Is Screening the Only Answer to Finding 'Missing' T2D Patients?

Liam Davenport

November 15, 2019

LONDON — While it is clear that mass screening for type 2 diabetes will be necessary to identify the 'missing million' undiagnosed patients in the UK, the exact form it should take is still very much a matter of debate, concluded healthcare professionals at the Diabetes Professional Care 2019 conference.

Dr Mike Sadler, conference chair and a clinical non-executive director at University Hospital Southampton NHS Foundation Trust, chaired a debate on whether targeted or population screening should be pursued and what form that would take, with the aim of presenting the results to NHS England.

He opened the discussion by noting that, by current estimates, around 1 in 70 people have undiagnosed type 2 diabetes.

This means that not only do the vast majority of people know someone in this situation, but also that it totals almost one million in the UK with undiagnosed disease.

Making the Case for Screening

Dr Sadler reminded the audience that this results in "unnecessary complications and suffering", and begs the question: "What can we do about this?"

He noted that, as far back as 1968, Wilson and Jungner were commissioned by the World Health Organisation to write a report on screening, and the resulting Principles and Practice of Screening for Disease is still a reference point in public health.

Among other criteria, the authors emphasise that screening is recommended when the natural history of the condition is understood, there is a test that is easy to perform and interpret, and treatment would be more effective if started early.

Dr Sadler said that type 2 diabetes clearly fulfils those and other criteria for screening, but the question remains how.

To explore some of the options, he asked Beth Kelly, a community diabetes specialist nurse at Southampton City, Solent NHS Trust, to discuss a project that they launched to bring screening to the community.

Their innovation was to bring targeted screening to football matches in an attempt to get to men, who often don't attend screening programmes, and potentially people with mental health issues, who are also hard to reach.

They used point of care HbA1c testing, and were present at the ground for 3 to 4 hours, catching people as they came in.

Time constraints, as well as the time taken to perform the test and only having a few testers, meant that they only managed to screen 103 individuals of 14,000 people who were at the match.

Of those tested, two were positive for type 2 diabetes and five were positive for non-diabetic hyperglycaemia, or pre-diabetes. Information on type 2 diabetes was given to all people who were screened.

They ran a similar programme at a cricket match, to try to target people from different ethnic origins.

The attendees at the cricket match, she said, were older than those at the football match and more affluent. Although the testers were able to be there for 6 hours, they "didn't find many positive results".

Population-wide Screening

Next, Abigail Kitt, senior quality improvement lead for diabetes, South East Clinical Networks, NHS England, made the case for population-wide screening of everyone over the age of 40 for type 2 diabetes.

She suggested sending a kit out in the post, similar to that used in bowel screening, with the returned kits used for diagnosis.

She pointed to successes with cervical and bowel cancer screening programmes and said "we should be doing that for type 2 diabetes". Catching the 'missing million' patients through screening would mean diagnosing them earlier, and increasing the likelihood that they could achieve remission.

This would be cost-effective compared with the costs of treating potential complications of undiagnosed diabetes.

Abigail Kitt said that, based on the figures Dr Sadler mentioned earlier, they expect around 2% of people would be diagnosed based on mass population screening, "so the cost of undiagnosing 98% is to be factored into that".

She added that, while she likes the idea of targeted screening and the chance it brings for face-to-face education, "it's time consuming, a lot of work, and a lot of organisation for those healthcare professionals".

Screening Policy Needed

Dr Sadler then threw the discussion open to the audience, saying that he and the team at the conference will take whatever they collectively decide to NHS England and try to move forward the idea of type 2 diabetes screening.

"I'm keen to seek to get this into some sort of policy," he said. "We can't continue what we're doing now, which is nothing, because this problem will get crazier and crazier and we'll be failing people, and I think that's the saddest part of all."

The first person to speak suggested that type 2 diabetes screening could be carried out on patients coming into the emergency department, as they all have to undergo a full blood count, and "adding an HbA1c to that is 70 pence, and that's 400 people screened per day, just in my hospital".

She pointed out that this approach, which would yield around five new cases per day, is already adopted in parts of Australia, where they found that 12% of people screened in one hospital were diagnosed.

Another audience member said that, when Diabetes UK were looked at the idea of population-based screening, they specified the criteria of age over 40, family history of diabetes, ethnic minority background, and any symptoms.

"But I'm not sure how effective that was," she added. "Certainly it was targeted but I've not seen any evidence or any results from that."

It was also pointed out by several audience members that the NHS Health Check, which is aimed at people aged 40–74 years, is meant to include type 2 diabetes assessment, but that does not mean that all individuals have blood glucose tests.

From the discussion that followed, it became clear that the inclusion of blood glucose screening in the Health Check was dependent on the local Clinical Commissioning Group, as HbA1c in nondiabetic individuals is not covered by the NHS Quality and Outcomes Framework.

Dr Sadler also noted that "harder to reach" populations, for example in more deprived communities, tend to be less likely to take up the check, undermining its potential as a screening tool.

Another suggestion was that everyone who applies to renew their driving licence would have to submit a blood sample, which could be tested for HbA1c levels.

More Than One Answer?

There then followed a lively and in-depth discussion of the merits and limitations of various other options over the course of the next 30 minutes, after which Dr Sadler attempted to summarise the discussion.

"We haven't got 'the answer', because there probably isn't one answer," he said.

"We have heard some fairly convincing stories about the potential for primary care to do this, and obviously we know many screening programmes have been centred on primary care.

"Given the right incentives, primary care has achieved enormously good uptake levels in things from vaccinations to cytology, so I think the germ of that is already in place.

"I think we are still worried about people who either aren't registered or just don't attend", Dr Sadler said, adding that he is "drawn to the idea of screening everybody who comes into emergency departments".

While he said the costs of that need to be considered, the argument with NHS England would be that they have money to invest in treatment and care, so "some of that has to be in diagnosis".

However, Dr Sadler's final point was that all the ideas need to be tested in pilot studies to provide evidence.

"What we need to do is encourage people to think about what seems to be suitable for their environment, to do it, and to write it up and come to meetings like this, because…we still don't know whether any of these work, [yet] actually a lot of these are potentially very easily auditable."

No conflicts of interest or funding declared.

Diabetes Professional Care 2019: The Live Debate: What is the best way to identify the 'missing million' undiagnosed people living with T2 diabetes?. Presented 30th October.


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