Diagnosing the undiagnosed with diabetes

Feasibility of using the TOSCA telescreening procedures for diabetic retinopathy

AIMS

The TOSCA project was set up to establish a tele-ophthalmology service to screen for diabetic retinopathy (DR) in Europe. The aim of this study was to determine the feasibility of establishing telemedicine-based digital screening for detecting DR and to evaluate the satisfaction of both patients and healthcare professionals with the screening procedures used within the TOSCA project.

METHODS

The study was a non-randomized, multicentre study carried out in four different countries over a period of 3 months. Patients (n = 390) with diabetes aged > 12 years were included. Two digital retinal images per eye (macular and nasal) were taken and exported to a central server. Patients were asked to complete a questionnaire to assess satisfaction. Accredited graders carried out grading remotely and the results were reported back to the referring centre. Previously graded patient data chosen randomly to represent examples of both DR and no DR were also sent anonymously to the grading centre at a frequency of approximately every 10 patients.

RESULTS

Most (99%) of the images were assessable enabling a retinopathy grade to be assigned to the patient. Patients found the retinal photography procedures acceptable; only 6% in one centre would not recommend the procedure. Healthcare professionals (photographers and graders) were also satisfied with the overall procedures. The average time taken to grade each patient was approximately 5 min.

CONCLUSIONS

This study demonstrated that it is feasible to electronically transmit and grade retinal images remotely using the TOSCA process. Built-in quality assurance procedures proved acceptable.

Screening for diabetes in an outpatient clinic population

BACKGROUND

Opportunistic disease screening is the routine, asymptomatic disease screening of patients at the time of a physician encounter for other reasons. While the prevalence of unrecognized diabetes in community populations is well known, the prevalence in clinical populations is unknown.

OBJECTIVE

To describe the prevalence, predictors, and clinical severity of unrecognized diabetes among outpatients at a major medical center.

DESIGN AND SETTING

A cross-sectional observational study at the Durham Veterans Affairs Medical Center.

SUBJECTS

Outpatients without recognized diabetes (N=1,253).

METHODS

We screened patients for diabetes by using an initial random Hemoglobin A1c (HbA1c) measurement, and then obtaining follow-up fasting plasma glucose (FPG) for all subjects with HbA1c > or =6.0%. A case of unrecognized diabetes was defined as either HbA1c > or =7.0% or FPG > or =7 mmol/L (126 mg/dL). Height and weight were obtained for all subjects. We also obtained resting blood pressure, fasting lipids, and urine protein in subjects with HbA1c > or =6.0%.

RESULTS

The prevalence of unrecognized diabetes was 4.5% (95% confidence interval [CI], 3.4 to 5.7). Factors associated with unrecognized diabetes were the diagnosis of hypertension (adjusted odds ratio [OR], 2.5; P=.004), weight >120% of ideal (adjusted OR, 2.2; P=.02), and history of a parent or sibling with diabetes (adjusted OR, 1.7; P=.06). Having a primary care provider did not raise or lower the risk for unrecognized diabetes (P=.73). Based on the new diagnosis, most patients (61%) found to have diabetes required a change in treatment either of their blood sugar or comorbid hypertension or hyperlipidemia in order to achieve targets recommended in published treatment guidelines. Patients reporting a primary care provider were no less likely to require a change in treatment (P=.20).

CONCLUSIONS

If diabetes screening is an effective intervention, opportunistic screening for diabetes may be the preferred method for screening, because there is substantial potential for case-finding in a medical center outpatient setting. A majority of patients with diabetes diagnosed at opportunistic screening will require a change in treatment of blood sugar, blood pressure, or lipids to receive optimal care.

Early detection of type 2 diabetes: the role of the community nurse

Recent changes to the diagnostic criteria for type 2 diabetes have raised concerns that if steps are not taken to address relevant issues, the number of diagnosed sufferers will escalate in future years, with a similar increase in the prevalence of associated complications. Research suggests that for many patients, complications are evident at the time of diagnosis, and may have been present for several years before a diagnosis was made. Late presentation is the cause of considerable morbidity and mortality among these patients, largely because undiagnosed complications are often irreversible by the time the underlying diabetes is discovered. The current emphasis on public health augments the need for community nurses to recognize warning signs, particularly in patients who are at an increased risk of developing diabetes. This article aims to raise awareness of early signs and symptoms, and gives a brief insight into some of the associated health problems. If community nurses are to play a significant role in reducing the potentially devastating effects of this disease, they will need to be involved tin educating patients and implementing screening and intervention programmes.

Knowledge of risk of developing diabetes mellitus among siblings of Type 2 diabetic patients

AIMS

We set out to investigate the extent to which siblings of diabetic subjects perceived themselves likely to develop Type 2 diabetes mellitus (DM) when offered screening tests.

METHODS

Nondiabetic siblings, aged 35-74 years, of Type 2 diabetic patients who were more than 35 years old at diagnosis had fasting plasma glucose measured in a study to determine heritability of diabetes. Questionnaires assessing perceived likelihood of developing, seriousness and knowledge about diabetes were completed. Logistic regression assessed factors predicting perceptions of diabetes risk.

RESULTS

Factors predicting diabetes on screening were male sex, increasing age and body mass index (BMI) > or = 30. Eighty-nine per cent of 540 eligible siblings completed questionnaires. Thirty-eight per cent saw themselves at increased risk of diabetes and 34% thought diabetes a serious problem. Predictors of perceiving an increased likelihood of developing diabetes were female sex, age 35-54 years vs. 55-74 years and having a parent with diabetes. BMI did not affect perceptions of likelihood.

CONCLUSION

A perception of reduced vulnerability to diabetes may occur due to unawareness of risk or minimization of risk. Feelings of invulnerability may affect emotional response to a subsequent result. It is not known whether providing more information about the risk of developing diabetes prior to screening would affect outcomes

Pharmacoeconomics of diabetes surveillance and detection programmes

Primary prevention of insulin-dependent diabetes mellitus (IDDM, type I diabetes) remains a research goal. Primary prevention of non-insulin-dependent diabetes mellitus (NIDDM, type II diabetes) is likely to remain part of general health education on healthy lifestyles. However, the often delayed diagnosis of type II diabetes, accompanied by early development of complications, offers opportunities for detection programmes, provided that these can overcome the hurdle of the low annual incidence of this disease. By contrast, programmes for the detection of arterial risk factors and treatable complications of previously diagnosed diabetes are well established as an integrated, and thus efficient, annual review. The results of such review guide the different forms of management programmes such as educational programmes for foot care and smoking, drug therapy for hypertension, dyslipidaemia and early nephropathy, and crisis management (laser photocoagulation) of proliferative retinopathy. Such annual review, additional to review of lifestyle and metabolic control, offers opportunities for on-going preventive education and is now the basis of quality development and needs assessment technologies.