Diabetes Prevention in a U.S. Healthcare System: A Portrait of Missed Opportunities
Published: American Journal of Preventive Medicine. January 2022
Where: University of Florida
To prevent diabetes in the US, doctors need to more consistently and rigorously diagnose and treat prediabetes.
What It Looked At
The study aimed to uncover gaps in diabetes prevention by investigating the rate at which large health systems comply with U.S. Preventive Services Task Force’s (USPSTF) guidelines for screening, diagnosing, and treating prediabetes. In other words, are doctors “missing opportunities” to identify and treat patients at risk for diabetes at a stage early enough to prevent it.
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Researchers enrolled more than 21,000 patients eligible for prediabetes screening at a large Florida health system from August 1, 2019, to October 31, 2020. It analyzed their electronic health records to evaluate adherence to USPSTF recommendations for prediabetes screening, diagnosis, and treatment.
Following USPSTF guidelines, the study marked a participant as having prediabetes if they tested positive twice for abnormal glucose metabolism identified by:
- 5.7% to 6.4% for hemoglobin A1c (HbA1c)
- Fasting plasma glucose levels within 100 mg/dL and 125 mg/dL
- Oral glucose tolerance test showing 140 mg/dL to 199 mg/dL
Researchers then assessed whether the participants who tested positive for prediabetes had been diagnosed with prediabetes. People who had ICD-9/ICD-10 code for prediabetes in their records were confirmed to have been diagnosed with prediabetes.
The study checked for evidence of metformin (a medication that lowers blood sugar levels) prescription or a formal lifestyle treatment plan in their records to see whether the diagnosed participants received treatment.
What’s Unique About This Study
Previous studies have examined prediabetes and came to a similar conclusion that it is being under-treated. However, those studies relied on limited data sources that didn’t capture a patient’s entire history or self-reported data.
What sets this study apart is its use of electronic health records on a large cohort of patients. This showed researchers how many people who qualified for prediabetes screening received the recommended two glucose tests. They also tracked how many people who scored in a prediabetes range on those tests received a diagnostic code for prediabetes and one of the recommended treatment options (either metformin or lifestyle intervention).
This dataset also allowed researchers to look at variations of these questions, such as:
- How many people received only one glucose test before getting a diagnosis or treatment?
- How many people got treatment but no formal diagnosis?
What It Found
The researchers found that out of 21,448 participants, 13,465 (62.8%) were screened according to USPSTF recommendations, and 3,430 were eligible for a prediabetes diagnosis, meaning they met the thresholds above on two tests. Only 185 (5.4%) were formally diagnosed with prediabetes. None of those diagnosed with prediabetes received treatment in line with USPSTF recommendations.
Furthermore, the study observed that:
- Men were less likely to be screened for prediabetes than women.
- The participants’ health insurance plan didn’t influence their screening chances.
- When researchers narrowed the diagnostic criteria to only one test, the number of participants who got a diagnosis rose from 5% of those eligible to 19%.
- Researchers identified 387 people who never got a formal diagnosis or a second test but received treatment anyway: 289 were prescribed metformin, while 98 were recommended lifestyle management options.
“I wasn’t particularly surprised because we know that 80 to 90% of people who have prediabetes don’t know they have it. But I was disappointed,” says lead author Arch G. Mainous III, Ph.D., Professor in the Department of Community Health and Family Medicine, College of Public Health and Health Professions at the University of Florida. “We also know that when a lot of physicians are presented with patients with high glucose levels, they don’t diagnose them.”
The researchers did not investigate reasons for these missed opportunities but had a few speculations on why the compliance rate for diagnosing and treating prediabetes was astonishingly low:
- Doctors may find it difficult talking about weight loss or other lifestyle recommendations with patients with prediabetes.
- Many patients may not be aware of diabetes prevention programs
- There may be inadequate time to inform patients with prediabetes about their preventive treatment options.
- Patients may refuse diagnosis or treatments.
- Patients’ insurance plans might not cover the appropriate medications or lifestyle treatment.
- There’s no financial incentive to encourage doctors to comply with diabetes prevention guidelines.
Why It Matters
More than 10% of the people in the US have diabetes, and 23% of that is undiagnosed. About 95% of diabetes cases are Type 2, a largely preventable condition that occurs when insulin resistance gets so severe the body is unable to regulate glucose effectively. According to the World Health Organization (WHO), it’s a leading cause of kidney failure, heart attacks, stroke, blindness, and lower limb amputation.
There are effective interventions for preventing diabetes. But the first step is to know whether you’re at high risk, Mainous explains.
Prediabetes is a reversible condition that precedes the development of diabetes. About 96 million adults in the US (one in three US adults) have prediabetes. Worse still, more than 80% of people with prediabetes are not aware they have it. And prediabetes alone is linked to an increased risk of stroke, heart disease, and Alzheimer’s. Studies also find prediabetes is associated with higher healthcare costs.
Numerous studies suggest that we can prevent diabetes if people with a high risk of developing it are identified, diagnosed, and recommended appropriate lifestyle and medication treatment. An NIH study showed that people at high risk of diabetes who participated in a lifestyle change program had a 58% lower chance of developing diabetes than a placebo group after three years.
According to Mainous, the next question for researchers is: How do we get diabetes prevention integrated into clinical practice?
A 2016 study found that physician attitudes about prediabetes influenced the likelihood that they would recommend interventions. The same survey also found that physicians thought patient motivation and circumstances might hinder their willingness and ability to access prediabetes screening and follow a treatment protocol. The study suggests that increasing physician awareness and education about prediabetes and ensuring patients are supported in following an intervention plan can both play a role in increasing screening and treatment.