Multilevel Variation in Diabetes Screening Within an Integrated Health System

Abstract

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 METHODSWe 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. RESULTSOf 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. Diabetes screening identifies individuals with undiagnosed, asymptomatic type 2 diabetes or prediabetes who are eligible for evidence-based interventions to prevent or delay type 2 diabetes and its complications. National screening guidelines, such as the American Diabetes Association (ADA) (1) and U.S. Preventive Services Task Force (USPSTF) (2), help clinicians identify individuals at increased risk for type 2 diabetes and target screening tests in clinical practice. Despite screening recommendations, .7 million U.S. adults with type 2 diabetes and 74 million U.S. adults with prediabetes remain undiagnosed (3). Nationally representative data indicate significant gaps

Prediabetes screening, treatment, and follow‐up in primary health care: a cross‐sectional survey

“…15 Previous research has also found that it tends to be clinical experience rather than guidelines that prompts screening 19 and that screening varies at the provider and the clinical level. 20 In the current study, we found that most of the centres that screened for prediabetes targeted people with other health problems, such as hypertension and obesity. Similar results have been found in other studies, 12,[20][21][22] where risk factors like polycystic ovary syndrome and highrisk ethnicity are not as well-recognised as the metabolic ones.…”

“…There are few studies on screening for prediabetes in primary health care. [15][16][17][18][19][20][21] Most have been carried out in the United States (US), [15][16][17][18][19][20] where the health care system differs from the system in Sweden. One took place in Malta.…”

“…4,8 Screening methods also vary in primary health care populations outside Sweden. 18,20 Thus, there is a need for clearer and more systematic guidelines for prediabetes.…”

Assessment of variation in long-term outcomes of integrated care initiatives in Dutch health care

“…Some general practitioners in care groups diagnose and refer patients to the integrated care program earlier than general practitioners in other care groups. 44 Therefore, simply taking all the patients newly included in the integrated care program for DM2 reduces the comparability of care group populations, producing bias in the results. Our selection made the study population more homogeneous, and thus comparisons between the care group populations were fairer as a result.…”

Alternative type 2 diabetes screening tests may reduce the number of U.S. adults with undiagnosed diabetes

“…Type 2 diabetes screening tests considered in this study include FPG ≥ 7.0 mmol/l, OGTT ≥ 11.1 mmol/l, HbA 1c ≥ 48 mmol/mol, opportunistic RPG > 6.7 mmol/l and GCT > 8.9 mmol/l ( Table S1). The gold standard for diagnosing type 2 diabetes was either FPG ≥ 7.0 mmol/l or OGTT ≥ 11.1 mmol/l because recent evidence suggests most clinicians diagnose diabetes with a single positive test [16].…”