PCPs Lack Awareness of Prediabetes,
Survey Finds

Nicola M. Parry, DVM

September 12, 2019

Despite more than two decades of studies showing that type 2 diabetes can be prevented or delayed by intensive lifestyle change such as the Diabetes Prevention Program (DPP), metformin therapy, or both, uptake of these remains quite low among US patients.

Indeed, study findings published online September 9 in the Journal of General Internal Medicine identified substantial gaps in prediabetes management at the primary care provider (PCP) level that significantly impact the care of this patient population.

Eva Tseng, MD, MPH, from Johns Hopkins University School of Medicine, Baltimore, Maryland, and colleagues found knowledge gaps related to prediabetes in key areas, including screening, laboratory diagnostic criteria, and patient management recommendations.

Tseng told Medscape Medical News these findings were similar to those from the group's previous regional survey of PCPs.

"Some important findings to highlight include that 25% of PCPs may be identifying patients as having prediabetes when they have diabetes," she said.

"Additionally, only about a third of PCPs refer patients with prediabetes to diabetes prevention lifestyle change programs for their initial management approach."

In their current study, Tseng and colleagues evaluated survey data collected from 298 US PCPs. Eligible participants included general practitioners who had completed residency training, general internists, and family physicians.

The survey questioned PCPs about risk factors for prediabetes screening, laboratory criteria for diagnosis of prediabetes, and recommendations for managing prediabetes. It also addressed their practice behaviors for managing the condition and identified what PCPs perceive as barriers and potential interventions to improve its management.

Only 15% of respondents correctly identified all 15 risk factors for prediabetes screening; typically, PCPs selected 10 of the 15 risk factors.

Similarly, only about 50% of respondents were aware of the laboratory criteria for diagnosing diabetes, while even fewer correctly identified the fasting glucose (42%) and Hb1Ac (31%) levels that would indicate prediabetes.

And only 8% of PCPs were aware that the American Diabetes Association recommends patients aim to lose at least 7% of body weight as part of a diabetes prevention lifestyle change program.

In fact, more than 20% of respondents were not following recommendations from any professional organization for the screening and management of prediabetes.

With respect to the practice behaviors of PCPs related to the initial management of prediabetes, only about one third (36%) reported referring patients to a diabetes prevention lifestyle change program, while 43% reported discussing metformin therapy.

Respondents identified key patient-level (especially lack of motivation, 94%) and system-level (especially lack of weight loss resources, 61%) barriers to managing prediabetes.

Interventions identified by respondents as useful for improving prediabetes management included increased availability of diabetes prevention programs (90%), insurance coverage for these programs (90%), better nutrition resources (88%), access to weight loss programs (86%), and coordination of referral to lifestyle change programs (84%).

Tseng said possible solutions for closing these gaps include not only systematic education efforts for PCPs at the institutional level, but also leveraging of tools through health information technology that place less burden on PCPs.

"Such tools may be able to facilitate automatic ordering of follow-up labs and referral of patients to local diabetes prevention lifestyle change programs," she explained.

"These types of tools require system-level changes and resources, which we want to emphasize as being extremely important for overcoming many of the barriers to type 2 diabetes prevention."

Shared Decision Making Could Help Patients Manage Prediabetes

Tannaz Moin, MD, MBA, MSHS, from the David Geffen School of Medicine at the University of California, Los Angeles, also stressed the need to bridge these gaps.

In an interview with Medscape Medical News, Moin said, "We really need to increase prediabetes awareness nationally and to ensure that both patients and providers understand the evidence-based options for diabetes prevention."

With this in mind, Moin and colleagues conducted the cluster randomized controlled Prediabetes Informed Decision and Education (PRIDE) trial to assess the effectiveness of shared decision making (SDM) in diabetes prevention.

Most US adults are not even aware they have prediabetes; therefore, the researchers hypothesized that SDM would help patients become prediabetes aware and empower them to make informed diabetes prevention choices aligned with their preferences.

They published 12-month results from the trial online August 30 in the Journal of General Internal Medicine.

The trial took place across 20 primary care clinics within a large regional health system; it included 351 patients who attended 10 clinics randomly assigned to provide pharmacist-led SDM, and 1028 control patients who attended 10 clinics that were randomly assigned to deliver usual care.

All patients were overweight or obese (BMI of 24 or higher) and had a glycated hemoglobin level of 5.7% to 6.4%, consistent with prediabetes.

Each patient in the SDM group had a private visit with a pharmacist who used an interactive decision aid (DA) to discuss prediabetes with the patient. The pharmacist also outlined four diabetes prevention options (DPP, DPP ± metformin, metformin alone, or usual care) and helped patients decide among the choices.

As a result of this intervention, at 4-month follow-up, the researchers found that more than 83% of patients in the SDM group picked a diabetes prevention strategy: 38% chose DPP (with or without metformin), 23% chose DPP, and 19% chose metformin. Approximately one third (32%) participated in nine or more DPP sessions.

By contrast, however, only 0.4% of patients in the control group engaged in any lifestyle change (such as DPP or any other weight loss program).

When Moin's team analyzed weight change outcomes at 12-month follow-up, they found significantly higher weight loss among SDM participants overall as compared with controls (5.2 lb vs 0.2 lb; P < .001).

This was irrespective of the diabetes prevention choice, she said, because the analysis also included patients who chose to take no action.

"Thus, it's possible that even patients who chose to take no action also made some lifestyle changes to improve their health and lower their type 2 diabetes risk."

Although SDM has been investigated in a variety of other clinical conditions, Moin believes this is the first study to apply it in the area of diabetes prevention. 

"I believe we are also one of the first studies to link a clinical outcome, such as 12-month weight loss, with an SDM intervention for overweight patients with prediabetes," she noted. 

SDM for diabetes prevention should be disseminated more broadly, she emphasized. 

"Incorporating allied health professionals, such as pharmacists or nurses, in SDM delivery may also address the burden faced by PCPs trying to address prediabetes in addition to numerous other health issues during time-constrained visits."

The PRIDE trial was supported by the National Institute of Diabetes and Digestive and Kidney Diseases, and the national survey study was supported by a Johns Hopkins Primary Care Consortium grant. Three authors report receiving grant support from the Department of Veterans Affairs; the UCLA Resource Centers for Minority Aging Research, Center for Health Improvement of Minority Elderly, through the National Institutes of Health (NIH)/National Institute on Aging; the NIH/National Center for Advancing Translational Sciences; an NIH Career Development Award; and the Barbara A. Levey and Gerald S. Levey Endowed Chair in Medicine at UCLA. One author reports serving as a member of the US Preventive Services Task Force. The remaining authors have disclosed no relevant financial relationships.

J Gen Intern Med. Published online September 9, 2019. Abstract

J Gen Intern Med. Published online August 30, 2019. Abstract

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