Interventions uncommon for prediabetes in primary care

Patients with prediabetes often don't receive recommended interventions to prevent diabetes progression, a recent study found.

Researchers at Johns Hopkins University in Baltimore used linked claims and data from electronic health records (EHRs) to perform a retrospective cohort study examining the care of patients with prediabetes and their risk for diabetes development. In a cohort of adults who had prediabetes based on laboratory measures from February 2016 to February 2021, the study measured ordering and completion of clinical services targeting prediabetes management and diabetes incidence over 12 months. Patients with a history of diabetes, those who had recently taken steroids, and those who had been pregnant in the past six months were excluded. Prediabetes was defined as an HbA1c level of 5.7% to 6.4% or a fasting glucose level of 100 to 125 mg/dL (5.6 to 6.9 mmol/L). As the EHR did not designate fasting status, the authors included only blood sugars drawn between 6 a.m. and 10 a.m. The results were published March 2 by the Journal of General Internal Medicine.

Overall, 3,888 patients with a laboratory diagnosis of prediabetes were included in the study cohort. One quarter had incident prediabetes at cohort entry, and the remainder had prevalent prediabetes. Mean age was 63 years, 65% were female, 55.0% were White, 34.5% were Black, and 3.0% were Hispanic. Over 12 months from cohort entry, 63.4% of patients had repeated glycemic testing, 10.4% had a primary care visit with a coded diagnosis of prediabetes, 1.0% were referred for nutrition services, and 5.4% were prescribed metformin. Patients usually completed laboratory orders and nutrition visits after referral and filled metformin prescriptions when they received them (79.2%, 75.7%, and 76.3%, respectively). Those with a higher glycemic level or body mass index (BMI) were more likely to receive clinical care for prediabetes. Within 12 months of cohort entry, 6% of patients with prediabetes had progressed to diabetes, and those who did were more likely to be Black, to have higher glycemic levels, and to have a BMI of 30 kg/m² or greater. In an adjusted model, Black patients had 1.44 times higher odds of developing diabetes than White patients.

Among other limitations, the data came from only one health system and part of the study took place during the COVID-19 pandemic, which could have affected lab completion rates, the authors noted. They concluded that approximately 6% of patients with prediabetes develop diabetes over one year of follow-up but that rates of clinical care activities targeted at prediabetes remain low. “Strategies to improve prediabetes diagnosis, [diabetes prevention program] and nutrition referrals, and metformin prescribing are urgently needed to improve prediabetes care delivery with the goal of preventing or delaying incident diabetes,” the authors wrote.