Improving Diabetes Screening in the Primary Care Clinic.

BACKGROUND: In our suburban primary care clinic, the average rate of screening for diabetes among eligible patients was only 51%, similar to national screening data. We conducted a quality improvement project to increase this rate. METHODS: During the 6-month preintervention phase, we collected baseline data on the percentage of eligible patients screened per week (percentage of patients with hemoglobin A1c checked in the prior 3 years out of patients eligible for screening who completed a visit during the week). We then implemented a two-phase intervention. In phase 1 (approximately 8 months), we generated an electronic health record (EHR) report to identify eligible patients and pended laboratory orders for physicians to sign. In phase 2 (approximately 3 months), we replaced the phase 1 intervention with an EHR clinical decision support tool that automatically identifies eligible patients. We compared screening rates in the preintervention vs. intervention period. For phase 1, we also assessed laboratory completion rates and the laboratory results. We surveyed physicians regarding intervention acceptability and satisfaction at 3, 6, 9, and 12 months during the intervention period. RESULTS: The weekly percentage of patients screened increased from an average of 51% in the preintervention phase to 65% in the intervention phase (p < 0.001). During phase 1, most patients underwent laboratory blood testing as recommended (83% within 3 months), and results were consistent with prediabetes in 23% and with diabetes in 4%. Overall, most physicians believed that the intervention appropriately identified patients due for screening and was helpful (100% of respondents agreed at 9 months vs. 71% at 3 months). CONCLUSION: We successfully implemented a systematic screening intervention involving a manual workflow and EHR tool and improved diabetes screening rates in our clinic.

Lower-Intensity Interventions for Prediabetes: A Systematic Review.

INTRODUCTION: Systematic reviews of interventions for diabetes prevention have focused on lifestyle interventions, including the Diabetes Prevention Program (DPP) and translations of the DPP. However, nationally, few people with prediabetes have joined or completed a DPP, with one cited barrier being committing to a yearlong program. This study was a systematic review to evaluate the effectiveness of lower-intensity lifestyle interventions for prediabetes on weight change, glycemia, and health behaviors. METHODS: English-language studies from PubMed, Embase, PsycINFO, and CINAHL from 2000 to February 23, 2022 were searched for RCTs of nonpregnant adults with prediabetes and elevated BMI and lower-intensity interventions (defined as ≤12 months and <14 sessions over 6 months). Two reviewers independently identified 11 trials, assessed study quality (using Cochrane risk-of-bias tool), and extracted data serially. A qualitative synthesis was conducted by outcome. RESULTS: Only 1 of 11 trials of lower-intensity interventions was of high quality (>80% follow-up rate and low risk of bias). This 6-month study compared an app with standardized dietary advice, showing a 3-kg greater body weight reduction and 0.2% greater reduction of HbA1c. DISCUSSION: The evidence on lower-intensity lifestyle interventions for diabetes prevention is limited by the small number and methodologic weaknesses of previous trials, and future research is needed in this area. Given the low uptake of and retention in evidence-based high-intensity programs, future work is needed to investigate the effectiveness of novel lower-intensity interventions offered with established DPP content of varying duration and intensity.

Engaging Payors and Primary Care Physicians Together in Improving Diabetes Prevention.

BACKGROUND: Type 2 diabetes can be prevented through lifestyle programs like the Diabetes Prevention Programs (DPP), but few people with prediabetes participate in them, in part because their insurance does not reliably cover DPPs. Prior studies have not focused on payor-level barriers. OBJECTIVE: To understand barriers to DPP uptake that exist and intersect at different levels (patients, PCPs, and payors) to inform strategies to improve diabetes prevention in primary care settings through interviews with PCPs and payors. DESIGN: From May 2020 to October 2021, we conducted remote, semi-structured interviews with PCPs and payors. PARTICIPANTS: PCPs were from primary care practices affiliated with one mid-Atlantic academic system. Payor leaders were from regional commercial, Medicare, and Medicaid plans. APPROACH: Using a standardized interview guide focused on barriers, facilitators, and potential intervention components, interviews were audio-recorded using Zoom and professionally transcribed. Two reviewers double-coded transcripts using the framework analytic approach. KEY RESULTS: We interviewed 16 PCPs from 13 primary care clinics and 7 payor leaders representing 6 insurance plans. Two themes emerged from PCP reports of patient-level barriers: (1) lack of programs and insurance coverage of resources to address nutrition and exercise and (2) inadequate resources to address social determinants of health that impact diabetes prevention. Among barriers PCPs faced, we identified two themes: (1) low PCP knowledge about DPPs and misperceptions of insurance coverage of DPPs and (2) inadequate clinical staff to address diabetes prevention. Barriers common to PCPs and payors included (1) absence of prediabetes quality measures and (2) inadequate engagement of PCPs and patients with payors. CONCLUSIONS: Discussions with PCPs and payors revealed systemic barriers that suggest important priorities to improve prediabetes clinical care, including universal coverage of DPPs, clarity about coverage benefits, data reporting and outreach by payors to PCPs, and adoption of appropriate prediabetes quality measures.

Long-term exposure to ambient fine particulate matter (PM2.5) and associations with cardiopulmonary diseases and lung cancer in Taiwan: a nationwide longitudinal cohort study.

BACKGROUND: Although a number of studies have reported on the health effects of fine particulate matter (PM2.5) exposure, particularly in North American and European countries as well as China, the evidence about intermediate to high levels of PM2.5 exposures is still limited. We aimed to investigate the associations between long-term exposure to PM2.5 and risk of cardiopulmonary disease incidence in Taiwan with intermediate levels of PM2.5 exposure. METHODS: A cohort of Taiwanese adults, who participated in the 2001, 2005, 2009 and 2013 National Health Interview Surveys, was followed through 2016 to identify cardiopulmonary disease onset. Exposure to PM2.5 was estimated by incorporating a widespread monitoring network of air quality monitoring stations and microsensors. We used time-dependent Cox regression models to examine the associations between the PM2.5 exposures and health outcomes, adjusting for individual characteristics and ecological covariates. The natural cubic spline functions were used to explore the non-linear effects of the PM2.5 exposure. RESULTS: A total of 62 694 adults from 353 towns were enrolled. Each 10-µg/m3 increase in 5-year average exposure to PM2.5 was associated with a 4.8% increased risk of incident ischaemic heart disease (95% CI: -3.3, 13.6), 3.9% increased risk of incident stroke (95% CI: -2.9, 11.1), 6.7% increased risk of incident diabetes (95% CI: 1.1, 12.7), 15.7% increased risk of incident lung cancer (95% CI: -0.9, 35.1) and 11.5% increased risk of incident chronic obstructive pulmonary disease (95% CI: -0.8, 25.2). The concentration-response curve showed that there was no statistical evidence of non-linearity for most of the disease outcomes except for ischaemic heart disease (P for non-linearity = 0.014). CONCLUSIONS: Long-term exposure to intermediate levels of ambient PM2.5 was associated with cardiopulmonary health outcomes. Our study adds value to future application and national burden of disease estimation in evaluating the health co-benefits from ambient air pollution reduction policy in Asian countries.

Clinical Care Among Individuals with Prediabetes in Primary Care: a Retrospective Cohort Study.

BACKGROUND: The incidence of diabetes in the general US population (6.7 per 1000 adults in 2018) has not changed significantly since 2000, suggesting that individuals with prediabetes are not connecting to evidence-based interventions. OBJECTIVE: We sought to describe the clinical care of individuals with prediabetes, determine patient factors associated with this care, and evaluate risk for diabetes development. DESIGN: Retrospective cohort study using linked claims and electronic health record data. PARTICIPANTS: We created a cohort of adults with prediabetes based on laboratory measures. We excluded patients with a prior history of diabetes, pregnancy in prior 6 months, or recent steroid use. MAIN MEASURES: We measured ordering and completion of clinical services targeting prediabetes management and diabetes incidence within 12 months following cohort entry. We tested the strength of the association between individuals' characteristics and outcomes of interest using bivariate and multiple logistic regression. RESULTS: Our cohort included 3888 patients with a laboratory diagnosis of prediabetes (incident or prevalent prediabetes). Within 12 months, 63.4% had repeat glycemic testing, yet only 10.4% had coded diagnoses of prediabetes, 1.0% were referred for nutrition services, and 5.4% were prescribed metformin. Most patients completed labs and nutrition visits when referred and filled metformin when prescribed. Individuals with a higher glycemic level or BMI were more likely to receive prediabetes clinical care. Six percent of individuals developed diabetes within 12 months of cohort entry and had higher glycemic levels and BMI ≥ 30 kg/m2. In the adjusted model, Black individuals had 1.4 times higher odds of developing diabetes than White individuals. CONCLUSIONS: Rates of prediabetes clinical care activities are low and have not improved. Strategies are urgently needed to improve prediabetes care delivery thereby preventing or delaying incident diabetes.

Identification of Prediabetes Discussions in Unstructured Clinical Documentation: Validation of a Natural Language Processing Algorithm.

BACKGROUND: Prediabetes affects 1 in 3 US adults. Most are not receiving evidence-based interventions, so understanding how providers discuss prediabetes with patients will inform how to improve their care. OBJECTIVE: This study aimed to develop a natural language processing (NLP) algorithm using machine learning techniques to identify discussions of prediabetes in narrative documentation. METHODS: We developed and applied a keyword search strategy to identify discussions of prediabetes in clinical documentation for patients with prediabetes. We manually reviewed matching notes to determine which represented actual prediabetes discussions. We applied 7 machine learning models against our manual annotation. RESULTS: Machine learning classifiers were able to achieve classification results that were close to human performance with up to 98% precision and recall to identify prediabetes discussions in clinical documentation. CONCLUSIONS: We demonstrated that prediabetes discussions can be accurately identified using an NLP algorithm. This approach can be used to understand and identify prediabetes management practices in primary care, thereby informing interventions to improve guideline-concordant care.

Effects of Behavioral Weight Loss and Metformin on IGFs in Cancer Survivors: A Randomized Trial.

CONTEXT: Higher levels of insulin-like growth factor-1 (IGF-1) are associated with increased risk of cancers and higher mortality. Therapies that reduce IGF-1 have considerable appeal as means to prevent recurrence. DESIGN: Randomized, 3-parallel-arm controlled clinical trial. INTERVENTIONS AND OUTCOMES: Cancer survivors with overweight or obesity were randomized to (1) self-directed weight loss (comparison), (2) coach-directed weight loss, or (3) metformin treatment. Main outcomes were changes in IGF-1 and IGF-1:IGFBP3 molar ratio at 6 months. The trial duration was 12 months. RESULTS: Of the 121 randomized participants, 79% were women, 46% were African Americans, and the mean age was 60 years. At baseline, the average body mass index was 35 kg/m2; mean IGF-1 was 72.9 (SD, 21.7) ng/mL; and mean IGF1:IGFBP3 molar ratio was 0.17 (SD, 0.05). At 6 months, weight changes were -1.0% (P = 0.07), -4.2% (P < 0.0001), and -2.8% (P < 0.0001) in self-directed, coach-directed, and metformin groups, respectively. Compared with the self-directed group, participants in metformin had significant decreases on IGF-1 (mean difference in change: -5.50 ng/mL, P = 0.02) and IGF1:IGFBP3 molar ratio (mean difference in change: -0.0119, P = 0.011) at 3 months. The significant decrease of IGF-1 remained in participants with obesity at 6 months (mean difference in change: -7.2 ng/mL; 95% CI: -13.3 to -1.1), but not in participants with overweight (P for interaction = 0.045). There were no significant differences in changes between the coach-directed and self-directed groups. There were no differences in outcomes at 12 months. CONCLUSIONS: In cancer survivors with obesity, metformin may have a short-term effect on IGF-1 reduction that wanes over time.

Effects of the Dietary Approaches to Stop Hypertension Diet and Sodium Reduction on Blood Pressure in Persons With Diabetes.

Elevated blood pressure and blood pressure-related morbidity are extraordinarily common in persons with diabetes. The Dietary Approaches to Stop Hypertension dietary pattern and dietary sodium reduction are recommended as lifestyle interventions in individuals with diabetes. However, these recommendations have largely been based on studies conducted in persons without diabetes. In this review, we summarize available evidence from trials that tested the effects of these 2 dietary interventions on blood pressure in people with diabetes. Overall, of the 3 trials (total n=151) that tested the effects of the Dietary Approaches to Stop Hypertension dietary pattern in persons with diabetes, 2 trials documented that the Dietary Approaches to Stop Hypertension dietary pattern lowered blood pressure. While 16 trials (total n=445) tested the effects of sodium reduction in persons with diabetes, results were inconsistent, likely because of design limitations, for example, brief duration, small sample size, and low baseline blood pressure levels, as well as differences in the mode of intervention delivery (behavioral interventions, feeding studies, and sodium supplements). In conclusion, there is a substantial need for additional research on the blood pressure lowering effects of the Dietary Approaches to Stop Hypertension diet and sodium reduction in people with diabetes and hypertension, given the high prevalence of hypertension and the dearth of high-quality trials in this population.

Methods and Risks of Bias in Natural Experiments in Obesity: Opportunities for the Future Informed by a Systematic Review.

OBJECTIVE: This paper promotes rigorous methods and designs currently underutilized in obesity research, informed by a recent systematic review of the methods and risks of bias in studies of policies, programs, and built environment changes for obesity prevention and control. METHODS: To determine the current state of the field, relevant databases from 2000 to 2017 were searched to identify studies that fit the inclusion criteria. Study design, analytic approach, and other details of study methods were abstracted. These findings inform recommendations for obesity researchers and the field as a whole. RESULTS: Previously identified were 156 natural experiment studies. Most were cross-sectional (35%), pre-post single group comparison (31%), or difference-in-differences designs (29%). Few used rigorous causal designs such as interrupted time series with more than two time points, propensity score methods, or instrumental variables. The potential relevance for obesity research is discussed, and recommendations for obesity researchers are provided. CONCLUSIONS: To strengthen natural experiment study designs and enhance the validity of results, researchers should carefully consider and control for confounding and selection of comparison groups and consider study designs that address these biases.

National Survey of Primary Care Physicians' Knowledge, Practices, and Perceptions of Prediabetes.

BACKGROUND: Despite strong evidence and national policy supporting type 2 diabetes prevention, little is known about type 2 diabetes prevention in the primary care setting. OBJECTIVE: Our objective was to assess primary care physicians' knowledge and practice regarding perceived barriers and potential interventions to improving management of prediabetes. DESIGN: Cross-sectional mailed survey. PARTICIPANTS: Nationally representative random sample of US primary care physicians (PCPs) identified from the American Medical Association Physician Masterfile. MAIN MEASURES: We assessed PCP knowledge, practice behaviors, and perceptions related to prediabetes. We performed chi-square and Fisher's exact tests to evaluate the association between PCP characteristics and the main survey outcomes. KEY RESULTS: In total, 298 (33%) eligible participants returned the survey. PCPs had limited knowledge of risk factors for prediabetes screening, laboratory diagnostic criteria for prediabetes, and management recommendations for patients with prediabetes. Only 36% of PCPs refer patients to a diabetes prevention lifestyle change program as their initial management approach, while 43% discuss starting metformin for prediabetes. PCPs believed that barriers to type 2 diabetes prevention are both at the individual level (e.g., patients' lack of motivation) and at the system level (e.g., lack of weight loss resources). PCPs reported that increased access to and insurance coverage of type 2 diabetes prevention programs and coordination of referral of patients to these resources would facilitate type 2 diabetes preventive efforts. CONCLUSIONS: Addressing gaps in PCP knowledge may improve the identification and management of people with prediabetes, but system-level changes are necessary to support type 2 diabetes prevention in the primary care setting.

A National Survey of Internal Medicine Primary Care Residency Program Directors.

BACKGROUND: The United States is facing a primary care physician shortage. Internal medicine (IM) primary care residency programs have expanded substantially in the past several decades, but there is a paucity of literature on their characteristics and graduate outcomes. OBJECTIVE: We aimed to characterize the current US IM primary care residency landscape, assess graduate outcomes, and identify unique programmatic or curricular factors that may be associated with a high proportion of graduates pursuing primary care careers. DESIGN: Cross-sectional study PARTICIPANTS: Seventy out of 100 (70%) IM primary care program directors completed the survey. MAIN MEASURES: Descriptive analyses of program characteristics, educational curricula, clinical training experiences, and graduate outcomes were performed. Bivariate and multivariate logistic regression analyses were used to determine the association between ≥ 50% of graduates in 2016 and 2017 entering a primary care career and program characteristics, educational curricula, and clinical training experiences. KEY RESULTS: Over half of IM primary care program graduates in 2016 and 2017 pursued a primary care career upon residency graduation. The majority of program, curricular, and clinical training factors assessed were not associated with programs that have a majority of their graduates pursuing a primary care career path. However, programs with a majority of program graduates entering a primary care career were less likely to have X + Y scheduling compared to the other programs. CONCLUSIONS: IM primary care residency programs are generally succeeding in their mission in that the majority of graduates are heading into primary care careers.

Influence of subsidies and promotional strategies on outcomes in a beneficiary-based commercial weight-loss programme.

To determine whether initial engagement, continued participation, and weight loss vary by subsidy and promotional strategies in a beneficiary-based, commercial weight-loss programme. We conducted a retrospective analysis of data from 2013 to 2016. Our dependent variables included initial engagement (≥1 calls; ≥2 weights), coach calls and weight change. Our independent variables were subsidy strategy (total subsidy (n = 9) vs cost sharing (n = 3)) and combination of promotional-subsidy strategies (mixed campaign + total subsidy (n = 6) vs mass media + total subsidy (n = 3)). We used logistic and linear regression analyses adjusted for beneficiary factors and clustering by organization. From 12 participating organizations, 26 068 beneficiaries registered of which 6215 initially engaged. Cost sharing was associated with significantly greater initial engagement as compared to total subsidy (OR 3.73, P < 0.001); however, no significant between-group differences existed in calls or weight change. Mass media + total subsidy group had significantly greater calls and weight loss at 12 months compared to mixed campaign + total subsidy (-2.6% vs -1.8%, P = 0.04). Cost sharing may promote greater initial engagement, although does not contribute to better participation or weight loss relative to total subsidy. If organizations elect total subsidy, then pairing this strategy with a mass media campaign may promote greater participation and weight loss among beneficiaries.

Effect of a Behavioral Weight Loss Intervention in People With Serious Mental Illness and Diabetes.

OBJECTIVE: Given the high prevalence of obesity and diabetes in patients with serious mental illness (SMI) and the lack of evidence on the effects of weight loss programs in SMI patients with diabetes, we evaluated the effectiveness of a behavioral weight loss intervention among SMI participants with and without diabetes. RESEARCH DESIGN AND METHODS: Using data from ACHIEVE, a randomized controlled trial to evaluate the effects of a behavioral weight loss intervention among overweight/obese people with SMI, we assessed and compared weight change from baseline to 18 months in participants with and without diabetes using a longitudinal mixed-effects model. RESULTS: Of the 291 trial participants, 82 (28.2%) participants had diabetes (34 and 48 in intervention and control groups, respectively) at baseline. Participants with diabetes were more likely to be taking antipsychotics (31.7% vs. 18.7%, P = 0.02). At 18 months, participants in the control group with diabetes lost 1.2 lb (0.6%) of body weight compared with 0.8 lb (0.7%) among those without diabetes. In the intervention group, participants with diabetes lost 13.7 lb (6.6%) of their initial body weight compared with 5.4 lb (2.9%) for those without diabetes. Corresponding net effects (intervention minus control) were 4.6 lb (2.2%) and 12.5 lb (6.0%) net weight reduction over 18 months in the no diabetes and the diabetes subgroups, respectively. However, the between-group difference in intervention effects was statistically nonsignificant (absolute weight change: P-interaction = 0.08; % weight change: P-interaction = 0.10). CONCLUSIONS: A behavioral weight loss intervention is effective among overweight and obese individuals with SMI regardless of their diabetes status.

Systematic Review of Natural Experiments for Childhood Obesity Prevention and Control.

CONTEXT: The National Academy of Medicine recommends childhood obesity prevention efforts making healthier options the passive choice. This review evaluated the effectiveness of population-level policies and programs from natural experiments for childhood obesity prevention. EVIDENCE ACQUISTION: The search included PubMed, CINAHL, PsycINFO, and EconLit from 2000 to 2017 for policies evaluated by natural experiments reporting childhood BMI outcomes. The studies were analyzed in 2017-2018. Interventions were classified by environmental focus (food/beverage, physical activity, or both) and stratified by setting (school, community, both). Risk of bias was evaluated for each study. EVIDENCE SYNTHESIS: Of 33 natural experiments, most (73%) took place in the school setting only. The most common environmental focus in any setting was food/beverage (48%). All four studies that focused on both food/beverage and physical activity in schools demonstrated decreased prevalence of overweight/obesity or BMI z-score by 0.04-0.17. BMI decreased in all four studies in both school and community settings. The largest effect size was a decrease in BMI z-score of 0.5, but most were <0.25. The risk of bias was high for most (76%) studies. Most (63%) of the eight studies with low/medium risk of bias took place in the school setting focused on the food/beverage environment; effects on BMI were mixed. CONCLUSIONS: Natural experiments evaluating school-based policies focusing on both the food/beverage and physical activity environments (versus targeting only one) consistently showed improvement in BMI. However, most studies had high risk of bias, highlighting the need for improved methods for evaluation of natural experiments for childhood obesity prevention.

Effectiveness of Policies and Programs to Combat Adult Obesity: a Systematic Review.

BACKGROUND: This systematic review identifies programs, policies, and built-environment changes targeting prevention and control of adult obesity and evaluates their effectiveness. METHODS: We searched PubMed, CINAHL, PsycINFO, and EconLit from January 2000 to March 2018. We included natural experiment studies evaluating a program, policy, or built-environment change targeting adult obesity and reporting weight/body mass index (BMI). Studies were categorized by primary intervention target: physical activity/built environment, food/beverage, messaging, or multiple. Two reviewers independently assessed the risk of bias for each study using the Effective Public Health Practice Project tool. RESULTS: Of 158 natural experiments targeting obesity, 17 reported adult weight/BMI outcomes. Four of 9 studies reporting on physical activity/built environment demonstrated reduced weight/BMI, although effect sizes were small with low strength of evidence and high risk of bias. None of the 5 studies targeting the food/beverage environment decreased weight/BMI; strength of evidence was low, and 2 studies were rated high risk of bias. DISCUSSION: We identified few natural experiments reporting on the effectiveness of programs, policies, and built-environment changes on adult obesity. Overall, we found no evidence that policies intending to promote physical activity and healthy eating had beneficial effects on weight/BMI and most studies had a high risk of bias. Limitations include few studies met our inclusion criteria; excluded studies in children and those not reporting on weight/BMI outcomes; weight/BMI reporting was very heterogeneous. More high-quality research, including natural experiments studies, is critical for informing the population-level effectiveness of obesity prevention and control initiatives in adults.

Methods for Evaluating Natural Experiments in Obesity: A Systematic Review.

Background: Given the obesity pandemic, rigorous methodological approaches, including natural experiments, are needed. Purpose: To identify studies that report effects of programs, policies, or built environment changes on obesity prevention and control and to describe their methods. Data Sources: PubMed, CINAHL, PsycINFO, and EconLit (January 2000 to August 2017). Study Selection: Natural experiments and experimental studies evaluating a program, policy, or built environment change in U.S. or non-U.S. populations by using measures of obesity or obesity-related health behaviors. Data Extraction: 2 reviewers serially extracted data on study design, population characteristics, data sources and linkages, measures, and analytic methods and independently evaluated risk of bias. Data Synthesis: 294 studies (188 U.S., 106 non-U.S.) were identified, including 156 natural experiments (53%), 118 experimental studies (40%), and 20 (7%) with unclear study design. Studies used 106 (71 U.S., 35 non-U.S.) data systems; 37% of the U.S. data systems were linked to another data source. For outcomes, 112 studies reported childhood weight and 32 adult weight; 152 had physical activity and 148 had dietary measures. For analysis, natural experiments most commonly used cross-sectional comparisons of exposed and unexposed groups (n = 55 [35%]). Most natural experiments had a high risk of bias, and 63% had weak handling of withdrawals and dropouts. Limitation: Outcomes restricted to obesity measures and health behaviors; inconsistent or unclear descriptions of natural experiment designs; and imperfect methods for assessing risk of bias in natural experiments. Conclusion: Many methodologically diverse natural experiments and experimental studies were identified that reported effects of U.S. and non-U.S. programs, policies, or built environment changes on obesity prevention and control. The findings reinforce the need for methodological and analytic advances that would strengthen evaluations of obesity prevention and control initiatives. Primary Funding Source: National Institutes of Health, Office of Disease Prevention, and Agency for Healthcare Research and Quality. (PROSPERO: CRD42017055750).

Survey of primary care providers' knowledge of screening for, diagnosing and managing prediabetes.

BACKGROUND: Prediabetes affects 86 million US adults, but primary care providers' (PCPs') knowledge, practices, attitudes and beliefs toward prediabetes are unclear. OBJECTIVE: Assess PCPs' (1) knowledge of risk factors that should prompt prediabetes screening, laboratory criteria for diagnosing prediabetes and guidelines for management of prediabetes; (2) management practices around prediabetes; (3) attitudes and beliefs about prediabetes. DESIGN: Self-administered written survey of PCPs. PARTICIPANTS: One hundred forty of 155 PCPs (90%) attending an annual provider retreat for academically affiliated multispecialty practices in the mid-Atlantic region. MAIN MEASURES: Descriptive analyses of survey questions on knowledge, management, and attitudes and beliefs related to prediabetes. Multivariate logistic regression was used to determine the association between provider characteristics (gender, race/ethnicity, years since training, specialty and provider type) and knowledge, management, and attitudes and beliefs about prediabetes. KEY RESULTS: Six percent of PCPs correctly identified all of the risk factors that should prompt prediabetes screening. Only 17% of PCPs correctly identified the laboratory parameters for diagnosing prediabetes based on both fasting glucose and hemoglobin A1c. Nearly 90% of PCPs reported close follow-up (within 6 months) of patients with prediabetes. Few PCPs (11%) selected referral to a behavioral weight loss program as the recommended initial management approach to prediabetes. PCPs agreed that patient-related factors are important barriers to lifestyle change and metformin use. Provider characteristics were generally not associated with knowledge, management, attitudes and beliefs about prediabetes in multivariate analyses. CONCLUSIONS: Addressing gaps in knowledge and the underutilization of behavioral weight loss programs in prediabetes are two essential areas where PCPs could take a lead in curbing the diabetes epidemic.