USPSTF recommends type 2 diabetes and abnormal blood glucose screening for adults at risk for diabetes, expanding previous criteria – October 16, 2014

The United States Preventive Services Task Force (USPSTF) recently released a draft recommendation on screening for abnormal glucose and type 2 diabetes, with a “B” recommendation calling for screening in adults who are at increased risk for diabetes, impaired fasting glucose, or impaired glucose tolerance. The guideline defines those at risk as adults 45 years or older, who are overweight or obese, or have a first-degree relative with diabetes. This new recommendation significantly expands upon the 2008 recommendation that only called for type 2 diabetes screening for individuals with high blood pressure, an important but insufficient marker. In fact, a 2013 study from the American Journal of Preventive Medicine found that the use of the 2008 USPSTF recommendations resulted in missing more than half of undiagnosed diabetes cases. The rationale for the USPSTF’s updated guideline stems from recent studies that show the benefits of lifestyle modification and long-term follow-up. Although we applaud the USPSTF for expanding the screening criteria, we also took note of the Task Force’s high bar – despite what seems like strong evidence for greatly expanded criteria, the Task Force only concluded with “moderate certainty” that expanded screening will lead to a “moderate net benefit.” From this language, we wonder what it will take to obtain an A recommendation...

The ADA, the Endocrine Society (which also participated in the review of the recommendations), and AACE have also all applauded these new guidelines in their own press releases and urged the upholding of the draft recommendation. In particular, the ADA has long been advocating for broader screening guidelines (see press releases from 2010 and 2012), arguing that it can better identify those with prediabetes and help get early treatment for those who need it. From what we understand, however, there isn’t a lot of pressure on screening and though screening is available to many, there are far more people who could take advantage of screening than do (even using the old criteria).

Diagnosing type 2 diabetes earlier should become a greater national priority – in the US, 29.1 million individuals have diabetes and an estimated eight million of those cases are undiagnosed. The estimated cost of undiagnosed diabetes is a staggering $18 billion annually, according to the ADA. Another 86 million American adults have prediabetes, and 90% of them don’t know it – see Ms. Kelly Close’s (The diaTribe Foundation, San Francisco, CA) slides on this unmet need here. All this said – there has been some improvement on this metric as we remember the old days in which nearly half of all those with diabetes were estimated to be undiagnosed (like is true today in many developing countries).

The USPSTF statement is currently available as a draft to receive public input until November 3 – please visit here if you are interested in submitting feedback.

• This updated guideline will make diabetes screening free for many more Americans, per the Affordable Care Act. As a reminder, ACA requires new insurance plans to provide preventive care without cost-sharing, but the provision of cost-free services relies exclusively on USPSTF “A” and “B” recommendations. The highly respected Ms. Shereen Arent (ADA, Alexandria, VA) stressed at this past ADA the need to work with the USPSTF to ensure that adequate free preventive services are offered to people with diabetes. This news, should it be finalized, is a victory for many advocacy groups and, in our eyes, the diabetes epidemic in the long run. We need to remove barriers to diabetes screening, and cost is certainly a low-hanging fruit – that said, many other incentives put in place to encourage screening would also be a help.
• In addition to the aforementioned criteria, the at-risk guideline includes several sub-populations: women with a history of gestational diabetes or polycystic ovarian syndrome along with certain racial/ethnic minorities (African Americans, American Indians/Alaska Natives, Asian Americans, Hispanics/Latinos, and Native Hawaiians/Pacific Islanders).
• Dr. Robert Ratner (Chief Medical Officer, ADA, Alexandria, VA) spoke enthusiastically in the ADA press release: “The American Diabetes Association is thrilled with the decision of the US Preventive Services Task Force to strengthen their recommendation and take into consideration the wealth of research pointing to the need for risk-factor based screening in type 2 diabetes. Early diagnosis of both type 2 and prediabetes is essential in improving the outcomes for these patients. Undeniable data show the efficacy and cost effectiveness of preventing diabetes. This new draft recommendation is a step in the right direction in the ongoing fight to Stop Diabetes®.”

-- by Melissa An, Adam Brown, and Kelly Close