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Using EHR’s to Track Prediabetes Recognition and Treatment

How quickly are clinicians identifying prediabetes in their patients, and then following up and treating it?… 

With an estimated one-quarter of Americans prediabetic it is more important than ever to look at ways to prevent progression of prediabetes to type 2 DM. Lifestyle changes and initiation of metformin are some methods that are proven to prevent or slow the progression to T2DM. Methods such as these are often underutilized as screening and treatment of prediabetes has been reported as very limited. A study by Schmittdiel, J. et al was designed to examine the clinical response to incident prediabetes range blood glucose levels in a large, integrated health delivery system.

This study was a retrospective cohort study that obtained its patients from the integrated EHR, which combines diagnosis, utilization, pharmacy, and laboratory records. The incident prediabetes cohort was made by selecting all patients in the system age 18 and older with laboratory defined prediabetes (FPG 100-125 mg/dL or A1C 5.7-6.4%) between Jan 2006 and Dec 31, 2010. Patients that were excluded from the cohort were those that had tested in this range within the last 2 years, those with a preexisting diagnosis of diabetes or prediabetes during this time, and those that progressed to diabetes within the first six months after their first laboratory value was recorded. The clinical responses to the first FPG or A1C values in the prediabetes range as classified above were determined by analyzing EHR data for 6 months following the patient’s classification as "prediabetic". The responses that were tracked include the following: retesting of blood glucose values, a recorded diagnosis of prediabetes or hyperglycemia, a metformin prescription fill, or a referral/visit to health education or nutritional services. Text-string searches within the EHR record progress notes were also used to look for documentation of a clinician-patient discussion of prediabetes or its management using search terms such as diet, lifestyle changes, diabetes, etc.

Of the 368,053 patients included in the prediabetes cohort, 43.5% of patients had evidence of a clinical response within 6 months. Metformin was initiated in less than 1% of patients, and less than 5% were referred to a program on wellness, health education or lifestyle changes. Clinical response rates were found to be greater in patients with higher FPG and A1C values, especially those with initial FPG values of 120-125 mg/dL.

The findings of this study show that those with the highest immediate risk of developing diabetes (based on higher baseline BG levels and higher BMI) were more likely to have some sort of clinical follow-up. Metformin use, however, was low amongst all patients and did not increase in those at highest risk. One possible reason for the lack of lifestyle interventions and metformin initiation may be a lack of evidence-based guidelines showing providers how to appropriately care for patients diagnosed with prediabetes. Additional research that looks at which evidence-based guidelines for prediabetes are most effective in improving outcomes in these patients would be beneficial, as well as how to encourage adoption of these guidelines in healthcare settings. There are some limitations to this study, including that results may not reflect care found in other settings. Also, text notes were searched in clinician’s progress notes and used as evidence of diabetes counseling. These notes may not be reflective of all prediabetes discussions that occurred between the patient and the physician as only certain search terms were used. Despite these limitations, the results of this study show that recognition and treatment of prediabetes are low, and further efforts need to be made to improve identification of prediabetes and its subsequent treatment.

Practice Pearls:
  • Patients with prediabetes who are at higher risk of developing T2DM due to elevated FPG or A1C values had higher rates of clinical follow-up and treatment.
  • Metformin initiation rates were low among all patients despite evidence showing it is effective at reducing the risk of progression to diabetes. 

Schmittdiel, J. et al. "Novel Use and Utility of Integrated Electronic Health Records to Assess Rates of Prediabetes Recognition and Treatment: Brief Report From and Integrated Electronic Health Records Pilot Study" Diabetes Care. 2014; 37(2): 565-568.