How Updated Diabetes, Prediabetes Screening Guidelines Improve Access

In 2021, the US Preventive Services Task Force (USPSTF) recommended prediabetes and diabetes screening for adults aged 35 to 70 years with overweight or obesity, reducing the youngest screening age from 40 years in its 2015 recommendation. The USPSTF also suggested considering earlier screening in racial and ethnic groups with higher risks of diabetes at younger ages or with lower body mass index (BMI).

According to an article published in the American Journal of Preventative Medicine, this not only helps identify more adults with prediabetes and diabetes compared with the 2015 guidelines, it also helps reach more adults across all racial and ethnic groups. The 5-year adjustment also demonstrated even higher screening sensitivity and performed most similarly across all racial and ethnic groups, potentially improving early detection of prediabetes and diabetes in diverse populations.

Specifically, the updated recommendation exhibited marginally higher sensitivity (58.6%; 95% CI, 55.5-61.6) than the 2015 version (52.9%; 95% CI, 49.7-56.0), and lower specificity (69.3%; 95% CI, 65.7-72.2) than in 2015 (76.4%; 95% CI, 73.3-79.2), and within each racial and ethnic group. Screening at lower ages and BMI thresholds resulted in even greater sensitivity and lower specificity, especially among Hispanic, non-Hispanic Black, and Asian adults.

“This is the first study examining the health equity implications of the recent USPSTF recommendation for prediabetes and diabetes screening by quantifying its clinical performance characteristics,” the authors said.

These results are based on screening results of 3243 total participants. Of this group, 1261 (weighted, 37.3%; 95% CI, 35.0%-39.7%) were eligible for screening according to the 2015 USPSTF criteria, and 1451 (weighted, 43.8%; 95% CI, 41.2%-46.3%) were eligible according to the 2021 criteria.

These subsamples are representative of 80.4 million and 94.3 million US adults, respectively, corresponding to a 14.8% proportionate increase in the total population eligible for screening between 2015 and 2021.

These percentages also increased across all racial and ethnic groups, with notable increases among Hispanic (30.6%), Asian (17.9%), Black (13.9%), and White (14.0%) populations since 2015.

Sociodemographic characteristics and clinical measurements of eligible adults between the 2 years were similar. In 2021, adults were more likely to self-report Hispanic ethnicity, lower socioeconomic status, and lack of health insurance or a usual source of primary care, and newly eligible adults also had lower levels of fasting glucose and HbA1c.

Regarding increased sensitivity, the absolute increase between the 2015 and 2021 criteria was 5.7% among the total populations, with an 11.1% increase among Hispanic adults, 6.6% among Black adults, 5.5% among Asian adults, and 4% among White adults.

Using the standard recommended BMI cutoff ≥25 kg/m2, the sensitivity of both the 2015 and 2021 screening criteria was significantly lower among Asian adults compared with other groups, and specificity was significantly higher.

Overall, these findings demonstrate that the 2021 USPSTF recommendation will identify a greater proportion of US adults with prediabetes and diabetes than the 2015 criteria in all race and ethnicity groups studied.

When it comes to diagnosing diabetes and prediabetes, achieving health equity also requires addressing structural barriers, including not having a usual primary care physician, not having health insurance, or having copays for screening tests based on insurance coverage. According to the authors, these barriers to screening are especially prevalent among adults that are now eligible under the 2021 guidelines, and could be best addressed through policy efforts.

“Expanding screening eligibility will likely increase healthcare costs, which highlights a need to study the costs and cost-effectiveness of any approach that is chosen,” the authors wrote. “It could also be valuable for future research to examine the use of prediabetes and diabetes screening criteria in practice, studying their impact on diagnosis, treatment, and outcomes in diverse populations.”

Reference

O’Brien MJ, Zhang Y, Bailey SC, et al. Screening for prediabetes and diabetes: clinical performance and implications for health equity. Am J Prev Med. Published online March 24, 2023. doi:10.1016/j.amepre.2023.01.007