Family physicians are routinely involved in the care of patients with prediabetes and diabetes. By some estimates,(link.springer.com) more than 90% of all patients in the United States who have diabetes see family physicians(www.ncbi.nlm.nih.gov) and other primary care clinicians for their condition.
To address the public health burden of prediabetes and diabetes, the CDC in 2010 created the National Diabetes Prevention Program,(www.cdc.gov) the key feature of which is a research-based, structured lifestyle change program(www.cdc.gov) that has been shown to significantly reduce the incidence of diabetes in at-risk people. A new study(www.jabfm.org) published in the July issue of the Journal of the American Board of Family Medicine found that although family physicians and other clinicians are highly skilled in screening for and managing diabetes, opportunities exist to raise awareness of the National DPP and similar resources.
Study Design and Methods
The research was designed as an implementation study with two components. First, the authors surveyed 31 clinicians at an academic family medicine clinic using a questionnaire on prediabetes and diabetes prevention. The researchers also analyzed the EHR data of all patients 18 and older seen in the clinic between 2015 and 2017.
- A study in the Journal of the American Board of Family Medicine examined the knowledge, attitudes and practices of clinicians at an academic family medicine clinic.
- Researchers found that clinicians are highly skilled at prediabetes screening and possess considerable knowledge in prediabetes management.
- Awareness of the National Diabetes Prevention Program was low, but opportunities exist for clinicians to overcome this barrier.
Following the U.S. Preventive Services Task Force's recommendation to screen adults ages 40-70 who have a BMI of 25 or higher for diabetes(www.uspreventiveservicestaskforce.org), the researchers obtained relevant patient data, such as hemoglobin A1c levels and metformin prescriptions. Of more than 15,000 patients seen at the clinic, 5,360 without a diabetes diagnosis met the USPSTF diabetes screening criteria.
Clinicians generally showed a high degree of knowledge of prediabetes and its health effects. For example,
- almost 97% knew the correct A1c range that indicated prediabetes,
- every clinician surveyed agreed that lifestyle modification was effective in preventing or delaying the onset of diabetes,
- almost 94% of clinicians thought prediabetes was a significant public health issue and
- nearly 65% considered screening for prediabetes a high priority.
On the other hand, only 45% of clinicians were aware of the National DPP and just over 48% knew how to refer a patient to a local DPP organization.
In terms of care, every clinician reported discussing metformin as a treatment option, recommended physical activity targets in line with national guidelines and recommended nutritional counseling to at least some (i.e., 25% or more) of their prediabetic patients. Regarding the DPP, only about 68% offered referrals to a national program to at least some prediabetic patients.
Diabetes screening coverage was high, but the application of findings to the patient record was inconsistent. More than 75% of patients who met the USPSTF screening criteria for diabetes but were not diagnosed with the disease had a documented A1c test result within the past three years -- far higher than the national average of 46%.(www.ncbi.nlm.nih.gov) However, although more than 1,400 patients met the USPSTF screening criteria and had an A1c test result indicative of prediabetes, only about half of those patients had the prediabetes diagnosis documented in their EHR.
The authors also compared the effects of point-of-care A1c testing versus lab-based testing. Of nearly 2,300 nondiabetic patients with an A1c test result in the prediabetes range, patients who received testing at the point of care were almost 15 times more likely to have prediabetes documentation in the EHR and 4.7 times more likely to receive a metformin prescription than patients who underwent lab-based A1c testing.
Some Findings Puzzle Authors
The limited awareness of and knowledge about DPPs surprised the researchers, given that one program was present in the same office building as the family medicine practice and a second program was located at the local health department. They attributed these findings to several factors, including
- the National DPP's relatively recent establishment,
- lack of awareness of social and community-based resources that may host DPPs, and
- lack of an electronic DPP referral system.
The researchers also were surprised that only half of patients who met the diagnostic criteria for prediabetes had the diagnosis in the EHR. One explanation was that the authors limited their query to the ICD-10 prediabetes code and did not include less specific ICD-9 codes that historically were used for patients with prediabetes and may still be used by some clinicians. They also suggested that delayed lab-based results may have caused some diagnostic information to not be entered into patient EHRs in a timely manner.
Study Author Comments
Corresponding author James Keck, M.D., M.P.H., an assistant professor in the Department of Family and Community Medicine at the University of Kentucky College of Medicine in Lexington, emphasized how crucial it is to catch prediabetes before it becomes more serious.
"Identifying someone at high risk of developing diabetes is very important," Keck told AAFP News. "With effective prevention programs we can improve patient health, prevent new cases of diabetes, spare clinicians from more 'sick care,' and reduce the burden of diabetes on the health care system."
Keck, who sees several patients who have prediabetes or diabetes, suggested that FPs could play an important role in disease management and prevention.
"Many of the patients that we care for on a daily basis have prediabetes," Keck said. "We can reduce their risk of developing type 2 diabetes substantially by engaging with them on lifestyle modification, particularly by referring them to DPPs."
DPPs could return the favor by engaging directly with primary care physicians.
"Much like pharmaceutical companies used to detail clinicians, organizations offering the National DPP should be proactively reaching out to local primary care clinics to discuss the benefits of the DPP and develop referral processes," Keck said.
Keck recommended that family physicians access the Prevent Diabetes STAT Toolkit,(preventdiabetesstat.org) a collaborative effort developed by the CDC and the AMA that includes patient-friendly materials and resources FPs can use to implement prediabetes screening, testing and referrals into their practices.
It should be noted that the AAFP offers several prediabetes and diabetes resources for its members, particularly in the area of patient care. The Academy's Neighborhood Navigator tool also provides FPs with links to resources designed to improve the social determinants of health in patients, which could reduce the risk of diabetes and related conditions.
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