by the area under the receiver operating characteristic curve (AUROC). RESULTS: Among 69,640 eligible patients, there were 129,170 hospitalizations, of which 29,410 (22.8%) were 30-day readmissions. The final model included age, sex, age-sex interaction, past diagnoses, US state of admission, number of admissions in the preceding year, index admission type, index admission diagnosis, discharge status, length of stay, and length of stay-sex interaction. The observed vs predicted plot showed good fit. The estimated AUROC of 0.761 was robust in analyses that assessed sensitivity to a range of model assumptions. CONCLUSIONS: Our model has moderate power for identifying hospitalized Medicaid patients with diabetes who are at high risk of readmission. It is a template for identifying patients at risk of readmission and for adjusting comparisons of 30-day readmission rates among sites or over time.

Clinical performance and health equity implications of the American Diabetes Association's 2023 screening recommendation for prediabetes and diabetes.

Introduction: The American Diabetes Association (ADA) recommends screening for prediabetes and diabetes (dysglycemia) starting at age 35, or younger than 35 years among adults with overweight or obesity and other risk factors. Diabetes risk differs by sex, race, and ethnicity, but performance of the recommendation in these sociodemographic subgroups is unknown. Methods: Nationally representative data from the National Health and Nutrition Examination Surveys (2015-March 2020) were analyzed from 5,287 nonpregnant US adults without diagnosed diabetes. Screening eligibility was based on age, measured body mass index, and the presence of diabetes risk factors. Dysglycemia was defined by fasting plasma glucose ≥100mg/dL (≥5.6 mmol/L) or haemoglobin A1c ≥5.7% (≥39mmol/mol). The sensitivity, specificity, and predictive values of the ADA screening criteria were examined by sex, race, and ethnicity. Results: An estimated 83.1% (95% CI=81.2-84.7) of US adults were eligible for screening according to the 2023 ADA recommendation. Overall, ADA's screening criteria exhibited high sensitivity [95.0% (95% CI=92.7-96.6)] and low specificity [27.1% (95% CI=24.5-29.9)], which did not differ by race or ethnicity. Sensitivity was higher among women [97.8% (95% CI=96.6-98.6)] than men [92.4% (95% CI=88.3-95.1)]. Racial and ethnic differences in sensitivity and specificity among men were statistically significant (P=0.04 and P=0.02, respectively). Among women, guideline performance did not differ by race and ethnicity. Discussion: The ADA screening criteria exhibited high sensitivity for all groups and was marginally higher in women than men. Racial and ethnic differences in guideline performance among men were small and unlikely to have a significant impact on health equity. Future research could examine adoption of this recommendation in practice and examine its effects on treatment and clinical outcomes by sex, race, and ethnicity.

Redesigning Recruitment and Engagement Strategies for Virtual Culinary Medicine and Medical Nutrition Interventions in a Randomized Trial of Patients with Uncontrolled Type 2 Diabetes.

In-person culinary medicine (CM) can improve health behaviors, but its translation to virtual platforms and impact on diabetes outcomes are not well described. We designed a pragmatic trial comparing the effectiveness of virtual CM (eCM) to Medical Nutrition Therapy on diabetes outcomes among patients with uncontrolled diabetes within a safety-net healthcare system. All participants were provided cooking equipment and food from a food pantry. Due to low initial eCM participation, recruitment was paused, and eight semi-structured interviews were conducted to solicit feedback on study appeal, operations, and barriers to participation. Rapid thematic analysis was used to modify study operations. We found that participants were interested in the study and motivated by health concerns. While they valued food distribution and cooking equipment, they highlighted transportation barriers and conflicts with the pick-up time/location. Some eCM participants expressed discomfort with the virtual platform or preferred to observe rather than cook along. Study operations were modified by (1) moving supply pick-up to a familiar community clinic and diversifying food pick-up locations; (2) offering an in-person orientation to the program to increase comfort with the virtual platform; (3) emphasizing the credibility and relatability of the eCM instructor and encouraging participation of family members. This redesign led to the recruitment of 79 participants, of whom 75% attended at least one class. In conclusion, participant feedback informed pragmatic changes in study operations that increased engagement in this ongoing trial and may inform future eCM program design.

A pilot randomized controlled trial comparing nutritious meal kits and no-prep meals to improve food security and diet quality among food pantry clients.

Background: Food pantry clients have high rates of food insecurity and greater risk for and prevalence of diet-related diseases. Many clients face time, resource, and physical constraints that limit their ability to prepare healthy meals using foods typically provided by pantries. We compared two novel approaches to alleviate those barriers and encourage healthier eating: meal kits, which bundle ingredients with a recipe on how to prepare a healthy meal, and nutritious no-prep meals, which can be eaten after thawing or microwaving. Methods: Participants were adult pantry clients from a large food pantry in the Southern sector of Dallas, Texas. We conducted a repeated measures between-subjects study with 70 clients randomized to receive 14-days of meal kits (n=35) or no-prep meals (n=35). Participants completed questionnaires at baseline and twoweek follow-up on demographics, hedonic liking of study meals, perceived dietary quality, and food security. Two-way repeated measures analysis of variance was used to examine group and time effects, and group by time interactions. We also describe feasibility and satisfaction outcomes to inform future implementation. Results: Sixty-six participants completed the study (94%). Participants were predominantly Hispanic or Latino(a) (63%) and African American or Black (31%) women (90%). There was a significant interaction on hedonic liking of study meals (ηp2=0.16, F(1,64)=11.78, p<.001), such that participants that received meal kits had greater improvements in hedonic liking over time than participants in the no-prep group. We observed significant improvements in perceived dietary quality (ηp2=0.36, F(1,64)=36.38, p<.001) and food security (ηp2=0.36, F(1,64)=36.38, p<.001) across both groups over time, but no between group differences or significant interactions indicating one intervention was more effective than the other. Program satisfaction was high across both groups, but higher among the meal kit group (ηp2=0.09, F(1,64)=6.28, p=.015). Conclusions: Results suggest nutritious meal kits and no-prep meals may be desirable nutrition intervention strategies for pantry clients and have potential to increase food security and perceived dietary quality in the short-term. Our findings are limited by a small sample and short follow-up. Future studies should continue to test both interventions, and include longer follow-up, objective measures of dietary quality, and relevant clinical outcomes. Trial Registration: This trial was registered on 25/10/2022 on Clinicaltrials.gov, identifier: NCT05593510.

Determining pediatric hypertension criteria: concordance between observed physician methods and guideline-recommended methods.

OBJECTIVE: To determine and evaluate the accuracy of methods physicians use to detect diagnostic criteria for pediatric hypertension [hypertensive blood pressures (BPs) on three or more occasions] in electronic health records (EHRs). METHODS: Methods used by pediatric-trained physicians (n = 12) to detect diagnostic criteria for hypertension in a simulation using a child's EHR data were directly observed, timed, and evaluated for accuracy. All physicians were given the same information regarding diagnostic criteria to eliminate knowledge gaps. Then, computer modeling and EHR data from 41 654 3-18-year-olds were used to simulate and compare the accuracy of detecting hypertension criteria using an observed-shorthand method vs. the guideline-recommended/gold-standard method. RESULTS: No physician used the guideline-recommended method of determining multiple time-of-care hypertension thresholds for child age/height at the time of each BP measure. One physician estimated the child's BP diagnosis without computing thresholds; 11 of 12 physicians determined the child's hypertension threshold from age/height data at the time of a current visit and applied/imputed this threshold to BP measured at all visits (current-visit threshold used to assess historical-visit BPs) to detect three separate BP elevations. Physicians took 2.3 min (95% confidence interval, 1.5-3.0) to declare a diagnosis. Sensitivity was 83.1% when applying the current-visit threshold to detect the guideline-recommended-BP-threshold diagnosis using EHR data. Specificity and positive-predictive/negative-predictive values ranged from 98.5 to 99.9%. CONCLUSION: Physicians applied a shorthand method to evaluate pediatric BPs. Computer-simulated comparison of the shorthand and guideline methods using clinical data suggest the shorthand method could yield an inaccurate impression of a child's BP history in 17% of pediatric ambulatory visits.

Value of Interprofessional Education: The VA Quality Scholars Program.

ABSTRACT: Interprofessional collaboration (IPC) has been shown to improve healthcare quality and patient safety; however, formal interprofessional education (IPE) training is insufficient. The VA Quality Scholars (VAQS) program exists to develop interprofessional leaders and scholars in healthcare improvement. The purpose of this study was to examine the impact of integrating interprofessional healthcare learners and designing an interprofessional curriculum for the national VAQS program. VAQS alumni (graduates from 2001 to 2017) across eight national sites (n = 102 [53.1%]) completed a web-based survey to assess alumni perceptions of IPC skill development during the program and IPC skill utilization in their careers. Alumni from 2009 and earlier were physicians; alumni after 2009 came from diverse health professional backgrounds. Overall, IPC and teamwork was identified as the most used skill (n = 82, 70%) during their career. When comparing the pre-IPE period and the post-IPE period, post-IPE alumni identified IPC and teamwork as the area of greatest skill development (n = 38). Integrating interprofessional trainees and robust IPE curricula enhanced an established and successful quality improvement (QI) training program. VAQS alumni endorsed the importance of IPC skills during their careers. The VAQS program is an example of how health professionals can successfully learn IPC skills in healthcare QI.

Evaluating the Validity of the Risk Perception Survey for Developing Diabetes Scale in a Safety-Net Clinic Population of English and Spanish Speakers.

PURPOSE: The purpose of this study is to examine the factor structure of the Risk Perception Survey for Developing Diabetes (RPS-DD) and test for factorial invariance by language (English, Spanish) and gender (males, females) in a clinically engaged, racially diverse, low-education population. METHODS: Adult patients seen in a safety-net health system (N = 641) answered an interviewer-administered survey via telephone in their preferred language (English: 42%, Spanish: 58%). Three constructs in the RPS-DD were assessed-personal control (2 items for internal control and 2 for external control), optimistic bias (2 items), and worry (2 items). Single and multigroup confirmatory factor analyses (CFAs) were performed using maximum-likelihood estimation to determine the factor structure and test for invariance. RESULTS: Contrary to previous psychometric analyses in white, educated populations, CFAs supported a 4-factor measurement model with internal and external control items loading onto separate factors. The 4-factor structure was equivalent between males and females. However, the structure varied by language, with the worry subscale items loading more strongly for English than Spanish speakers. CONCLUSIONS: The RPS-DD can be used to investigate group differences across gender and language and to help understand if interventions have differential effects for subgroups at high risk for diabetes. Given the increasing prevalence of diabetes among Spanish speakers, researchers should continue to examine the psychometric properties of the RPS-DD, particularly the worry subscale, to improve its validity and clinical utility.

Patient Preparation for Outpatient Blood Work and the Impact of Surreptitious Fasting on Diagnoses of Diabetes and Prediabetes.

OBJECTIVE: To describe patient preparation for routine outpatient blood work and examine the implications of surreptitious fasting on interpretation of glucose results. PATIENTS AND METHODS: We designed a survey and administered it between September 1, 2016, and April 30, 2017, to assess fasting behaviors in a convenience sample of 526 adults presenting for outpatient blood work in 2 health systems between 7 am and 12 pm. We reviewed the electronic health records to extract glucose results. We describe the frequency of clinician-directed fasting and surreptitious fasting. In those surreptitiously fasting, we describe the frequency of missed diagnoses of prediabetes and diabetes. RESULTS: Of 526 participants, 330 (62.7%) self-identified as fasting, and 304 (92.1%) of those fasting met American Diabetes Association fasting criteria. Only 131 (24.9%) of those fasting were told to fast by their health care team. Almost 50% (257 of 526) believed it was important to fast for every blood test. Of the 64 patients with diabetes who were taking insulin, 37 (57.8%) fasted and took their insulin as prescribed. Among the 89 patients without diabetes who fasted without knowledge of their health care team and had glucose tested, 2 (2.2%) had a missed diagnosis of diabetes and 18 (20.2%) had a missed diagnosis of prediabetes. CONCLUSION: Fasting for outpatient blood work is common, and patients frequently fast without awareness of their health care team. Failure to capture fasting status at the time of glucose testing is a missed opportunity to identify undiagnosed cases of diabetes and prediabetes.

Multilevel Variation in Diabetes Screening Within an Integrated Health System.

OBJECTIVE: Variation in diabetes screening in clinical practice is poorly described. We examined the interplay of patient, provider, and clinic factors explaining variation in diabetes screening within an integrated health care system in the U.S. RESEARCH DESIGN AND METHODS: We conducted a retrospective cohort study of primary care patients aged 18-64 years with two or more outpatient visits between 2010 and 2015 and no diagnosis of diabetes according to electronic health record (EHR) data. Hierarchical three-level models were used to evaluate multilevel variation in screening at the patient, provider, and clinic levels across 12 clinics. Diabetes screening was defined by a resulted gold standard screening test. RESULTS: Of 56,818 patients, 70% completed diabetes screening with a nearly twofold variation across clinics (51-92%; P < 0.001). Of those meeting American Diabetes Association (ADA) (69%) and U.S. Preventive Services Task Force (USPSTF) (36%) screening criteria, three-quarters were screened with a nearly twofold variation across clinics (ADA 53-92%; USPSTF 49-93%). The yield of ADA and USPSTF screening was similar for diabetes (11% vs. 9%) and prediabetes (38% vs. 36%). Nearly 70% of patients not eligible for guideline-based screening were also tested. The USPSTF guideline missed more cases of diabetes (6% vs. 3%) and prediabetes (26% vs. 19%) than the ADA guideline. After adjustment for patient, provider, and clinic factors and accounting for clustering, twofold variation in screening by provider and clinic remained (median odds ratio 1.97; intraclass correlation 0.13). CONCLUSIONS: Screening practices vary widely and are only partially explained by patient, provider, and clinic factors available in the EHR. Clinical decision support and system-level interventions are needed to optimize screening practices.

Hispanic representation in diabetes cardiovascular outcomes trials.

Objective: To examine Hispanic/Latino representation in diabetes cardiovascular outcomes trials for novel antidiabetic drugs. Research design and methods: We compared Hispanic/Latino representation, age, gender and body mass index in diabetes cardiovascular outcomes trials published from January 2008 to October 2018 to Hispanic adults with diabetes in the National Health Examination and Nutrition Survey over the same time period. Results: Hispanics/Latinos comprised 18.5 % of trial subjects, which was similar to the proportion of US adults with diabetes who identify as Hispanic. Trial subjects were significantly younger, more likely to be female, and more obese than US Hispanics/Latinos. At least 10 different Latin American countries and territories were represented across the 10 trials. Conclusions: US Hispanics/Latinos differ from subjects in diabetes cardiovascular outcomes trials, which may limit generalizability of trial results.

Increasing exposure to angiotensin-converting enzyme inhibitors in pregnancy.

OBJECTIVE: The objective of the study was to identify angiotensin-converting enzyme (ACE) inhibitor prescription-filling trends in pregnant women. STUDY DESIGN: This was a retrospective cohort study in women continuously enrolled in Tennessee Medicaid during pregnancy who delivered a live infant or had a fetal death between 1986-2003 (n = 262,179). RESULTS: ACE inhibitor exposures increased more than 4-fold: from 11.2 per 10,000 pregnancies in 1986-1988 to 58.9 per 10,000 pregnancies by 2003 (adjusted risk ratio [RR], 4.49; 95% confidence interval [CI], 2.78-7.25). Exposures in the second and third trimesters nearly tripled (RR, 2.88; 95% CI, 1.45-5.75) and did not decrease following a US Food and Drug Administration black box warning against such use in 1992. Exposures were most common among women 35 years of age or older. CONCLUSION: Despite evidence of fetal complications associated with ACE inhibitor use during pregnancy, the number of pregnant women with pregnancy-related ACE inhibitor exposures increased steadily between 1986-2003. Better methods are needed to reduce fetal exposure to potentially teratogenic prescribed medications.

Improving Performance on Preventive Health Quality Measures Using Clinical Decision Support to Capture Care Done Elsewhere and Patient Exceptions.

Preventive services required for performance measurement often are completed in outside health systems and not captured in electronic medical records (EMRs). A before-after study was conducted to examine the ability of clinical decision support (CDS) to improve performance on preventive quality measures, capture clinician-reported services completed elsewhere, and patient/medical exceptions and to describe their impact on quality measurement. CDS improved performance on colorectal cancer screening, osteoporosis screening, and pneumococcal vaccination measures ( P < .05) but not breast or cervical cancer screening. CDS captured clinician-reported services completed elsewhere (2% to 10%) and patient/medical exceptions (<3%). Compared to measures using only within-system data, including services completed elsewhere in the numerator improved performance: pneumococcal vaccine (73% vs 82%); breast (69% vs 75%), colorectal (58% vs 70%), and cervical cancer (53% vs 62%); and osteoporosis (72% vs 75%) screening ( P < .05). Visit-based CDS can capture clinician-reported preventive services, and accounting for services completed elsewhere improves performance on quality measures.

A User-Centered Glucose-Insulin Data Display for the Inpatient Setting.

Inpatient management of insulin-dependent diabetes (IDD) is a complex task that requires clinicians to cognitively process information across distinct domains in different locations of the electronic medical record (EMR). Current data displays are not optimized to support insulin management by end users. We sought to develop a set of user-centered displays of capillary glucose data and insulin dose to improve inpatient management of IDD. Our proposed conceptual data display prototype is designed to simplify the presentation and visualization of key information needed for treatment decisions. The goal is also to enhance clinician's ability to identify opportunities to optimize insulin dosing and decrease end users' cognitive load and error rates.

Performance of a Random Glucose Case-Finding Strategy to Detect Undiagnosed Diabetes.

INTRODUCTION: Random glucose <200 mg/dL is associated with undiagnosed diabetes but not included in screening guidelines. This study describes a case-finding approach using non-diagnostic random glucose values to identify individuals in need of diabetes testing and compares its performance to current screening guidelines. METHODS: In 2015, cross-sectional data from non-fasting adults without diagnosed diabetes or prediabetes (N=7,161) in the 2007-2012 National Health and Nutrition Examination Surveys were analyzed. Random glucose and survey data were used to assemble the random glucose, American Diabetes Association (ADA), and U.S. Preventive Services Task Force (USPSTF) screening strategies and predict diabetes using hemoglobin A1c criteria. RESULTS: Using random glucose ≥100 mg/dL to select individuals for diabetes testing was 81.6% (95% CI=74.9%, 88.4%) sensitive, 78% (95% CI=76.6%, 79.5%) specific and had an area under the receiver operating curve (AROC) of 0.80 (95% CI=0.78, 0.83) to detect undiagnosed diabetes. Overall performance of ADA (AROC=0.59, 95% CI=0.58, 0.60), 2008 USPSTF (AROC=0.62, 95% CI=0.59, 0.65), and 2015 USPSTF (AROC=0.64, 95% CI=0.61, 0.67) guidelines was similar. The random glucose strategy correctly identified one case of undiagnosed diabetes for every 14 people screened, which was more efficient than ADA (number needed to screen, 35), 2008 USPSTF (44), and 2015 USPSTF (32) guidelines. CONCLUSIONS: Using random glucose ≥100 mg/dL to identify individuals in need of diabetes screening is highly sensitive and specific, performing better than current screening guidelines. Case-finding strategies informed by random glucose data may improve diabetes detection. Further evaluation of this strategy's effectiveness in real-world clinical practice is needed.