Understanding Provider Decisions about Screening for Type 2 Diabetes Mellitus (T2DM)

in Adult Primary Care Clinics

Dina Hafez, MDDepartment of Internal Medicine and Pediatrics

Robert Wood Johnson Clinical Scholars Program (VA Scholar) VA Ann Arbor Health Care System

University of Michigan Health System

Jeffrey Kullgren, MD, MS, MPH Department of Internal Medicine

VA Ann Arbor Health Care System University of Michigan Health System

Background

• Type 2 diabetes mellitus (T2DM) is the 7th leading cause of death in the U.S.

• 29.1 million U.S. adults have T2DM– 9.3% of the population

• 86 million U.S. adults have prediabetes– 1 in 3 adults

http://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf

T2DM screening guidelines

American Diabetes Association (ADA) recommends periodic screening the following populations for T2DM:

• All individuals over the age of 45 years • Overweight adults (BMI ≥ 25) with at least

one additional risk factor such as physical inactivity, cardiovascular disease, or family history of T2DM

ADA diagnostic criteria

Prediabetes Diabetes

FPG 100-125 mg/dL5.6 mmol/L - 6.9 mmol/L

≥ 126 mg/dL ≥ 7.0 mmol/L

OGTT 140 mg/dL – 199 mg/dL 7.8 mmol/L – 11.0 mmol/L

≥ 200 mg/dL ≥ 11.1 mmol/L

HA1c 5.7% - 6.4% ≥ 6.5%

Undetected Disease

• T2DM: 25% undetected

• Prediabetes: 90% undetected

WHY DO SO MANY CASES REMAIN UNDIAGNOSED?

Specific Aims

1. To describe T2DM screening practices among primary care providers and explore patient and provider factors that affect these practices

2. To characterize primary care providers’ interpretation and clinical response to abnormal T2DM screening test results and explore patient and provider factors that influence these behaviors

3. To identify strategies primary care providers use to communicate T2DM screening test results to their patients and explore patient and provider factors that influence these strategies

Methods

Chart-stimulated recall (CSR)

• Interview strategy that utilizes the clinician’s own documentation to elucidate the rationale for specific clinical decisions

• Effective means of assessing the provider decision-making process– Colorectal and prostate cancer screening

• 3-6 CSR interviews provide valid and reliable assessment of physician behavior

Provider Recruitment

• Recruited 20 University of Michigan primary care providers

– Internal Medicine, Internal Medicine-Pediatrics, Family Medicine

– ≥ 0.5 FTEs devoted to outpatient, clinical practice

– Excluded trainees

Chart Selection • Non-diabetic patients • Age ≥ 45 years • Not screened for T2DM within year prior to

interview date • Clinic visit within 2-weeks of interview date• Stratified sampling of visit types

– Annual physical (health maintenance exam) – Return visit

Chart-stimulated Recall Interviews • Conducted in-person

• Trained medical student

• Providers had access to EMR

• 30-45 minutes in duration

• Audiotaped and transcribed

• Analyzed using modified grounded theory

Topics Covered in Interview Guide

1. Provider screening decision 2. Reason(s) for screening decision 3. Screening test used 4. Provider interpretation of test result5. Communication of result to patient6. Barriers to screening

Results

Mean age (SD) 60.2 (12.4)

Mean BMI (SD) 30.39 (6.4)

Female, N(%)  30 (61.2%)

Race Black, N(%) White, N(%)

6 (7.3%) 41 (83.7%)

Hispanic ethnicity, N(%)

0 (0%)

Patient Demographics (N=49)

Patient Comorbidities (N=49)

Hyperlipidemia 25 (46.2%) Hypertension 22 (40.7%) Active smoker 6 (11.1%) Cardiovascular disease 4 (7.4%) Prediabetes 11 (20.3%) History of gestational diabetes mellitus

0 (0%)

Polycystic ovarian syndrome 0 (0%)

Provider screening decision • Screened (N=22)

• Not screened (N=19)

• Incidentally screened (N=8)

Reasons Providers Screened

Provider reason for screening N Follow-up of previously abnormal screening test

13

Overweight or obese 10 Age 10 Hypertension 5Dyslipidemia 5High-risk ethnic or racial group 2Family History 1History of vascular disease 1Sedentary lifestyle 0

Reasons Providers Did Not Screen

Provider reason for not screening N Visit for reason other than annual physical examination

12

Aware of normal screening test result within past 3 years

10

Normal weight 2Lack of time 2Knowledge of upcoming annual physical examination 2

“ The visit that he came in for was an acute visit for a specific reason, not related to diabetes and so we didn’t discuss

screening. It looks like he had scheduled his wellness visit for the year several months in the future…”

Screening tests

• Hemoglobin A1c was the most commonly used screening test (N=15)

“ it’s something that I am more familiar and comfortable with as far as screening practices and I think it provides more clear data point over time as opposed to a one time sugar which [is not] a great indicator…”

Test Result Interpretation

• Physicians correctly interpreted T2DM screening test result the majority of the time (N=19)

• Incorrect interpretation occurred when the screening test result was within the lower limit of the prediabetic range (N=3)

“[Her Ha1c was] 5.7, which is upper limit of normal and is actually improvement from the past couple of years.”

Test Result Communication

• All test results were communicated to the patient– Written communication (N=15)– Office visit (N=4) – Telephone (N=3)

“I explained…that his blood sugars were falling in what we call pre-diabetes range, which…means that we should start talking about lifestyle changes, and other things to try to prevent progression to full blown diabetes.”

Physician-identified Barriers to Screening

• Patient-related factors“…sometimes the patient is not very receptive they have the flu. They don’t feel like…getting blood work that day.”

• Lack of time

• Absence of EMR prompts

Conclusions

• Physicians often considered previously abnormal T2DM screening test results and patient weight and age when making screening decision

• Visit type other than annual physical examination was the predominant reason physicians did not screen

• Hemoglobin A1c was the most commonly ordered T2DM screening test

• Providers usually interpret T2DM screening test results correctly and communicate result to the patient

Limitations

• Qualitative study within a single academic medical center

• Lacked NP and PA participation

• Medical student interviewers

Future Directions

• Finish coding transcripts and data analysis

• Explore physician diagnosis and treatment of prediabetes

• Targeted interventions– “Best Practice Advisory”

Thank you

• National Med-Peds Residency Association • Dr. Jeff Kullgren • Evan Martin (M3) and Daniel Nelson (M2) • Robert Wood Johnson Foundation • Ann Arbor VA Health System

QUESTIONS? dhafez@med.umich.edu

References 1. CDC - National Diabetes Statistics Report, 2014 - Publications - Diabetes DDT. Available at:

http://www.cdc.gov/diabetes/pubs/statsreport14.htm. 2. 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(15):1577–1589.3. Tuomilehto J, Lindström J, Eriksson JG, et al. Prevention of type 2 diabetes mellitus by changes

in lifestyle among subjects with impaired glucose tolerance. N Engl J Med. 2001;344(18):1343–1350.

4. Group DPPR, others. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346(6):393.

5. The Diabetes Prevention Program Research Group. The 10-Year Cost-Effectiveness of Lifestyle Intervention or Metformin for Diabetes Prevention: An intent-to-treat analysis of the DPP/DPPOS. Diabetes Care. 2012;35(4):723-730. doi:10.2337/dc11-1468.

6. Dall TM, Narayan KM, Gillespie KB, 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(1):12.

7. Sheehy AM, Flood GE, Tuan W-J, Liou J, Coursin DB, Smith MA. Analysis of Guidelines for Screening Diabetes Mellitus in an Ambulatory Population. Mayo Clin Proc. 2010;85(1):27-35. doi:10.4065/mcp.2009.0289.

References8. Ealovega MW, Tabaei BP, Brandle M, Burke R, Herman WH. Opportunistic screening for diabetes

in routine clinical practice. Diabetes Care. 2004;27(1):9–12.9. Schmittdiel JA, Adams SR, Segal J, 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(2):565-568.

10. 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(12):1681-1688. doi:10.1007/s11606-007-0396-9.

11. 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(7):901-907.

12. Rochefort CM, Morlec J, Tamblyn RM. What differentiates primary care physicians who predominantly prescribe diuretics for treating mild to moderate hypertension from those who do not? A comparative qualitative study. BMC Fam Pract. 2012;13(1):9.

13. Chart audit and chart stimulated recall as methods of needs assessment in continuing professional health education - Jennett - 2005 - Journal of Continuing Education in the Health Professions - Wiley Online Library. Available at: http://onlinelibrary.wiley.com/doi/10.1002/chp.1340180306/abstract. Accessed July 28, 2014.

 

T2DM screening practices: University of Michigan Health System

• Retrospective chart review

• 8,286 non-diabetic patients ≥ 45 yrs

• 5,752 patients (69%) were appropriately screened

• 202 patients (4%) had abnormal test results, but only 77 patients (38%) had appropriate follow-up

Ealovega MW, Tabaei BP, Brandle M, Burke R, Herman WH. Opportunistic screening for diabetes in routine clinical practice. Diabetes Care. 2004;27(1):9–12.

Chart-stimulated recall

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(4):376-392.

Chart-stimulated recall

Rochefort CM, Morlec J, Tamblyn RM. What differentiates primary care physicians who predominantly prescribe diuretics for treating mild to moderate hypertension from those who do not? A comparative qualitative study. BMC Fam. Pract. 2012;13(1):9.

Chart-stimulated recall

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(7):901-907.

Sample CSR Protocol

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(7):901-907.

Sample CSR Protocol

Barriers and facilitators

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(7):901-907.

1. Identification / management of prediabetes

Group DPPR, others. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346(6):393.

2. Early Detection of T2DM

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(15):1577–1589.

Unanswered questions

1. What factors influence provider T2DM screening practices?

2. How do providers interpret T2DM screening test results and what factors influence clinical response?

3. What strategies do providers use to communicate T2DM screening test results to patients?