Doctors often overlook this very common disease

John Murphy, MDLinx | September 25, 2019

One in three US adults (ie, 84.1 million Americans) has prediabetes, which puts them at high risk for developing type 2 diabetes. Fortunately, people with prediabetes can likely prevent or delay type 2 diabetes with reasonable lifestyle changes. Unfortunately, many primary care physicians (PCPs) aren’t providing the proper care needed to help patients with prediabetes make those changes, according to researchers in a recent study in the Journal of General Internal Medicine.

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One in three US adults have prediabetes, but many PCPs don’t know enough about the health condition to diagnose it or provide proper care for their patients.

From a survey of randomly selected PCPs, researchers at Johns Hopkins Medicine and the CDC found that physicians had limited knowledge of risk factors for prediabetes screening, laboratory diagnostic criteria for prediabetes, and management recommendations for patients with prediabetes.

“Our survey findings suggest that these gaps contribute to doctors underscreening for and missing diagnoses of prediabetes, and in turn, not referring patients to type 2 diabetes prevention programs,” said lead author Eva Tseng, MD, MPH, assistant professor of medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.

These gaps may result from a healthcare system that may limit physicians’ abilities to provide the best evidence-based care due to factors such as performance measures, insurance reimbursement, cultural expectations, insufficient tools, and limited staffing resources, the researchers noted.

“Along with closing the PCP knowledge gaps our survey identified, we believe the problem needs to be addressed at the healthcare system level,” said co-author Nisa Maruthur, MD, MHS, associate professor of medicine at Johns Hopkins. “This includes concerted efforts to make both health care providers and patients more aware of available type 2 diabetes prevention programs, encouraging patient enrollment in these programs, and getting insurance companies to understand their value and cover the costs.”

Currently, 90% of US adults with prediabetes don’t know they have it—a statistic that hasn’t changed in a decade.

Gaps in PCPs’ knowledge of prediabetes

For this study, the researchers sent surveys to 1,000 randomly selected PCPs (general internists, family physicians, and general practitioners). Nearly 300 PCPs returned the survey, for a response rate of 33%. The majority of respondents (50.5%) were 60 years of age and older, and in practice for more than 20 years. Internal medicine, family medicine, and general practitioners were represented equally.

As their initial management strategy for prediabetes, only 36% of PCPs said they refer patients to a diabetes prevention lifestyle change program, while 43% discuss starting metformin for prediabetes. (Physicians could choose more than one answer to this question.)

“Our results also suggest that 25% of PCPs may be identifying people as having prediabetes when they actually have diabetes, which could lead to delays in getting those patients proper diabetes care and management,” Dr. Maruthur said.

Other notable findings:

  • On average, respondents selected just 10 out of 15 correct risk factors for prediabetes, most often missing that African Americans and Native Americans are two groups at high risk. Only 15% of physicians correctly identified all 15 risk factors.

  • About 50% of PCPs selected the correct criteria for diabetes with lower rates for prediabetes—42% selected the correct range for fasting glucose and 31% for HbA1c tests that would identify prediabetes. One-fourth of PCPs reported using non-fasting glucose for prediabetes screening, even though no such diagnostic criteria exist.

  • Only 8% knew that a 7% weight loss is the minimum recommended by the American Diabetes Association as part of a diabetes prevention lifestyle change program.

  • PCPs identified both patient- and system-level barriers to—and facilitators for—diabetes prevention in primary care. Physicians felt most strongly that important barriers to lifestyle modification for their patients include lack of motivation (94%), limited or lack of success with prior lifestyle modification (79%), and stress in their lives (70%).

  • Among potential interventions for improving prediabetes management, PCPs reported that increased availability of (90%) and insurance coverage for (90%) diabetes prevention programs, improved nutrition resources (88%) and access to weight loss programs (86%), and coordination of patients’ referral to lifestyle change programs (84%) would be helpful.

“Our national survey findings suggest that gaps in PCP knowledge contribute to the inadequate diagnosis of prediabetes and referral to diabetes prevention interventions,” the authors wrote. “In addition to provider education, addressing system-level barriers to type 2 diabetes prevention is important and will require partnerships with community resources and leveraging of health information technology.”

Dr. Tseng said: “We believe that what was learned from our survey can have implications for changing national guidelines and policies regarding type 2 diabetes prevention, including establishing measures of quality for diagnosing and managing prediabetes.”

In the survey, PCPs reported that increased access to, and insurance coverage of, type 2 diabetes prevention programs and coordination of referral of patients to these resources would facilitate type 2 diabetes preventive efforts.

Dr. Tseng added: “The public can help by advocating for more insurers to cover prevention programs, along with insisting that public health stakeholders expand access to and availability of these interventions.”

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