{"id":1103,"date":"2016-07-26T14:39:46","date_gmt":"2016-07-26T14:39:46","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/?p=1103"},"modified":"2017-08-21T10:50:13","modified_gmt":"2017-08-21T10:50:13","slug":"primary-care-corner-with-geoffrey-modest-md-uspstf-diabetes-screening-misses-most-people","status":"publish","type":"post","link":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/07\/26\/primary-care-corner-with-geoffrey-modest-md-uspstf-diabetes-screening-misses-most-people\/","title":{"rendered":"Primary Care Corner with Geoffrey Modest MD: USPSTF Diabetes Screening Misses Most People"},"content":{"rendered":"<p><strong>By Dr. Geoffrey Modest<\/strong><\/p>\n<p>A study looked at the sensitivity\/specificity of the current USPSTF guidelines for diabetes screening in a community setting, finding over\u00a0half the cases are missed (see\u00a0<a href=\"http:\/\/journals.plos.org\/plosmedicine\/article\/asset?id=10.1371%2Fjournal.pmed.1002074.PDF\">http:\/\/journals.plos.org\/plosmedicine\/article\/asset?id=10.1371%2Fjournal.pmed.1002074.PDF<\/a> ). The USPSTF in 2015 recommended diabetes screening for those aged 40-70 and who are overweight\/obese.<\/p>\n<p>Details:<\/p>\n<ul>\n<li>Retrospective analysis of electronic health record data of 50,515 adult primary care patients seen between 2008-2010 in 6\u00a0health centers in the Midwest and Southwest, followed for up to 3 years (median 1.9). [This screening was prior to the 2015 USPSTF guidelines]<\/li>\n<li>18,846 (37%) were &gt;40 yo; 33,537 (66%)\u00a0were overweight or obese; 39,061 (77%) were racial\/ethnic minorities (35% Black, 334% Hispanic, 9% other)<\/li>\n<li>They excluded patients with dysglycemia (glucose intolerance or diabetes) at baseline<\/li>\n<li>They then compared the actual findings of dysglycemia (by the usual fasting or post-prandial sugar\/A1c) criteria with who would have not been screened if adhering to the later-published 2015 USPSTF guidelines<\/li>\n<\/ul>\n<p>Results:<\/p>\n<ul>\n<li>29,946 (59%) had a glycemic test within 3 y of follow-up<\/li>\n<li>8,478 of them developed dysglycemia (78% by using the A1C criteria)<\/li>\n<li>12,679 (25%)\u00a0of the 50,515 patients overall would have been eligible for screening per the 2015 USPSTF guidelines\n<ul>\n<li>Overall sensitivity of the guidelines was 45.0% (43.9-46.1%)<\/li>\n<li>Overall specificity was 71.9% (71.3-72.5%)<\/li>\n<li>PPV was 38.8% and NPV was 76.8%<\/li>\n<li>Subgroup analysis:\n<ul>\n<li>Compared to normal weight:\u00a0overweight people\u00a0had 31% more dysglycemia; obese 145% increase<\/li>\n<li>PCOS 124% increase<\/li>\n<li>Dramatic increases in dysglycemia in those with increasing number of diabetes risk factors (the Am Diabetes Assn risk factors as noted below)<\/li>\n<\/ul>\n<\/li>\n<li>On multivariate analysis, significant associations with the development of dysglycemia: age &gt;40, overweight\/obese, nonwhite race\/ethnicity, hypertension, PCOS, history of gestational diabetes, family history of diabetes<\/li>\n<li>Dysglycemia cases in\u00a0racial\/ethnic minorities were significantly less likely to be eligible for USPSTF-guideline based screening, though they had higher odds for\u00a0developing dysglycemia (OR for Black patients 1.24; Hispanic 1.46). The sensitivity for different racial\/ethnic groups was:\n<ul>\n<li>White:\u00a054.5%<\/li>\n<li>Black: 50.3%<\/li>\n<li><strong>Hispanic\/Latino: 37.7%<\/strong><\/li>\n<li>And the lower sensitivity in racial\/ethnic minorities reflects the greater proportion of patients who developed dysglycemia at a normal weight and under 40 yo\u00a0(e.g., <strong>20% of Hispanic\/Latino patients of normal weight developed dysglycemia, as well as 31% of those &lt;40yo<\/strong><strong>)<\/strong><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>Commentary:<\/p>\n<ul>\n<li>Diabetes is really common: from the USPSTF document: \u201capproximately 86 million Americans aged 20 years or older have IFG or IGT. Approximately 15% to 30% of these persons will develop type 2 diabetes within 5 years if they do not implement lifestyle changes to improve their health\u201d<\/li>\n<li>Many studies over the last several decades in several different countries\u00a0show that <strong>intensive<\/strong> <strong>lifestyle interventions can prevent or at least delay the development of diabetes<\/strong>, with reasonable argument that this would significantly decreased the associated micro- and macrovascular morbidity. This strongly supports the likely utility of screening\/potential for earlier intervention.<\/li>\n<li>It should be noted that the Am Diabetes Assn has much more expansive guidelines (see\u00a0<a href=\"http:\/\/care.diabetesjournals.org\/content\/suppl\/2015\/12\/21\/39.Supplement_1.DC2\/2016-Standards-of-Care.pdf\">http:\/\/care.diabetesjournals.org\/content\/suppl\/2015\/12\/21\/39.Supplement_1.DC2\/2016-Standards-of-Care.pdf<\/a> , p16)\u00a0for testing asymptomatic adults:\n<ul>\n<li>All\u00a0overweight (BMI &gt;25, or &gt;23 in Asian-Americans) with at least one additional risk factor: physical inactivity, first-degree relative with diabetes, members of high-risk\u00a0ethnic group (African American, Latino, Native American, Pacific Islander), women who\u00a0had baby &gt;9 # or had gestational diabetes, hypertension, HDL &lt;35 or triglyceride &gt;250, other clinical condition associated with diabetes (e.g. acanthosis nigricans), history of CVD<\/li>\n<li>In absence of above, everyone at age 45<\/li>\n<\/ul>\n<\/li>\n<li>The NICE guidelines in the UK focus on those at high diabetes risk, independent of obesity (see\u00a0<a href=\"https:\/\/www.diabetes.org.uk\/Documents\/About%20Us\/What%20we%20say\/Position%20Statement%20-%20Early%20identification%20of%20people%20with%20Type%202%20diabetes%20(Nov%202015).pdf\">https:\/\/www.diabetes.org.uk\/Documents\/About%20Us\/What%20we%20say\/Position%20Statement%20-%20Early%20identification%20of%20people%20with%20Type%202%20diabetes%20(Nov%202015).pdf<\/a> )<\/li>\n<li>There are clear limitations of this study. This was not a prospective study of all-comers to assess the prevalence of dysglycemia, along with\u00a0individual risk factors. And even in the PLoS analysis, they do not disaggregate the issues of age&lt;40 and normal weight (i.e., it is not entirely clear if normal weight people who also are &lt;40 yo have a significant incidence of dysglycemia). [On my brief search, I was quite surprised at how little epidemiological data was available on the prevalence of glucose intolerance in the US population, including different ethnicities\/other subgroups.]<\/li>\n<li>My experience absolutely reflects the results of the PLoS study: we find many people who have either glucose intolerance or diabetes who would not qualify under the current USPSTF guidelines (I have been using\u00a0the Am Diabetic Assn guidelines, though I should add that in our health center, a very large % of our patients under age 40 do qualify for testing by these guidelines). However, though this study is not definitive, it really raises the ante: it seems that a fair number of patients under 40yo or\u00a0with normal weight have dysglycemia. And it seems to me that the benefits (early reinforcement of intensive lifestyle changes) far outweigh the risks\u2026.<\/li>\n<\/ul>\n","protected":false},"excerpt":{"rendered":"<p>Primary Care Corner with Geoffrey Modest MD: USPSTF Diabetes Screening Misses Most People  [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/07\/26\/primary-care-corner-with-geoffrey-modest-md-uspstf-diabetes-screening-misses-most-people\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":148,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[14283],"tags":[],"class_list":["post-1103","post","type-post","status-publish","format-standard","hentry","category-archive"],"jetpack_featured_media_url":"","jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/1103","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/users\/148"}],"replies":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/comments?post=1103"}],"version-history":[{"count":0,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/1103\/revisions"}],"wp:attachment":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/media?parent=1103"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/categories?post=1103"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/tags?post=1103"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}