An Interrupted Time Series Analysis to Determine the Effect of an Electronic Health Record–Based Intervention on Appropriate Screening for Type 2 Diabetes in Urban Primary Care Clinics in New York City
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OBJECTIVE To determine the impact of a health system–wide primary care diabetes management system, which included targeted guidelines for type 2 diabetes (T2DM) and prediabetes (dysglycemia) screening, on detection of previously undiagnosed dysglycemia cases. RESEARCH DESIGN AND METHODS Intervention included electronic health record (EHR)–based decision support and standardized providers and staff training for using the American Diabetes Association guidelines for dysglycemia screening. Using EHR data, we identified 40,456 adults without T2DM or recent screening with a face-to-face visit (March 2011–December 2013) in five urban clinics. Interrupted time series analyses examined the impact of the intervention on trends in three outcomes: 1) monthly proportion of eligible patients receiving dysglycemia testing, 2) two negative comparison conditions (dysglycemia testing among ineligible patients and cholesterol screening), and 3) yield of undiagnosed dysglycemia among those tested. RESULTS Baseline monthly proportion of eligible patients receiving testing was 7.4–10.4%. After the intervention, screening doubled (mean increase + 11.0% [95% CI 9.0, 13.0], proportion range 18.6–25.3%). The proportion of ineligible patients tested also increased (+5.0% [95% CI 3.0, 8.0]) with no concurrent change in cholesterol testing (+0% [95% CI −0.02, 0.05]). About 59% of test results in eligible patients showed dysglycemia both before and after the intervention. CONCLUSIONS Implementation of a policy for systematic dysglycemia screening including formal training and EHR templates in urban academic primary care clinics resulted in a doubling of appropriate testing and the number of patients who could be targeted for treatment to prevent or delay T2DM.Keywords:
Prediabetes
Electronic health record
This chapter provides a description of physical and metabolic characteristics of persons with diabetes and prediabetes and is based primarily on data from the National Health and Nutrition Examination Surveys 2005–2010. The 2010 American Diabetes Association guidelines were used to define undiagnosed diabetes and prediabetes. Among participants with diabetes, mean glycosylated hemoglobin (A1c) concentrations were highest in those with diagnosed diabetes treated by insulin or oral diabetes medication (7.4%), followed by undiagnosed diabetes defined by A1c or fasting plasma glucose (6.9%), and lowest among those with untreated diagnosed diabetes (6.3%) and undiagnosed diabetes defined by A1c, fasting plasma glucose, or 2-hour plasma glucose (6.3%). Mean fasting plasma glucose concentrations were highest in those with treated diabetes (153 mg/dL) and undiagnosed diabetes defined by A1c or fasting plasma glucose (149 mg/dL) and generally lower among those with untreated diagnosed diabetes (137 mg/dL) and undiagnosed diabetes defined by A1c, fasting plasma glucose, or 2-hour plasma glucose (130 mg/dL). Mean 2-hour plasma glucose concentrations were higher in those with undiagnosed diabetes (243 mg/dL for A1c and fasting plasma glucose definition; 235 mg/dL for A1c, fasting plasma glucose, and 2-hour plasma glucose definition) than in people with untreated diagnosed diabetes (183 mg/dL; 2-hour plasma glucose was not measured in participants with treated diagnosed diabetes). Participants with prediabetes by definition had lower A1c, fasting plasma glucose, and 2-hour plasma glucose concentrations than those with diabetes, and participants with normal glucose regulation had the lowest concentrations. Mean fasting insulin concentrations were generally higher in people with undiagnosed diabetes than in people with diagnosed diabetes (insulin users were excluded). Participants with prediabetes generally had lower fasting insulin concentrations than those with undiagnosed diabetes, and those with normal glucose regulation had the lowest fasting insulin concentrations.The prevalence of family history of diabetes was generally highest among people with diagnosed diabetes (69%), followed by undiagnosed diabetes (49% for A1c and fasting plasma glucose definition; 45% for A1c, fasting plasma glucose, and 2-hour plasma glucose definition), and was lowest in those with prediabetes (39%) and normal glucose regulation (33%). People with diabetes had higher mean body mass index and systolic blood pressure than people with prediabetes, and those with normal glucose regulation had the lowest means. The relationship between diabetes and cholesterol level differed by age group. Mean levels of total cholesterol, low-density lipoprotein (LDL) cholesterol, and triglycerides were generally higher in people with diabetes age 20–44 years than in people with prediabetes or normal glucose regulation. Conversely, mean levels of total cholesterol, LDL cholesterol, and triglycerides were generally lower in people with diabetes age 45–64 years than those with prediabetes or normal glucose regulation. The prevalence of C-reactive protein ≥10 mg/L was generally higher among people with diabetes than among people with prediabetes, and people with normal glucose regulation generally had the lowest prevalence. Women with diagnosed diabetes had a higher age-standardized mean number of live births than women who had not been diagnosed with diabetes. Individuals with diagnosed diabetes reported a higher prevalence of fair or poor health than those with prediabetes or normal glucose regulation.
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To examine the magnitude and types of hospitalizations among persons with prediabetes, undiagnosed diabetes, and diagnosed diabetes.
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What would happen if one could develop diabetes as quickly as catching the common cold? Well of course this is not the case, but diabetes is becoming more and more common in the United States. From the period 1980 through 2002, the number of Americans diagnosed with diabetes mellitus more than doubled (from 5.8 million people to 13 million people). New evidence reveals that one in three Americans born in 2000 will develop diabetes sometime during their lifetime. Diabetes has the greatest impact on older adults, women, and particular racial and ethnic groups. One in five adults over the age of 65 has diabetes. African Americans, Hispanics, Native American Indians and Alaska Native adults are two to three times more likely than Caucasian adults to have diabetes. In addition to these statistics, an estimated 41 million United States adults aged 40-74 have prediabetes. Prediabetes is defined as blood glucose elevated more than normal, but not increased enough to be classified as that of diabetes mellitus. Fasting blood glucose levels greater than 100 mg/dl but less than 126 mg/dl is characteristic of prediabetes. These people are at great risk for developing diabetes.
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Aims. To investigate the epidemiology of diabetes diagnosis and screening in Australian general practice. Methods. Cross-sectional study using electronic health records of 1,522,622 patients aged 18+ years attending 544 Australian general practices (MedicineInsight database). The prevalence of diagnosed diabetes and diabetes screening was explored using all recorded diagnoses, laboratory results, and prescriptions between 2016 and 2018. Their relationship with patient sociodemographic and clinical characteristics was also investigated. Results. Overall, 7.5% (95% CI 7.3, 7.8) of adults had diabetes diagnosis, 0.7% (95% CI 0.6, 0.7) prediabetes, and 0.3% (95% CI 0.3, 0.3) unrecorded diabetes/prediabetes (elevated glucose levels without a recorded diagnosis). Patients with unrecorded diabetes/prediabetes had clinical characteristics similar to those with recorded diabetes, except for a lower prevalence of overweight/obesity (55.5% and 69.9%, respectively). Dyslipidaemia was 1.8 times higher (36.2% vs. 19.7%), and hypertension was 15% more likely (38.6% vs. 33.8%) among patients with prediabetes than with diabetes. Diabetes screening (last three years) among people at high risk of diabetes was 55.2% (95% CI 52.7, 57.7), with lower rates among young or elderly males. Conclusions. Unrecorded diabetes/prediabetes is infrequent in Australian general practice, but prediabetes diagnosis was also lower than expected. Diabetes screening among high-risk individuals can be improved, especially in men, to enhance earlier diabetes diagnosis and management.
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OBJECTIVE Diabetes in older age is heterogeneous, and the treatment approach varies by patient characteristics. We characterized the short-term all-cause and cardiovascular mortality risk associated with hyperglycemia in older age. RESEARCH DESIGN AND METHODS We included 5,791 older adults in the Atherosclerosis Risk in Communities Study who attended visit 5 (2011–2013; ages 66–90 years). We compared prediabetes (HbA1c 5.7% to <6.5%), newly diagnosed diabetes (HbA1c ≥6.5%, prior diagnosis <1 year, or taking antihyperglycemic medications <1 year), short-duration diabetes (duration ≥1 year but <10 years [median]), and long-standing diabetes (duration ≥10 years). Outcomes were all-cause and cardiovascular mortality (median follow-up of 5.6 years). RESULTS Participants were 58% female, and 24% had prevalent cardiovascular disease. All-cause mortality rates, per 1,000 person-years, were 21.2 (95% CI 18.7, 24.1) among those without diabetes, 23.7 (95% CI 20.8, 27.1) for those with prediabetes, 33.8 (95% CI 25.2, 45.5) among those with recently diagnosed diabetes, 29.6 (95% CI 25.0, 35.1) for those with diabetes of short duration, and 48.6 (95% CI 42.4, 55.7) for those with long-standing diabetes. Cardiovascular mortality rates, per 1,000 person-years, were 5.8 (95% CI 4.6, 7.4) among those without diabetes, 6.6 (95% CI 5.2, 8.5) for those with prediabetes, 11.5 (95% CI 7.0, 19.1) among those with recently diagnosed diabetes, 8.2 (95% CI 5.9, 11.3) for those with diabetes of short duration, and 17.3 (95% CI 13.8, 21.7) for those with long-standing diabetes. After adjustment for other cardiovascular risk factors, prediabetes and newly diagnosed diabetes were not significantly associated with a higher risk of all-cause mortality (hazard ratio [HR] 1.03 [95% CI 0.85, 1.23] and HR 1.31 [95% CI 0.94, 1.82], respectively) or cardiovascular mortality (HR 1.00 [95% CI 0.70, 1.43] and HR 1.35 [95% CI 0.74, 2.49], respectively). Excess mortality risk was primarily concentrated among those with long-standing diabetes (all-cause: HR 1.71 [95% CI 1.40, 2.10]; cardiovascular: HR 1.72 [95% CI 1.18, 2.51]). CONCLUSIONS In older adults, long-standing diabetes has a substantial and independent effect on short-term mortality. Older individuals with prediabetes remained at low mortality risk over a median 5.6 years of follow-up.
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Background Pre-diabetes occurs when blood glucose is elevated (indicated by a fasting plasma glucose level between 100–125 mg/dL), but not high enough to warrant a diabetes diagnosis. Prediabetes is highly correlated with a subsequent diabetes diagnosis within 5 years, and is an independent risk factor for heart disease. Obesity is a significant risk factor for both prediabetes and diabetes. Patients with pre-diabetes can prevent or substantially delay diabetes onset by increasing physical activity and losing weight.
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Introduction In studies that enrolled people with prevalent pre-diabetes of unknown duration, lifestyle intervention (LI) delayed progression to type 2 diabetes (T2D) but did not reverse pre-diabetes in most participants. Here, we assessed the effects of LI among individuals with pre-diabetes of known duration to determine whether outcomes are related to duration of pre-diabetes. Research design and methods The Pathobiology and Reversibility of Prediabetes in a Biracial Cohort study initiated LI in subjects with incident pre-diabetes during follow-up of initially normoglycemic African Americans and European Americans with parental T2D. Participants were stratified into those initiating LI after <3, 3–5, or >5 years of pre-diabetes diagnosis. Assessments included anthropometry, body fat, fasting and 2-hour plasma glucose (FPG, 2hPG), and insulin sensitivity and secretion. The outcomes were normal glucose regulation (NGR; ie, normal FPG and 2hPG), persistent pre-diabetes, or T2D. Participants who maintained normal FPG and normal 2hPG levels during follow-up served as the control. The control subjects did not receive lifestyle or other intervention to alter the course of glycemia or body weight. Results Of 223 participants (age 53.3±9.28 years, body mass index 30.6±6.70 kg/m 2 ), 72 (control) maintained normoglycemia during follow-up and 138 subjects with incident pre-diabetes initiated LI after 4.08±2.02 years (range 3 months–8.3 years) of diagnosis. Compared with control, LI participants showed decrease in glucose, weight, and body fat; 42.8% reverted to NGR, 50% had persistent pre-diabetes, and 7.2% developed T2D after 5 years. These outcomes were similar across race and pre-diabetes duration strata, but greater glycemic decrease occurred when LI was initiated within 5 years of pre-diabetes diagnosis. Conclusions Ninety-three per cent of adults with parental T2D who initiated LI within 3 months to 8.3 years of developing pre-diabetes did not progress to T2D; nearly half reverted to NGR. Trial registration number NCT02027571 .
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Diabetes mellitus affects almost one in 10 individuals in Germany. So far, little is known about the diabetes prevalence in maximum care hospitals. We assessed the diabetes prevalence, proportion of undiagnosed cases, the effectiveness of diabetes screening in a university hospital, the consequences for hospital stay and acquired complications.Over a 4 week period we determined HbA1c from 3 733 adult patients which were hospitalized at the university hospital of Tuebingen and had an available blood sample. Diabetes diagnosis was defined as HbA1c≥6.5% and/or previously documented diabetes diagnosis, prediabetes was defined as HbA1c≥5.7% and <6.5% without history of previous diabetes.23.68% of the patients had prediabetes and 22.15% had diabetes with a high variation between the specialised departments (range 5-43%). The rate of unknown diabetes was 3.7%, the number needed to screen was 17 in patients older than 50 years. Patients with diabetes had a prolonged hospital stay compared to the mean length of stay for their diagnosis related group (diabetes: 1.47±0.24 days; no diabetes: -0.18±0.13 days, p=0.0133). The prevalence of hospital acquired complications was higher in diabetic patients (diabetes: 197 of 630; no diabetes: 447 of 2 459, p<0.0001).Every fourth patient in the university hospital had diabetes and every second had either prediabetes or diabetes. It is also worthwhile to screen for unknown diabetes in patients over the age of 50. The high prevalence and negative consequences of diabetes require screening and intensified specialized diabetes treatment in hospitals.
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