Screening for Abnormal Glucose Metabolism in Patients at Risk of Developing Diabetes

Percentage of adult patients with risk factors for type 2 diabetes who are due for glycemic screening for whom the screening process was initiated during the measurement period

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This measure was developed by the American Medical Association with support from a measure development team at Health Services Advisory Group and a technical expert panel (TEP) that included representatives from stakeholder organizations, guideline developers, quality measure experts, payers, clinical operations, and patients/caregivers.

This measure is critical to identifying patients with prediabetes who may benefit from interventions to prevent type 2 diabetes and identification of undiagnosed type 2 diabetes. The Centers for Disease Control and Prevention (CDC) estimates that approximately 96 million American adults have prediabetes.[1] They note that more than 80% of adults with prediabetes are not aware that they have the condition. Regular screening for prediabetes is a critical first step to helping patients avoid the disability and costs associated with progression to type 2 diabetes. 

The measure gives credit for three types of tests that can be used to detect abnormal glucose metabolism: HbA1c, oral glucose tolerance, and fasting plasma glucose. When considering which plasma glucose screening codes to include in the measure, the measure development team carefully considered two potential unintended consequences related to the limited use of accompanying fasting status codes. If the measure specified plasma glucose screening too narrowly, it could incentivize over screening, which would impose added burden on clinicians and increased costs to some patients. Alternatively, if the measure specified plasma glucose screening too broadly, it could give credit for non-fasting plasma glucose tests that are not adequate for diagnostic purposes.   

In the test data, the most common plasma glucose code ordered by both sites was LOINC 2345-7, which does not specify ‘fasting’ in the test description. However, one of the practices also consistently used an accompanying LOINC code, 49541-5, which is used to indicate a patient’s fasting status at the time of the lab.  Approximately 90% of the 2345-7 plasma glucose tests were fasting according to the 49541-5 LOINC. The team also found that lab companies (e.g., Labcorp) advise patients to fast for at least 8 hours ahead of the 2345-7 plasma glucose blood draw. Code 2345-7 is the glucose test included in basic and comprehensive metabolic panels in serum or plasma, which also recommend fasting for at least 8 hours prior to the blood draw. 

A sensitivity analysis compared the measure denominator and numerator with and without the plasma glucose code 2345-7 and found that excluding that code would overestimate the denominator population eligible for screening by approximately 110% and undercount patients with an adequate screening in the numerator by approximately 85%. Including plasma glucose code 2345-7 would underestimate the denominator population by approximately 3% and overcount patients with adequate screening in the numerator by approximately 5%. Therefore, the measure specifications give credit for plasma glucose code 2345-7 because the risk of encouraging over-testing and imposing additional costs on patients outweighs the risk of accepting a relatively small number of non-fasting plasma glucose test results. If the accompanying fasting status LOINC code for glucose tests is used more reliably in the future, the measure can be modified to require fasting for all plasma glucose tests but, in the meantime, the technical expert panel agreed that this approach is acceptable given the benefits of screening and low risk of unintended consequences.

The following evidence statements are quoted verbatim from the clinical guidelines:

Evidence Supporting Denominator Criteria: 
Inclusion Criteria
The USPSTF recommends screening for prediabetes and type 2 diabetes in adults aged 35 to 70 years who have overweight or obesity. Clinicians should offer or refer patients with prediabetes to effective preventive interventions.[2] (Grade B)

Exclusion Criteria
Evidence on the optimal screening interval for adults with an initial normal glucose test result is limited. Cohort and modeling studies suggest that screening every 3 years may be a reasonable approach for adults with normal blood glucose levels.[2] 

Evidence Supporting Numerator Criteria: 
Prediabetes and type 2 diabetes can be detected by measuring fasting plasma glucose or HbA1c level, or with an oral glucose tolerance test. A fasting plasma glucose level of 126 mg/dL (6.99 mmol/L) or greater, an HbA1c level of 6.5% or greater, or a 2-hour post-load glucose level of 200 mg/dL (11.1 mmol/L) or greater are consistent with the diagnosis of type 2 diabetes. A fasting plasma glucose level of 100 to 125 mg/dL (5.55-6.94 mmol/L), an HbA1c level of 5.7% to 6.4%, or a 2-hour post-load glucose level of 140 to 199 mg/dL (7.77-11.04 mmol/L) are consistent with prediabetes.[2]

Higher score indicates better quality

Reference Type: CITATION

Reference Text: '[1] Prevalence of prediabetes among adults. Centers for Disease Control and Prevention, 30 Sept. 2022, https://www.cdc.gov/diabetes/data/statistics-report/prevalence-of-prediabetes.html. Accessed 14 Nov. 2022.'

Reference Type: CITATION

Reference Text: '[2] Davidson KW, Barry MJ, Mangione CM, et al. Screening for Prediabetes and Type 2 Diabetes: US Preventive Services Task Force Recommendation Statement. Jama. 2021;326(8):736-743.'

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The measure is limited to patients aged 35 to 70 with overweight or obesity because it is recommended that all patients with those risk factors be screened for diabetes at least once every three years. However, this measure is not intended to discourage screening at younger ages, which the USPSTF recommends considering for adults with overweight or obesity and any of the following risk factors: 

  - Race/ethnicity with disproportionately high incidence and prevalence of diabetes (American Indian/Alaska Native, Asian American, Black, Hispanic/Latino, or Native Hawaiian/Pacific Islander persons) 
  - Family history of diabetes
  - History of gestational diabetes
  - History of polycystic ovarian syndrome

It is recommended that every patient evaluated by this measure also identify payer, race, ethnicity, and sex, so that results may be reported back to the provider in a stratified manner. If the measure is used for accountability purposes, only the overall rate should be used.

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All patients with at least two office visits or one preventive visit during the measurement period who have the following risk factors for type 2 diabetes:
  - Most recent BMI ≥25 kg/m2 (BMI ≥23 kg/m2 for Asian patients) during measurement period AND
  - Age 35-70 at start of measurement period

All patients in the initial population

- Patient is pregnant during measurement period 
- Patient with diagnosis of advanced illness or limited life expectancy during measurement period
- Patient with diagnosis of diabetes during 2-year look-back period
- Patient with diagnosis of prediabetes during 2-year look-back period
- Patient with glycemic screening performed during 2-year look-back period

Patients who had a glycemic screening test performed and result documented during the measurement period

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1) Ethnicity
2) Race
3) Payer 
4) Sex

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