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Tseng E, Hsu YJ, Nigrin C, Clark JM, Marsteller JA, Maruthur NM. Improving Diabetes Screening in the Primary Care Clinic. Jt Comm J Qual Patient Saf 2023; 49:698-705. [PMID: 37704484 PMCID: PMC10828116 DOI: 10.1016/j.jcjq.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 07/26/2023] [Accepted: 07/28/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND In our suburban primary care clinic, the average rate of screening for diabetes among eligible patients was only 51%, similar to national screening data. We conducted a quality improvement project to increase this rate. METHODS During the 6-month preintervention phase, we collected baseline data on the percentage of eligible patients screened per week (percentage of patients with hemoglobin A1c checked in the prior 3 years out of patients eligible for screening who completed a visit during the week). We then implemented a two-phase intervention. In phase 1 (approximately 8 months), we generated an electronic health record (EHR) report to identify eligible patients and pended laboratory orders for physicians to sign. In phase 2 (approximately 3 months), we replaced the phase 1 intervention with an EHR clinical decision support tool that automatically identifies eligible patients. We compared screening rates in the preintervention vs. intervention period. For phase 1, we also assessed laboratory completion rates and the laboratory results. We surveyed physicians regarding intervention acceptability and satisfaction at 3, 6, 9, and 12 months during the intervention period. RESULTS The weekly percentage of patients screened increased from an average of 51% in the preintervention phase to 65% in the intervention phase (p < 0.001). During phase 1, most patients underwent laboratory blood testing as recommended (83% within 3 months), and results were consistent with prediabetes in 23% and with diabetes in 4%. Overall, most physicians believed that the intervention appropriately identified patients due for screening and was helpful (100% of respondents agreed at 9 months vs. 71% at 3 months). CONCLUSION We successfully implemented a systematic screening intervention involving a manual workflow and EHR tool and improved diabetes screening rates in our clinic.
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Movahedi M, Farajzadegan Z, Khadivi R. Middle-aged Health Checks Program Outputs in Non-communicable Diseases Screening in Iran. Int J Prev Med 2019; 10:128. [PMID: 31516669 PMCID: PMC6710917 DOI: 10.4103/ijpvm.ijpvm_168_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Accepted: 06/09/2018] [Indexed: 11/04/2022] Open
Abstract
Background The aim of the present study is identifying the outputs of middle-aged health checks program (MAHCP) in Isfahan province in central of Islamic Republic of Iran. Methods This is a cross-sectional study. During 30 months, from March 2014 to September 2016, 30-59 years old females and males were screened for abdominal obesity, overweight, obesity, physical inactivity, dyslipidemia, hypertension, diabetes, and also breast, skin, cervix, colorectal, and prostate cancers in all health houses, health posts, and health centers in the province. Based on the data bank of the family health office of the health center of Isfahan province, we estimated the outputs of MAHCP. Results The utilization rate of MAHCP was 0.39-273.06 per 1000 middle-aged population (MAP). The utilization rate in 2015 was higher for women (43.02-273.06 per 1000 MAP), particularly in rural areas (273.06 per 1000 MAP). The case detection rate of physical inactivity was 26.40-498.6, abdominal obesity was 16.50-428.38, overweight was 38.73-365.59, obesity was 3.30-261.99, and body mass index (BMI) ≥25 was 63.21-593.41 per 1000 MAP. Also dyslipidemia was 21.51-171.62, hypertension was12.33-53.88, and diabetes mellitus was 10.71 - 36.99 per 1000 MAP. Cancers detection rate in women included: breast cancers (99.52-330.32), skin (14.24-245.52), cervix (11.94-87.43), and colorectal (0-47.4) per 100,000 MAP. Cancer detection rate in men included: skin (0-59.18), colorectal (0-80.06), and prostate (0-42.03) per 100,000 MAP. Conclusions The MAHCP utilization rate in both the genders, particularly in men, was lower than it had been expected.
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Affiliation(s)
- Marjan Movahedi
- Department of Family and Community Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ziba Farajzadegan
- Department of Family and Community Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Reza Khadivi
- Department of Family and Community Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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Sathish T, Shaw JE, Tapp RJ, Wolfe R, Thankappan KR, Balachandran S, Oldenburg B. Targeted screening for prediabetes and undiagnosed diabetes in a community setting in India. Diabetes Metab Syndr 2019; 13:1785-1790. [PMID: 31235095 DOI: 10.1016/j.dsx.2019.03.042] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Accepted: 03/26/2019] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND OBJECTIVES Data to support the use of risk scores in screening programs to detect people with prediabetes and undiagnosed diabetes in low- and middle-income countries are limited. We evaluated a targeted screening program involving a diabetes risk score in a community setting in India in terms of its uptake, yield, and costs. METHODS In the Kerala Diabetes Prevention Program, 2586 individuals (age 30-60 years) without known diabetes were screened using a two-step procedure. Step 1: screening with the Indian Diabetes Risk Score at participants' homes by trained non-medical staff. Step 2: oral glucose tolerance test (OGTT) among those with IDRS score ≥60 ("screen-positive") at community-based clinics. Screening costs were expressed in 2013 US dollars. RESULTS 96.3% of those invited for the IDRS screening consented and 79.1% of screen-positives attended clinics for an OGTT. Older age and male gender were associated with higher IDRS uptake. Female gender, higher monthly household expenditure, and higher IDRS score were associated with higher OGTT uptake. The number needed to screen (yield) to detect one person with prediabetes and undiagnosed diabetes was two and six, respectively. The average screening cost of identifying one person with prediabetes and undiagnosed diabetes was $33.8 and $116.5, respectively. CONCLUSION This targeted screening program had a high uptake and high yield for prediabetes and undiagnosed diabetes in a community setting in India. Alternative strategies are likely required to enhance the uptake of screening in certain groups.
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Affiliation(s)
- Thirunavukkarasu Sathish
- Melbourne School of Population and Global Health, The University of Melbourne, 235 Bouverie St, Carlton, VIC, 3053, Australia; Population Health Research Institute, McMaster University, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada.
| | - Jonathan E Shaw
- Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, Victoria, 3004, Australia; School of Public Health and Preventive Medicine, Monash University, Alfred Hospital Commercial Road, Melbourne, VIC, 3004, Australia
| | - Robyn J Tapp
- Melbourne School of Population and Global Health, The University of Melbourne, 235 Bouverie St, Carlton, VIC, 3053, Australia; Population Health Research Institute, St George's, University of London, Cranmer Terrace, London, SW17 ORE, United Kingdom
| | - Rory Wolfe
- School of Public Health and Preventive Medicine, Monash University, Alfred Hospital Commercial Road, Melbourne, VIC, 3004, Australia
| | - Kavumpurathu R Thankappan
- Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, 695011, Kerala, India
| | - Sajitha Balachandran
- Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, 695011, Kerala, India
| | - Brian Oldenburg
- Melbourne School of Population and Global Health, The University of Melbourne, 235 Bouverie St, Carlton, VIC, 3053, Australia
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Banerjee S, Garrison LP, Flum DR, Arterburn DE. Cost and Health Care Utilization Implications of Bariatric Surgery Versus Intensive Lifestyle and Medical Intervention for Type 2 Diabetes. Obesity (Silver Spring) 2017; 25:1499-1508. [PMID: 28722299 PMCID: PMC5769931 DOI: 10.1002/oby.21927] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 06/06/2017] [Accepted: 06/07/2017] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The aim of this study was to compare the cost and health care utilization of patients with obesity and type 2 diabetes mellitus (T2DM) randomized into either Roux-en-Y gastric bypass (RYGB) surgery or an intensive lifestyle and medical intervention (ILMI). METHODS This analysis (N = 745) is based on 2-year follow-up of a small randomized controlled trial (RCT); adult patients with obesity and T2DM were recruited between 2011 and 2012 from Kaiser Permanente Washington. Comparisons were made for patients randomized into either RYGB (N = 15) or ILMI (N = 17). RESULTS There were no significant cost savings for RYGB versus ILMI patients through the follow-up years. Pharmacy cost was lower for RYGB versus ILMI patients by about $900 in year 2 versus year 0; however, inpatient and emergency room costs were higher for surgery patients in follow-up years relative to year 0. Median total cost for nonrandomized patients was higher in year 0 and in year 2 compared to randomized patients. CONCLUSIONS Bariatric surgery is not cost saving in the short term. Moreover, the costs of patients who enter into RCTs of RYGB may differ from the costs of those who do not enter RCTs, suggesting use of caution when using such data to draw inferences about the general population with obesity.
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Affiliation(s)
- Souvik Banerjee
- Department of Medicine, Boston University School of Medicine, Boston, MA
| | | | - David R. Flum
- Departments of Medicine and Surgery, University of Washington, Seattle, WA
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Hafez D, Nelson DB, Martin EG, Cohen AJ, Northway R, Kullgren JT. Understanding type 2 diabetes mellitus screening practices among primary care physicians: a qualitative chart-stimulated recall study. BMC FAMILY PRACTICE 2017; 18:50. [PMID: 28376802 PMCID: PMC5381083 DOI: 10.1186/s12875-017-0623-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 03/30/2017] [Indexed: 11/29/2022]
Abstract
Background Early diagnosis and treatment of prediabetes and type 2 diabetes mellitus (T2DM) can prevent future health problems, yet many individuals with these conditions are undiagnosed. This could be due, in part, to primary care physicians’ (PCP) screening practices, about which little is known. The objectives of this study were to identify factors that influence PCPs’ decisions to screen patients for T2DM and to characterize their interpretation and communication of screening test results to patients. Methods We conducted semi-structured chart-stimulated recall interviews with 20 University of Michigan Health System (UMHS) primary care physicians. PCPs were asked about their recent decisions to screen or not screen 134 purposively sampled non-diabetic patients who met American Diabetes Association criteria for screening for T2DM. Interviews were audio-recorded, transcribed, and analyzed using qualitative directed content analysis. Data on patient demographic characteristics and comorbidities were abstracted from the electronic health record. Results The most common reasons PCPs gave for not screening 63 patients for T2DM were knowledge of a previously normal screening test (49%) and a visit for reasons other than a health maintenance examination (48%). The most common reasons PCPs gave for screening 71 patients for T2DM were knowledge of a previously abnormal screening test (49%), and patients’ weight (42%) and age (38%). PCPs correctly interpreted 89% of screening test results and communicated 95% of test results to patients. Among 24 patients found to have prediabetes, PCPs usually (58%) recommended weight loss and increased physical activity but never recommended participation in a Diabetes Prevention Program or use of metformin. Conclusions Previous screening test results, visit types, and patients’ weight and age influenced PCPs’ decisions to screen for T2DM. When patients were screened, test results were generally correctly interpreted and consistently communicated. Recommendations to patients with prediabetes could better reflect evidence-based strategies to prevent T2DM. Electronic supplementary material The online version of this article (doi:10.1186/s12875-017-0623-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Dina Hafez
- VA Ann Arbor Healthcare System, 2800 Plymouth Road, Building 14, Room G100-36, Ann Arbor, MI, 48109-2800, USA. .,Robert Wood Johnson Foundation Clinical Scholars Program, University of Michigan, Ann Arbor, MI, USA. .,University of Michigan Medical School, Ann Arbor, MI, USA. .,University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA.
| | | | - Evan G Martin
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Alicia J Cohen
- Robert Wood Johnson Foundation Clinical Scholars Program, University of Michigan, Ann Arbor, MI, USA.,University of Michigan Medical School, Ann Arbor, MI, USA.,University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
| | | | - Jeffrey T Kullgren
- VA Ann Arbor Healthcare System, 2800 Plymouth Road, Building 14, Room G100-36, Ann Arbor, MI, 48109-2800, USA.,University of Michigan Medical School, Ann Arbor, MI, USA.,University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
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Vrca Botica M, Carkaxhiu L, Kern J, Pavlić Renar I, Botica I, Zelić I, Iliev D, Vrca A. How to improve opportunistic screening by using EMRs and other data. The prevalence of undetected diabetes mellitus in target population in Croatia. Public Health 2017; 145:30-38. [PMID: 28359387 DOI: 10.1016/j.puhe.2016.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 12/08/2016] [Accepted: 12/09/2016] [Indexed: 01/18/2023]
Abstract
OBJECTIVES Opportunistic screening for type 2 diabetes (T2D) has not been adopted as part of routine practice. The aim of the study was to investigate the yield of opportunistic target screening for T2D in Croatia and to evaluate the process of screening by using data from electronic medical record. STUDY DESIGN We conducted opportunistic screening in 23 general practitioners (GPs) in a population of 13,344 patients aged 45-70 years. METHODS First, after excluding patients with T2D, patients with risk factors for T2D were derived from the electronic medical record and GP's assessment during the preconsultation phase. Second, those with data about normoglycemia in past three years were excluded. Remaining patients started the consultation phase during their usual visit, when they were offered capillary fasting plasma glucose testing in the next consultation. RESULTS Prevalence of T2D was 10.9% (new 1.4%). A total of 5568 (46.1%) patients had risks and 2849 (51.2%) had data about normoglycemia in the last three years. Using those data, number needed to invite to screening (NNI) was reduced to half: from 46.1% to 22.5%. One hundred eighty-four patients were screened positive for T2D in two capillary fasting plasma glucose tests (yield 9.8%). Number needed to screen (NNS) in order to detect one T2D was 10.3 patients. Among risks for T2D, overweight was the best predictive factor for undiagnosed T2D (odds ratio [OR]: 2.11, confidence interval [CI]:1.41-3.15, P < .001). Logistic regression showed that in targeted population, overweight patients with a family history in fold were 2.5 times more likely to have T2D (OR: 2.54, CI 1.78-.61, P < .001). CONCLUSIONS Total yield in targeted population was 1,4%. By using data about normoglycemia from EMRs, NNI was reduced by half and NNS was 10.3 patients. Our findings suggest the model for improvement in opportunistic screening.
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Affiliation(s)
- M Vrca Botica
- Department of Family Medicine, University of Zagreb, School of Medicine, Zagreb, Croatia.
| | - L Carkaxhiu
- Department of Family Medicine, University of Prishtina, Prishtina, Kosovo.
| | - J Kern
- Department of Informatics, University of Zagreb, School of Medicine, Zagreb, Croatia.
| | - I Pavlić Renar
- Department of Endocrinology, University Hospital Zagreb, Croatia.
| | - I Botica
- Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Zagreb, Croatia.
| | - I Zelić
- Private Family Practice Bukovje, Croatia.
| | - D Iliev
- Department of Family Medicine, University of Skopje, Macedonia.
| | - A Vrca
- Department of Neurology, Clinical Hospital Dubrava, Zagreb, Croatia.
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van Velthoven MH, Mastellos N, Majeed A, O'Donoghue J, Car J. Feasibility of extracting data from electronic medical records for research: an international comparative study. BMC Med Inform Decis Mak 2016; 16:90. [PMID: 27411943 PMCID: PMC4944506 DOI: 10.1186/s12911-016-0332-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Accepted: 07/05/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Electronic medical records (EMR) offer a major potential for secondary use of data for research which can improve the safety, quality and efficiency of healthcare. They also enable the measurement of disease burden at the population level. However, the extent to which this is feasible in different countries is not well known. This study aimed to: 1) assess information governance procedures for extracting data from EMR in 16 countries; and 2) explore the extent of EMR adoption and the quality and consistency of EMR data in 7 countries, using management of diabetes type 2 patients as an exemplar. METHODS We included 16 countries from Australia, Asia, the Middle East, and Europe to the Americas. We undertook a multi-method approach including both an online literature review and structured interviews with 59 stakeholders, including 25 physicians, 23 academics, 7 EMR providers, and 4 information commissioners. Data were analysed and synthesised thematically considering the most relevant issues. RESULTS We found that procedures for information governance, levels of adoption and data quality varied across the countries studied. The required time and ease of obtaining approval also varies widely. While some countries seem ready for secondary uses of data from EMR, in other countries several barriers were found, including limited experience with using EMR data for research, lack of standard policies and procedures, bureaucracy, confidentiality, data security concerns, technical issues and costs. CONCLUSIONS This is the first international comparative study to shed light on the feasibility of extracting EMR data across a number of countries. The study will inform future discussions and development of policies that aim to accelerate the adoption of EMR systems in high and middle income countries and seize the rich potential for secondary use of data arising from the use of EMR solutions.
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Affiliation(s)
| | - Nikolaos Mastellos
- Global eHealth Unit, Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Azeem Majeed
- Global eHealth Unit, Department of Primary Care and Public Health, Imperial College London, London, UK
| | - John O'Donoghue
- Global eHealth Unit, Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Josip Car
- Global eHealth Unit, Department of Primary Care and Public Health, Imperial College London, London, UK. .,Lee Kong Chian School of Medicine, Imperial College & Nanyang Technological University, Singapore, Singapore.
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Zhan Y, Hu D, Yu J. Current status of glucose test prescription for hypertensive outpatients. Clin Exp Hypertens 2016; 38:550-4. [PMID: 27392259 DOI: 10.3109/10641963.2016.1174250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES The prescription of glucose test for essential hypertensive patients is estimated to be very low in cardiology clinics, but it has not been well studied. The aim of the present study aimed to investigate glucose test prescription for the hypertensive outpatients. METHODS Five thousand two hundred and forty hypertensive outpatients without previous known diabetes were recruited consecutively by cardiologists from >90 hospitals. Blood glucose prescription records were collected by special investigators. RESULTS Of the 5240 hypertensive outpatients recruited, only 258 (4.92%) were prescribed glucose tests, and 12.17% and 42.61% of them were diagnosed with diabetes mellitus and impaired glucose tolerance, respectively. Patients' hypertension stage, cardiovascular disease history, diabetes family history, dyslipidemia, and hospital level were associated with higher odds of glucose tests prescription. CONCLUSION Glucose tests were poorly prescribed for hypertensive outpatients in China. It was highly recommended to raise cardiologists' awareness to prescribe glucose tests for hypertensive outpatients who were with high cardiovascular risk factors.
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Affiliation(s)
- Yiqiang Zhan
- a School of Public Health , Institute of Clinical Epidemiology, Fudan University , Shanghai , P. R. China
| | - Dayi Hu
- b Heart Center , Peking University People's Hospital , Beijing , P. R. China
| | - Jinming Yu
- a School of Public Health , Institute of Clinical Epidemiology, Fudan University , Shanghai , P. R. China
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Savitha AK, Gopalakrishnan S, Umadevi R, Rama R. The Need for Patient Follow-up Strategies to Confirm Diabetes Mellitus in Large Scale Opportunistic Screening. J Clin Diagn Res 2016; 10:LE01-4. [PMID: 27042490 DOI: 10.7860/jcdr/2016/16320.7314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 12/25/2015] [Indexed: 11/24/2022]
Abstract
Diabetes mellitus is a metabolic disorder characterized by chronic hyperglycaemia with disturbances of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action, or both. Type 2 (non-insulin dependent) Diabetes mellitus is one of the preventable non communicable disease resulting in increased morbidity and mortality in developing countries like India. It is characterized by disorders of insulin action and/or insulin secretion. Number of people with Type 2 Diabetes is growing rapidly worldwide with economic development, ageing populations, increasing urbanisation, dietary changes, reduced physical activity and lifestyle changes. The global prevalence of diabetes is 9%, while in India it is 8.63% and in Tamil Nadu it is 10.4%. National and State programmes on Diabetes control are implemented to combat the disease burden. A detailed review of the programme modules, operational guidelines and visit to health facilities were done to understand the implementation process related to control of Diabetes mellitus. As part of these programmes, opportunistic screening is implemented for target population. Though these programmes are unique, there are few lacunae identified which are missing opportunities and time consuming. There are no strategies so far in such programmes to make the screened positive cases to undergo confirmatory tests. Since screening is only opportunistic, the screened positive cases can be subjected to undergo confirmatory tests by different methods. The specified roles and responsibilities of health staffs at various levels to ensure follow up should also be framed and followed. The objective of this article is to review the existing strategies and to suggest the need for follow up pathways to be adopted from the first contact level to the level of final confirmation for better compliance.
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Affiliation(s)
- A K Savitha
- Post Graduate, Department of Community Medicine, Sree Balaji Medical College and Hospital , Chromepet, Chennai, Tamil Nadu, India
| | - S Gopalakrishnan
- Professor and Head of Department, Department of Community Medicine, Sree Balaji Medical College and Hospital , Chromepet, Chennai, Tamil Nadu, India
| | - R Umadevi
- Professor, Department of Community Medicine, Sree Balaji Medical College and Hospital , Chromepet, Chennai, Tamil Nadu, India
| | - R Rama
- Assistant Professor, Department of Community Medicine, Sree Balaji Medical College and Hospital , Chromepet, Chennai, Tamil Nadu, India
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Hng TM, Hor A, Ravi S, Feng X, Lin J, Astell-Burt T, Chipps D, McLean M, Maberly G. Diabetes case finding in the emergency department, using HbA1c: an opportunity to improve diabetes detection, prevention, and care. BMJ Open Diabetes Res Care 2016; 4:e000191. [PMID: 27284456 PMCID: PMC4893859 DOI: 10.1136/bmjdrc-2015-000191] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Revised: 04/19/2016] [Accepted: 04/21/2016] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE We assessed the efficacy of routine glycated hemoglobin (HbA1c) testing to detect undiagnosed diabetes and prediabetes in an urban Australian public hospital emergency department (ED) located in an area of high diabetes prevalence. METHODS Over 6 weeks, all patients undergoing blood sampling in the ED had their random blood glucose measured. If ≥5.5 mmol/L (99 mg/dL), HbA1c was measured on the same sample. HbA1c levels ≥6.5% (48 mmol/mol) and 5.7-6.4% (39-46 mmol/mol) were diagnostic of diabetes and prediabetes, respectively. Hospital records were reviewed to identify patients with previously diagnosed diabetes. RESULTS Among 4580 presentations, 2652 had blood sampled of which 1267 samples had HbA1c measured. Of these, 487 (38.4%) had diabetes (either HbA1c≥6.5% or a prior diagnosis), and a further 347 (27.4%) had prediabetes. Among those with diabetes, 32.2% were previously undiagnosed. CONCLUSIONS Routine HbA1c testing in the ED identifies a large number of people with undiagnosed diabetes and prediabetes, and provides an opportunity to improve their care.
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Affiliation(s)
- Tien-Ming Hng
- Western Sydney Local Health District, Blacktown Hospital, Blacktown, New South Wales, Australia
- School of Medicine, Western Sydney University, Parramatta, New South Wales, Australia
| | - Amanda Hor
- Western Sydney Local Health District, Blacktown Hospital, Blacktown, New South Wales, Australia
- School of Health and Society, University of Wollongong, Wollongong, New South Wales, Australia
| | - Sumathy Ravi
- Western Sydney Local Health District, Blacktown Hospital, Blacktown, New South Wales, Australia
| | - Xiaoqi Feng
- Western Sydney Local Health District, Blacktown Hospital, Blacktown, New South Wales, Australia
- School of Health and Society, University of Wollongong, Wollongong, New South Wales, Australia
- Early Start Research Institute, University of Wollongong, Wollongong, New South Wales, Australia
| | - Jaime Lin
- Western Sydney Local Health District, Blacktown Hospital, Blacktown, New South Wales, Australia
| | - Thomas Astell-Burt
- School of Science and Health, Western Sydney University, Parramatta, New South Wales, Australia
- School of Geography and Geosciences, University of St Andrews, St Andrews, UK
| | - David Chipps
- Western Sydney Local Health District, Blacktown Hospital, Blacktown, New South Wales, Australia
| | - Mark McLean
- Western Sydney Local Health District, Blacktown Hospital, Blacktown, New South Wales, Australia
- School of Medicine, Western Sydney University, Parramatta, New South Wales, Australia
| | - Glen Maberly
- Western Sydney Local Health District, Blacktown Hospital, Blacktown, New South Wales, Australia
- School of Medicine, Western Sydney University, Parramatta, New South Wales, Australia
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Luijks H, Biermans M, Bor H, van Weel C, Lagro-Janssen T, de Grauw W, Schermer T. The Effect of Comorbidity on Glycemic Control and Systolic Blood Pressure in Type 2 Diabetes: A Cohort Study with 5 Year Follow-Up in Primary Care. PLoS One 2015; 10:e0138662. [PMID: 26426904 PMCID: PMC4591264 DOI: 10.1371/journal.pone.0138662] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 09/02/2015] [Indexed: 12/20/2022] Open
Abstract
Aims To explore the longitudinal effect of chronic comorbid diseases on glycemic control (HbA1C) and systolic blood pressure (SBP) in type 2 diabetes patients. Methods In a representative primary care cohort of patients with newly diagnosed type 2 diabetes in The Netherlands (n = 610), we tested differences in the five year trend of HbA1C and SBP according to comorbidity profiles. In a mixed model analysis technique we corrected for relevant covariates. Influence of comorbidity (a chronic disease already present when diabetes was diagnosed) was tested as total number of comorbid diseases, and as presence of specific disease groups, i.e. cardiovascular, mental, and musculoskeletal disease, malignancies, and COPD. In subgroup effect analyses we tested if potential differences were modified by age, sex, socioeconomic status, and BMI. Results The number of comorbid diseases significantly influenced the SBP trend, with highest values after five years for diabetes patients without comorbidity (p = 0.005). The number of diseases did not influence the HbA1C trend (p = 0.075). Comorbid musculoskeletal disease resulted in lower HbA1C at the time of diabetes diagnosis, but in higher values after five years (p = 0.044). Patients with cardiovascular diseases had sustained elevated levels of SBP (p = 0.014). Effect modification by socioeconomic status was observed in some comorbidity subgroups. Conclusions Presence of comorbidity in type 2 diabetes patients affected the long-term course of HbA1C and SBP in this primary care cohort. Numbers and types of comorbidity showed differential effects: not the simple sum of diseases, but specific types of comorbid disease had a negative influence on long-term diabetes control parameters. The complex interactions between comorbidity, diabetes control and effect modifiers require further investigation and may help to personalize treatment goals.
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Affiliation(s)
- Hilde Luijks
- Department of Primary and Community Care, Radboud university medical center, Nijmegen, The Netherlands
- * E-mail:
| | - Marion Biermans
- Department of Primary and Community Care, Radboud university medical center, Nijmegen, The Netherlands
| | - Hans Bor
- Department of Primary and Community Care, Radboud university medical center, Nijmegen, The Netherlands
| | - Chris van Weel
- Department of Primary and Community Care, Radboud university medical center, Nijmegen, The Netherlands
- Australian Primary Health Care Research Institute, Australian National University, Canberra, Australia
| | - Toine Lagro-Janssen
- Department of Primary and Community Care, Radboud university medical center, Nijmegen, The Netherlands
| | - Wim de Grauw
- Department of Primary and Community Care, Radboud university medical center, Nijmegen, The Netherlands
| | - Tjard Schermer
- Department of Primary and Community Care, Radboud university medical center, Nijmegen, The Netherlands
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Kumar S, Shewade HD, Vasudevan K, Durairaju K, Santhi VS, Sunderamurthy B, Krishnakumari V, Panigrahi KC. Effect of mobile reminders on screening yield during opportunistic screening for type 2 diabetes mellitus in a primary health care setting: A randomized trial. Prev Med Rep 2015; 2:640-4. [PMID: 26844130 PMCID: PMC4721301 DOI: 10.1016/j.pmedr.2015.08.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Objective. We wanted to study whether mobile reminders increased follow-up for definitive tests resulting in higher screening yield during opportunistic screening for diabetes. Methods. This was a facility-based parallel randomized controlled trial during routine outpatient department hours in a primary health care setting in Puducherry, India (2014). We offered random blood glucose testing to non-pregnant non-diabetes adults with age >30 years (667 total, 390 consented); eligible outpatients (random blood glucose ≥ 6.1 mmol/l, n = 268) were requested to follow-up for definitive tests (fasting and postprandial blood glucose). Eligible outpatients either received (intervention arm, n = 133) or did not receive mobile reminder (control arm, n = 135) to follow-up for definitive tests. We measured capillary blood glucose using a glucometer to make epidemiological diagnosis of diabetes. The trial was registered with Clinical Trial Registry of India (CTRI/2014/10/005138). Results. 85.7% of outpatients in intervention arm returned for definitive test when compared to 53.3% in control arm [Relative Risk = 1.61, (0.95 Confidence Interval — 1.35, 1.91)]. Screening yield in intervention and control arm was 18.6% and 10.2% respectively. Etiologic fraction was 45.2% and number needed to screen was 11.9. Conclusion. In countries like India, which is emerging as the diabetes capital of the world, considering the wide prevalent use of mobile phones, and real life resource limited settings in which this study was carried out, mobile reminders during opportunistic screening in primary health care setting improve screening yield of diabetes. First RCT to determine the effect of mobile reminders on screening yield for diabetes mellitus. Operational research conducted in real world primary health care setting. Outpatients with random blood glucose ≥ 6.1 mmol/l among adults >30y were eligible for definitive tests. Mobile reminders for eligible outpatients was introduced as a reminder system.
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Key Words
- CI, confidence interval
- CTRI, Clinical Trial Registry of India
- Diabetes mellitus, type 2
- FBG, fasting blood glucose
- HbA1C, glycosylated hemoglobin
- India
- Loss to follow-up
- NNS, number needed to screen
- NPCDCS, National Programme for Prevention and Control of Diabetes, Cardiovascular diseases and Stroke
- OPD, Out Patient Department
- Operational research
- Opportunistic screening
- Outpatients
- PHC, Primary Health Centre
- PPBG, postprandial blood glucose
- Primary Health Centre
- Primary health care
- RBG, random blood glucose
- RCT, randomized controlled trial
- Randomized controlled trial
- Reminder system
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Affiliation(s)
- Sathish Kumar
- Indira Gandhi Medical College and Research Institute (IGMCRI), Puducherry, India
| | | | - Kavita Vasudevan
- Indira Gandhi Medical College and Research Institute (IGMCRI), Puducherry, India
| | - Kathamuthu Durairaju
- Primary Health Centre, Lawspet, Department of Health and Family Welfare, Puducherry, India
| | - V S Santhi
- Primary Health Centre, Lawspet, Department of Health and Family Welfare, Puducherry, India
| | | | - Velavane Krishnakumari
- Primary Health Centre, Lawspet, Department of Health and Family Welfare, Puducherry, India
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Peckham S, Falconer J, Gillam S, Hann A, Kendall S, Nanchahal K, Ritchie B, Rogers R, Wallace A. The organisation and delivery of health improvement in general practice and primary care: a scoping study. HEALTH SERVICES AND DELIVERY RESEARCH 2015. [DOI: 10.3310/hsdr03290] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundThis project examines the organisation and delivery of health improvement activities by and within general practice and the primary health-care team. The project was designed to examine who delivers these interventions, where they are located, what approaches are developed in practices, how individual practices and the primary health-care team organise such public health activities, and how these contribute to health improvement. Our focus was on health promotion and ill-health prevention activities.AimsThe aim of this scoping exercise was to identify the current extent of knowledge about the health improvement activities in general practice and the wider primary health-care team. The key objectives were to provide an overview of the range and type of health improvement activities, identify gaps in knowledge and areas for further empirical research. Our specific research objectives were to map the range and type of health improvement activity undertaken by general practice staff and the primary health-care team based within general practice; to scope the literature on health improvement in general practice or undertaken by health-care staff based in general practice and identify gaps in the evidence base; to synthesise the literature and identify effective approaches to the delivery and organisation of health improvement interventions in a general practice setting; and to identify the priority areas for research as defined by those working in general practice.MethodsWe undertook a comprehensive search of the literature. We followed a staged selection process involving reviews of titles and abstracts. This resulted in the identification of 1140 papers for data extraction, with 658 of these papers selected for inclusion in the review, of which 347 were included in the evidence synthesis. We also undertook 45 individual and two group interviews with primary health-care staff.FindingsMany of the research studies reviewed had some details about the type, process or location, or who provided the intervention. Generally, however, little attention is paid in the literature to examining the impact of the organisational context on the way services are delivered or how this affects the effectiveness of health improvement interventions in general practice. We found that the focus of attention is mainly on individual prevention approaches, with practices engaging in both primary and secondary prevention. The range of activities suggests that general practitioners do not take a population approach but focus on individual patients. However, it is clear that many general practitioners see health promotion as an integral part of practice, whether as individual approaches to primary or secondary health improvement or as a practice-based approach to improving the health of their patients. Our key conclusion is that there is currently insufficient good evidence to support many of the health improvement interventions undertaken in general practice and primary care more widely.Future ResearchFuture research on health improvement in general practice and by the primary health-care team needs to move beyond clinical research to include delivery systems and be conducted in a primary care setting. More research needs to examine areas where there are chronic disease burdens – cancer, dementia and other disabilities of old age. Reviews should be commissioned that examine the whole prevention pathway for health problems that are managed within primary care drawing together research from general practice, pharmacy, community engagement, etc.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Stephen Peckham
- Centre for Health Services Studies, University of Kent, Kent, UK
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Jane Falconer
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Steve Gillam
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Alison Hann
- Public Health and Policy Studies, Swansea University, Swansea, UK
| | - Sally Kendall
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hertfordshire, UK
| | - Kiran Nanchahal
- Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Benjamin Ritchie
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Rebecca Rogers
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Andrew Wallace
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Department of Social Policy, University of Lincoln, Lincoln, UK
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Exploring the impact of chronic obstructive pulmonary disease (COPD) on diabetes control in diabetes patients: a prospective observational study in general practice. NPJ Prim Care Respir Med 2015; 25:15032. [PMID: 25906025 PMCID: PMC4532160 DOI: 10.1038/npjpcrm.2015.32] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 01/12/2015] [Accepted: 02/10/2015] [Indexed: 01/11/2023] Open
Abstract
Background: Little is known about the association between COPD and diabetes control parameters. Aims: To explore the association between comorbid COPD and longitudinal glycaemic control (HbA1C) and systolic blood pressure (SBP) in a primary care cohort of diabetes patients. Methods: This is a prospective cohort study of type 2 diabetes patients in the Netherlands. In a mixed model analysis, we tested differences in the 5-year longitudinal development of HbA1C and SBP according to COPD comorbidity (present/absent). We corrected for relevant covariates. In subgroup effect analyses, we tested whether potential differences between diabetes patients with/without COPD were modified by age, sex, socio-economic status (SES) and body mass index (BMI). Results: We analysed 610 diabetes patients. A total of 63 patients (10.3%) had comorbid COPD. The presence of COPD was not significantly associated with the longitudinal development of HbA1C (P=0.54) or SBP (P=0.33), but subgroup effect analyses showed significant effect modification by SES (P<0.01) and BMI (P=0.03) on SBP. Diabetes patients without COPD had a flat SBP trend over time, with higher values in patients with a high BMI. For diabetes patients with COPD, SBP gradually increased over time in the middle- and high-SES groups, and it decreased over time in those in the low-SES group. Conclusions: The longitudinal development of HbA1C was not significantly associated with comorbid COPD in diabetes patients. The course of SBP in diabetes patients with COPD is significantly associated with SES (not BMI) in contrast to those without COPD. Comorbid COPD was associated with longitudinal diabetes control parameters, but it has complex interactions with other patient characteristics. Further research is needed.
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Klein Woolthuis EP, de Grauw WJC, Cardol M, van Weel C, Metsemakers JFM, Biermans MCJ. Patients' and partners' illness perceptions in screen-detected versus clinically diagnosed type 2 diabetes: partners matter! Fam Pract 2013; 30:418-25. [PMID: 23407657 DOI: 10.1093/fampra/cmt003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In type 2 diabetes, educational interventions that target differences between patients' and partners' illness perceptions have been advocated. OBJECTIVE To investigate how the route to diagnosis of type 2 diabetes (through screening versus clinical symptoms) affects illness perceptions of patients and their partners. METHODS In a cross-sectional study, we enrolled patients aged 40-75 years from general practices in the Netherlands with a new diagnosis of type 2 diabetes (≤3 years), detected by either screening (n = 77) or clinical symptoms (n = 32). Patients and their partners each completed a postal Brief Illness Perception Questionnaire (Brief IPQ), and up-to-date clinical data were obtained from their GP. The Brief IPQ scores of the screening and clinical diagnosis groups were compared for both patients and partners, and multiple variable linear regression models with Brief IPQ scores as outcomes were developed. RESULTS The route to diagnosis did not appear to have a strong influence on patients' illness perceptions but did influence illness perceptions of their partners. Partners of patients diagnosed through screening perceived greater consequences for their own life, had a stronger feeling that their patient-partners had control over their diabetes, were more concerned about their partners' diabetes, and believed that their patient-partners experienced more diabetes symptoms, compared with partners of patients who were diagnosed through clinical symptoms. CONCLUSIONS The route to diagnosis of type 2 diabetes has a greater impact on the illness perceptions of partners than that of patients. Professionals in diabetes education and treatment should consider these differences in their approach to patient care.
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Affiliation(s)
- Erwin P Klein Woolthuis
- Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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16
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Engström S, Berne C, Gahnberg L, Svärdsudd K. Effectiveness of screening for diabetes mellitus in dental health care. Diabet Med 2013; 30:239-45. [PMID: 22946629 DOI: 10.1111/dme.12009] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIMS The aim of the present study was to test the effectiveness of opportunistic blood glucose screening in a cooperational framework between dental and primary health care. METHODS Altogether, 1568 subjects, age 20-75 years, with no previous history of diabetes, who came for a regular dental examination, had their non-fasting blood glucose measured with a portable blood glucose meter. Subjects with a concentration of ≥ 6.7 mmol/l (121 mg dl(-1) ) were referred to their primary healthcare centre for follow-up. The outcome, a diagnosis of diabetes mellitus, was obtained from primary healthcare centre and hospital patient records, during 3 years after screening. RESULTS Of the 155 (9.9%) subjects who screened positive, 139 (89.7%) came to their primary healthcare centre within the 3-year follow-up period and nine (5.8%) were diagnosed as having diabetes mellitus according to the World Health Organization criteria. Of the 1413 subjects who screened negative, 1137 (80.5%) came to the primary healthcare centre and eight (0.6%) were found to have diabetes mellitus. Screening sensitivity was 52.9%, specificity 90.6% and positive predictive value 5.8%. The number of subjects needed to screen to find one case of diabetes was 196. Delineating the study population to those 40- to 75-year-olds with a BMI ≥ 25 kg/m(2) , and 30-to 75-year-olds with a BMI ≥ 30 kg/m(2) , the numbers needed to screen was reduced to 96. CONCLUSIONS Cooperation between dental and primary care for high blood glucose screening and follow-up appears to be a feasible method for early diagnosis of diabetes.
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Affiliation(s)
- S Engström
- Uppsala University, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine Section, Uppsala, Sweden.
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17
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Klein Woolthuis EP, de Grauw WJC, van Keeken SM, Akkermans RP, van de Lisdonk EH, Metsemakers JFM, van Weel C. Vascular outcomes in patients with screen-detected or clinically diagnosed type 2 diabetes: Diabscreen study follow-up. Ann Fam Med 2013; 11:20-7. [PMID: 23319502 PMCID: PMC3596031 DOI: 10.1370/afm.1460] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
PURPOSE Screening guidelines for type 2 diabetes recommend targeting high-risk individuals. Our objective was to assess whether diagnosis of type 2 diabetes based on opportunistic targeted screening results in lower vascular event rates compared with diagnosis on the basis of clinical signs or symptoms. METHODS In a prospective, nonrandomized, observational study, we enrolled patients aged 45 to 75 years from 10 family practices in the Netherlands with a new diagnosis of type 2 diabetes, detected either by (1) opportunistic targeted screening (n = 359) or (2) clinical signs or symptoms (n = 206). Patients in both groups received the same guideline-concordant diabetes care. The main group outcome measure was a composite of death from cardiovascular disease (CVD), nonfatal myocardial infarction, and nonfatal stroke. RESULTS Baseline vascular disease was more prevalent in the opportunistic targeted screening group, mainly ischemic heart disease (12.3% vs 3.9%, P = .001) and nephropathy (16.9% vs 7.1%, P = .002). After a mean follow-up of 7.7 years (SD = 2.4 years) and 7.1 years (SD = 2.7 years) for the opportunistic targeted screening and clinical diagnosis groups, respectively, composite primary event rates did not differ significantly between the 2 groups (9.5% vs 10.2%, P = .78; adjusted hazard ratio 0.67, 95% confidence interval, 0.36-1.25; P = .21). There were also no significant differences in the separate event rates of deaths from CVD, nonfatal myocardial infarction, and nonfatal strokes. CONCLUSIONS Opportunistic targeted screening for type 2 diabetes detected patients with higher CVD morbidity at baseline when compared with clinical diagnosis but showed similar CVD mortality and major CVD morbidity after 7.7 years. Opportunistic targeted screening and guided care appears to improve vascular outcomes in type 2 diabetes in primary care.
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Affiliation(s)
- Erwin P Klein Woolthuis
- Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud University Nijmegen Medical Centre, The Netherlands.
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Echouffo-Tcheugui JB, Mayige M, Ogbera AO, Sobngwi E, Kengne AP. Screening for hyperglycemia in the developing world: rationale, challenges and opportunities. Diabetes Res Clin Pract 2012; 98:199-208. [PMID: 22975016 DOI: 10.1016/j.diabres.2012.08.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Revised: 07/17/2012] [Accepted: 08/09/2012] [Indexed: 01/06/2023]
Abstract
BACKGROUND The prevalence of diabetes and prediabetes are increasingly high in developing countries, where detection rates remain very low. This manuscript discusses the rationale, challenges and opportunities for early detection of diabetes and prediabetes in developing countries. METHODS PubMed was searched up to March 2012 for studies addressing screening for hyperglycemia in developing countries. Relevant studies were summarized through key questions derived from the Wilson and Junger criteria. RESULTS In developing countries, diabetes predominantly affects working-age persons, has high rates of complications and devastating economic impacts. These countries are ill-equipped to handle advanced stages of the disease. There are acceptable and relatively simple tools that can aid screening in these countries. Interventions shown to be cost-effective in preventing diabetes and its complications in developed countries can be used in screen-detected people of developing countries. However, effective implementation of these interventions remains a challenge, and the costs and benefits of diabetes screening in these settings are less well-known. Implementing screening policies in developing countries will require health systems strengthening, through creative funding and staff training. CONCLUSIONS For many compelling reasons, screening for hyperglycemia preferably targeted, should be a policy priority in developing countries. This will help reorient health systems toward cost-saving prevention.
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Affiliation(s)
- Justin B Echouffo-Tcheugui
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA.
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Pereira Gray DJ, Evans PH, Wright C, Langley P. The cost of diagnosing Type 2 diabetes mellitus by clinical opportunistic screening in general practice. Diabet Med 2012; 29:863-8. [PMID: 22313143 DOI: 10.1111/j.1464-5491.2012.03607.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
AIMS Type 2 diabetes is associated with serious complications and shortens life. Its prevalence is increasing rapidly worldwide and no cure is available. One logical response is to diagnose the condition as early as possible. Clinical opportunistic screening is one mechanism for making the diagnosis before symptoms are reported. This paper reports the cost of using this technique in UK general practice. METHODS In one UK general practice, the electronic medical records were searched to determine the number of blood glucose and oral glucose tolerance tests undertaken for non-pregnant adults without known diabetes over three consecutive years. The laboratory, staff and administrative costs associated with these screening tests were calculated. The records of all patients newly diagnosed with Type 2 diabetes during the same period were reviewed to identify diagnoses made by clinical opportunistic screening. Total costs were divided by the number of diagnoses to determine a cost per diagnosis detected by opportunistic screening. RESULTS During the study period, 5720 screening tests were conducted for 2763 patients. Over the 3 years, 86 patients were diagnosed with Type 2 diabetes, 54 (63%) via screening (yield 2.0%; number needed to screen 51.2). The screening costs totalled £ 20,372. The average cost per new screen-detected diagnosis was £ 377. CONCLUSIONS Almost two-thirds of new cases of Type 2 diabetes can be detected before symptoms are reported, at reasonable cost by opportunistic screening in general practice, without the use of extra resources. As an affordable alternative to population screening, clinical opportunistic screening merits further consideration.
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Abstract
BACKGROUND The effect of bariatric surgery on health care utilization and costs among individuals with type 2 diabetes remains unclear. OBJECTIVE To examine health care utilization and costs in an insured cohort of individuals with type 2 diabetes after bariatric surgery. RESEARCH DESIGN Cohort study derived from administrative data from 2002 to 2008 from 7 Blue Cross Blue Shield Plans. PARTICIPANTS Seven thousand eight hundred six individuals with type 2 diabetes who had bariatric surgery. MEASURES Cost (inpatient, outpatient, pharmacy, and others) and utilization (number of inpatient days, outpatient visits, specialist visits). RESULTS Compared with presurgical costs, the ratio of hospital costs (excluding the initial surgery), among beneficiaries who had any hospital costs, was higher in years 2 through 6 of the postsurgery period and increased over time [post 1: odds ratio (OR)=0.58; 95% confidence interval (CI), 0.50-0.67; post 6: OR=3.43; 95% CI, 2.60-4.53]. In comparison with the presurgical period, the odds of having any health care costs was lower in the postsurgery period and remained relatively flat over time. Among those with hospitalizations, the adjusted ratio of inpatient days was higher after surgery (post 1: OR=1.05; 95% CI, 0.94-1.16; post 6: OR=2.77; 95% CI, 1.57-4.90). Among those with primary care visits, the adjusted OR was lower after surgery (post 1: OR=0.80; 95% CI, 0.78-0.82; post 6: OR=0.66; 95% CI, 0.57-0.76). CONCLUSIONS : In the 6 years after surgery, individuals with type 2 diabetes did not have lower health care costs than before surgery.
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van den Donk M, Sandbaek A, Borch-Johnsen K, Lauritzen T, Simmons RK, Wareham NJ, Griffin SJ, Davies MJ, Khunti K, Rutten GEHM. Screening for type 2 diabetes. Lessons from the ADDITION-Europe study. Diabet Med 2011; 28:1416-24. [PMID: 21679235 DOI: 10.1111/j.1464-5491.2011.03365.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- M van den Donk
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands
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Echouffo-Tcheugui JB, Ali MK, Griffin SJ, Narayan KMV. Screening for type 2 diabetes and dysglycemia. Epidemiol Rev 2011; 33:63-87. [PMID: 21624961 DOI: 10.1093/epirev/mxq020] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
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.
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Affiliation(s)
- Justin B Echouffo-Tcheugui
- Department of Global Health, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA 30322, USA.
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Menchine MD, Arora S, Camargo CA, Ginde AA. Prevalence of undiagnosed and suboptimally controlled diabetes by point-of-care HbA1C in unselected emergency department patients. Acad Emerg Med 2011; 18:326-9. [PMID: 21362098 DOI: 10.1111/j.1553-2712.2011.01014.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The objective was to estimate the glycemic control of patients with known diabetes and to assess the prevalence of undiagnosed diabetes in an unselected emergency department (ED) population. Secondary objectives include evaluating the prevalence of undiagnosed diabetes in high-risk groups of ED patients such as Hispanic patients, African Americans, and patients with body mass index (BMI) ≥ 30 kg/m(2) . METHODS A convenience sample of adult ED patients was screened for diabetes using a National Glycohemoglobin Standardization Program-certified point-of-care (POC) glycated hemoglobin (HbA1C) meter at a single academic medical center during eight 24-hour periods. Diabetes was defined as HbA1C ≥ 6.5%, consistent with new American Diabetes Association (ADA) guidelines. RESULTS Of the 1,611 patients evaluated in the ED during the study period, 313 were included in the study sample. Of these, 15% reported a history of diabetes, 42% of whom were suboptimally controlled. An additional 14% of the study sample was found to have previously undiagnosed diabetes. In our limited sample, the prevalence of previously undiagnosed diabetes in Hispanics, African Americans, and patients with BMI ≥ 30 kg/m(2) was 14, 27, and 22%, respectively. CONCLUSIONS Patients in our sample had a high prevalence of suboptimally controlled and undiagnosed diabetes. New POC HbA1C devices and simplified diagnostic criteria for diabetes significantly enhance the possibility of ED-based screening programs. Future research should validate our findings in a broader array of EDs and study the acceptance of such ED-based diabetes screening programs.
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Affiliation(s)
- Michael D Menchine
- Department of Emergency Medicine, University of Southern California Keck School of Medicine, Los Angeles, CA, USA.
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Chun TH, Inoue M, Morisaki H, Yamanaka I, Miyamoto Y, Okamura T, Sato-Kusubata K, Weiss SJ. Genetic link between obesity and MMP14-dependent adipogenic collagen turnover. Diabetes 2010; 59:2484-94. [PMID: 20660624 PMCID: PMC3279534 DOI: 10.2337/db10-0073] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE In white adipose tissue, adipocytes and adipocyte precursor cells are enmeshed in a dense network of type I collagen fibrils. The fate of this pericellular collagenous web in diet-induced obesity, however, is unknown. This study seeks to identify the genetic underpinnings of proteolytic collagen turnover and their association with obesity progression in mice and humans. RESEARCH DESIGN AND METHODS The hydrolysis and degradation of type I collagen at early stages of high-fat diet feeding was assessed in wild-type or MMP14 (MT1-MMP)-haploinsufficient mice using immunofluorescent staining and scanning electron microscopy. The impact of MMP14-dependent collagenolysis on adipose tissue function was interrogated by transcriptome profiling with cDNA microarrays. Genetic associations between MMP14 gene common variants and obesity or diabetes traits were examined in a Japanese cohort (n = 3,653). RESULTS In adult mice, type I collagen fibers were cleaved rapidly in situ during a high-fat diet challenge. By contrast, in MMP14 haploinsufficient mice, animals placed on a high-fat diet were unable to remodel fat pad collagen architecture and display blunted weight gain. Moreover, transcriptional programs linking type I collagen turnover with adipogenesis or lipogenesis were disrupted by the associated decrease in collagen turnover. Consistent with a key role played by MMP14 in regulating high-fat diet-induced metabolic programs, human MMP14 gene polymorphisms located in proximity to the enzyme's catalytic domain were closely associated with human obesity and diabetes traits. CONCLUSIONS Together, these findings demonstrate that the MMP14 gene, encoding the dominant pericellular collagenase operative in vivo, directs obesogenic collagen turnover and is linked to human obesity traits.
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Affiliation(s)
- Tae-Hwa Chun
- Division of Metabolism, Endocrinology and Diabetes, the Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA.
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Klein Woolthuis EP, de Grauw WJC, van Weel C. Opportunistic screening for type 2 diabetes in primary care. Lancet 2010; 376:683-4. [PMID: 20801397 DOI: 10.1016/s0140-6736(10)61332-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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