Type 2 diabetes undiagnosed in a third of people with known hyperglycemia
medwireNews: A large proportion of people with documented hyperglycemia are still not clinically diagnosed with type 2 diabetes for up to 1 year later, US study data show.
Anjali Gopalan and colleagues, from Kaiser Permanente Northern California in Oakland and Santa Clara, USA, found that 30.2% of 18,356 adults from their institution who first had an elevated glycated hemoglobin (HbA1c) level (≥48 mmol/mol; ≥6.5%) between 2014 and 2015 remained undiagnosed with type 2 diabetes 1 year later.
The findings raise questions regarding the use of electronic health records (EHRs), Gopalan and co-authors remark in Diabetes Care.
They say: “Although EHRs provide easy access to available HbA1c data, this may not be sufficient to trigger the documentation and subsequent care processes for people with newly diagnosed Type 2 diabetes.”
The team adds: “Ensuring timely Type 2 diabetes diagnoses may require EHR advances that more explicitly and automatically connect available test results to diabetes diagnoses and prompt early intervention towards the goal of improved Type 2 diabetes outcomes.”
The researchers report that individuals with lower mean index HbA1c values (48–<53 mmol/mol; 6.5–<7.0%) were a significant 5.95 times more likely to remain undiagnosed than those with higher index HbA1c (53–<64 mmol/mol; 7.0–<8.0%).
People aged 70 years and older were a significant 1.40 times more likely to remain undiagnosed than those aged 50–59 years, while the likelihood was 1.35-fold higher for people with prediabetes than for those without, and 1.26-fold higher for Black versus White individuals.
Gopalan et al say there could be several reasons for the delayed diagnoses, including the fact that “providers may not formally document a diagnosis unless they are initiating pharmacological treatment, because ordering a prescription medication requires an associated ICD-9/10 code.”
Since people with lower index HbA1c values may be less likely to be prescribed medications, they would also be less likely to have a documented diagnosis, the researchers note.
They add: “This documentation practice may also explain the observed associations between undiagnosed diabetes with older age and prior prediabetes diagnoses. Given the less-stringent HbA1c targets recommended for older adults, providers may be less likely to start pharmacological treatment and, therefore, would be less likely to document a new clinical diagnosis.”
The team also found that, after adjustment for age, index HbA1c, and race/ethnicity, undiagnosed people were significantly less likely to receive diabetes-related education (adjusted odds ratio [aOR]=0.08), a retinal examination (aOR=0.02), and treatment with metformin (aOR=0.06).
Although these findings were expected, they “help to quantify the early intervention opportunities that may be missed when diagnoses are delayed,” say the researchers.
They conclude: “Regardless of formal Type 2 diabetes diagnosis status, all the examined individuals arguably have some level of impaired glucose tolerance and could benefit from health education and the initiation of metformin therapy.”
By Laura Cowen
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