Predicting diabetes

Frederick Brancati (Baltimore, MD) discussed diabetes screening. Approaches using age, sex, BMI, family history, hypertension, and lifestyle as predictive measures have shown good performance in cross-sectional and prospective studies, and capillary glucose measurement adds further value, although the public health impact of such approaches has not been determined. In the Diabetes Prevention Program (DPP), 158,177 individuals were screened, with 3,819 randomized. Those whose fasting capillary glucose was 90–115 mg/dl had increased risk of impaired glucose tolerance (IGT); levels ≥130 mg/dl were 250 times as likely as levels <90 mg/dl to be associated with IGT. Patrick O'Connor (Minneapolis, MN) pointed out that health plans have become very interested in identifying and treating diabetes and addressed the question of whether systematic identification of pre-diabetes by screening leads to better health outcomes than would occur without screening. Developing an approach to identification and subsequent interventions that would be cost-effective is an important priority. O'Connor reviewed responses to a survey of medical directors of 35 plans, caring for a total of 47 million individuals, focused on awareness of cardiometabolic risk. At-risk enrollees can be identified by age, BMI, sex, race, laboratory test results, physician diagnoses, smoking history, and prescription data based on pharmacy claims, although lack of electronic medical records is “a weak link.” Duration of treatment and of illnesses (including diabetes) and other aspects of medical history are not readily available.

Nonetheless, using all the available information, it certainly is possible to identify individuals at increased diabetes risk. Two approaches are taken: 1) direct outreach to large numbers of people for prevention of adverse outcome or 2) case management of smaller numbers of people at much higher risk. …