Screening for diabetes in general practice: cross sectional population study

A systematic review of diabetes risk assessment tools in sub-Saharan Africa

Objectives

To systematically review all current studies on diabetes risk assessment tools used in SSA to diagnose diabetes in symptomatic and asymptomatic patients.

Methods

Tools were identified through a systematic search of PubMed, Ovid, Google Scholar, and the Cochrane Library for articles published from January 2010 to January 2020. The search included articles reporting the use of diabetes risk assessment tool to detect individuals with type 2 diabetes in SSA. A standardized protocol was used for data extraction (registry #177726).

Results

Of the 825 articles identified, 39 articles met the inclusion criteria, and three articles reported tools used in SSA population but developed for the Western population. None was validated in SSA population. All but three articles were observational studies (136 and 58,657 study participants aged between the ages of 15 and 85 years). The Finnish Medical Association risk tool, World Health Organization (WHO) STEPS instrument, General Practice Physical Activity Questionnaire (GPPAQ), Rapid Eating and Activity Assessment for Patients (REAP), and an anthropometric tool were the most frequently used non-invasive tools in SSA. The accuracy of the tools was measured using sensitivity, specificity, or area under the receiver operating curve. The anthropometric predictor variables identified included age, body mass index, waist circumference, positive family of diabetes, and activity levels.

Conclusions

This systematic review demonstrated a paucity of validated diabetes risk assessment tools for SSA. There remains a need for the development and validation of a tool for the rapid identification of diabetes for targeted interventions.

Determinants of Adherence to Diabetes Screening in Iranian Adults With a Positive Family History of Diabetes

OBJECTIVES

Insufficient evidence exists regarding factors that affect screening adherence among people with a family history of diabetes, who comprise roughly half of all patients with diabetes. Therefore, we aimed to identify the determinants of diabetes screening adherence in adults with a family history of diabetes who had not yet been diagnosed with diabetes.

METHODS

This cross-sectional study was conducted at selected urban primary healthcare facilities in Tehran, Iran. The study population was clinically non-diabetic adults above 20 years of age with a family history of diabetes in at least 1 first-degree relative. All eligible people identified on randomly-selected days of the month were invited to join the study.

RESULTS

Among 408 participants, 128 (31.4%) had received a fasting blood glucose check during the last year. Using binary logistic regression, the independent predictors of screening adherence were knowledge of adverse effects of diabetes such as sexual disorders (odds ratio [OR], 3.05) and renal failure (OR, 2.73), the impact of family members' advice on receiving diabetes screening (OR, 2.03), recommendation from a healthcare provider to have a fasting blood glucose check (OR, 2.61), and intention to have a fasting blood glucose check within the next 6 months (OR, 2.85). Other variables that predicted screening adherence were age (OR, 1.05), job (being a housekeeper; OR, 3.39), and having a college degree (OR, 3.55).

CONCLUSIONS

Knowledge of the adverse effects of diabetes, physicians' and healthcare providers' advice about the benefits of early disease detection, and family members' advice were independent predictors of screening adherence.

Mobile phone ownership and willingness to receive mHealth services among patients with diabetes mellitus in South-West, Nigeria

Introduction

mobile phone technology is increasingly used to overcome traditional barriers to limiting access to diabetes care. This study evaluated mobile phone ownership and willingness to receive and pay for mobile phone-based diabetic services among people with diabetes in South-West, Nigeria.

Methods

two hundred and fifty nine patients with diabetes were consecutively recruited from three tertiary health institutions in South-West, Nigeria. Questionnaire was used to evaluate mobile phone ownership, willingness to receive and pay for mobile phone-based diabetic health care services via voice call and text messaging.

Results

97.3% owned a mobile phone, with 38.9% and 61.1% owning smartphone and basic phone respectively. Males were significantly more willing to receive mobile-phone-based health services than females (81.1% vs 68.1%, p=0.025), likewise married compared to unmarried [77.4% vs 57.1%, p=0.036]. Voice calls (41.3%) and text messages (32.4%), were the most preferred modes of receiving diabetes-related health education with social media (3.1%) and email (1.5%) least. Almost three-quarter of participants (72.6%) who owned mobile phone, were willing to receive mobile phone-based diabetes health services. The educational status of patients (adjusted OR [AOR]: 1.7{95% CI: 1.6 to 2.1}), glucometers possession (AOR: 2.0 [95% CI: 1.9 to 2.1) and type of mobile phone owned (AOR: 2.9 [95% CI: 2.8 to 5.0]) were significantly associated with the willingness to receive mobile phone-based diabetic services.

Conclusion

the majority of study participants owned mobile phones and would be willing to receive and pay for diabetes-related healthcare delivery services provided the cost is minimal and affordable.

Google Trends can improve surveillance of Type 2 diabetes

Recent studies demonstrate that people are increasingly looking online to assess their health, with reasons varying from personal preferences and beliefs to inability to book a timely appointment with their local medical practice. Records of these activities represent a new source of data about the health of populations, but which is currently unaccounted for by disease surveillance models. This could potentially be useful as evidence of individuals' perception of bodily changes and self-diagnosis of early symptoms of an emerging disease. We make use of the Experian geodemographic Mosaic dataset in order to extract Type 2 diabetes candidate risk variables and compare their temporal relationships with the search keywords, used to describe early symptoms of the disease on Google. Our results demonstrate that Google Trends can detect early signs of diabetes by monitoring combinations of keywords, associated with searches for hypertension treatment and poor living conditions; Combined search semantics, related to obesity, how to quit smoking and improve living conditions (deprivation) can be also employed, however, may lead to less accurate results.

Cardiovascular disease risk factors in a Nigerian population with impaired fasting blood glucose level and diabetes mellitus

Background

Diabetes is a risk factor for cardiovascular diseases (CVDs) and there are reports of increasing prevalence of prediabetes in Nigeria. This study therefore characterised CVDs risk factors in subjects with impaired fasting glucose (IFG) and diabetes.

Methods

Data from 4 population-based cross-sectional studies on 2447 apparently healthy individuals from 18 - 89 years were analysed. Anthropometric, blood pressure and biochemical parameters were collected and classified. Individuals with IFG (prediabetes) and diabetes were merged each for positive cases of dyslipidaemia, high blood pressure (HBP) or obesity. Optimal Discriminant and Hierarchical Optimal Classification Tree Analysis (HO-CTA) were employed.

Results

Overall prevalence of IFG and diabetes were 5.8% (CI: 4.9 – 6.7%) and 3.1% (CI: 2.4 – 3.8%), respectively. IFG co-morbidity with dyslipidaemia (5.0%; CI: 4.1 – 5.8%) was the highest followed by overweight/obese (3.1%; CI: 2.5 – 3.8%) and HBP (1.8%; CI: 1.3 – 2.4%). The predicted age of IFG or diabetes and their co-morbidity with other CVD risk factors were between 40 – 45 years. Elevated blood level of total cholesterol was the most predictive co-morbid risk factor among IFG and diabetes subjects. Hypertriglyceridaemia was an important risk factor among IFG-normocholesterolaemic-overweight/obese individuals.

Conclusion

The higher prevalence of co-morbidity of CVD risk factors with IFG than in diabetes plus the similar age of co-morbidity between IFG and diabetes highlights the need for risk assessment models for prediabetes and education of individuals at risk about factors that mitigate development of diabetes and CVDs.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3910-3) contains supplementary material, which is available to authorized users.

Screening patients with ischaemic heart disease and hypertension for undiagnosed diabetes

Diabetes mellitus is an important condition with a significant morbidity and mortality. Up to 50% of people with diabetes may be as yet undiagnosed. Widespread population screening so far has had a low uptake and yield. This study is a cross-sectional survey screening for undiagnosed diabetes amongst patients with ischaemic heart disease (IHD) or hypertension, in a semi-rural practice in Scotland. The results produced a screening uptake of 83.7% and a yield of 3.48% for patients with IHD, and an uptake of 79.65% and a yield of 3% for hypertensive patients. To identify one new case of diabetes we had to screen 24 patients with IHD and 33 with hypertension. This was feasible within an organised review system for patients with these conditions with no additional resource implications. The study is limited by the lack of multi-ethnic mix, rural setting, relative affluence, and the existing organised chronic disease management plans in this practice. This may underestimate the yield if screening were to be extended to both groups nationally. More work is needed to see if such screening for diabetes is feasible and worthwhile on a national basis.

Are undiagnosed IGT/IFG and type 2 diabetes common in heart disease and hypertension?

Diabetes mellitus causes significant morbidity and mortality, and up to 50% of people with diabetes may be as yet undiagnosed. Additionally impaired glucose tolerance (IGT) is known to increase vascular risk and the risk of developing diabetes.

The aim of this study was to look for IGT and/or impaired fasting glucose (IFG) and undiagnosed diabetes amongst patients with hypertension and patients with ischaemic heart disease (IHD) as part of an annual structured assessment.

In IHD patients the uptake was 83.45% with a yield of 2.47% for undiagnosed diabetes and 12.39% for IGT/IFG. In hypertensive patients the uptake was 75.84% with a yield of 2.01% for undiagnosed diabetes and 18.54% for IGT/IFG.

We concluded that looking for undiagnosed type 2 diabetes and patients with IGT/IFG in primary care may be worthwhile amongst patients with hypertension or IHD.

The Uptake of Screening for Type 2 Diabetes and Prediabetes by Means of Glycated Hemoglobin versus the Oral Glucose Tolerance Test among 18 to 60-Year-Old People of South Asian Origin: A Comparative Study

Background

Direct comparisons of the effect of a glycated haemoglobin measurement or an oral glucose tolerance test on the uptake and yield of screening in people of South Asian origin have not been made. We evaluated this in 18 to 60-year-old South Asian Surinamese.

Materials and Methods

We invited 3173 South Asian Surinamese for an oral glucose tolerance test between June 18^th 2009- December 31^st 2009 and 2012 for a glycated hemoglobin measurement between April 19^th 2010-November 11^th, 2010. Participants were selected from 48 general practices in The Hague, The Netherlands. We used mixed models regression to analyse differences in response and participation between the groups. We described differences in characteristics of participants and calculated the yield as the percentage of all cases identified, if all invitees had been offered screening with the specified method.

Results

The response and participation in the glycated hemoglobin group was higher than in the group offered an oral glucose tolerance test (participation 23.9 vs. 19.3; OR: 1.30, 95%-confidence interval1.01–1.69). After adjustment for age and sex, characteristics of participants were similar for both groups. Overall, glycated hemoglobin identified a similar percentage of type 2 diabetes cases but a higher percentage of prediabetes cases, in the population than the oral glucose tolerance test.

Conclusion

We found that glycated hemoglobin and the oral glucose tolerance test may be equally efficient for identification of type 2 diabetes in populations of South Asian origin. However, for programs aimed at identifying people at high risk of type 2 diabetes (i.e. with prediabetes), the oral glucose tolerance test may be a less efficient choice than glycated hemoglobin.

High prevalence of type 2 diabetes and pre-diabetes in adult Zoroastrians in Yazd, Iran: a cross-sectional study

Background:

The prevalence of type 2 diabetes mellitus (T2DM) varies among ethnic groups. We aimed to estimate the prevalence of diagnosed and undiagnosed diabetes mellitus, impaired fasting glucose (IFG), and impaired glucose tolerance (IGT) for the first time in an ethnic population, specifically Zoroastrian citizens in Yazd, Iran whose ages were 30 or older.

Methods:

In a cross-sectional study, participants aged≥30 years were selected using systematic random sampling. An inventory, including socio-demographic data, was completed. Weight, height, body mass index (BMI), and blood pressure (BP) were measured using standard methods. Also, blood levels of glucose, triglycerides (TG), total cholesterol (TC), high density lipoprotein (HDL), low density lipoprotein (LDL), urea, creatinine (Cr), and uric acid were measured. The latest criteria established by the American Diabetes Association (ADA) were used to diagnose DM.

Results:

The mean age of the participants (n=403) was 56.9±12.8 years. The total prevalence of diabetes, including previously diagnosed and undiagnosed diabetes, IFG, and IGT was 26.1%, 18.6%, 7.5%, 34.7% and 25.8%, respectively. Participants with diabetes had higher fasting blood sugar (FBS) (P<0.001), oral glucose tolerance test (OGTT) (P<0.001), urea (P=0.019), BMI (P=0.001), systolic blood pressures (P<0.001), TG (P=0.007) and lower HDL (P=0.034) than patients with IFG, IGT, and normoglycemic subjects.

Conclusions:

The current study showed a high prevalence of T2DM in the Zoroastrian population of Yazd, Iran. One-third of the total cases with diabetes were undiagnosed.

Community health awareness of diabetes (CHAD): description of a community-wide diabetes awareness demonstration program and its feasibility

OBJECTIVE

This article describes the Community Health Awareness Diabetes (CHAD) program and its feasibility. Developing and testing the feasibility of strategies to detect diabetes in the community is an important primary care issue. The CHAD program was designed to be a feasible and reproducible, low-cost community program to identify high-risk individuals for subsequent diabetes screening by their family doctors.

METHODS

Participants from Grimsby, Ontario, older than age 40, were invited to self-risk-assess for diabetes using a validated questionnaire and 2 near-patient blood tests (capillary blood glucose and glycosylated hemoglobin). Some participants were self-selected, having seen advertising for the program, others were invited by a letter from their family doctor. None of the participants had pre-existing diabetes. Numbers and characteristics of participants, numbers found at risk and satisfaction of participants were examined.

RESULTS

There were 588 participants in CHAD. Of these, the majority had received invitation letters, the majority of participants were seniors and were females, 526 did not have pre-existing diabetes and 16% of participants (n=84 of 526) were identified as being at high risk for diabetes. Participants at high risk of diabetes had significantly more modifiable risk factors, including higher fat, fast food and salt intake, and higher systolic blood pressure. Satisfaction with the program was high.

CONCLUSIONS

The CHAD program was feasible and participants were satisfied with it. Participants had a large number of modifiable risk factors. This program could be repeated in other communities and modified to suit the infrastructure of the area.

Noninvasive skin fluorescence spectroscopy for detection of abnormal glucose tolerance

The ENGINE study evaluated noninvasive skin fluorescence spectroscopy (SFS) for detection of abnormal glucose tolerance (AGT). The AGT detection performance of SFS was compared to fasting plasma glucose (FPG) and hemoglobin A1C (A1C). The study was a head-to-head comparison of SFS to FPG and A1C in an at-risk population of 507 subjects, with no prior diagnosis of diabetes, each of whom received a 75 g, two-hour oral glucose tolerance test (OGTT). Subjects were measured by SFS on multiple days in fasting and non-fasting states. SFS data were acquired and analyzed with the SCOUT DS® device (VeraLight, Albuquerque, NM, USA). Disease truth was AGT, defined as OGTT ≥ 7.8 mmol/L. Sensitivity, false positive rate (FPR), ROC area, and equal error rate (EER) for detection of AGT were computed. The reproducibility of SFS and FPG was assessed. The AGT sensitivity of SFS at the device's recommended screening threshold of 50 was 75.2%, higher than that of FPG (thresholds of 5.6 mmol/L or 6.1 mmol/L) and A1C (thresholds of 5.7% or 6.0%). The SFS FPR was 42.1%, comparable to an A1C threshold of 5.7% (FPR = 43.5%). The EERs of SFS, FPG and A1C were similar, as were the partial ROC areas for FPRs of 20-50%. The reproducibility of SFS was 7.7% versus 8.1% for FPG. SFS had similar AGT detection performance to FPG and A1C and is a viable alternative to screening individuals for AGT.

Body size preference among Yoruba in three Nigerian communities

Following our previous observation of an aversion to weight reduction in Nigerians with type 2 diabetes, we measured several parameters of body dimensions and preferences in otherwise healthy adults in three communities to study the phenomenon further. The study population of 524 participants (304 F) was 99.8% of Yoruba ethnic origin with a mean age of 43.9 ± 17.2 years. Females had a significantly (p > 0.001) higher body mass index (BMI), waist circumference, hip circumference compared to the males; the values being 24.55 ± 5.5 vs. 21.75 ± 3.71 kg/m(2); 84.98 ± 12.67 vs. 80.92 ± 9.85 cm; 96.32 ± 12.94 vs. 89.36 ± 8.06 cm, respectively. There was a high level of satisfaction amongst respondents with their body size (Kendall's t = 0.52, p < 0.001) which they also predicted with a high degree of certainty even without the prior use of a weighing scale. The relationship between current body size (CBI) and BMI emerged as CBI = 1.22 + 0.32 BMI. In the 41% of respondents who expressed unhappiness with their current body size, there was a strong aversion for a smaller body size and the preference was often for a bigger body figure. Strikingly, many more women than men were less dissatisfied with their bigger body sizes. Stepwise regression indicated that CBI and gender were the two most important variables that best related to casual blood sugar (RBS) among the factors entered. The mathematical relationship between these variables that emerged was: [Formula: see text] where gender = 0 for male and 1 for female. The results suggest that larger body sizes were positively viewed in these communities consistent with our previous observations in type 2 diabetes.

Noninvasive skin fluorescence spectroscopy is comparable to hemoglobin A1c and fasting plasma glucose for detection of abnormal glucose tolerance

AIM

We compare performance of noninvasive skin fluorescence spectroscopy (SFS), fasting plasma glucose (FPG), and hemoglobin A1c (A1C) for detection of abnormal glucose tolerance (AGT).

METHODS

The NSEEDS trial evaluated SFS, FPG, and A1C in an at-risk population of 479 previously undiagnosed subjects from nine US centers, each of whom received a 75 g, 2 h oral glucose tolerance test (OGTT). Skin fluorescence spectra were collected and analyzed with SCOUT DS® devices. Disease truth was AGT, defined as OGTT ≥140 mg/dl. Abnormal glucose tolerance sensitivity, false positive rate (FPR), and receiver operating characteristic (ROC) curves were computed for each measurement technique. Skin fluorescence spectroscopy reproducibility was also assessed.

RESULTS

The AGT sensitivity of SFS was 68.2%, higher than that of FPG (thresholds of 100 and 110 mg/dl) and A1C (thresholds of 5.7% and 6.0%). The FPR of SFS was 37.7%, comparable to A1C at the 5.7% threshold (30.7%). Partial ROC areas of SFS, FPG, and A1C were similar for FPRs of 20-50% (average sensitivities of 64.0%, 59.0%, and 68.6%, respectively). The interday coefficient of variation for SFS was 7.6%.

CONCLUSIONS

Skin fluorescence spectroscopy has similar screening performance to FPG and A1C and is a viable approach for detection of AGT.

Pattern and predictors of dyslipidemia in patients with type 2 diabetes mellitus

Dyslipidemia is a major risk factor for macro-vascular complications in patients with type 2 diabetes mellitus (T2DM). Present study explored pattern and predictors of dyslipidemia in Bangladeshi T2DM patients. The cross-sectional study is conducted among 366 consecutive eligible T2DM patients aged >30 years, BIRDEM diabetic hospital, during July-to-December 2010. Physical examination, diabetic profile, lipid profile and serum createnine was performed. Adjusted odds ratio and confidence limit were generated through binary logistic regression. Most frequent form (59.3%) of dyslipidemia is low HDL. Duration of T2DM is significantly correlated with TC (P<0.05), HDL (P<0.05) and LDL (P<0.05) in both male and female. Glycemic control in terms of HbA1c >7% appeared as predictor of dyslipidemia (P<0.01). Duration T2DM is associated with increased risk of having higher TC (P<0.05), LDL (P<0.05) and lower HDL (P<0.01) and does not seem to affect triglyceride (P>0.05). T2DM with comorbid hypertension seems to predict hyper tri-glyceridemia and lower HDL. Both TC-HDL ratio and LDL-HDL ratio appeared as good predictor of all four parameters of dyslipidemia (P<0.01). The characteristic features of diabetic dyslipidemia are low HDL, high triglyceride and LDL cholesterol level. Low HDL level is the most frequent type of abnormality. Poor glycemic control, prolonged duration, coexisting hypertension predicts dyslipidemia in T2DM.

Utility of hemoglobin A1c for the identification of individuals with diabetes and prediabetes in a Chinese high risk population

BACKGROUND

The aim of the study was to assess the utility of Hemoglobin A1c (HbA1c) to identify individuals with undiagnosed DM and prediabetes (preDM) in the high risk population of Chinese people.

METHODS

A total of 424 high risk individuals without known diabetes, who met at least three of the high risk factors for DM (hypertension, abnormal blood lipid, family history of DM and high BMI) were selected for this study, HbA1c, fasting plasma concentrations of glucose (FPG) and a 75 g oral glucose tolerance test (OGTT) were measured. The performance of HbA1c in relation to undiagnosed DM and preDM investigated through receiver operating characteristic (ROC) curves, the reference for DM and preDM, are according to the 2011 WHO-FPG/OGTT criteria and the appropriate cut-off points of HbA1c for DM and preDM were assessed. The properties of HbA1c diagnosing DM and preDM were also compared with that of the fasting plasma glucose (FPG).

RESULTS

It was shown that the AUC (area under the curve) of the ROC curve for HbA1c predicting undiagnosed DM was similar to that of FPG, and the cut-off point of HbA1c 6.2% was optimal for predicting DM, with a sensitivity of 66%, and a specificity of 91%. Furthermore, the cut-off point of HbA1c was 5.9% for preDM with a sensitivity of 70%, a specificity of 87%.

CONCLUSION

Collectively, this study found that the measurement of HbA1c may be efficient to diagnosis undiagnosed both DM and preDM with the cut-off point of 6.2% and 5.9%, respectively.

Intensive multifactorial intervention improves modelled coronary heart disease risk in screen-detected Type 2 diabetes mellitus: a cluster randomized controlled trial

AIMS

To compare the effects of intensive multifactorial cardiovascular risk intervention with standard care in screen-detected Type 2 diabetes.

METHODS

Twenty general practices randomly invited 30 950 adults without diagnosed diabetes for screening (World Health Organization, 1999). In a cluster randomized controlled trial, screen-detected cases were assigned by practice allocation to receive intensive protocol-driven cardiovascular risk management (n = 146) or standard care (n = 199) according to local guidelines. Intensive intervention was designed to achieve an HbA(1c) of 48 mmol/mol (6.5%), blood pressure < 130/80 mmHg and total cholesterol < 3.5 mmol/l. Primary outcome was modelled 5-year coronary heart disease risk (UKPDS-CHD). Analysis was via intention to treat.

RESULTS

After 1.1 years 339 (98%) individuals were still participating. There were significant reductions in HbA(1c) , blood pressure and total cholesterol from baseline in both groups [mean change for total study population -27.7 mmol/mol (-0.62%), -11.64/10.01 mmHg, -1.11 mmol/l]. After adjustment for baseline and clustering, significant inter-group differences were observed in mean changes from baseline for HbA(1c) {-28.5 mmol/mol [-0.7% (1.4)] vs. -27.5 mmol/mol [-0.6% (1.6)], P = 0.001}, blood pressure [systolic -16.2 (19.6) vs. -8.4 (18.6) mmHg, P < 0.001], total cholesterol [-1.3 (1.3) vs. -1.0 (1.2) mmol/l, P < 0.001] and weight [-3.8 (5.5) vs. -2.2 (5.5) kg, P = 0.01] in favour of intensive treatment. UKPDS 5-year coronary heart disease risk was reduced by 3.2% and 2.3%, respectively (P < 0.0001). Intensive intervention was associated with more lipid-lowering and anti-hypertensive but not hypoglycaemic medication use [odds ratios 2.5 (1.4-4.4), 5.5 (2.4-11.5), 1.6 (0.8-2.3); compared with standard care, P < 0.001, P = 0.003, P = 0.65]. Treatment satisfaction responses were superior with intensive intervention, with no increase in self-reported hypoglycaemia.

CONCLUSION

Intensive intervention in patients with diabetes identified through systematic non-risk-factor-based screening significantly reduces modelled coronary heart disease risk. This is achieved predominantly with lipid-lowering and anti-hypertensive treatments with no adverse effect on quality of life or hypoglycaemia.

Evaluation of a risk factor scoring model in screening for undiagnosed diabetes in China population

OBJECTIVE

To develop a risk scoring model for screening for undiagnosed type 2 diabetes in Chinese population.

METHODS

A total of 5348 subjects from two districts of Jinan City, Shandong Province, China were enrolled. Group A (2985) included individuals from east of the city and Group B (2363) from west of the city. Screening questionnaires and a standard oral glucose tolerance test (OGTT) were completed by all subjects. Based on the stepwise logistic regression analysis of Group A, variables were selected to establish the risk scoring model. The validity and effectiveness of this model were evaluated in Group B.

RESULTS

Based on stepwise logistic regression analysis performed with data of Group A, variables including age, body mass index (BMI), waist-to-hip ratio (WHR), systolic pressure, diastolic pressure, heart rate, family history of diabetes, and history of high glucose were accepted into the risk scoring model. The risk for having diabetes increased along with aggregate scores. When Youden index was closest to 1, the optimal cutoff value was set up at 51. At this point, the diabetes risk scoring model could identify diabetes patients with a sensitivity of 83.3% and a specificity of 66.5%, making the positive predictive value 12.83% and negative predictive value 98.53%. We compared our model with the Finnish and Danish model and concluded that our model has superior validity in Chinese population.

CONCLUSIONS

Our diabetes risk scoring model has satisfactory sensitivity and specificity for identifying undiagnosed diabetes in our population, which might be a simple and practical tool suitable for massive diabetes screening.

Record-based, stepwise screening for type 2 diabetes integrated into an annual cardiovascular care review system: Findings from a UK general practice

AIMS

Screening high-risk individuals for type 2 diabetes (T2DM) is recommended by many organisations. We report results from a pragmatic stepwise T2DM screening programme integrated into an annual review system in a UK general practice.

METHODS

Patients with hypertension, cardiovascular disease or chronic kidney disease attending an annual review were screened for dysglycaemia by random blood glucose (RBG) measurement. At the discretion of the usual doctor, individuals with an RBG≥6.1 mmol/l were invited to return for fasting blood glucose (FBG) or HbA(1C) measurement, allowing diagnosis of T2DM.

RESULTS

786 eligible patients were invited for T2DM screening as part of their annual review. 544 attended screening, of whom 120 had an RBG≥6.1 mmol/l. 40 individuals attended FBG measurement and 8 individuals attended HbA(1C) measurement, leading to 9 T2DM diagnoses. The positive predictive value of the test for T2DM was 19% and the laboratory cost was £91 per patient diagnosed with T2DM.

CONCLUSIONS

It is feasible to integrate a simple T2DM screening programme within an annual review system in a UK general practice. Different strategies may be required to increase initial attendance and ensure completion of the screening programme.

Screening for type 2 diabetes. Lessons from the ADDITION-Europe study

AIMS

To describe and compare attendance rates and the proportions of people identified with Type 2 diabetes mellitus in people with previously unknown diabetes who participated in screening programmes undertaken in general practice in the UK, Denmark and the Netherlands as part of the ADDITION-Europe study.

METHODS

In Cambridge, routine computer data searches were conducted to identify individuals aged 40-69 years at high risk of Type 2 diabetes using the Cambridge Diabetes Risk Score. In Denmark, the Danish Diabetes Risk Score was mailed to individuals aged 40-69 years, or completed by patients visiting their general practitice. In the Netherlands, the Hoorn Symptom Risk Questionnaire was mailed to individuals aged 50-69 years. In these three centres, high-risk individuals were invited to attend subsequent steps in the screening programme, including random blood glucose, HbA(1c) , fasting blood glucose and/or oral glucose tolerance test. In Leicester, eligible people aged 40-69 years were invited directly for an oral glucose tolerance test. In all centres, Type 2 diabetes was defined according to World Health Organization 1999 diagnostic criteria.

RESULTS

Attendance rates ranged from 20.2% (oral glucose tolerance test in Leicester without pre-stratification) to 95.1% (random blood glucose in opportunistic screening in Denmark in high-risk people). The percentage of people with newly detected Type 2 diabetes from the target population ranged from 0.33% (Leicester) to 1.09% (the Netherlands).

CONCLUSIONS

Screening for Type 2 diabetes was acceptable and feasible, but relatively few participants were diagnosed in all participating centres. Different strategies may be required to increase initial attendance and ensure completion of screening programmes.

Screening for diabetes using an oral glucose tolerance test within a western multi-ethnic population identifies modifiable cardiovascular risk: the ADDITION-Leicester study

AIMS/HYPOTHESIS

The aim of this study was to determine the frequency of undiagnosed glucose abnormalities and the burden of cardiovascular disease (CVD) risk among south Asians and white Europeans attending a systematic screening programme for type 2 diabetes (ADDITION-Leicester) and to estimate the achievable risk reduction in individuals identified with glucose disorders.

METHODS

Random samples of individuals (n = 66,320) from 20 general practices were invited for a 75 g OGTT and CVD risk assessment. Ten-year CVD risk among screen-detected people with diabetes or impaired glucose regulation (IGR) (impaired fasting glycaemia and/or impaired glucose tolerance [IGT]) was computed using the Framingham-based ETHRISK engine and achievable risk reduction was predicted using relative reductions for treatments extracted from published trials.

RESULTS

A total of 6,041 participants (48% male, 22% south Asian) aged 40-75 years inclusive were included. Undiagnosed glucose disorders occurred more frequently in south Asians than white Europeans; age and sex adjusted odds ratios were 1.74 (95% CI 1.42-2.13) and 2.30 (95% CI 1.68-3.16) for IGT and diabetes respectively. Prevalence of any undetected glucose disorder was 17.5% in the whole cohort. Adjusted 10-year risk was similar in screen-detected people with IGR and diabetes (18.3% vs 21.6%), and was higher in south Asians across the glucose spectrum. Absolute CVD risk reductions of up to 13% in those with screen-detected type 2 diabetes and 6% in IGR are achievable using existing cardioprotective therapies.

CONCLUSIONS/INTERPRETATION

Population screening with an OGTT identifies a significant burden of modifiable CVD risk, especially within south Asian groups. Strategies enticing this population to consider screening programmes are urgently needed as significant risk reduction is possible once a glucose abnormality is identified.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00318032.

FUNDING

The project is funded for support and treatment costs by NHS Department of Health Support for Science and project grants.

Cardiovascular screening for men at high risk in Heart of Birmingham Teaching Primary Care Trust: the 'Deadly Trio' programme

BACKGROUND

The Deadly Trio programme offered cardiovascular health checks to men over 40 in inner-city Birmingham. The aim was to increase diagnosis of diabetes, cardiovascular and kidney disease among this deprived and ethnically diverse population. Either patients' own general practitioners (GPs) were paid to provide health checks or patients were invited to an alternative provider.

METHODS

Routine data were sought from 68 participating practices. Logistic regression analysis was undertaken to determine the patient and practice factors associated with being screened and with being added to a disease register.

RESULTS

Data were obtained from 58 practices; 5871 (24.3%) of 24 166 eligible men were screened. Screening uptake was higher in those with a recorded phone number, South Asians and Blacks but lower in smokers. Compared to the alternative provider, uptake was higher among men registered with single-handed (but not multi-partner) GPs paid to provide health checks. South Asian, older and screened men were more often added to disease registers. Men with missing information and GP-screened men were less likely to be added to registers.

CONCLUSIONS

The programme achieved higher screening uptake and diagnosis of disease among minority ethnic men. Single-handed GPs paid to provide screening (and their patients) were more responsive than multi-partner practices.

Screening for type 2 diabetes and dysglycemia

Type 2 diabetes mellitus (T2DM) and dysglycemia (impaired glucose tolerance and/or impaired fasting glucose) are increasingly contributing to the global burden of diseases. The authors reviewed the published literature to critically evaluate the evidence on screening for both conditions and to identify the gaps in current understanding. Acceptable, relatively simple, and accurate tools can be used to screen for both T2DM and dysglycemia. Lifestyle modification and/or medication (e.g., metformin) are cost-effective in reducing the incidence of T2DM. However, their application is not yet routine practice. It is unclear whether diabetes-prevention strategies, which influence cardiovascular risk favorably, will also prevent diabetic vascular complications. Cardioprotective therapies, which are cost-effective in preventing complications in conventionally diagnosed T2DM, can be used in screen-detected diabetes, but the magnitude of their effects is unknown. Economic modeling suggests that screening for both T2DM and dysglycemia may be cost-effective, although empirical data on tangible benefits in preventing complications or death are lacking. Screening for T2DM is psychologically unharmful, but the specific impact of attributing the label of dysglycemia remains uncertain. Addressing these gaps will inform the development of a screening policy for T2DM and dysglycemia within a holistic diabetes prevention and control framework combining secondary and high-risk primary prevention strategies.

A Chinese diabetes risk score for screening of undiagnosed diabetes and abnormal glucose tolerance

BACKGROUND

This study is aimed at developing and evaluating a diabetes risk score (DRS) to predict incident diabetes and screen for undiagnosed diabetes and abnormal glucose tolerance in the Chinese population.

METHODS

Three DRS instruments were respectively developed and validated based on the data collected from a 10-year longitudinal health checkup-based population of 1,851 individuals without diabetes at baseline. The efficiency on glucose abnormality screening was evaluated based on the testing of a cross-sectional sample of 699 individuals without known diabetes.

RESULTS

The DRS consisting of age, hypertension, history of high blood glucose, body mass index, fasting plasma glucose, serum triglycerides, and serum high-density lipoprotein-cholesterol had the best prediction properties (area under curve [AUC] = 0.734 [95% confidence interval 0.702-0.766] and 0.759 [0.686-0.831] in exploratory and validation cohorts, respectively). The DRS had a sensitivity of 64.5% and 72.9%, respectively, and a specificity of 71.6% and 63.9%, respectively, with an optimal cutoff of 4. AUCs were 0.828 (0.797-0.860) and 0.909 (0.884-0.933) for detecting abnormal glucose tolerance and diabetes, respectively, through cross-sectional screening. Performance of the oral glucose tolerance test (OGTT) in selected subjects with DRS ≥ 4 led to the identification of 76.2% cases of abnormal glucose tolerance and 100% cases of diabetes, while avoiding an OGTT in 52.8% of the study group.

CONCLUSIONS

The DRS instrument including age, hypertension, history of high blood glucose, body mass index, fasting plasma glucose, triglycerides, and high-density lipoprotein-cholesterol is practical and effective in predicting incident diabetes and screening glucose abnormality in the Chinese population.

Evaluation of the Finnish Diabetes Risk Score as a screening tool for impaired fasting glucose, impaired glucose tolerance and undetected diabetes

AIM

To evaluate the performance of FINDRISC as a screening tool for prediabetes - impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) and undetected diabetes (UDD) in subjects at risk of developing diabetes.

SUBJECTS AND METHODS

2169 subjects with at least one risk factor for diabetes completed the FINDRISC questionnaire and underwent an oral glucose tolerance test. FINDRISC performance was assessed using the area under the receiver operating characteristic curve (AUC-ROC).

RESULTS

56.6% of subjects demonstrated normal glucose tolerance (NGT), 14.5% - IFG, 11.4% - IGT and 17.5% - UDD. NGT group demonstrated mean FINDRISC 10.1±3.4, IFG group - 13.8±4.3 (p<0.0001 vs. NGT), IGT group - 14.4±5.4 (p<0.0001 vs. NGT) and UDD group - 15.5±4.8 (p<0.0001 vs. NGT and IFG, p<0.01 vs. IGT). The AUC-ROC was 0.70 (95% CI 0.67-0.73) for UDD and 0.71 (95% CI 0.69-0.73) for undetected prediabetes and diabetes. The FINDRISC cut-off value of 10 to identify both prediabetes and diabetes had sensitivity of 84% and specificity of 61%.

CONCLUSIONS

FINDRISC is a feasible, non-invasive and useful tool for identifying subjects at risk for undetected diabetes and prediabetes. Laboratory screening should be performed in subjects with FINDRISC higher than 10.

Comparison of different stepwise screening strategies for type 2 diabetes: Finding from Danish general practice, Addition-DK

AIM

To examine attendance, number of people with T2DM and costs of three different stepwise screening strategies for T2DM in general practice (GP).

METHODS

Diabetes risk questionnaires were mailed to individuals aged 40-69 years from 45 general practices in 2001-2002 and individuals at high risk for T2DM, were asked to contact their GP to arrange a screening test. In 2005-2006, 26 general practices were randomised into two different opportunistic screening programmes (OP-direct and OP-subsequent) and risk questionnaires were distributed to individuals aged 40-69 years during GP consultations. In the OP-direct approach, high-risk individuals were offered to start the screening during the actual consultation while high-risk individuals in the OP-subsequent approach, were invited to a screening test at a later date. We report attendance, number of people with T2DM and costs of each screening approach.

RESULTS

The mail-distributed approach identified 0.8% of the target population with T2DM, the OP-direct approach and the OP-subsequent approach, 0.9% and 0.5% respectively. Cost per person with T2DM was in the mail-distributed approach: € 1058, OP-direct approach: € 707 and the OP-subsequent approach: € 727.

CONCLUSION

This study indicates that opportunistic screening identifies the same level of unknown diabetes as a mail-distributed approach but with lower costs.

Selected risk factors of diabetes mellitus among road transport drivers

OBJECTIVES

Road transport drivers are one of the professional groups whose activities have a strong impact on public safety. In view of the nature of their professional activity, the drivers are at a higher risk of obesity and hypertension, and thus, indirectly, of carbohydrate metabolism disorders such as diabetes mellitus.

MATERIALS AND METHODS

Medical documentation was a source of data for the reported study. It derived from medical examinations of truck and bus drivers applying for the new category II driving licence or for prolongation of the one they already had.

RESULTS

Excessive body weight was recorded in 62.6% of the study population; 45.3% had overweight and 17.4% were diagnosed with obesity. Hypertension was noted in the medical records of 36.7% drivers. The prevalence of abnormal BP values was increasing with age. Overweight was found to be a risk factor for hypertension. Hyperglycaemia was found in 47.5% of the drivers and was also increasing with age.

CONCLUSION

In road transport drivers, the high prevalence of excessive body weight and elevated arterial blood pressure as the risk factors for diabetes indicates a need to undertake multidimensional actions targeted on this particular profession and involving various health care sectors. Prophylactic and detailed pre-placement examinations should be considered, depending on the rate and intensity of the disorders diagnosed. This should be coupled with an introduction of primary and secondary prophylactic activities and monitoring of relevant treatment. A close collaboration with the patient's GP is necessary.

Who attends a UK diabetes screening programme? Findings from the ADDITION-Cambridge study

AIMS

One of the factors influencing the cost-effectiveness of population screening for Type 2 diabetes may be uptake. We examined attendance and practice- and individual-level factors influencing uptake at each stage of a diabetes screening programme in general practice.

METHODS

A stepwise screening programme was undertaken among 135, 825 people aged 40-69 years without known diabetes in 49 general practices in East England. The programme included a score based on routinely available data (age, sex, body mass index and prescribed medication) to identify those at high risk, who were offered random capillary blood glucose (RBG) and glycosylated haemoglobin tests. Those screening positive were offered fasting capillary blood glucose (FBG) and confirmatory oral glucose tolerance tests (OGTT).

RESULTS

There were 33 539 high-risk individuals invited for a RBG screening test; 24 654 (74%) attended. Ninety-four per cent attended the follow-up FBG test and 82% the diagnostic OGTT. Seventy per cent of individuals completed the screening programme. Practices with higher general practitioner staff complements and those located in more deprived areas had lower uptake for RBG and FBG tests. Male sex and a higher body mass index were associated with lower attendance for RBG testing. Older age, prescription of antihypertensive medication and a higher risk score were associated with higher attendance for FBG and RBG tests.

CONCLUSIONS

High attendance rates can be achieved by targeted stepwise screening of individuals assessed as high risk by data routinely available in general practice. Different strategies may be required to increase initial attendance, ensure completion of the screening programme, and reduce the risk that screening increases health inequalities.

Identifying populations at high risk for diabetes with the Behavioral Risk Factor Surveillance System, Rhode Island, 2003

INTRODUCTION

We evaluated the feasibility of applying a previously validated diabetes risk score (DRS) to state-based surveillance data from the Behavioral Risk Factor Surveillance System (BRFSS) to assess population risk for developing type 2 diabetes or having undiagnosed type 2 diabetes.

METHODS

We conducted a cross-sectional analysis of 1,969 adults aged 30 to 60 years who self-reported never having been diagnosed with diabetes. The Danish DRS was applied to the 2003 Rhode Island BRFSS data by using 6 categorical variables: age, sex, body mass index, known hypertension, leisure-time physical activity, and family history of diabetes. The DRS was the sum of these individual scores, which ranged from 0 to 60; a score of 31 or more was considered high-risk.

RESULTS

We found that 436 study participants, representing 23% of Rhode Island adults aged 30 to 60 years, had a high DRS. In the final model, adults with at least some college education were 43% less likely to have a high DRS, compared to adults with a high school diploma. Adults with no health insurance were 54% more likely to have a high DRS compared with insured adults.

CONCLUSION

By adding a family history question in odd years to correspond to the hypertension module in the BRFSS, routinely available state-level surveys can be used with a DRS to monitor populations at high risk for developing type 2 diabetes. In Rhode Island, almost one-fourth of adults aged 30 to 60 years were at high risk for having undiagnosed diabetes or developing diabetes. Adults with lower education and without health insurance were at highest risk.

Mobile phone ownership among Nigerians with diabetes

BACKGROUND

A survey was undertaken to determine the number of individuals who have access to Mobile phones among those attending our Diabetes clinic in order to explore whether this could replace or become an adjunct to street home address as contact information.

METHOD

An observer-based questionnaire was administered to capture parameters of interest at the weekly diabetes clinic in order to answer the survey question

RESULTS

130 individuals aged 15-80 years who attended the clinic in the month of May 2008 were surveyed. Eighty nine (89) patients had active Mobile phone and lines while 70.8% of these were females. Strikingly, 37% percent of the study populations were from across states boundaries and other geographic areas but majority reside in Ilorin metropolis where the facility is based.

CONCLUSION

The results indicate that over two thirds of those with diabetes attending the clinic had active Mobile phone line and this could be used as an adjunct to or replace street address as a contact particular between patients and their professional care givers.

An active strategy to identify individuals eligible for type 2 diabetes prevention by lifestyle intervention in Dutch primary care: the APHRODITE study

BACKGROUND

Several trials have shown the potential of lifestyle intervention programmes for prevention of type 2 diabetes. The effectiveness of implementation of these programmes into daily practice is now being studied in several countries. The 'Active Prevention in High Risk individuals of Diabetes Type 2 in Eindhoven' (APHRODITE) study investigates whether type 2 diabetes prevention by lifestyle intervention is effective in Dutch primary care. In this article we describe the process of recruiting the study participants.

OBJECTIVE

To assess the reach of an active strategy to recruit participants for a programme on type 2 diabetes prevention by lifestyle intervention in Dutch primary care.

METHODS

A diabetes risk questionnaire was sent to general practice patients aged 40-70 years. Individuals with a risk score above threshold were invited for an admission interview with the GP and an oral glucose tolerance test (OGTT). All individuals with non-diabetic glucose levels were asked to participate in the intervention study.

RESULTS

In total, 8752 (54.6%) of the individuals returned the questionnaire in time. Of all high-risk individuals (n = 1533), 73.1% contacted their practice to schedule a consultation with the GP. Response rates varied significantly among practices.

CONCLUSIONS

Using invitational letters, a substantial amount of individuals could be motivated to participate in a programme on type 2 diabetes prevention by lifestyle intervention in Dutch primary care. Further research is needed on what kind of strategy would be most effective and efficient to screen for individuals at high risk for type 2 diabetes in primary care.

Yield of opportunistic targeted screening for type 2 diabetes in primary care: the diabscreen study

PURPOSE

In screening for type 2 diabetes, guidelines recommend targeting high-risk individuals. Our objectives were to assess the yield of opportunistic targeted screening for type 2 diabetes in primary care and to assess the diagnostic value of various risk factors.

METHODS

In 11 family practices (total practice population = 49,229) in The Netherlands, we conducted a stepwise opportunistic screening program among patients aged 45 to 75 years by (1) identifying high-risk individuals (=1 diabetes risk factor) and low-risk individuals using the electronic medical record, (2) obtaining a capillary fasting plasma glucose measurement, repeated on a separate day if the value was greater than 110 mg/dL, and (3) obtaining a venous sample if both capillary fasting plasma glucose values were greater than 110 mg/dL and at least 1 sample was 126 mg/dL or greater. We calculated the yield (percentage of invited patients with undiagnosed diabetes), number needed to screen (NNS), and diagnostic value of the risk factors (odds ratio and area under the receiver operating characteristic curve).

RESULTS

We invited for a first capillary measurement 3,724 high-risk patients seen during usual care and a random sample of 465 low-risk patients contacted by mail. The response rate was 90% and 86%, respectively. Ultimately, 101 high-risk patients (2.7%; 95% confidence interval [CI], 2.2%-3.3%; NNS = 37) and 2 low-risk patients (0.4%; 95% CI, 0.1%-1.6%; NNS = 233) had undiagnosed diabetes (P <.01). The prevalence of diabetes among patients 45 to 75 years old increased from 6.1% to 6.8% as a result. Among diagnostic models containing various risk factors, a model containing obesity alone was the best predictor of undiagnosed diabetes (odds ratio = 3.2; 95% CI, 2.0-5.2; area under the curve=0.63).

CONCLUSIONS

The yield of opportunistic targeted screening was fair; obesity alone was the best predictor of undiagnosed diabetes. Opportunistic screening for type 2 diabetes in primary care could target middle-aged and older adults with obesity.

Evaluating the impact of a national pilot screening programme for type 2 diabetes in deprived areas of England

BACKGROUND

A pilot programme designed to systematically screen for type 2 diabetes was introduced in 24 general practices in England selected for their high levels of socio-economic deprivation and multi-ethnic populations.

OBJECTIVE

To evaluate the impact of screening on the prevalence of type 2 diabetes.

METHODS

A prospective audit of screening activity in pilot practices and comparison of the change in prevalence of diabetes in pilot and comparison practices were conducted.

RESULTS

Of 41,400 individuals invited for screening from a population of 165,828 in pilot practices, 25,356 (61%) were screened. Three hundred and fifty-eight (0.22%) new cases of diabetes were detected among those screened. Only 69% of those with a positive screening test had diagnostic testing recorded and only 19% had a record of an oral glucose tolerance test. The absolute increase in the prevalence of diagnosed diabetes was 0.53% in pilot practices and 0.42% in comparison practices.

CONCLUSIONS

The 'real world' nature of the programme and dependence on routine data collection systems makes results more difficult to interpret but also enabled problems with implementation, not evident from previous research, to be identified. It is likely that the low diagnostic yield was largely due to a high level of ad hoc screening activity outside the pilot protocol and inadequate access to diagnostic testing after a positive screening test. In particular, implementation of screening for diabetes in primary care should not be undertaken without robust assessment of the resources required for diagnostic testing and follow-up and adequate clinical audit.

High prevalence of undiagnosed diabetes and abnormal glucose tolerance in the Iranian urban population: Tehran Lipid and Glucose Study

BACKGROUND

To estimate the prevalence of diagnosed and undiagnosed diabetes mellitus, impaired fasting glucose (IFG), impaired glucose tolerance (IGT), and combined IFG/IGT in a large urban Iranian population aged > or = 20 years.

METHODS

The study population included 9,489 participants of the Tehran Lipid and Glucose Study with full relevant clinical data. Age-standardized prevalence of diabetes and glucose intolerance categories were reported according to the 2003 American Diabetes Association definitions. Age-adjusted logistic regression models were used to estimate the numbers needed to screen (NNTS) to find one person with undiagnosed diabetes.

RESULTS

The prevalence of diagnosed and undiagnosed diabetes, isolated IFG, isolated IGT, and combined IFG/IGT were 8.1%, 5.1%, 8.7%, 5.4% and 4.0% in men and 10%, 4.7%, 6.3%, 7.6%, and 4.5% in women respectively. Participants with undiagnosed diabetes had higher age, body mass index (BMI), waist circumference, systolic and diastolic blood pressures, triglycerides (all p values <0.001) and lower HDL-cholesterol (only in women, p < 0.01) compared to normoglycemic subjects. Undiagnosed diabetes was associated with family history of diabetes, increased BMI (> or = 25 kg/m2), abdominal obesity, hypertriglyceridemia, hypertension and low HDL-cholesterol levels. Among men, a combination of increased BMI, hypertension, and family history of diabetes led to a NNTS of 1.6 (95% CI: 1.57-1.71) and among women a combination of family history of diabetes and abdominal obesity, yielded a NNTS of 2.2 (95% CI: 2.1-2.4).

CONCLUSION

In conclusion, about one third of Tehranian adults had disturbed glucose tolerance or diabetes. One- third of total cases with diabetes were undiagnosed. Screening individuals with BMI > or = 25 kg/m2 (men), hypertension (men), abdominal obesity (women) and family history of diabetes may be more efficient.

A simple clinical score for type 2 diabetes mellitus screening in the Canary Islands

AIM

To develop a straightforward risk score for type 2 diabetes (DM2) screening to use in clinical practice.

METHODS

A sample of 6237 adult inhabitants of the Canary Islands (Spain) was randomly divided into two subgroups: one yielded data used to develop the instrument, and the other yielded data used for validation testing. Performance of the instrument was compared in persons with clinically diagnosed DM2 and undiagnosed diabetes. The risk score, calculated by multivariate logistic regression, included the potential risk variables that yielded the highest odds ratio in the univariate analysis. A cut-off point for screening purposes was established at a 99% negative predictive value.

RESULTS

In men, variables included in the risk score were age, waist/height ratio, familial antecedents of diabetes, and systolic blood pressure (ROC curve 0.837, 95% CI: 0.803-0.871). In women, the risk score contained the same variables plus gestational diabetes history (ROC curve 0.874, 95% CI: 0.847-0901). Excluding systolic blood pressure from the score had no significant effect on the area under the curve. This instrument resulted valid only for people aged less than 55 years.

CONCLUSIONS

This simple risk score for DM2 would be easy to apply in clinical practice.

Best practice in primary care pathology: review 10

This tenth best practice review examines four series of common primary care questions in laboratory medicine: (i) antenatal testing in pregnant women; (ii) estimated glomerular filtration rate calculation; (iii) safety testing for methotrexate; and (iv) blood glucose measurement in diabetes. The review is presented in question-answer format, referenced for each question series. The recommendations represent a precis of guidance found using a standardised literature search of national and international guidance notes, consensus statements, health policy documents and evidence-based medicine reviews, supplemented by Medline Embase searches to identify relevant primary research documents. They are not standards but form a guide to be set in the clinical context. Most are consensus rather than evidence-based. They will be updated periodically to take account of new information.

HCV and diabetes. A two-question-based reappraisal

We used available studies to answer two clinically relevant questions, i.e. whether those with type 2 diabetes should undergo hepatitis C virus screening and whether hepatitis C virus positive individuals should be screened for diabetes. Four reasons argue against the hypothesis of screening diabetics for hepatitis C virus. First, although it induces insulin resistance, hepatitis C virus is not directly diabetogenic. Second, the clinical phenotype of hepatitis C virus-associated type 2 diabetes might be a clue to target the specific diabetic population to be screened. Third, diabetic patients are expected to be poor responders to antivirals and evidence that this might result in recovery from type 2 diabetes is insufficient. Fourth, no econometric data are available in the specific subset of those with type 2 diabetes. Case finding of type 2 diabetes in those with hepatitis C virus infection, in contrast, might be considered in those patients with type 2 diabetes who have cirrhosis, in whom--due to increased prevalence and severity of hepatic encephalopathy--diabetes is associated with increased mortality. Preliminary evidence suggests that the prognosis of cirrhosis might benefit from improved glycemic control and thus from earlier diagnosis of type 2 diabetes. Finally, studies are needed to ascertain the most cost-effective strategy of case-finding type 2 diabetes among those who are hepatitis C virus-infected. In conclusion, available data enabled us to answer the two questions. Hepatitis C virus screening should best be restricted to those (lean) diabetic patients with (advanced) liver disease. Glucose tolerance testing should best be performed in those with hepatitis C virus-related cirrhosis. However, additional studies are needed to support the cost-effectiveness of our conclusions.

Clinical and cost-effectiveness of primary prevention of Type 2 diabetes in a 'real world' routine healthcare setting: model based on the KORA Survey 2000

AIMS

To analyse the clinical and cost-effectiveness of the primary prevention of Type 2 diabetes in a 'real world' routine healthcare setting using population-based data (KORA Survey in Augsburg, Germany, total population approximately 600,000).

METHODS

Decision analytic model, time horizon 3 years.

INTERVENTIONS

Staff education, targeted screening and lifestyle modification or metformin in people aged 60-74 years with a body mass index of > or = 24 kg/m(2) and prediabetic status (fasting glucose 5.3-6.9 mmol/l and 2-h post load glucose 7.8-11.0 mmol/l) (target population approximately 72,500), according to the Diabetes Prevention Program trial.

MAIN OUTCOME MEASURES

Cases of Type 2 diabetes prevented, cost (Euro), incremental cost-effectiveness ratios (ICERs).

RESULTS

Under model assumptions, 14 908 people in the target population would develop diabetes if there was no intervention, 184 cases would be avoided with lifestyle intervention and 42 cases with metformin intervention. From the perspective of statutory health insurance and society, costs for lifestyle modification were 856,507 euro (574,241 pounds) and 4,961,340 euro (3,326,307 pounds), respectively, and for metformin 797,539 euro (534,706 pounds) and 1,335,204 euro(895,181 pounds). Up to 5% of the costs were due to staff education and up to 36% to screening. Lifestyle was more cost effective than metformin. ICERs for lifestyle vs. 'no intervention' were 4664 euro (3127 pounds) and 27,015 euro (18,112 pounds) per case prevented from the statutory health insurance and societal perspective.

CONCLUSIONS

Total cost and cost per case of diabetes avoided was high. Staff education and screening had a considerable impact. In view of the low participation in a routine healthcare setting, with both strategies only a small number of cases of diabetes would be prevented. Before implementing the programme, efforts should be made to improve patient participation in order to achieve better clinical and cost-effectiveness of the prevention of Type 2 diabetes in 'real world' clinical practice.

A community-based screening campaign for the detection of diabetes mellitus and hypertension in the eastern province, saudi arabia: methods and participation rates

OBJECTIVE

To describe a community-based diabetes and hypertension screening campaign, the percentage of screened positive individuals, identified the participation rate, and the factors affecting the participation. CAMPAIGN DESIGN AND METHODS: A community-based screening campaign whose main objective was the screening for diabetes and hypertension was conducted in the Eastern Province of Saudi Arabia for three and half months in the year 2004. A structured questionnaire was used. Diabetes mellitus was diagnosed on the basis of repeated detection of a fasting blood sugar equal to or more than 126 mg/dl, and hypertension when the blood pressure was 140/90 mm Hg or more.

RESULTS

Of the 650,000 target population, 214,381 (33%) participated, and 197,681 questionnaire were completed. Of the number of individuals screened, 31,711 (16%) were positive for abnormal blood pressure and /or glucose, and needed confirmation of their results. Only 17296 (54.5%) of them were referred to health facilities for confirmation of results

CONCLUSION

Community screening campaigns for diabetes mellitus and hypertension is extremely efficient in identifying undiagnosed diabetic and hypertensive individuals. The most successful strategy for the screening and confirmation of results was through PHCCs, especially in the rural areas, where there was good organization and strict adherence to guidelines on methodology.

Assessment of diabetes screening by general practitioners in France: the EPIDIA Study

AIM

To audit Type 2 diabetes screening in general practice in France and to determine the frequency of undiagnosed diabetes in patients at high risk, after systematic screening and diagnosis.

METHODS

For this study, 288 general practitioners volunteered to include all consecutive non-diabetic patients aged < 65 years who had at least two risk factors for diabetes, whatever the reason for consultation. If a plasma glucose had not been recorded in the previous 12 months, a fasting plasma glucose (FPG) was performed, with a second test if FPG >or= 7.0 mmol/l.

RESULTS

There were 5950 patients included. The most frequent diabetes risk factors were: age >or= 40 years, 92%; overweight [body mass index (BMI) >or= 27 kg/m2], 59%; treated hypertension, 48%; treated dyslipidaemia, 37%; family history of diabetes, 24%. Of these subjects at high risk for diabetes, 88% had a FPG measurement in their medical record (75% measured during the preceding 12 months). In the 1499 patients in whom FPG was measured, diabetes was diagnosed in 40 patients (2.7% 95% CI 1.9-3.5) and 22% had impaired fasting glucose (IFG). Thus, the frequency of undiagnosed diabetes in the 5950 high-risk patients was 0.67% (0.46-0.88).

CONCLUSION

Screening for diabetes by general practitioners in France appears to be adequate and undiagnosed diabetes is rare in patients with risk factors for diabetes, at least in those consulting the general practitioners studied.

What determines the cost-effectiveness of diabetes screening?

AIMS/HYPOTHESIS

The cost-effectiveness of screening for diabetes is unknown but has been modelled previously. None of these models has taken account of uncertainty. We aimed to describe these uncertainties in a model where the outcome was CHD risk.

SUBJECTS AND METHODS

Our model used population data from the Danish Inter99 study, and simulations were run in a theoretical population of 1,000,000 individuals. CHD risk was estimated using the UK Prospective Diabetes Study (UKPDS) risk engine, and risk reduction from published randomised clinical trials. Probabilistic sensitivity analysis was used to provide confidence intervals for modelled outputs. Uncertain parameter values were independently simulated from distributions derived from existing literature and deterministic sensitivity analysis performed using multiple model runs under different strategy choices and using extreme parameter estimates.

RESULTS

In the least conservative model (low costs and multiplicative risk reduction for combined treatments), the 95% confidence interval of the incremental cost-effectiveness ratio varied from pound23,300-82,000. The major contributors to this uncertainty were treatment risk reduction model parameters: the risk reduction for hypertension treatment and UKPDS risk model intercept. Overall cost-effectiveness ratio was not sensitive to decisions about which groups to screen, nor the costs of screening or treatment. It was strongly affected by assumptions about how treatments combine to reduce risk.

CONCLUSIONS/INTERPRETATION

Our model suggests that there is considerable uncertainty about whether or not screening for diabetes would be cost-effective. The most important but uncertain parameter is the effect of treatment. In addition to directly influencing current policy decisions, health care modelling can identify important unknown or uncertain parameters that may be the target of future research.

Diabetes: how are we diagnosing and initially managing it?

PURPOSE

We undertook this study to examine the symptoms, clinical events, and types of health care encounters that preceded the diagnosis of diabetes mellitus in adults, and to examine changes in glycemic control and cardiovascular risk factors in the first year after a diabetes diagnosis.

METHODS

We conducted a historical cohort study of patients in a large multispecialty medical group in Minnesota. Among 55,121 adults who were continuously enrolled in the health plan and receiving care at the study medical group from January 1, 1993, to December 31, 1996, we identified 504 who received a new diagnosis of diabetes in 1995 or 1996. Our main outcome measures were the type of symptoms at diagnosis; the clinical circumstances and type of encounter that led to diabetes diagnosis; and changes in glycemic control (assessed by hemoglobin A1c [HbA1c] value), low-density lipoprotein cholesterol level, blood pressure (BP), aspirin use, and body weight in the first year after diagnosis, ascertained from a detailed review of medical records.

RESULTS

Almost one third (32.3%) of adults with newly diagnosed diabetes had symptoms of hyperglycemia at initial diagnosis. Compared with patients who did not have hyperglycemia symptoms at diagnosis, those who did were younger and more often male, and had lower comorbidity scores and higher HbA1c values (9.9% vs 8.1%) at diagnosis (P <.01 for each comparison). In the 12 months after diagnosis, the group as a whole had significant improvements (P <.001) in HbA1c values (from 8.8% to 7.1%), systolic blood pressure (137.5 to 133.2 mm Hg), diastolic blood pressure (80.7 to 77.3 mm Hg), weight (207.7 to 201.1 lb), and aspirin use (15.3% to 26.1%). Improvements were seen in all patient subgroups, including those defined by symptoms at diagnosis and by visit type at diagnosis.

CONCLUSIONS

Primary care practices may improve detection of undiagnosed diabetes in primary care and improve 1-year outcomes by being vigilant for symptoms of diabetes, by evaluating those at high risk for this disorder, and by instituting appropriate treatments at the time of diagnosis.

Relative role of major risk factors for Type 2 diabetes development in the historical cohort of the Brisighella Heart Study: an 8-year follow-up

AIM

The aim of this study was to evaluate and quantify the role of different risk factors in the long-term development of Type 2 diabetes mellitus in a rural Italian population.

METHODS

The Brisighella Heart Study (BHS; 1972-2003) is a prospective, population-based longitudinal epidemiological cohort involving 2939 randomly selected subjects, aged 14-84 years, resident in the rural Italian town of Brisighella. For this study, we randomly selected 1441 adult subjects representative of the Brisighella population; consecutively visited during three BHS surveys. A step-wise Cox regression analysis determined the prognostic significance of each independent risk factor for the development of Type 2 diabetes in the 8-year long follow-up.

RESULTS

Blood pressure, high-density lipoprotein cholesterol, triglycerides, physical activity, total energy intake, and drug treatment had no effect on the incidence of diabetes. Age was a significant predictor of Type 2 diabetes when inserted alone in the model (P = 0.007), but irrelevant when adjusted for baseline body mass index (BMI) and or fasting plasma glucose. Among these with impaired fasting glucose (IFG), the diabetes incidence/year was estimated to be 6.6% for men and 11.2% for women (P < 0.001). Basal glycaemia under 6.1 mmol/l were not significant long-term predictors of diabetes development, while higher basal glycaemia and each level BMI were.

CONCLUSION

Our findings confirm that IFG and BMI predict Type 2 diabetes development in our population. This should help to identify effective approaches to prevention.

Relationship between self-reported prevalence of diabetes mellitus using the Cornell Medical Index (CMI) and prevalence determined by glycosylated hemoglobin (HbA(1c)) in an elderly community-dwelling population

Reports of diabetes mellitus samples in community-dwelling unselected populations suggest a prevalence of 6%. A further 3% of unknown diabetes mellitus subjects are suggested when using formal biochemical methods of diagnosis. In this study, we present the prevalence of diabetes mellitus by self-reports using the CMI and concomitant biochemical detection in 436 community-dwelling older adults who have participated in a 20-year-study of age and cognitive performance in Manchester, UK. Twenty-three of the group reported that they had diagnosed diabetes mellitus, three individuals had a raised HbA(1c) of greater than 7.0% on random testing, but no knowledge of having diabetes mellitus. These individuals were re-contacted and three said they subsequently had a diagnosis of diabetes mellitus made within the two years following the questionnaire. We conclude that in an older population of community-dwelling subjects the numbers of undiagnosed cases of diabetes mellitus is lower than anticipated, based on large unselected population samples. The greater opportunity to interact with health care professionals who may consider screening for diabetes mellitus may explain these findings.

Controlling the diabetes epidemic: how should we screen for undiagnosed diabetes and dysglycaemia?

AIMS

To compare the detection of undiagnosed diabetes and dysglycaemia (impaired glucose tolerance, impaired fasting glucose, diabetes) using risk factors and laboratory measures of glycaemia.

METHODS

Casual blood glucose samples were taken from 1899 (69.4% of 2737 invited) European, Maori and Pacific Islands subjects aged 40-79 years from randomly selected households in South Auckland, New Zealand. Of these, 534 attended for a 75-g oral glucose tolerance test (OGTT) if an elevated result was identified [327/478 (68.4%)] or if randomly selected with a 'normal' screening result [207/308 (67.2%)].

RESULTS

Several Europeans with undiagnosed diabetes (25.0%) and dysglycaemia (31.4%) had no diabetes risk factors. Most Maori and Pacific Islanders had at least one risk factor. The area under the receiver operating curve (ROC) for the detection of undiagnosed diabetes was 0.92 (0.89-0.95) using fasting glucose, 0.86 (0.82-0.90) using HbA1c, 0.75 (0.69-0.80) using random glucose, but 0.60 (0.55-0.66) using risk factor screening. The ROC for detecting any dysglycaemia was 0.88 (0.85-0.90), 0.68 (0.64-0.71), 0.72 (0.69-0.75), 0.61 (0.58-0.65), respectively. Screening using fasting glucose (the best test) detected 90.4% of new diabetes and 78.4% of dysglycaemia; risk factor screening followed by fasting glucose detected significantly less cases [88 (82-93)% and 86 (82-89)%, respectively] with 9.2% less OGTTs.

CONCLUSIONS

Using risk factors for the identification of who should receive a blood test for dysglycaemia adds little to direct screening with the risk of missing some with significant hyperglycaemia. Screening for dysglycaemia may best be undertaken using blood tests without initial risk factor symptom screening.

The Coronary Artery Revascularisation in Diabetes (CARDia) trial: background, aims, and design

BACKGROUND

Patients with diabetes have an increased incidence and severity of ischemic heart disease, which leads to an increased requirement for coronary revascularization. Comparative information regarding mode of revascularization--coronary artery bypass graft surgery surgery (CABG) or percutaneous coronary intervention (PCI)--is limited, mainly confined to a subanalysis of the Bypass Angioplasty Revascularization (BARI) trial, suggesting a mortality benefit of CABG over PCI. No prospective trial has specifically compared these modes of revascularization in patients with diabetes.

OBJECTIVE

The Coronary Artery Revascularisation in Diabetes (CARDia) trial is designed to address the hypothesis that optimal PCI is not inferior to modern CABG as a revascularization strategy for diabetics with multivessel or complex single-vessel coronary disease. The primary end point is a composite of death, nonfatal myocardial infarction, and cerebrovascular accident at 1 year.

METHOD

A total of 600 patients with diabetes are to be randomized to either PCI or CABG, with few protocol restrictions on operative techniques or use of new technology. This gives a power of 80% to detect non-inferiority of PCI assuming that the PCI 1-year event rate is 9%. A cardiac surgeon and a cardiologist must agree that a patient is suitable for revascularization by either technique prior to recruitment into the study. Twenty-one centers in the United Kingdom and Ireland are recruiting patients. Data on cost effectiveness, quality of life, and neurocognitive function are being collected. Long-term (3-5 year) follow-up data will also be collected.

Cost-effectiveness analysis of different screening procedures for type 2 diabetes: the KORA Survey 2000

OBJECTIVE

To compare the cost-effectiveness of different type 2 diabetes screening strategies using population-based data (KORA Survey; Augsburg, Germany; subjects aged 55-74 years), including participation data.

RESEARCH DESIGN AND METHODS

The decision analytic model, which had a time horizon of 1 year, used the following screening strategies: fasting glucose testing, the oral glucose tolerance test (OGTT) following fasting glucose testing in impaired fasting glucose (IFG) (fasting glucose + OGTT), OGTT only, and OGTT if HbA(1c) was >5.6% (HbA(1c) + OGTT), all with or without first-step preselection (p). The main outcome measures were costs (in Euros), true-positive type 2 diabetic cases, incremental cost-effectiveness ratios (ICERs), third-party payers, and societal perspectives.

RESULTS

After dominated strategies were excluded, the OGTT and HbA(1c) + OGTT from the perspective of the statutory health insurance remained, as did fasting glucose + OGTT and HbA(1c) + OGTT from the societal perspective. OGTTs (4.90 per patient) yielded the lowest costs from the perspective of the statutory health insurance and fasting glucose + OGTT (10.85) from the societal perspective. HbA(1c) + OGTT was the most expensive (21.44 and 31.77) but also the most effective (54% detected cases). ICERs, compared with the next less effective strategies, were 771 from the statutory health insurance and 831 from the societal perspective. In the Monte Carlo analysis, dominance relations remained unchanged in 100 and 68% (statutory health insurance and societal perspective, respectively) of simulated populations.

CONCLUSIONS

The most effective screening strategy was HbA(1c) combined with OGTT because of high participation. However, costs were lower when screening with fasting glucose tests combined with OGTT or OGTT alone. The decision regarding which is the most favorable strategy depends on whether the goal is to identify a high number of cases or to incur lower costs at reasonable effectiveness.