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Farmer AJ, Shine B, Armitage LC, Murphy N, James T, Guha N, Rea R. The potential for utilising in-hospital glucose measurements to detect individuals at high risk of previously undiagnosed diabetes: Retrospective cohort study. Diabet Med 2022; 39:e14918. [PMID: 35839301 PMCID: PMC9543037 DOI: 10.1111/dme.14918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 06/23/2022] [Accepted: 07/13/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Many people with undiagnosed diabetes have hyperglycaemia when admitted to hospital. Inpatient hyperglycaemia can be an indication of diabetes mellitus but can also indicate a stress response. This study reports the extent to which an in-hospital maximum observed random glucose measurement is an indicator of the need for in-hospital (or subsequent) HbA1c measurement to look for undiagnosed diabetes. METHODS Blood glucose, HbA1c, age and sex were collected for all adults following admission to a UK NHS trust hospital from 1 January 2019 to 31 December 2020. We restricted the analysis to those participants who were registered with a GP practice that uses the trust laboratory and who had at least some tests requested by those practices since 2008. We stratified individuals according to their maximum in-hospital glucose measurement and report the number of these with HbA1c measurement ≥48 mmol/mol (6.5%) prior to the index admission, and during and after admission. We calculated an estimated proportion of individuals in each blood glucose stratum without a follow-up HbA1c who could have undiagnosed diabetes. RESULTS In toal, 764,241 glucose measurements were recorded for 81,763 individuals who were admitted to the Oxford University Hospitals Trust. The median (Q1, Q3) age was 70 (56, 81) years, and 53% were males. Of the population, 70.7% of individuals declared themselves to be of White ethnicity, 3.1% of Asian background, and 1.1% of Black background, with 23.1% unstated. Of those individuals, 22,375 (27.4%) had no previous HbA1c measurement recorded. A total of 1689 individuals had a diabetes-range HbA1c during or after their hospital admission (2.5%) while we estimate an additional 1496 (2.2%) may have undiagnosed diabetes, with the greatest proportion of these having an in-hospital glucose of ≥15 mmol/L. We estimate that the number needed to detect a possible new case of diabetes falls from 16 (in-hospital glucose 8 mmol/L to <9 mmol/L) to 4 (14 mmol/L to <15 mmol/L). CONCLUSION The number of people who need to be tested to identify an individual who may have diabetes decreases as a testing threshold based on maximum in-hospital glucose concentration increases. Among those with hyperglycaemia and no previous HbA1c measurement in the diabetes range, there appears to be a lack of subsequent HbA1c measurement. This work identifies the potential for integrating the testing and follow-up of people, with apparently unrecognised hospital hyperglycaemia across primary and secondary care.
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Affiliation(s)
- Andrew J. Farmer
- Nuffield Department of Primary Care Health SciencesUniversity of OxfordOxfordUK
| | - Brian Shine
- Oxford University Hospitals NHS Foundation TrustOxfordUK
| | - Laura C. Armitage
- Nuffield Department of Primary Care Health SciencesUniversity of OxfordOxfordUK
| | - Noel Murphy
- Oxford University Hospitals NHS Foundation TrustOxfordUK
| | - Tim James
- Oxford University Hospitals NHS Foundation TrustOxfordUK
| | - Nishan Guha
- Oxford University Hospitals NHS Foundation TrustOxfordUK
| | - Rustam Rea
- Oxford University Hospitals NHS Foundation TrustOxfordUK
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Ray E, Culliford D, Kruk H, Gillett K, North M, Astles CM, Hicks A, Johnson M, Lin SX, Orlando R, Thomas M, Jordan RE, Price D, Konstantin M, Wilkinson TMA. Specialist respiratory outreach: a case-finding initiative for identifying undiagnosed COPD in primary care. NPJ Prim Care Respir Med 2021; 31:7. [PMID: 33574260 PMCID: PMC7878732 DOI: 10.1038/s41533-021-00219-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 01/06/2021] [Indexed: 12/18/2022] Open
Abstract
COPD remains largely undiagnosed or is diagnosed late in the course of disease. We report findings of a specialist outreach programme to identify undiagnosed COPD in primary care. An electronic case-finding algorithm identified 1602 at-risk patients from 12 practices who were invited to attend the clinic. Three hundred and eighty-three (23.9%) responded and 288 were enrolled into the study. Forty-eight (16.6%) had undiagnosed mild and 28 (9.7%) had moderate airway obstruction, meeting spirometric diagnostic criteria for COPD. However, at 12 months only 8 suspected COPD patients (10.6%) had received a diagnostic label in their primary care record. This constituted 0.38% of the total patient population, as compared with 0.31% of control practices, p = 0.306. However, if all patients with airway obstruction received a coding of COPD, then the diagnosis rate in the intervention group would have risen by 0.84%. Despite the low take-up and diagnostic yield, this programme suggests that integrated case-finding strategies could improve COPD recognition.
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Affiliation(s)
- Emma Ray
- NIHR ARC Wessex, Faculty of Health Sciences, University of Southampton, Southampton, UK
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - David Culliford
- NIHR ARC Wessex, Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Helen Kruk
- NIHR ARC Wessex, Faculty of Health Sciences, University of Southampton, Southampton, UK
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Kate Gillett
- NIHR ARC Wessex, Faculty of Health Sciences, University of Southampton, Southampton, UK
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Mal North
- NIHR ARC Wessex, Faculty of Health Sciences, University of Southampton, Southampton, UK
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Carla M Astles
- NIHR ARC Wessex, Faculty of Health Sciences, University of Southampton, Southampton, UK
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Alexander Hicks
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Matthew Johnson
- NIHR ARC Wessex, Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Sharon Xiaowen Lin
- NIHR ARC Wessex, Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Rosanna Orlando
- NIHR ARC Wessex, Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Mike Thomas
- Department of Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Rachel E Jordan
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - David Price
- Observational and Pragmatic Research Institute, Singapore, Singapore
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Mita Konstantin
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Tom M A Wilkinson
- Faculty of Medicine, University of Southampton, Southampton, UK.
- NIHR Biomedical Research Centre, University Hospitals Southampton NHS Foundation Trust, Southampton, UK.
- Wessex Investigational Sciences Hub, University of Southampton Faculty of Medicine, Southampton General Hospital, Southampton, UK.
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Soguero-Ruiz C, Mora-Jiménez I, Mohedano-Munoz MA, Rubio-Sanchez M, Miguel-Bohoyo PD, Sanchez A. Visually guided classification trees for analyzing chronic patients. BMC Bioinformatics 2020; 21:92. [PMID: 32164533 PMCID: PMC7069159 DOI: 10.1186/s12859-020-3359-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background Chronic diseases are becoming more widespread each year in developed countries, mainly due to increasing life expectancy. Among them, diabetes mellitus (DM) and essential hypertension (EH) are two of the most prevalent ones. Furthermore, they can be the onset of other chronic conditions such as kidney or obstructive pulmonary diseases. The need to comprehend the factors related to such complex diseases motivates the development of interpretative and visual analysis methods, such as classification trees, which not only provide predictive models for diagnosing patients, but can also help to discover new clinical insights. Results In this paper, we analyzed healthy and chronic (diabetic, hypertensive) patients associated with the University Hospital of Fuenlabrada in Spain. Each patient was classified into a single health status according to clinical risk groups (CRGs). The CRGs characterize a patient through features such as age, gender, diagnosis codes, and drug codes. Based on these features and the CRGs, we have designed classification trees to determine the most discriminative decision features among different health statuses. In particular, we propose to make use of statistical data visualizations to guide the selection of features in each node when constructing a tree. We created several classification trees to distinguish among patients with different health statuses. We analyzed their performance in terms of classification accuracy, and drew clinical conclusions regarding the decision features considered in each tree. As expected, healthy patients and patients with a single chronic condition were better classified than patients with comorbidities. The constructed classification trees also show that the use of antipsychotics and the diagnosis of chronic airway obstruction are relevant for classifying patients with more than one chronic condition, in conjunction with the usual DM and/or EH diagnoses. Conclusions We propose a methodology for constructing classification trees in a visually guided manner. The approach allows clinicians to progressively select the decision features at each of the tree nodes. The process is guided by exploratory data analysis visualizations, which may provide new insights and unexpected clinical information.
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Affiliation(s)
- Cristina Soguero-Ruiz
- Department of Signal Theory and Communications, Telematics and Computing Systems, Rey Juan Carlos University, Fuenlabrada, Spain.
| | - Inmaculada Mora-Jiménez
- Department of Signal Theory and Communications, Telematics and Computing Systems, Rey Juan Carlos University, Fuenlabrada, Spain
| | | | - Manuel Rubio-Sanchez
- Department of Computer Science & Statistics, Rey Juan Carlos University, Fuenlabrada, Spain
| | | | - Alberto Sanchez
- Department of Computer Science & Statistics, Rey Juan Carlos University, Fuenlabrada, Spain.,Research Center for Computational Simulation, Montegancedo, Spain
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van Valkengoed IGM, Vlaar EMA, Nierkens V, Middelkoop BJC, Stronks K. 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. PLoS One 2015; 10:e0136734. [PMID: 26317417 PMCID: PMC4552828 DOI: 10.1371/journal.pone.0136734] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 06/30/2015] [Indexed: 12/25/2022] Open
Abstract
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 18th 2009- December 31st 2009 and 2012 for a glycated hemoglobin measurement between April 19th 2010-November 11th, 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.
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Affiliation(s)
- Irene G. M. van Valkengoed
- Department of Public Health, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
- * E-mail:
| | - Everlina M. A. Vlaar
- Department of Public Health, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Vera Nierkens
- Department of Public Health, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Barend J. C. Middelkoop
- Department of Public Health, Leiden University Medical Centre, Leiden, The Netherlands
- Public Health Service, The Hague, The Netherlands
| | - Karien Stronks
- Department of Public Health, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
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Oyegbade OO, Abioye-Kuteyi EA, Kolawole BA, Ezeoma IT, Bello IS. Screening for diabetes mellitus in a Nigerian family practice population. S Afr Fam Pract (2004) 2014. [DOI: 10.1080/20786204.2007.10873612] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
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Díez Pérez C, Rodríguez Ferro R, Penín Álvarez M. Prevalence and cost of possibly unnecessary venous blood glucose measurements in primary care. ENDOCRINOLOGIA Y NUTRICION : ORGANO DE LA SOCIEDAD ESPANOLA DE ENDOCRINOLOGIA Y NUTRICION 2013; 60:513-516. [PMID: 23791772 DOI: 10.1016/j.endonu.2013.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Revised: 03/03/2013] [Accepted: 03/04/2013] [Indexed: 06/02/2023]
Abstract
The American Diabetes Association issues annually its recommendations for diabetes mellitus screening. Although there is a high proportion of people with undiagnosed diabetes in the general population, it is suspected that many of these screening tests could be needless. An analysis was made of the number of venous blood glucose measurements that did not meet the American Diabetes Association requirements performed in 150 people seen in primary care. On average, an unnecessary venous blood glucose measurement is performed every 15 months. The number is significantly higher in people over 45 years of age, and also in women as compared to men (although with a p value slighty higher than 0.05).
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Affiliation(s)
- Coral Díez Pérez
- Centro de Salud Teis, Atención Primaria Área Sanitaria de Vigo, España.
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7
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Wilmot EG, Edwardson CL, Biddle SJH, Gorely T, Henson J, Khunti K, Nimmo MA, Yates T, Davies MJ. Prevalence of diabetes and impaired glucose metabolism in younger 'at risk' UK adults: insights from the STAND programme of research. Diabet Med 2013; 30:671-5. [PMID: 23506383 DOI: 10.1111/dme.12173] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/13/2013] [Indexed: 01/10/2023]
Abstract
AIMS Rising rates of obesity have led to an increasing prevalence of Type 2 diabetes mellitus in young people. Uncertainty exists over the utility of screening younger adults for Type 2 diabetes, as existing data sets have focused on mature (> 40 years) cohorts. The aim of this study was to determine the prevalence of impaired glucose metabolism in higher risk younger adults. METHODS Overweight (with an additional risk factor) or obese adults (18-40 years) were recruited for the Sedentary Time And Diabetes (STAND) randomized controlled trial. Measures included an oral glucose tolerance test, HbA1c , biochemical and anthropometric data. RESULTS One hundred and ninety-three individuals (68% female; median age 33.8 years; median BMI 33.9 kg/m²) were recruited. Forty-three per cent had a first-degree family history of Type 2 diabetes. Previously undiagnosed Type 2 diabetes was present in 4.7% (n = 9). Of participants, 18.1% (n = 35) had impaired glucose metabolism: 4.7% (n = 9) HbA1c ≥ 48 mmol/mol (6.5%); 9.3% (n = 18) HbA1c 42-46 mmol/mol (6.0-6.4%); 3.1% (n = 6) Type 2 diabetes on oral glucose tolerance test; 6.2% (n = 12) isolated impaired glucose tolerance; 2.1% (n = 4) isolated impaired fasting glucose; 1% (n = 2) both impaired fasting glucose and impaired glucose tolerance. Of participants, 58.5% (n = 113) had dyslipidaemia, 28.0% (n = 54) had hypertension, 31.1% (n = 60) were vitamin D deficient and 7.3% (n = 14) had abnormal liver function. CONCLUSIONS This study identified a high prevalence of Type 2 diabetes and impaired glucose regulation in overweight and obese younger adults. These findings require confirmation in a larger, representative, population.
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Affiliation(s)
- E G Wilmot
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.
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8
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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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9
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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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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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12
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Sargeant LA, Simmons RK, Barling RS, Butler R, Williams KM, Prevost AT, Kinmonth AL, Wareham NJ, Griffin SJ. Who attends a UK diabetes screening programme? Findings from the ADDITION-Cambridge study. Diabet Med 2010; 27:995-1003. [PMID: 20722672 PMCID: PMC3428846 DOI: 10.1111/j.1464-5491.2010.03056.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
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.
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Graffy J, Grant J, Williams K, Cohn S, Macbay S, Griffin S, Kinmonth AL. More than measurement: practice team experiences of screening for type 2 diabetes. Fam Pract 2010; 27:386-94. [PMID: 20403926 PMCID: PMC2908159 DOI: 10.1093/fampra/cmq022] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The feasibility, cost-effectiveness and best means to implement population screening for type 2 diabetes remain to be established. OBJECTIVE To learn from the experiences of practice staff undertaking a diabetes screening programme in order to inform future screening initiatives. METHODS Qualitative analysis of interviews with staff in six general practices in the 'ADDITION-Cambridge' trial; three randomly allocated to intensively manage screen-detected patients and three providing usual care. We conducted semi-structured interviews with seven nurses, four doctors, three health care assistants and four managers. Four researchers analysed the transcripts practice by practice, preparing vignettes and comparing interpretations. Participants commented on a summary report. RESULTS Each practice team implemented the screening and intervention programme differently, depending on numbers at risk and decisions about staff contributions. Several emphasized the importance of administrative support. As they screened, they extended the reach of the programme, testing patients outside the target group if requested, checking other risk factors, providing health information and following up people with impaired glucose tolerance. Staff felt that patients accepted the screening and subsequent management as any other clinical activity. CONCLUSIONS Although those developing screening programmes attempt to standardize them, primary care teams need to adapt the work to fit local circumstances. Staff need a sense of ownership, training, well-designed information technology systems and protected time. Furthermore, screening is more than measurement; at the individual level, it is a complete health care interaction, requiring individual explanations, advice on health-related behaviour and appropriate follow-up. The UK 'NHS Health Checks' programme should embrace these findings.
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Affiliation(s)
- Jonathan Graffy
- Institute of Public Health, General Practice & Primary Care Research Unit, University of Cambridge, Robinson Way, Cambridge CB2 0SR, UK.
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14
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Williamson DF, Narayan KMV. Identification of persons with dysglycemia: terminology and practical significance. Prim Care Diabetes 2009; 3:211-217. [PMID: 19762297 DOI: 10.1016/j.pcd.2009.08.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2009] [Revised: 08/18/2009] [Accepted: 08/25/2009] [Indexed: 11/26/2022]
Abstract
Allocating scarce resources for dysglycemia intervention requires identification of persons who will benefit. Identification has two steps: screening followed by diagnosis. Lowering a screening test's cut-off score identifies more persons with dysglycemia, but causes more normoglycemic persons to receive diagnostic testing. Raising a test's cut-off score reduces needless diagnostic testing, but increases the number falsely identified as not having dysglycemia. With limited budgets for intervention, raising a screening test's cut-off score may be appropriate. With ample budgets, lowering the test's cut-off score may be appropriate. Screening tests are most efficient in populations with high prevalence of dysglycemia.
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Affiliation(s)
- David F Williamson
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA.
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Klein Woolthuis EP, de Grauw WJC, van Gerwen WHEM, van den Hoogen HJM, van de Lisdonk EH, Metsemakers JFM, van Weel C. Yield of opportunistic targeted screening for type 2 diabetes in primary care: the diabscreen study. Ann Fam Med 2009; 7:422-30. [PMID: 19752470 PMCID: PMC2746521 DOI: 10.1370/afm.997] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
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.
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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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Abstract
AIMS Diabetes UK estimates a quarter of UK cases of diabetes are undiagnosed; 750,000 people have undiagnosed diabetes in addition to 2.25 million with known diabetes, but research studies examining this are contradictory. The aim was to determine the prevalence of, and risk factors for, undiagnosed diabetes in the population of England aged > 50 years and to calculate the percentage of cases of undiagnosed diabetes. METHODS This was a cross-sectional study in a nationally representative sample of 6739 people aged 52-79 years from the English Longitudinal Study of Ageing (ELSA) 2004/2005. Diabetes cases were ascertained by self-reported doctor diagnosis of diabetes. A fasting plasma glucose measurement after a minimum of 8-h fast was available for 2387 (38% of the participants without diabetes). Undiagnosed diabetes cases were based on a fasting plasma glucose >or= 7.0 mmol/l. RESULTS The overall weighted prevalence of diabetes was 9.1%; 502 people (7.5%) had self-reported diabetes (9.0% of men and 6.0% of women); 36 (1.7%) had undiagnosed diabetes (2.6% of men and 0.8% of women). Of cases of diabetes, 18.5% were undiagnosed (22% in men, 12% in women). Significant risk factors for undiagnosed diabetes were male sex, higher body mass index, waist circumference, systolic blood pressure and triglycerides. CONCLUSIONS In 2004 the prevalence of undiagnosed diabetes, and the proportion of cases of diabetes that were undiagnosed, appear smaller than in previous studies. This is likely to be due to increased awareness of diabetes and improved clinical care resulting in many of those with previously undetected disease having been diagnosed.
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Affiliation(s)
- M B Pierce
- Department of Epidemiology and Public Health, University College London, London, UK.
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Can type 2 diabetes be prevented in UK general practice? A lifestyle-change feasibility study (ISAIAH). Br J Gen Pract 2008; 58:541-7. [PMID: 18682012 DOI: 10.3399/bjgp08x319701] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The increasing incidence of type 2 diabetes mellitus is attributed to increasing weight, reduced physical activity, and poor diet quality. Lifestyle change in patients with pre-diabetes can reduce progression to diabetes but this is difficult to achieve in practice. AIM To study the effectiveness of a lifestyle-change intervention for pre-diabetes in general practice. DESIGN OF THE STUDY A feasibility study. SETTING A medium-sized general practice in Sheffield. METHOD Participants were 33 patients with pre-diabetes. The intervention was a 6-month delayed entry comparison of usual treatment with a lifestyle-change programme: increased exercise and diet change, either reduction in glycaemic load, or reduced-fat diet. The main outcome measures were weight, body mass index (BMI), waist circumference, fasting glucose, lipid profile, and nutrition. RESULTS A statistically significant difference was observed between control and intervention groups in three markers for risk of progression to diabetes (weight (P<0.03), BMI (P<0.03), and waist circumference (P<0.001)). No significant differences in fasting glucose or lipid profiles were seen. Aggregated data showed a statistically non-significant improvement in all the measures of metabolic risk of progression to diabetes in the low-glycaemic-load group when compared with a low-fat-diet group (P>0.05). Significant total energy, fat, and carbohydrate intake reduction was achieved and maintained in both groups. CONCLUSION A lifestyle-change intervention feasibility programme for pre-diabetic patients was implemented in general clinical practice. The potential of a low-glycaemic-load diet to be more effective than a low-fat diet in promoting change in the features associated with progression to diabetes is worthy of further investigation.
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Goyder E, Wild S, Fischbacher C, Carlisle J, Peters J. Evaluating the impact of a national pilot screening programme for type 2 diabetes in deprived areas of England. Fam Pract 2008; 25:370-5. [PMID: 18765406 DOI: 10.1093/fampra/cmn054] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- E Goyder
- School of Health and Related Research, University of Sheffield, Sheffield, UK.
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Troughton J, Jarvis J, Skinner C, Robertson N, Khunti K, Davies M. Waiting for diabetes: perceptions of people with pre-diabetes: a qualitative study. PATIENT EDUCATION AND COUNSELING 2008; 72:88-93. [PMID: 18367365 DOI: 10.1016/j.pec.2008.01.026] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2007] [Revised: 12/27/2007] [Accepted: 01/28/2008] [Indexed: 05/26/2023]
Abstract
OBJECTIVES This study sought to inform the development of an educational intervention for people with pre-diabetes in the UK by ascertaining individuals' experience of screening and diagnosis, their appraisal of the condition, and experience of health service delivery from diagnosis to 1 year post-diagnosis. METHODS Qualitative interviews directed by framework methodology. Fifteen people diagnosed with pre-diabetes from the community (Midlands, UK) as part of a screening programme. RESULTS Respondents consistently expressed the need for education and support at diagnosis. Dominating all respondents' narratives was the theme of 'uncertainty', which linked to two further themes of seriousness and taking action. These themes were influenced by respondents' prior experience and appraisal of both diabetes and pre-diabetes and their interpretation of health professionals' attitudes and actions towards them. CONCLUSIONS Patients identified as having pre-diabetes currently emphasise their uncertainties about their diagnosis, its physical consequences and subsequent management. Interventions to enable the increasing numbers of individuals with pre-diabetes to manage their health optimally should evolve to address these uncertainties. PRACTICE IMPLICATIONS Those delivering services to those at risk of, or diagnosed with, pre-diabetes should be aware of patient needs and tailor care to support and shape perceptions to enhance health-maintaining behaviours.
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Janssen PGH, Gorter KJ, Stolk RP, Rutten GEHM. Do characteristics of practices and general practitioners influence the yield of diabetes screening in primary care? The ADDITION Netherlands study. Scand J Prim Health Care 2008; 26:160-5. [PMID: 18609249 PMCID: PMC3409604 DOI: 10.1080/08037050802117924] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVE To investigate whether the yield of population-based diabetes screening is influenced by characteristics of the general practitioner (GP) and the practice. DESIGN Cross-sectional study. SETTING Seventy-nine general practices in the south-western region of the Netherlands. SUBJECTS From 2002 to 2004, 56 978 people were screened for diabetes. GPs completed a questionnaire containing items on the GP (age, gender, employment, special interest in diabetes, providing insulin therapy) and the practice (setting, location, number of patients from ethnic minority groups, specific diabetes clinic, involvement of practice assistant, practice nurse or diabetes nurse in diabetes care). MAIN OUTCOME MEASURES The ratio screen-detected diabetic patients/known diabetic patients per practice (SDM/KDM) and the number of detected diabetic patients per practice adjusted for practice size and age distribution (SDM per standardized practice). RESULTS The yield of screening per practice varied widely. Higher age of the GP (regression coefficient 0.20; 95% confidence interval, CI 0.07-0.34), urban location (-4.60; 95% CI -6.41 to -2.78) and involvement of the practice assistant (2.27; 95% CI 0.49-4.06) were independently associated with SDM/KDM. Using the other outcome variable, results were similar. Additionally, cooperation with a diabetes nurse was associated with a lower yield. CONCLUSION A lower yield of screening, reflecting a lower prevalence of undiagnosed diabetes, was found in practices of younger GPs and in urban practices. A lower yield was not associated with an appropriate practice organization regarding diabetes care nor with a specialty of the GP in diabetes. The wide variation in the yield of screening stresses the importance of a screening programme in each general practice.
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Affiliation(s)
- Paul G H Janssen
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, The Netherlands.
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Evans PH, Greaves C, Winder R, Fearn-Smith J, Campbell JL. Development of an educational 'toolkit' for health professionals and their patients with prediabetes: the WAKEUP study (Ways of Addressing Knowledge Education and Understanding in Pre-diabetes). Diabet Med 2007; 24:770-7. [PMID: 17403125 DOI: 10.1111/j.1464-5491.2007.02130.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
AIMS To identify key messages about pre-diabetes and to design, develop and pilot an educational toolkit to address the information needs of patients and health professionals. METHODS Mixed qualitative methodology within an action research framework. Focus group interviews with patients and health professionals and discussion with an expert reference group aimed to identify the important messages and produce a draft toolkit. Two action research cycles were then conducted in two general practices, during which the draft toolkit was used and video-taped consultations and follow-up patient interviews provided further data. Framework analysis techniques were used to examine the data and to elicit action points for improving the toolkit. RESULTS The key messages about pre-diabetes concerned the seriousness of the condition, the preventability of progression to diabetes, and the need for lifestyle change. As well as feedback on the acceptability and use of the toolkit, four main themes were identified in the data: knowledge and education needs (of both patients and health professionals); communicating knowledge and motivating change; redesign of practice systems to support pre-diabetes management and the role of the health professional. The toolkit we developed was found to be an acceptable and useful resource for both patients and health practitioners. CONCLUSIONS Three key messages about pre-diabetes were identified. A toolkit of information materials for patients with pre-diabetes and the health professionals and ideas for improving practice systems for managing pre-diabetes were developed and successfully piloted. Further work is needed to establish the best mode of delivery of the WAKEUP toolkit.
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Affiliation(s)
- P H Evans
- Primary Care, Peninsula Medical School, Exeter, UK.
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Cogneau J, Balkau B, Weill A, Liard F, Simon D. Assessment of diabetes screening by general practitioners in France: the EPIDIA Study. Diabet Med 2006; 23:803-7. [PMID: 16842487 PMCID: PMC1959404 DOI: 10.1111/j.1464-5491.2006.01877.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
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.
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