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.

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.

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.

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.

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.

The diabetes nutrition education study randomized controlled trial: A comparative effectiveness study of approaches to nutrition in diabetes self-management education.

OBJECTIVE: To compare the effectiveness of different approaches to nutrition education in diabetes self-management education and support (DSME/S). METHODS: We randomized 150 adults with type 2 diabetes to either certified diabetes educator (CDE)-delivered DSME/S with carbohydrate gram counting or the modified plate method versus general health education. The primary outcome was change in HbA1C over 6 months. RESULTS: At 6 months, HbA1C improved within the plate method [-0.83% (-1.29, -0.33), P<0.001] and carbohydrate counting [-0.63% (-1.03, -0.18), P=0.04] groups but not the control group [P=0.34]. Change in HbA1C from baseline between the control and intervention groups was not significant at 6 months (carbohydrate counting, P=0.36; modified plate method, P=0.08). In a pre-specified subgroup analysis of patients with a baseline HbA1C 7-10%, change in HbA1C from baseline improved in the carbohydrate counting [-0.86% (-1.47, -0.26), P=0.006] and plate method groups [-0.76% (-1.33, -0.19), P=0.01] compared to controls. CONCLUSION: CDE-delivered DSME/S focused on carbohydrate counting or the modified plate method improved glycemic control in patients with an initial HbA1C between 7 and 10%. PRACTICE IMPLICATIONS: Both carbohydrate counting and the modified plate method improve glycemic control as part of DSME/S.

Random blood glucose: a robust risk factor for type 2 diabetes.

CONTEXT: Although random blood glucose (RBG) values are common in clinical practice, the role of elevated RBG values as a risk factor for type 2 diabetes is not well described. OBJECTIVE: This study aimed to examine nondiagnostic, RBG values as a risk factor for type 2 diabetes DESIGN: This was a cross-sectional study of National Health and Nutrition Examination Surveys (NHANES) participants (2005-2010). PARTICIPANTS: Nonfasting NHANES participants (n = 13 792) without diagnosed diabetes were included. PRIMARY OUTCOME: The primary outcome was glycemic status (normal glycemia, undiagnosed prediabetes, or undiagnosed diabetes) using hemoglobin HbA1C as the criterion standard. ANALYSIS: Multinomial logistic regression examined associations between diabetes risk factors and RBG values according to glycemic status. Associations between current U.S. screening strategies and a hypothetical RBG screening strategy with undiagnosed diabetes were examined. RESULTS: In unadjusted analyses, a single RBG ≥ 100 mg/dL (5.6 mmol/L) was more strongly associated with undiagnosed diabetes than any single risk factor (odds ratio [OR], 31.2; 95% confidence interval [CI], 21.3-45.5) and remained strongly associated with undiagnosed diabetes (OR, 20.4; 95% CI, 14.0-29.6) after adjustment for traditional diabetes risk factors. Using RBG < 100 mg/dL as a reference, the adjusted odds of undiagnosed diabetes increased significantly as RBG increased. RBG 100-119 mg/dL (OR 7.1; 95% CI 4.4-11.4); RBG 120-139 mg/dL (OR 30.3; 95% CI 20.0-46.0); RBG ≥ 140 mg/dL (OR 256; 95% CI 150.0-436.9). As a hypothetical screening strategy, an elevated RBG was more strongly associated with undiagnosed diabetes than current United States Preventative Services Task Force guidelines (hypertension alone; P < .0001) and similar to American Diabetes Association guidelines (P = .12). CONCLUSIONS: A single RBG ≥ 100 mg/dL is more strongly associated with undiagnosed diabetes than traditional risk factors. Abnormal RBG values are a risk factor for diabetes and should be considered in screening guidelines.