Detecting type 2 diabetes and prediabetes among asymptomatic adults in the United States: modeling American Diabetes Association versus US Preventive Services Task Force diabetes screening guidelines

Abstract

BackgroundScreening to detect prediabetes and diabetes enables early prevention and intervention. This study describes the number and characteristics of asymptomatic, undiagnosed adults in the United States who could be detected with prediabetes and type 2 diabetes using the American Diabetes Association (ADA) guidelines compared to the United States Preventive Services Task Force (USPSTF) guidelines.MethodsWe developed predictive models for undiagnosed diabetes and prediabetes using polytomous logistic regression from data on risk factors in the 2003–2010 National Health and Nutrition Examination Survey (n = 19,056). We applied these predictive models to the 2010 Medical Expenditure Panel Survey, which contains health care use data, to generate probabilities of undiagnosed diabetes and undetected prediabetes for each adult. We summed individual probabilities to estimate the number of adults who would be detected with prediabetes and/or type 2 diabetes if screened under ADA or USPSTF guidelines. We analyzed health care use patterns of people at high risk for diabetes.ResultsIn 2010, 59.1 million adults met the USPSTF screening criteria including 24.4 million people with undetected prediabetes and 3.7 million people with undiagnosed diabetes. In comparison, among the 86.3 million people who met the ADA screening criteria, there were 33.9 million with undetected prediabetes and 4.6 million with undiagnosed type 2 diabetes. The ADA guidelines detected 38.9% more cases of prediabetes and 24.3% more cases of type 2 diabetes compared to the USPSTF guidelines. Subgroup analysis showed that ADA guidelines would detect 78% more cases of diabetes among the age 54 and younger population, in 40% more blacks, and in more than twice as many Hispanics than USPSTF guidelines. Only 58% of adults meeting ADA guidelines and 70% meeting USPSTF guidelines had ≥ 1 primary care office visit in 2010.ConclusionsCompared to USPSTF guidelines, ADA guidelines would screen more people and detect more cases of both prediabetes and type 2 diabetes, though a substantial percentage of patients with undetected cases had no contact with a primary care provider in 2010. Addressing the problem of large numbers of undetected prediabetes and type 2 diabetes cases will require new strategies for screening.

Value of Lifestyle Intervention to Prevent Diabetes and Sequelae

“…44 Applied to the 2012 estimate of 86 million with prediabetes, this suggests that potentially 26À37 million case patients in 2012 could have been detected and enrolled in treatment.…”

Prediabetes Screening and Treatment in Diabetes Prevention: The Impact of Physician Attitudes

“…14,15 In 2008 the USPSTF revised its guidelines to recommend sulted in many cases of undiagnosed diabetes being missed, and did not provide direction on diabetes prevention via prediabetes. 16,17 In October 2015, 4 months before data collection for this survey, the USPSTF revised its guidelines to recommend screening for prediabetes, thereby having both the ADA and the USPSTF recommending screening for prediabetes. 3 The results of this study showed that respondents who were less positive in their attitudes toward prediabetes were less likely to say that they followed national guidelines on diabetes prevention.…”

Should we screen for type 2 diabetes among asymptomatic individuals? Yes

“…For example, the latest UK modelling suggests that only 25% of those with diabetes are now undiagnosed [22], half of the 50% quoted historically. This Treating hyperglycaemia in type 2 diabetes from diagnosis reduces micro-and macrovascular outcomes and mortality over 10 years [14] Managing IFG/IGT reduces progression to type 2 diabetes over 15 years [18] Intensive management of screen-detected diabetes reduces incidence of cardiovascular events and death over 5 years in the UK [11] In the Ely trial, testing for diabetes using an OGTT with repeated OGTT after 5 years was associated with non-significant reductions in all-cause mortality, significantly lower ABPI and non-significantly reduced rates of retinopathy in those in the screening group who were diagnosed with diabetes vs unscreened individuals [5,6] In the 2015 US Preventive Services Task Force systematic review, all seven health economic modelling studies reported screening (vs no screening) at age 40-45 is associated with incremental cost-effectiveness ratios of < $15,000/quality-adjusted life year (QALY), which is well under the traditional thresholds for cost-effectiveness [3] Lessons from diabetes screening studies 1 2 4 5 3 is likely to be the result of opportunistic screening in primary care. These developments increasingly suggest that both policy makers and primary care practitioners believe that equipoise has now been reached for screening for undiagnosed diabetes, and the only questions that remain are who and how to screen.…”

“…Evidence from diabetes screening studies A systematic review in 2014, to update the 2008 US Preventive Services Task Force recommendations [3], concluded that, while treatment for impaired fasting glucose (IFG)/impaired glucose tolerance (IGT) delayed progression to (type 2) diabetes, screening for diabetes did not improve mortality rates. This conclusion was based upon two studies: (1) the Anglo-Danish-Dutch study of intensive treatment in people with screen-detected diabetes in primary care (ADDITION)-Cambridge trial (n = 16,047; high risk men and women, aged 40-69 years; 10 year duration) [4], with a mortality HR of 1.06 (95% CI 0.90, 1.25); and (2) the Ely trial (n = 4936; all men and women aged 40-65 years; 18 year duration) [5] .…”