'Untapped Opportunity': Diabetes Screening in the ER

HAMBURG, Germany – Screening for type 2 diabetes in emergency departments could find thousands of undiagnosed cases of glucose intolerance among patients who may not have been picked up otherwise.

The researchers, led by Edward Jude, MD, consultant in diabetes and endocrinology at Tameside and Glossop Integrated Care NHS Foundation Trust in Ashton-under-Lyne, UK, suggest that such screening might offer a means of outreach to find those in greatest need of care.

"Screening for diabetes should be performed in all adult patients attending accident and emergency (A&E) and should be incorporated into the guidelines, to reduce burden on both patients and healthcare services in the long run," said Jude, who presented the findings at this year's annual meeting of the European Association for the Study of Diabetes (EASD).

The ongoing prospective, UK-based study identified 420 (30%) cases of prediabetes and 120 (9%) of type 2 diabetes in a busy A&E department in England. A further 848 (61%) had normal blood glucose levels. Jude also pointed out that, "risk scores should take ethnicity into consideration."

"With estimates of up to 30% of people with diabetes undiagnosed (approximately 1 million undiagnosed in the UK), it's important to find these people with hyperglycemia to reduce the longer-term risk of microvascular and macrovascular complications," he remarked, noting that glucose intolerance can go undetected for up to 10 years, which can lead to long-term complications such as heart disease, nerve damage, and retinopathy.

Some screening programs are in place in the UK, but uptake is only around 50%, Jude pointed out. "We are missing a lot of people, and furthermore, hospital patients are not routinely screened for diabetes," he said, noting the opportunity, as shown by their data, "for a simple and inexpensive blood test to be used in people attending A&E, given the prevalence of hyperglycemia in hospital patients is much higher than the general population."

Commenting on the work, Emily Sims, MD, associate professor of pediatrics, Center for Diabetes and Metabolic Disease, Indiana University School of Medicine, Indianapolis, told Medscape Medical News: "Any time you can screen and identify a condition earlier in the process where there's potential to make an impact than there's benefit there."

Sims, who was not involved with the study, noted that certain populations were hard to reach and that emergency room screening might offer an opportunity to find and treat these people. "With type 2 diabetes these are often populations that aren't engaging in regular care, so if we can catch people when they're in the emergency room then I'm very supportive of that."

An Untapped Opportunity to Find the Thousands of Undiagnosed

To investigate if A&E screening might offer an untapped opportunity, Jude instigated the study at his own A&E department. In total, 1388 individuals were screened for type 2 diabetes using the A1c test. In addition, demographic data were recorded including ethnicity as well as risk factors for diabetes such as body mass index (BMI) in the overweight/obese category and these data fed into calculation of the Finnish Diabetes Risk Score (FINDRISC) to identify those at risk of developing type 2 diabetes.

The FINDRISC identifies those people at risk for diabetes and requires no laboratory testing, only using age, BMI, physical activity, vegetable and fruit intake, medical treatment of hypertension, hyperglycemia history, and family history to determine risk of developing diabetes. Scores over 20 are considered as very high risk of developing type 2 diabetes, while a score of 12-20 as moderate and high risk. Diagnoses of prediabetes (A1c 5.7% - 6.4%) and type 2 diabetes (A1c > 6.5%) were made according to UK National Institute for Health and Care Excellence (NICE) and American Diabetes Association guidelines.

Of those people screened, 91.6% were White. They found that 8.6% of patients (120) were diagnosed with type 2 diabetes, in an equal split between men and women, with average age 56 years, average A1c 6.8%, average weight 94 kg (207 lb) and average BMI 31.2 kg/m². A further 30.2% (420) individuals were found to have prediabetes with average age 57 years, average A1c. 5.9%, average weight 82 kg (180 lb), and average BMI 28.6 kg/m². The remaining 61% (848) had normal blood glucose levels, had average age 51 years, average A1c 5.3%, average weight 81 kg (178 lb) and mean BMI 28.4 kg/m².

"Tameside, where I work, is quite a socially deprived area of the UK and we found that 59.6% were current or previous smokers," added Jude. "We were surprised at the prevalence of hypertension in both those with prediabetes and type 2 diabetes." According to NICE criteria, 35.4% and 30% had hypertension in prediabetes and diabetes respectively.

In particular, people of South Asian and other ethnic backgrounds had a higher incidence of glucose intolerance compared to White people (42.7% vs 37.8% respectively) and were twice as likely to be diagnosed with prediabetes (odds ratio [OR], 1.90; 95% CI, 1.22 - 1.96) or diabetes (OR, 2.61; 95% CI, 1.37 - 4.99).

Turning to the FINDRISC score results, the researchers found that a one unit increase in the score was associated with a 7% (OR, 1.07; 95% CI, 1.04 - 1.10) increased risk for prediabetes, and a 15% increased risk for diabetes (OR, 1.15; 95% CI, 1.10 - 1.20), after adjusting for age and sex. According to the NICE criteria, people with a FINDRISC score over 20 had an odds ratio of 6.09 for prediabetes (P = .004), and 10.11 (P = .003) for type 2 diabetes.

When the FINDRISC score was adjusted for ethnicity, the adjusted odds ratio was 2.88 (95% CI, 1.72 - 4.83) and 2.66 (95% CI, 1.47 - 4.81) for prediabetes and type 2 diabetes, respectively, for every unit increase in score. "When we adjusted for age and sex we saw that ethnicity went up nearly threefold," reported Jude.

Jude told Medscape Medical News that visitors to A&E in the UK have routine blood tests for other factors such as a full blood count, liver function, and kidney function, and that "the blood collected for this could also be used to measure A1c, and it isn't that expensive to do A1c, so I think it could be incorporated."

Jude has received advisory board honoraria and grant/research support from Sanofi and has received speaker honoraria from Bayer AG, Boehringer Ingelheim, Eli Lilly, Novo Nordisk, Menarini, and Sanofi. Sims has received consulting fees from Sanofi.

European Association for the Study of Diabetes (EASD): Abstract 352. To be presented October 5, 2023.

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