How diabetes risk assessment tools are implemented in practice: a systematic review

AWARE A novel web application to rapidly assess cardiovascular risk in type 2 diabetes mellitus

AIM

To describe the development of the AWARE App, a novel web application for the rapid assessment of cardiovascular risk in Type 2 Diabetes Mellitus (T2DM) patients. We also tested the feasibility of using this App in clinical practice.

METHODS

Based on 2019 European Society of Cardiology/European Association for the Study of Diabetes criteria for cardiovascular risk stratification in T2DM, the AWARE App classifies patients into very high (VHCVR), high (HCVR) and moderate (MCVR) cardiovascular risk categories. In this retrospective clinical study, we employed the App to assess the cardiovascular risk of T2DM patients, while also collecting data about current glycaemic control and pharmacological treatment.

RESULTS

2243 T2DM consecutive patients were evaluated. 72.2% of the patients were VHCVR, 8.9% were HCVR, 0.8% were MCVR while 18.2% did not fit into any of the risk categories and were classified as "moderate-to-high" (MHCVR). Compared with the other groups, patients with VHCVD were more frequently ≥ 65 years old (68.9%), with a longer disease duration (≥ 10 years [56.8%]), a history of cardiovascular disease (41.4%), organ damage (35.5%) and a higher numbers of cardiovascular risk factors. Patients with MHCVD generally had disease duration < 10 years (96%), younger age (50-60 years [55%]), no history of cardiovascular disease, no organ damage, and 1-2 cardiovascular risk factors (89%). Novel drugs such as Glucagon Like Peptyde 1 Receptor Agonists or Sodium-Glucose Linked Transporter 2 inhibitors were prescribed only to 26.3% of the patients with VHCVR and to 24.7% of those with HCVR. Glycaemic control was unsatisfactory in this patients population (HbA1c 7.5 ± 3.4% [58.7 ± 13.4 mmol/mol]).

CONCLUSIONS

The AWARE App proved to be a practical tool for cardiovascular risk stratification of T2DM patients in real-world clinical practice.

Measurement of Perceived Risk of Developing Diabetes Mellitus: A Systematic Literature Review

BACKGROUND

This systematic review describes approaches to measuring perceived risk of developing type 2 diabetes among individuals without diagnoses and describes the use of theories, models, and frameworks in studies assessing perceived risk. While a systematic review has synthesized perceived risk of complications among individuals with diabetes, no reviews have systematically assessed how perceived risk is measured among those without a diagnosis.

METHODS

Medline, PubMed, PsycINFO, and CINAHAL databases were searched for studies conducted through October 2022 with measures of perceived risk among adults ≥ 18 years without a diabetes diagnosis. Extracted data included study characteristics, measures, and health behavior theories, models, or frameworks used.

RESULTS

Eighty-six studies met inclusion criteria. Six examined perceived risk scales' psychometric properties. Eighty measured perceived risk using (1) a single item; (2) a composite score from multiple items or subconstructs; and (3) multiple subconstructs but no composite score. Studies used items measuring "comparative risk," "absolute or lifetime risk," and "perceived risk" without defining how each differed. Sixty-four studies used cross-sectional designs. Twenty-eight studies mentioned use of health behavior theories in study design or selection of measures.

DISCUSSION

There was heterogeneity in how studies operationalized perceived risk; only one third of studies referenced a theory, model, or framework as guiding design or scale and item selection. Use of perceived lifetime risk, absolute risk, or comparative risk limits comparisons across studies. Consideration of context, target population, and how data are utilized is important when selecting measures; we present a series of questions to ask when selecting measures for use in research and clinical settings. This review is the first to categorize how perceived risk is measured in the diabetes prevention domain; most literature focuses on perceived risk among those with diabetes diagnoses. Limitations include exclusion of non-English and gray literature and single reviewer screening and data extraction.

Pharmacy diabetes screening trial (PDST): Outcomes of a national clustered RCT comparing three screening methods for undiagnosed type 2 diabetes (T2DM) in community pharmacy

AIMS

To compare the effectiveness of three pharmacy-based screening methods for type 2 diabetes (T2DM): (1) risk assessment (AUSDRISK) alone (Group A); AUSDRISK followed by a point of care test if AUSDRISK ≥12; either (2) HbA1c (Group B); or (3) small capillary blood glucose test (Group C).

METHODS

A cluster RCT with a nationally representative sample of Australian pharmacies was implemented with random allocation of eligible pharmacies to Groups A, B or C. GP referral was based on prespecified cut offs. Diagnoses were considered positive if confirmed by a GP, pathology laboratory, or national diabetes register.

RESULTS

Of the 14,093 people screened in 339 pharmacies, 3059 participants met group-specific referral criteria: 1775 (45%) (Group A); 893 (17%) (Group B); and 391 (8%) (Group C). For the total screened population rates of T2DM diagnoses were significantly higher in Group B (1.5%), compared with Groups A (< 0.8%) and C (< 0.6%) with the odds of detection in Group B compared with Group A (1.8 [1.0;3.0]), and no difference between Groups A and C.

CONCLUSIONS

In community pharmacy, the most effective method to uncover undiagnosed T2DM was a stepwise approach; initial risk assessment; and if appropriate an HbA1C POC test and referral.

Preferences and Perspectives of Australian General Practitioners Towards a New "Four-in-One" Risk Assessment Tool for Preventative Health: The LEAD! GP Project

BACKGROUND

Dementia risk reduction is a public health priority and general practitioners (GPs) play a pivotal role in preventative healthcare. Therefore, risk assessment tools should be designed with GPs' preferences and perspectives in mind.

OBJECTIVE

The LEAD! GP project aimed to investigate Australian GPs' preferences and perspectives relating to design, use and implementation of a new risk assessment tool that simultaneously calculates risk for four outcomes- dementia, diabetes mellitus, myocardial infarct, and stroke.

METHODS

A mixed methods study using semi-structured interviews of a diverse group of 30 Australian GPs was conducted. Interview transcripts were analyzed thematically. Demographics and questions that elicited categorical answers were analyzed descriptively.

RESULTS

Overall, GPs felt that preventative healthcare was important with some finding it rewarding, and others finding it difficult. GPs currently use many risk assessment tools. GPs' perception of the usefulness and negatives/barriers of tools related to clinical practice applicability, patient engagement, and practical aspects. The largest barrier was lack of time. GPs responded positively to the concept of a four-in-one tool and preferred it to be relatively short, supported by practice nurses and some patient involvement, linked to education resources, available in different formats, and integrated into practice software.

CONCLUSION

GPs recognize the importance of preventative healthcare and the potential benefit of a new tool that simultaneously predicts risk for those four outcomes. Findings provide important guidance to inform the final development and piloting of this tool with potential to improve efficiency and practical integration of preventative healthcare for dementia risk reduction.

Establishment of dynamic nomogram and risk score models for T2DM: a retrospective cohort study in Beijing

BACKGROUND

Health interventions can delay or prevent the occurrence and development of diabetes. Dynamic nomogram and risk score (RS) models were developed to predict the probability of developing type 2 diabetes mellitus (T2DM) and identify high-risk groups.

METHODS

Participants (n = 44,852) from the Beijing Physical Examination Center were followed up for 11 years (2006-2017); the mean follow-up time was 4.06 ± 2.09 years. Multivariable Cox regression was conducted in the training cohort to identify risk factors associated with T2DM and develop dynamic nomogram and RS models using weighted estimators corresponding to each covariate derived from the fitted Cox regression coefficients and variance estimates, and then undergone internal validation and sensitivity analysis. The concordance index (C-index) was used to assess the accuracy and reliability of the model.

RESULTS

Of the 44,852 individuals at baseline, 2,912 were diagnosed with T2DM during the follow-up period, and the incidence density rate per 1,000 person-years was 16.00. Multivariate analysis indicated that male sex (P < 0.001), older age (P < 0.001), high body mass index (BMI, P < 0.05), high fasting plasma glucose (FPG, P < 0.001), hypertension (P = 0.015), dyslipidaemia (P < 0.001), and low serum creatinine (sCr, P < 0.05) at presentation were risk factors for T2DM. The dynamic nomogram achieved a high C-index of 0.909 in the training set and 0.905 in the validation set. A tenfold cross-validation estimated the area under the curve of the nomogram at 0.909 (95% confidence interval 0.897-0.920). Moreover, the dynamic nomogram and RS model exhibited acceptable discrimination and clinical usefulness in subgroup and sensitivity analyses.

CONCLUSIONS

The T2DM dynamic nomogram and RS models offer clinicians and others who conduct physical examinations, respectively, simple-to-use tools to assess the risk of developing T2DM in the urban Chinese current or retired employees.

Impact of applying a diabetes risk score in primary care on change in physical activity: a pragmatic cluster randomised trial

AIM

There is little evidence of the impact of diabetes risk scores on individual diabetes risk factors, motivation for behaviour changes and mental health. The aim of this study was to investigate the effect of applying a noninvasive diabetes risk score in primary care as component of routine health checks on physical activity and secondary outcomes.

METHODS

Cluster randomised trial, in which primary care physicians (PCPs), randomised (1:1) by minimisation, enrolled participants with statutory health insurance without known diabetes, ≥ 35 years of age with a body mass index ≥ 27.0 kg/m². The German Diabetes Risk Score was applied as add-on to the standard routine health check, conducted in the controls. Primary outcome was the difference in participants' physical activity (International Physical Activity Questionnaire) after 12 months. Secondary outcomes included body mass index, perceived health, anxiety, depression, and motivation for lifestyle change. Analysis was by intention-to-treat principle using mixed models.

RESULTS

36 PCPs were randomised; remaining 30 PCPs (intervention: n = 16; control: n = 14) recruited 315 participants (intervention: n = 153; controls: n = 162). A slight increase in physical activity was observed in the intervention group with an adjusted mean change of 388 (95% confidence interval: - 235; 1011) metabolic equivalents minutes per week. There were no relevant changes in secondary outcomes.

CONCLUSIONS

The application of a noninvasive diabetes risk score alone is not effective in promoting physical activity in primary care.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov (NCT03234322, registration date: July 31, 2017).

Oral glucose tolerance testing as a complement to fasting plasma glucose in screening for type 2 diabetes: population-based cross-sectional analyses of 146 000 health examinations in Västerbotten, Sweden

OBJECTIVE

To assess the effect of adding an oral glucose tolerance test (OGTT) to fasting plasma glucose (FPG) in terms of detection of type 2 diabetes (T2D) and impaired glucose tolerance (IGT).

DESIGN

Retrospective analysis of serial cross-sectional screening study.

SETTING

Population-based health examinations within primary care in Västerbotten County, Sweden.

PARTICIPANTS

Individuals aged 40- 50 and 60 years with participation from 1985 to 2017. Those with previously diagnosed diabetes and FPG≥7 mmol/L were excluded.

PRIMARY AND SECONDARY OUTCOME MEASURES

Prevalence of hyperglycaemia on the OGTT (IGT and T2D defined as 2-hour postload capillary plasma glucose of 8.9-12.1 mmol/L and ≥12.2 mmol/L, respectively). Analyses were further stratified by age, sex and risk factor burden to identify groups at high or low risk of IGT and T2D on testing. The numbers needed to screen (NNS) to prevent one case of T2D through detection and treatment of IGT was estimated, combining prevalence numbers with average progression rates and intervention effects from previous meta-analyses.

RESULTS

The prevalence of IGT ranged from 0.9% (95% CI 0.7% to 1.1%) to 29.6% (95% CI 27.4% to 31.7%), and the prevalence of T2D ranged from 0.06% (95% CI 0.02% to 0.11%) to 7.0% (95% CI 5.9% to 8.3%), depending strongly on age, sex and risk factor burden. The estimated NNS to prevent one case of T2D through detection and lifestyle treatment of IGT ranged from 1332 among 40-year-old men without risk factors, to 39 among 60-year-old women with all risk factors combined.

CONCLUSIONS

The prevalence of hyperglycaemia on OGTT is highly dependent on age, sex and risk factor burden; OGTT should be applied selectively to high-risk groups to avoid unnecessary testing in the general population.

Diabetes Mellitus Diagnosis and Screening in Australian General Practice: A National Study

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.

What is the effectiveness of a personalised video story after an online diabetes risk assessment? A Randomised Controlled Trial

Background

Online risk assessment tools for type 2 diabetes communicate risk information to motivate individuals to take actions and reduce their risk if needed. The impact of these tools on follow-up behaviours (e.g., General Practitioner (GP) visits, improvement in health behaviours) is unknown. This study examined effectiveness of a personalised video story and text-based message on GP and health professional visitations and health behaviours, of individuals assessed as ‘high risk’ following completion of the online Australian Type 2 Diabetes Risk Assessment Tool (AUSDRISK).

Methods

A Randomised Controlled Trial (conducted between October 2018 and April 2019) included 477 participants with a high score (≥12). The control group received a text-based message (TM) and the intervention group received both the text-based message and a personalised video story (TM+VS) encouraging them to take follow-up action. Participants reported follow-up actions (one- and three months), and physical activity (PA), dietary behaviours and body weight (baseline, one and three months). Generalized Linear Mixed Models and chi-squared tests were used to test differences in outcomes between groups over time.

Results

The intervention was not more effective for the TM+VS group compared to the TM only group (p-values>0.05 for all outcomes). More participants in the TM only group (49.8% compared to 40.0% in the VS+TM group) visited either a GP or health professional (p = 0.18). During the 3-month follow-up: 44.9% of all participants visited a GP (36.7%) and/or other health professional (31.0%). Significant improvements were found between baseline and three months, in both groups for weekly physical activity, daily fruit and vegetable intake and weight status.

Conclusions

Messages provided with online diabetes risk assessment tools to those with high-risk, positively influence GP and health professional visitations and promote short-term improvements in health behaviours that may contribute to an overall reduction in the development of type 2 diabetes.

Trial registration

Australia New Zealand Clinical Trials Registry; ACTRN12619000809134.

Characterizing screening strategies for type 2 diabetes in high-risk ethnic communities: a scoping review protocol

OBJECTIVE

This review aims to identify the characteristics of screening strategies for type 2 diabetes to determine the most pragmatic approach to improve relevance to high-risk community groups from ethnically diverse backgrounds.

INTRODUCTION

Type 2 diabetes is increasingly contributing to the global burden of disease and is more common in some community groups. Although screening underpins the success of primary prevention programs for type 2 diabetes, screening of high-risk community groups from ethnically diverse backgrounds require different screening protocols and can be challenging. These strategies have never been systematically scoped.

INCLUSION CRITERIA

This scoping review will consider screening strategies for type 2 diabetes that target high-risk ethnic community groups. Studies with adults older than 18 years will be considered for inclusion. Screening strategies may include, but are not limited to, risk-assessment questionnaires, blood tests, or both, using an opportunistic approach involving general practices or a targeted approach toward high-risk community groups from ethnically diverse backgrounds. Experimental and observational quantitative studies and mixed methods studies will be included.

METHODS

MEDLINE, CINAHL, PsycINFO, Informit, ProQuest, Web of Science, and Scopus will be searched. Studies will be screened for inclusion by two independent reviewers, and data will be extracted using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. Results will be summarized in tables accompanied by narrative text.

Screening for Diabetes and Prediabetes

Overt type 2 diabetes mellitus (T2DM) is preceded by prediabetes and latent diabetes (lasts 9-12 years). Key dysglycemia screening tests are fasting plasma glucose and hemoglobin A1C. Screen-detected T2DM benefits from multifactorial management of cardiovascular risk beyond glycemia. Prediabetes is best addressed by lifestyle modification, with the goal of preventing T2DM. Although there is no trial evidence of prediabetes/T2DM screening effectiveness, simulations suggest that clinic-based opportunistic screening of high-risk individuals is cost-effective. The most rigorous extant recommendations are those of the American Diabetes Association and US Preventive Services Task Force, which advise opportunistic 3-yearly screening.

Implementation of the CANRISK Tool: A Qualitative Exploration Among Allied Health Professionals in Canada

OBJECTIVES

Launched in 2011 by the Public Health Agency of Canada, the Canadian Diabetes Risk Questionnaire (CANRISK) is a self-assessment tool validated in a Canadian sample, but its uptake has never been assessed. We sought to determine the level of current use of the CANRISK tool, identify common facilitators and barriers to its use and recommend future improvements.

METHODS

Ten professional allied health organizations across Canada were contacted for in-depth interviews. Contextual content and thematic analysis were used to analyze the qualitative data set.

RESULTS

According to allied health professionals, the tool is widely used, appealing and needed, and is being used for risk screening and health promotion. Respondents also identified the need to provide support and next steps for users identified as high risk. Still, several barriers to implementation were found, including readability, offensive or confusing language and difficulty ascertaining body measurements.

CONCLUSIONS

The CANRISK is a valuable diabetes risk assessment tool in Canada, particularly for allied health organizations.

How to optimize the design and implementation of risk prediction tools: focus group with patients with IgA nephropathy

Background

IgA nephropathy (IgAN) is a common type of chronic immune-mediated kidney disease with variable risk of progression to end-stage kidney disease. Risk stratification helps clinicians weight the potential risks and benefits of immunosuppressive therapy for individual patients, and can inform patient-centred communication. No prior research examined barriers of risk predication tools (RPT) specific to IgAN. The purpose of this study was to explore determinants (facilitators, barriers) of RPT use from the patient perspective.

Methods

We conducted a single focus group with English-speaking adults aged 18 or older with biopsy-proven IgAN. We asked about how they would use an IgAN RPT, and how to improve its design and implementation. We analyzed the transcript using constant comparison to inductively derive themes, and complied with qualitative research reporting criteria.

Results

The 5 participants were Caucasian men who varied in age from 35 to 55. The glomerular filtration rate ranged from 29 to 71 mL/min/1.73m², and proteinuria ranged from 0.36 to 1.41 g/d. Participants identified both benefits and harms of the risk score. They said physicians should first ask patients for permission to use it. To make it more useful, participants offered suggestions to enhance RTP design: visual display, information on how to interpret the risk score, risk categories, health implications, modifiable risk factors, multiple scenarios, and comparison with similar patients. They offered additional suggestions to enhance RPT implementation: it should not replace patient-provider discussion, it should be accompanied by self-management education so that patients can take an active role in their health. Participants appreciated information from members of the multidisciplinary team in addition to physicians. Participants also said that physicians should monitor patient emotions or concerns on an ongoing basis.

Conclusions

Patients with IgAN identified numerous ways to enhance the design and use of an RPT. Others could use this information to design and implement RPTs for patients with other conditions, but should employ user-centred design to develop RPTs that address patient preferences.

Three-component non-invasive risk score for undiagnosed diabetes in Chinese people: Development, validation and longitudinal evaluation

AIMS/INTRODUCTION

To develop a new non-invasive risk score for undiagnosed diabetes in Chinese people, and to evaluate the incident diabetes risk in those with high-risk scores, but no diabetes on initial testing.

MATERIALS AND METHODS

A total of 2,609 participants with no known diabetes (aged 25-74 years) who underwent oral glucose tolerance tests in Hong Kong (HK) were investigated for independent risk factors of diabetes to develop a categorization point scoring system, the Non-invasive Diabetes Score (NDS). This NDS was validated in a cross-sectional study of 2,746 participants in Shaanxi, China. HK participants tested to not have diabetes at baseline were assessed for subsequent incident diabetes rates.

RESULTS

In the HK cohort, hypertension, age and body mass index were the key independent risk factors selected to develop the NDS, with ≥28 out of 50 NDS points considered as high risk. The area under the receiver operating characteristic curve for undiagnosed diabetes was 0.818 and 0.720 for the HK and Shaanxi cohort, respectively. The negative predictive value was 97.4% (HK) and 95.8% (Shaanxi); the number needed to screen to identify one case of diabetes was five (HK) and 11 (Shaanxi), respectively. Among those that tested non-diabetes at baseline, individuals with NDS ≥28 had a threefold risk of incident diabetes during the subsequent 20.9 years, compared with those with NDS <28 (P < 0.001), with a steeper rise in incident diabetes observed in those with NDS at higher tertiles.

CONCLUSIONS

This new three-component risk score is a user-friendly tool for diabetes screening, and might inform the subsequent testing interval for high-risk non-diabetes individuals.

Evaluation and refinement of the PRESTARt tool for identifying 12-14 year olds at high lifetime risk of developing type 2 diabetes compared to a clinicians assessment of risk: a cross-sectional study

BACKGROUND

Traditionally Type 2 Diabetes Mellitus (T2DM) was associated with older age, but is now being increasingly diagnosed in younger populations due to the increasing prevalence of obesity and inactivity. We aimed to evaluate whether a tool developed for community use to identify adolescents at high lifetime risk of developing T2DM agreed with a risk assessment conducted by a clinician using data collected from five European countries. We also assessed whether the tool could be simplified.

METHODS

To evaluate the tool we collected data from 636 adolescents aged 12-14 years from five European countries. Each participant's data were then assessed by two clinicians independently, who judged each participant to be at either low or high risk of developing T2DM in their lifetime. This was used as the gold standard to which the tool was evaluated and refined.

RESULTS

The refined tool categorised adolescents at high risk if they were overweight/obese and had at least one other risk factor (High waist circumference, family history of diabetes, parental obesity, not breast fed, high sugar intake, high screen time, low physical activity and low fruit and vegetable intake). Of those found to be at high risk by the clinicians, 93% were also deemed high risk by the tool. The specificity shows that 67% of those deemed at low risk by the clinicians were also found to be a low risk by the tool.

CONCLUSIONS

We have evaluated a tool for identifying adolescents with risk factors associated with the development of T2DM in the future. Future work to externally validate the tool using prospective data including T2DM incidence is required.

The clinical utility of the AUSDRISK tool in assessing change in type 2 diabetes risk in overweight/obese volunteers undertaking a healthy lifestyle intervention

The objective of this study was to assess the clinical utility of the AUSDRISK tool for determining risk of Type 2 diabetes mellitus (T2DM). In this secondary analysis from the HealthTrack study, the AUSDRISK tool was applied to data from overweight/obese volunteers completing a lifestyle intervention trial. Participants were volunteer residents of the Illawarra region recruited in 2014–2015. From 377 trial participants (BMI 25–40 kg/m², 25–54 yr), 161 provided data required for measurement of AUSDRISK, collected at 0 and 12 months. They had been randomised to one of two lifestyle interventions (±a healthy food sample, 30 g walnuts/day, I and IW) delivered by dietitians, or a control intervention (C) delivered by nurse practitioners. HbA1c measures were considered for comparison. At baseline the AUSDRISK score indicated n = 83 (51.5%) were at high risk of T2DM within 5 years (≥12 points). After 12 months the proportion scored as high risk significantly decreased in the IW group (51.5% vs 33.3%; p = 0.005), but not I (51.2% vs 39.0%; p = 0.063) or C group (51.9% vs 38.9%; p = 0.065). By comparison, HbA1c measures indicated high risk in n = 24 (17%) of 139 participants at baseline and borderline non-significant changes over time in the randomised groups. In conclusion, the AUSDRISK tool has reasonable clinical utility in identifying T2DM risk in clinical samples of overweight/obese individuals.

Diagnostic accuracy of the Finnish Diabetes Risk Score (FINDRISC) for undiagnosed T2DM in Peruvian population

AIMS

To assess the diagnostic accuracy of the Finnish Diabetes Risk Score (FINDRISC) for undiagnosed T2DM and to compare its performance with the Latin-American FINDRISC (LA-FINDRISC) and the Peruvian Risk Score.

MATERIALS AND METHODS

A population-based study was conducted. T2DM and undiagnosed T2DM were defined using oral glucose tolerance test (OGTT). Risk scores assessed were FINDRISC, LA-FINDRISC and Peruvian Risk Score. Diagnostic accuracy of risk scores was estimated using the c-statistic and the area under the ROC curve (aROC). A simplified version of FINDRISC was also derived.

RESULTS

Data from 1609 individuals, mean age 48.2 (SD: 10.6), 810 (50.3%) women, were collected. A total of 176 (11.0%; 95%CI: 9.4%-12.5%) were classified as having T2DM, and 71 (4.7%; 95%CI: 3.7%-5.8%) were classified as having undiagnosed T2DM. Diagnostic accuracy of the FINDRISC (aROC=0.69), LA-FINDRISC (aROC=0.68), and Peruvian Risk Score (aROC=0.64) was similar (p=0.15). The simplified FINDRISC, with 4 variables, had a slightly better performance (aROC=0.71) than the other scores.

CONCLUSION

The performance of FINDRISC, LA-FINDRISC and Peruvian Risk Score for undiagnosed T2DM was similar. A simplified FINDRISC can perform as well or better for undiagnosed T2DM. The FINDRISC may be useful to detect cases of undiagnosed T2DM in resource-constrained settings.

Determinants of 20-year non-progression to Type 2 diabetes in women at very high risk: the E3N cohort study

AIMS

To identify the most important determinants associated with not developing Type 2 diabetes in women considered to be at very high risk.

METHODS

Between 1995 and 2014, we followed 402 women from the E3N cohort study who were considered to be at very high risk of Type 2 diabetes based on the D.E.S.I.R. score. We then computed a classification and regression tree model to identify, among a large set of risk factors, the top risk factors associated with not having Type 2 diabetes at the end of the follow-up.

RESULTS

During follow-up, 117 women (29%) were diagnosed with Type 2 diabetes, while 285 (71%) were still free of the disease in 2014. A low Western dietary pattern score was the top characteristic associated with not developing Type 2 diabetes, as only 20% of the women at very high risk in the E3N study with that characteristic developed Type 2 diabetes (compared with 29% overall). In women with a moderate or high Western dietary pattern score, the most important characteristic associated with not developing Type 2 diabetes was a high total dietary antioxidant capacity, as only 26% of these women ultimately developed Type 2 diabetes.

CONCLUSIONS

We showed that the top characteristic associated with not developing Type 2 diabetes, despite being at very high risk, was a healthy diet, characterized by limiting Western dietary habits, but with a high intake of antioxidant-rich foods. This underscores the importance of diet in the prevention of Type 2 diabetes in people at high risk.

Protocol of a cluster randomized trial to investigate the impact of a type 2 diabetes risk prediction model on change in physical activity in primary care

BACKGROUND

Little evidence exists on the impact of diabetes risk scores, e.g. on physicians and patient's behavior, perceived risk of persons, shared-decision making and particularly on patient's health. The aim of this study is to investigate the impact of a non-invasive type 2 diabetes risk prediction model in the primary health care setting as component of routine health checks on change in physical activity.

METHODS

Parallel group cluster randomized controlled trial including 30 primary care physicians (PCPs) and 300 participants in the region of Düsseldorf and surrounding urban and rural municipalities, West Germany. On cluster level, PCPs will be randomized into intervention or control group using a biased coin minimization technique. Participants in the control group are going to have a routine health check "Check-up 35" which is recommended biannually for all people ≥35 years of age in Germany. In the intervention group, the routine health check is expanded by usage of a non-invasive diabetes risk prediction model (German Diabetes Risk Score). Primary outcome is change in physical activity after 1 year. Secondary outcomes include aspects of targeted counseling, motivation of participant's to change lifestyle, perceived and objectively measured diabetes risk, acceptance of diabetes risk scores, quality of life, depression and anxiety. Patients will be followed over 12 months. Hierarchical or mixed models will be conducted, including a random intercept to adjust for cluster, the respective baseline value, and covariates to compare the groups.

DISCUSSION

This pragmatic cluster randomized controlled trial will enhance our knowledge on the clinical impact of diabetes risk scores for the first time in the real-life primary health care setting.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03234322 , registered on July 28, 2017.

Validation of DIABSCORE in screening for Type 2 Diabetes and prediabetes in Tunisian population

AIMS

To perform a validation of DIABSCORE in a sample of Tunisian adults and find out the optimal cut-off point for screening of Type 2 diabetes (T2D) and prediabetes.

METHODS

225 adults 18-75 years and a subgroup of 138 adults (18-54 years), with undiagnosed T2D from the region of Cap-Bon, Tunisia were included in the present study. The DIABSCORE was calculated based on: age, waist/height ratio, family history of T2D and gestational diabetes. Receiver operating characteristics (ROC) curves and areas under curve (AUC) were obtained. The T2D and prediabetes prevalences odds ratios (OR) between patients exposed and not exposed to DIABSCORE≥90 and DIABSCORE≥80, respectively were calculated in both age ranges.

RESULTS

For screening of T2D the best value was DIABSCORE = 90 with a highest sensitivity (Se), negative predictive value (NPV) and lower negative likelihood ratio in participants aged 18-75 yr (Se = 97%; NPV = 97%) when compared to participants aged 18-54 yr (Se = 95%; NPV = 97%); for prediabetes, the best Se and NPV were for DIABSCORE = 80 in both age groups, but it showed a disbalanced sensitivity-specificity. The ROC curves for T2D showed a similar AUC in both age ranges (AUC = 0.62 and AUC = 0.61 respectively). The ROC curves for prediabetes showed a highest AUC in those aged 18-54 years than the older ones (AUC = 0.62 and AUC = 0.57, respectively). The prevalences OR of T2D for DIABSCORE≥90 was higher than for DIABSCORE≥80 in both age ranges. Nevertheless, the prevalences OR of prediabetes for DIABSCORE≥90 was half of the detected for DIABSCORE≥80 in both age ranges.

CONCLUSION

The DIABSCORE is a simple clinical tool and accurate method in screening for T2D and prediabetes in the adult Tunisian population.

Diabetes Risk Assessment in Latinas: Effectiveness of a Brief Diabetes Risk Questionnaire for Detecting Prediabetes in a Community-Based Sample

OBJECTIVE

Numerous validated questionnaires use self-reported data to quantify individuals' risk of having diabetes or developing it in the future. Evaluations of these tools have primarily used nationally representative data, limiting their application in clinical and community settings. This analysis tested the effectiveness of the American Diabetes Association (ADA) risk questionnaire for identifying prediabetes in a community-based sample of Latinas.

METHODS

Data were collected using the ADA risk questionnaire and assessing A1C. Among 204 participants without diabetes, we examined the association between individual characteristics and glycemic status. We then calculated the performance characteristics (sensitivity, specificity, positive predictive value [PPV], and negative predictive value [NPV]) of the ADA risk questionnaire for detecting prediabetes, using A1C results as the gold standard to define the outcome.

RESULTS

All participants were women of self-reported Hispanic/Latino ethnicity. Their mean ADA risk score was 5.6 ± 1.6. Latinas who had prediabetes were older, with significantly higher rates of hypertension and a higher ADA risk score than those without prediabetes. At a risk score ≥5-the threshold for high risk set by the ADA-the questionnaire had the following test performance characteristics: sensitivity 77.8%, specificity 41.7%, PPV 76.2%, and NPV 43.9%.

CONCLUSION

The ADA risk questionnaire demonstrates reasonable performance for identifying prediabetes in a community-based sample of Latinas. Our data may guide other groups' use of this tool in the same target population. Future research should examine the effectiveness of this questionnaire for recruiting diverse populations into diabetes prevention programs. In addition, unique diabetes risk assessment tools for specific target populations are needed and may outperform questionnaires developed using nationally representative data.

The association of unemployment with glucose metabolism: a systematic review and meta-analysis

OBJECTIVES

Unemployment has been linked with poor health. We hypothesized that being unemployed is associated with disorders of glucose metabolism and performed a systematic review and meta-analysis of the literature to ascertain the relationship.

METHODS

We searched the databases of Scopus, Medline Ovid and Web of Science for population-based original studies for past 20 years. Random effects meta-analyses were used to estimate odds ratios (OR) with 95% confidence intervals (CI) for prediabetes and type 2 diabetes among the unemployed as compared to those employed, separately for men and women when possible.

RESULTS

Out of 981 articles found, 12 articles were included in the systematic review and eight articles in the meta-analyses. Unemployment was associated with 1.6-fold odds for prediabetes (OR 1.58; 95% CI 1.07-2.35), and 1.7-fold odds for type 2 diabetes (OR 1.72; 95% CI 1.14-2.58) in the total sample. The corresponding associations for type 2 diabetes were also found stratified for men (OR 1.53; 95% CI 1.47-1.60) and women (OR 1.60; 95% CI 1.33-1.92).

CONCLUSIONS

Unemployment is associated with prediabetes and type 2 diabetes, global concerns of public health with potential for prevention.

Clinical applicability and cost-effectiveness of DIABSCORE in screening for type 2 diabetes in primary care

AIMS

To evaluate the applicability and cost-effectiveness of a clinical risk score (DIABSCORE) to screen for type 2 diabetes in primary care patients.

METHODS

Multicenter cross-sectional study of 10,508 adult no previously diagnosed with diabetes, in 2 Spanish regions (Canary Islands and Valencian Community). The variables comprising DIABSCORE were age, waist to height ratio, family history of diabetes and gestational diabetes. ROC curves were obtained; the diabetes prevalences odds ratios (HbA1c ≥6.5%) between patients exposed and not exposed to DIABSCORE ≥100, and to fasting blood glucose ≥126mg/dL were calculated. The opinions of both the professionals and the patients concerning DIABSCORE were collected, and a cost-effectiveness analysis was performed.

RESULTS

In both regions, the valid cut-off point for diabetes (DIABSCORE=100), showed an area under the curve >0.80. The prevalences odds ratio of diabetes for DIABSCORE ≥100 was 9.5 (3.7-31.5) in Canarian and 18.3 (8.0-51.1) in Valencian; and for glucose ≥126mg/dL it was, respectively, 123.0 (58.8-259.2) and 303.1 (162.5-583.8). However, glucose ≥126mg/dL showed a low sensitivity (below 48% in both communities) as opposed to DIABSCORE ≥100 (above 90% in both regions). Professionals (100%) and patients (75%) satisfaction was greater when using DIABSCORE rather than glucose measurement for diabetes screening. The cost of each case of diabetes identified was lower with DIABSCORE ≥100 (7.6 € in Canarian and 8.3 € in Valencian) than glucose ≥126mg/dL (10.8 € and 10.5 €, respectively).

CONCLUSIONS

DIABSCORE is an applicable and cost-effective screening method for type 2 diabetes in primary care.

Nurse Practitioner Perceptions of a Diabetes Risk Assessment Tool in the Retail Clinic Setting

IN BRIEF This article describes a study to gain insight into the utility and perceived feasibility of the American Diabetes Association's Diabetes Risk Test (DRT) implemented by nurse practitioners (NPs) in the retail clinic setting. The DRT is intended for those without a known risk for diabetes. Researchers invited 1,097 NPs working in the retail clinics of a nationwide company to participate voluntarily in an online questionnaire. Of the 248 NPs who sent in complete responses, 114 (46%) indicated that they used the DRT in the clinic. Overall mean responses from these NPs indicated that they perceive the DRT as a feasible tool in the retail clinic setting. Use of the DRT or similar risk assessment tools in the retail clinic setting can aid in the identification of people at risk for type 2 diabetes.

Risk prediction of major complications in individuals with diabetes: the Atherosclerosis Risk in Communities Study

AIMS

To develop a prediction equation for 10-year risk of a combined endpoint (incident coronary heart disease, stroke, heart failure, chronic kidney disease, lower extremity hospitalizations) in people with diabetes, using demographic and clinical information, and a panel of traditional and non-traditional biomarkers.

METHODS

We included in the study 654 participants in the Atherosclerosis Risk in Communities (ARIC) study, a prospective cohort study, with diagnosed diabetes (visit 2; 1990-1992). Models included self-reported variables (Model 1), clinical measurements (Model 2), and glycated haemoglobin (Model 3). Model 4 tested the addition of 12 blood-based biomarkers. We compared models using prediction and discrimination statistics.

RESULTS

Successive stages of model development improved risk prediction. The C-statistics (95% confidence intervals) of models 1, 2, and 3 were 0.667 (0.64, 0.70), 0.683 (0.65, 0.71), and 0.694 (0.66, 0.72), respectively (p < 0.05 for differences). The addition of three traditional and non-traditional biomarkers [β-2 microglobulin, creatinine-based estimated glomerular filtration rate (eGFR), and cystatin C-based eGFR] to Model 3 significantly improved discrimination (C-statistic = 0.716; p = 0.003) and accuracy of 10-year risk prediction for major complications in people with diabetes (midpoint percentiles of lowest and highest deciles of predicted risk changed from 18-68% to 12-87%).

CONCLUSIONS

These biomarkers, particularly those of kidney filtration, may help distinguish between people at low versus high risk of long-term major complications.

Prediction of 10-year vascular risk in patients with diabetes: the AD-ON risk score

AIMS

To formulate a combined cardiovascular risk score in diabetes that could be useful both to physicians and healthcare funders.

METHODS

Data were derived from the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation Observational (ADVANCE-ON) study, a randomized controlled trial (mean duration 5 years) with a post-randomization follow-up (mean 4.9 years), that included 11 140 high-risk patients with diabetes. The outcome analysed was the occurrence of either fatal or non-fatal macrovascular or renal disease. A Cox regression model was used to determine weightings in the risk score. The resultant score was recalibrated to each of three major global regions, as covered by the ADVANCE-ON study.

RESULTS

Over a median of 9.9 years, 1145 patients experienced at least one component of the combined outcome event. The resultant score, the AD-ON risk score, incorporated 13 demographic or clinical variables. Its discrimination was modest [c-statistic = 0.668 (95% confidence interval 0.651, 0.685)] but its calibration was excellent (predicted and observed risks coincided well, within disparate global regions). In terms of the integrated discrimination improvement index, its performance was marginally superior, over a 10-year risk horizon, to existing risk scores in clinical use, from a restricted version of the same data, for macrovascular and renal disease separately.

CONCLUSIONS

The AD-ON risk score has advantages over the existing vascular risk scores in diabetes that used data from the original ADVANCE trial, which treat macrovascular and renal diseases separately. These advantages include its simplicity of use and global application.

Development and Validation of a Simple Risk Score for Undiagnosed Type 2 Diabetes in a Resource-Constrained Setting

Objective. To develop and validate a risk score for detecting cases of undiagnosed diabetes in a resource-constrained country. Methods. Two population-based studies in Peruvian population aged ≥35 years were used in the analysis: the ENINBSC survey (n = 2,472) and the CRONICAS Cohort Study (n = 2,945). Fasting plasma glucose ≥7.0 mmol/L was used to diagnose diabetes in both studies. Coefficients for risk score were derived from the ENINBSC data and then the performance was validated using both baseline and follow-up data of the CRONICAS Cohort Study. Results. The prevalence of undiagnosed diabetes was 2.0% in the ENINBSC survey and 2.9% in the CRONICAS Cohort Study. Predictors of undiagnosed diabetes were age, diabetes in first-degree relatives, and waist circumference. Score values ranged from 0 to 4, with an optimal cutoff ≥2 and had a moderate performance when applied in the CRONICAS baseline data (AUC = 0.68; 95% CI: 0.62-0.73; sensitivity 70%; specificity 59%). When predicting incident cases, the AUC was 0.66 (95% CI: 0.61-0.71), with a sensitivity of 69% and specificity of 59%. Conclusions. A simple nonblood based risk score based on age, diabetes in first-degree relatives, and waist circumference can be used as a simple screening tool for undiagnosed and incident cases of diabetes in Peru.

Predictive modeling for incident and prevalent diabetes risk evaluation

With half of individuals with diabetes undiagnosed worldwide and a projected 55% increase of the population with diabetes by 2035, the identification of undiagnosed and high-risk individuals is imperative. Multivariable diabetes risk prediction models have gained popularity during the past two decades. These have been shown to predict incident or prevalent diabetes through a simple and affordable risk scoring system accurately. Their development requires cohort or cross-sectional type studies with a variable combination, number and definition of included risk factors, with their performance chiefly measured by discrimination and calibration. Models can be used in clinical and public health settings. However, the impact of their use on outcomes in real-world settings needs to be evaluated before widespread implementation.

Comparison of two methods for assessing diabetes risk in a pharmacy setting in Australia

Background

Since 2007, the Australian Know your numbers (KYN) program has been used in community settings to raise awareness about blood pressure and stroke. In 2011, the program was modified to include assessment for type 2 diabetes risk. However, it is unclear which approach for assessing diabetes risk in pharmacies is best. We compared two methods: random (non-fasting) blood glucose testing (RBGT); and the Australian type 2 diabetes risk assessment tool (AUSDRISK); according to 1) identification of ‘high risk’ participants including head-to-head sensitivity and specificity; 2) number of referrals to doctors; and 3) feasibility of implementation.

Methods

117 Queensland pharmacies voluntarily participated and were randomly allocated to RBGT and AUSDRISK or AUSDRISK only. Although discouraged, pharmacies were able to change allocated group prior to commencement. AUSDRISK is a validated self-administered questionnaire used to calculate a score that determines the 5-year risk of developing type 2 diabetes. AUSDRISK (score 12+) or RBGT (≥5.6 mmol/I) indicates a high potential risk of diabetes. Median linear regression was used to compare the two measures. Staff from 68 pharmacies also participated in a semi-structured interview during a site visit to provide feedback.

Results

Data were submitted for 5,483 KYN participants (60% female, 66% aged >55 years, 10% history of diabetes). Approximately half of the participants without existing diabetes were identified as ‘high risk’ based on either RBGT or AUSDRISK score. Among participants who undertook both measures, 32% recorded a high RBGT and high AUSDRISK. There was a significant association between RBGT and AUSDRISK scores. For every one point increase in AUSDRISK score there was a half point increase in RBGT levels (coefficient 0.55, 95% CI: 0.28, 0.83). Pharmacy staff reported that AUSDRISK was a simple, low cost and efficient method of assessing diabetes risk compared with RBGT, e.g. since management of sharps is not an issue.

Conclusions

In a large, community-based sample of Australians about half of the participants without diabetes were at ‘high risk ‘of developing diabetes based on either AUSDRISK or RBGT results. AUSDRISK was considered to be an acceptable method for assessing the risk of diabetes using opportunistic health checks in community pharmacies.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2458-14-1227) contains supplementary material, which is available to authorized users.