ED Screening Program Picks Up Lots of Undiagnosed Diabetes Cases

More than half of at-risk patients screened for diabetes at an urban emergency department (ED) were identified as having an abnormal HbA1c during a pilot program, researchers reported.

The program was designed to flag the electronic health records (EHRs) of patients at risk for type 2 diabetes with a “best practice alert.” During the 3-month study period, alerts were triggered for about 30% of the 8,441 patients visiting the Chicago ED, explained Kirstie Danielson, PhD, of the University of Illinois Chicago, and colleagues in JAMA Network Open.

Of the 2,074 who ultimately had an HbA1c test performed (some were excluded due to a laboratory error or if no test was ordered), 1,085 had an abnormal HbA1c, with prediabetes identified in 70% and diabetes in 30%, including 62 individuals with severe diabetes, according to the findings.

Danielson’s group noted that EDs have successfully implemented screening for HIV and substance abuse, but “ED screening for [type 2 diabetes] in underserved populations that is built into daily clinical care and uses clinical recommendations has not been developed.”

Screening parameters were based on the American Diabetes Association recommendations, and flagged all patients ages 45 or older, or ages 18 to 44 with a body mass index (BMI) of 25 or higher without a prior history of diabetes or HbA1c reading within the past 3 years in the EHR. From there, the clinician had the option to add an HbA1c test to the patient’s labs.

“Our ED screening program identified a substantial number of patients with undiagnosed prediabetes and [type 2 diabetes] or undermanaged disease, particularly racial and ethnic minority individuals and low-income patients,” the researchers wrote.`

Standard HbA1c cutoffs were used for prediabetes (5.7-6.4%), diabetes (≥6.5%), and severe diabetes (≥10%).

Study staff attempted to get in contact with all patients who had an abnormal HbA1c result, but Danielson’s group said they could only get ahold of 352 patients. Of this group, 25% said they had previously received a prediabetes or diabetes diagnosis but only 58% said they subsequently received treatment for it. The other 75% who had an abnormal HbA1c said they were never previously diagnosed.

“The pilot sample reached by telephone was likely biased toward higher socioeconomic status, indicating those not reached are likely more underserved,” the researchers pointed out. “Next steps involve testing implementation strategies to link these new patients to diabetes education and care.”

“Questions remain including whether this approach could be useful in EDs in similar urban settings or rural communities and whether targeting outreach to those with higher HbA1c levels will be more cost-effective,” they added.

Danielson’s group highlighted that this was a generally underserved population. Half had public insurance and another 4% were uninsured.

Among the 352 patients with elevated HbA1c levels whom staff were able to get into contact with, the average age was 52, BMI was 33, and 55% were women. About 65% were Black, 20% were Hispanic, and 10% were white. Only about 72% of patients had a primary care clinician.

The most common reason for the ED visit was pertaining to the cardiovascular system (16.5%), though this was more common cause for those with newly identified type 2 diabetes (21.7%).