Top

04-04-2017 | Screening | Article

Understanding type 2 diabetes mellitus screening practices among primary care physicians: a qualitative chart-stimulated recall study

Journal: BMC Family Practice

Authors: Dina Hafez, Daniel B. Nelson, Evan G. Martin, Alicia J. Cohen, Rebecca Northway, Jeffrey T. Kullgren

Publisher: BioMed Central

Abstract

Background

Early diagnosis and treatment of prediabetes and type 2 diabetes mellitus (T2DM) can prevent future health problems, yet many individuals with these conditions are undiagnosed. This could be due, in part, to primary care physicians’ (PCP) screening practices, about which little is known. The objectives of this study were to identify factors that influence PCPs’ decisions to screen patients for T2DM and to characterize their interpretation and communication of screening test results to patients.

Methods

We conducted semi-structured chart-stimulated recall interviews with 20 University of Michigan Health System (UMHS) primary care physicians. PCPs were asked about their recent decisions to screen or not screen 134 purposively sampled non-diabetic patients who met American Diabetes Association criteria for screening for T2DM. Interviews were audio-recorded, transcribed, and analyzed using qualitative directed content analysis. Data on patient demographic characteristics and comorbidities were abstracted from the electronic health record.

Results

The most common reasons PCPs gave for not screening 63 patients for T2DM were knowledge of a previously normal screening test (49%) and a visit for reasons other than a health maintenance examination (48%). The most common reasons PCPs gave for screening 71 patients for T2DM were knowledge of a previously abnormal screening test (49%), and patients’ weight (42%) and age (38%). PCPs correctly interpreted 89% of screening test results and communicated 95% of test results to patients. Among 24 patients found to have prediabetes, PCPs usually (58%) recommended weight loss and increased physical activity but never recommended participation in a Diabetes Prevention Program or use of metformin.

Conclusions

Previous screening test results, visit types, and patients’ weight and age influenced PCPs’ decisions to screen for T2DM. When patients were screened, test results were generally correctly interpreted and consistently communicated. Recommendations to patients with prediabetes could better reflect evidence-based strategies to prevent T2DM.

2014 Diabetes Report Card - diabetesreportcard2014.pdf [Internet]. [cited 2016 May 27]. Available from: http://www.cdc.gov/diabetes/pdfs/library/diabetesreportcard2014.pdf

Gerstein HC, Santaguida P, Raina P, Morrison KM, Balion C, Hunt D, et al. Annual incidence and relative risk of diabetes in people with various categories of dysglycemia: A systematic overview and meta-analysis of prospective studies. Diabetes Res Clin Pract. 2007;78:305–12.PubMedCrossRef

Holman RR, Paul SK, Bethel MA, Matthews DR, Neil HAW. 10-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med. 2008;359:1577–89.PubMedCrossRef

Group DPPR, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346:393.CrossRef

Perreault L, Temprosa M, Mather KJ, Horton E, Kitabchi A, Larkin M, et al. Regression From Prediabetes to Normal Glucose Regulation Is Associated With Reduction in Cardiovascular Risk: Results From the Diabetes Prevention Program Outcomes Study. Diabetes Care [Internet]. 2014 [cited 2014 Jul 27]; Available from: http://care.diabetesjournals.org/cgi/doi/10.2337/dc14-0656

Prevent Diabetes STAT | General Public [Internet]. Prev. Diabetes STAT. [cited 2016 May 27]. Available from: http://www.preventdiabetesstat.org

Final Recommendation Statement: Abnormal Blood Glucose and Type 2 Diabetes Mellitus: Screening - US Preventive Services Task Force [Internet]. [cited 2016 May 27]. Available from: http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/screening-for-abnormal-blood-glucose-and-type-2-diabetes

Alex ADA 1701 NBS, ria, 1-800-Diabetes V 22311. National Diabetes Prevention Program Named the First Preventive Health Initiative Eligible for Medicare Coverage via CMMI Expansion [Internet]. Am. Diabetes Assoc. [cited 2016 May 27]. Available from: http://www.diabetes.org/newsroom/press-releases/2016/national-dpp-named-first-preventive-health-initiative-eligible-for-medicare.html

Health Plans Preventing Diabetes and Improving Well-Being [Internet]. AHIP. 2016 [cited 2016 May 27]. Available from: https://www.ahip.org/diabetes/

10.

Gopalan A, Lorincz IS, Wirtalla C, Marcus SC, Long JA. Awareness of Prediabetes and Engagement in Diabetes Risk–Reducing Behaviors. Am J Prev Med. 2015;49:512–9.PubMedCrossRef

11.

Centers for Disease Control and Prevention. National Diabetes Statistics Report: Estimates and Its Burden in the United States [Internet]. [cited 2016 May 27]. Available from: http://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf

12.

Reddy ST, Endo J, Gupta S, Tekian A, Park YS. A Case for Caution: Chart-Stimulated Recall. J Grad Med Educ. 2015;7:531–5.PubMedPubMedCentralCrossRef

13.

Goulet F, Jacques A, Gagnon R, Racette P, Sieber W. Assessment of Family Physicians’ Performance Using Patient Charts: Interrater Reliability and Concordance With Chart-Stimulated Recall Interview. Eval Health Prof. 2007;30:376–92.PubMedCrossRef

14.

Guerra CE, Schwartz JS, Armstrong K, Brown JS, Halbert CH, Shea JA. Barriers of and Facilitators to Physician Recommendation of Colorectal Cancer Screening. J Gen Intern Med. 2007;22:1681–8.PubMedPubMedCentralCrossRef

15.

Guerra CE, Jacobs SE, Holmes JH, Shea JA. Are Physicians Discussing Prostate Cancer Screening with Their Patients and Why or Why Not? A Pilot Study. J Gen Intern Med. 2007;22:901–7.PubMedPubMedCentralCrossRef

16.

American Diabetes Association. Standards of Medical Care in Diabetes--2014. Diabetes Care. 2014;37:S14–80.CrossRef

17.

Dall TM, Narayan KM, Gillespie KB, Gallo PD, Blanchard TD, Solcan M, et al. Detecting type 2 diabetes and prediabetes among asymptomatic adults in the United States: modeling American Diabetes Association versus US Preventive Services Task Force diabetes screening guidelines. Popul Health Metr. 2014;12:12.PubMedPubMedCentralCrossRef

18.

Laine C. The annual physical examination: needless ritual or necessary routine? Ann Intern Med. 2002;136:701–3.PubMedCrossRef

19.

Mitka M. Studies continue to show no benefit from annual physicals in healthy adults. JAMA. 2012;308:2321–2.PubMedCrossRef

20.

Flocke SA, Stange KC, Goodwin MA. Patient and visit characteristics associated with opportunistic preventive services delivery. J Fam Pract. 1998;47(3):202-08. PMID 9752372.

21.

Stange KC, Flocke SA, Goodwin MA. Opportunistic preventive services delivery. Are time limitations and patient satisfaction barriers? J Fam Pract. 1998;46(5):419–24.

22.

Kikano GE, Flocke SA, Gotler RS, Stange KC. Are you practicing 'opportunistic' prevention? Fam Pract Manag. 2000;7(3):56.

23.

Klein Woolthuis EP, de Grauw WJC, van Gerwen WHEM, van den Hoogen HJM, van de Lisdonk EH, Metsemakers JFM, et al. Yield of Opportunistic Targeted Screening for Type 2 Diabetes in Primary Care: The Diabscreen Study. Ann Fam Med. 2009;7:422–30.PubMedCrossRef

24.

Jennett P, Affleck L. Chart audit and chart stimulated recall as methods of needs assessment in continuing professional health education. The Journal of Continuing Education in Health Professions. 1998;18:163–71.

25.

Hsieh H-F, Shannon SE. Three Approaches to Qualitative Content Analysis. Qual Health Res. 2005;15:1277–88.PubMedCrossRef

26.

Potter WJ, Levine‐Donnerstein D. Rethinking validity and reliability in content analysis. J Appl Commun Res. 1999;27:258–84.CrossRef

27.

Thomas J, Harden A. Methods for thematic synthesis of qualitative research in systematic reviews. BMC Medical Research Methodology. 2008;8:45.

28.

Francis JJ, Johnston M, Robertson C, Glidewell L, Entwistle V, Eccles MP, et al. What is an adequate sample size? Operationalising data saturation for theory-based interview studies. Psychol Health. 2010;25:1229–45.PubMedCrossRef

29.

Standards of Medical Care in Diabetes—2014 [Internet]. [cited 2014 Jul 28]. Available from: http://care.diabetesjournals.org/content/37/Supplement_1/S14.full.pdf+html

30.

national-diabetes-report-web.pdf [Internet]. [cited 2016 Mar 31]. Available from: http://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf

31.

Ealovega MW, Tabaei BP, Brandle M, Burke R, Herman WH. Opportunistic screening for diabetes in routine clinical practice. Diabetes Care. 2004;27:9–12.PubMedCrossRef

32.

Dexheimer JW, Talbot TR, Sanders DL, Rosenbloom ST, Aronsky D. Prompting Clinicians about Preventive Care Measures: A Systematic Review of Randomized Controlled Trials. J Am Med Inform Assoc. 2008;15:311–20.PubMedPubMedCentralCrossRef

33.

Reminder Systems for Immunizations and Preventive Services [Internet]. [cited 2016 May 27]. Available from: http://www.ahrq.gov/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/health-promotion-education/strategy6r-reminder-systems.html

34.

Davis K, Schoenbaum SC, Audet A-M. A 2020 vision of patient-centered primary care. J Gen Intern Med. 2005;20:953–7.PubMedPubMedCentralCrossRef

35.

Schmittdiel JA, Adams SR, Segal J, Griffin MR, Roumie CL, Ohnsorg K, et al. Novel Use and Utility of Integrated Electronic Health Records to Assess Rates of Prediabetes Recognition and Treatment: Brief Report From an Integrated Electronic Health Records Pilot Study. Diabetes Care. 2014;37:565–8.PubMedPubMedCentralCrossRef

36.

Moin T, Li J, Duru OK, Ettner S, Turk N, Keckhafer A, et al. Metformin Prescription for Insured Adults With Prediabetes From 2010 to 2012: A Retrospective Cohort Study. Ann Intern Med. 2015;162:542.PubMedPubMedCentralCrossRef

37.

Yarnall KS, Pollak KI, Østbye T, Krause KM, Michener JL. Primary care: is there enough time for prevention? Am J Public Health. 2003;93:635–41.PubMedPubMedCentralCrossRef

Be confident that your patient care is up to date

Medicine Matters is being incorporated into Springer Medicine, our new medical education platform.

Alongside the news coverage and expert commentary you have come to expect from Medicine Matters diabetes, Springer Medicine's complimentary membership also provides access to articles from renowned journals and a broad range of Continuing Medical Education programs. Create your free account »