Emergency Department Screening Program Useful in Identifying Undiagnosed Diabetes

Kirstie K. Danielson, PhD

New research into an urban emergency department (ED) screening program suggests its usefulness in identifying undiagnosed type 2 diabetes (T2D).

The program identified a substantial number of patients with undiagnosed prediabetes or T2D or undermanaged disease and was particularly helpful in identifying racial and ethnic minority individuals and low-income patients

“Questions remain including whether this approach could be useful in EDs in similar urban settings or rural communities and whether targeting outreach to those with high HbA1c levels will be more cost-effective,” wrote corresponding author Kirstie K. Danielson, PhD, Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, University of Illinois Chicago.

Urban EDs often serve as primary care for racial and ethnic minorities and underserved patients who have the highest burden of T2D. As Danielson notes, ED screening for T2D in underserved populations that are built into daily clinical care and use clinical recommendations have not been developed. Based on the institution’s successful implementation of ED screening for HIV and hepatitis C virus, the team developed and piloted an ED T2D screening program.

The program was piloted in a Chicago ED from February – April 2021 and followed the STROBE reporting guideline. A best practice alert (BPA) was built into the electronic medical record (EMR) that flagged ED patients at risk for T2D. Clinicians were given the option to add hemoglobin A1c (HbA1c) measurements if the blood was drawn.

The screening was based on American Diabetes Association recommendations in place during development: all patients 45 years or older or those aged 18 to 44 years with a body mass index of ≥25 and with no history of diabetes and no HbA1c measurement in the last 3 years in the EMR. Since HbA1c measures were not immediate, patients were called to provide results and inquire about prior awareness and treatment of diabetes.

A total of 8441 patients visited the ED during the pilot study and the BPA triggered tests for 2576, of whom 2074 had an HbA1c result. Of these patients, 1085 patients (52.3%) had an abnormal result.

This included 758 (69.9%) with prediabetes (HbA1c level, 5.7% - 6.4%) and 327 (30.1%) with diabetes (HbA1c level, 6.5%). When using an international definition, 342 patients (31.5%) had prediabetes (HbA1c level, 6.0% - 6.4%). Of those in the diabetes range, 62 patients had severe diabetes (HbA1c level, 10%).

Of the 352 patients contacted by telephone and making up the study sample, the mean age was 52.2 years, 192 (54.5%) were women and 160 (45.5%) were men. Further demographic data show 69 (19.6%) were Hispanic, 228 (64.8%) were non-Hispanic Black, 34 (9.7%) were non-Hispanic White, and 21 (6.0%) were non-Hispanic Other (Asian, >1 race and ethnicity, or unknown race or ethnicity).

The median income of patients' zip codes was at the 44th percentile of the US income and 176 patients (50.0%) had public insurance, while 14 (4.0%) were uninsured. Results indicate 88 patients (25.0%) self-reported a previous diagnosis of diabetes or T2D, but only 51 of these patients (58.0%) reported receiving treatment.

“Next steps involve testing implementation strategies to link these new patients to diabetes education and care,” Danielson wrote.

The research letter, “Prevalence of Undiagnosed DIabetes Identified by a Novel Electronic Medical Record Diabetes Screening Program in an Urban Emergency Department in the US,” was published in JAMA Network Open.