Thursday, August 28, 2008

The Missed Patient with Diabetes

Xuanping Zhang and colleagues from the CDC have just published an interesting paper on the prevalence of undiagnosed diabetes. Using data from NHANES (a nationally representative survey), they found that adults without insurance are more likely to have undiagnosed diabetes than those with insurance. Being uninsured for more than a year was associated with 2.5-fold increased risk of having diabetes without a dignosis.

The main message, of course, is that we need much broader (dare I say "universal?") health coverage so we can intervene early and prevent the nasty complications of diabetes. However, Charlie MacLean (my nearly silent partner) brought up an interesting issue: What about insured patients? How often do we miss them? Can we use the laboratory registry to find folks with incidental blood sugar results that warrant a diagnostic work-up?

There are (at least) a few problems: What thresholds should we use? Probably 126 mg/dl for fasting and 200 mg/dl for non-fasting samples to start. Eventually, we could probably work out the risk of diabetes at lower levels of glucose.

How many are there? Damon Lease, our colleague who has done quality management at a small community hospital guestimates that he finds a few dozen a month. A regional registry might find many, many!

Whom should we notify? A blood sugar ordered as part of a chemistry profile in, say, the ER, might get overlooked in the hurly-burly of that setting. The best person to judge its significance and orchestrate follow-up is the Primary Care Provider. However, figuring out who the PCP is from administrative data (and even an EHR) is fraught with difficulty.

So, there are some challenges, but we may be able to take a bite out of the missed diabetes problem.


The Missed Patient With Diabetes: How access to health care affects the
detection of diabetes
Xuanping Zhang, Linda S. Geiss, Yiling J. Cheng, Gloria L. Beckles, Edward
W. Gregg, and Henry S. Kahn
Diabetes Care 2008;31 1748-1753


  1. Ben,

    I have a system in place at our small community hospital to notify the providers when a glucose test exceeds exactly the boundaries you mentioned. It's the non-fasting glucoses that are the most interesting in some ways, because the tests are usually ordered for some reason other than a suspicion of diabetes.

    Each of our primary care providers receives a color-coded report from me every two months. Every patient on their list who wasn't there two months ago is flagged by the color green. In many cases, the provider is well aware by that time that the patient is diabetic. But, when the patient shows up on the list and the provider is "surprised" to see the name, it's usually because the patient had a high non-fasting glucose result as part of some sort of standard metabolic panel - something a harried, overworked primary care provider might miss or dismiss easily.

    Yes, an EHR/EMR system can help with this kind of monitoring by raising flags to the provider, but like you, I wonder just how many patients are out there, where a clue to diabetes has been provided to the provider, and it's been missed.

  2. Damon,

    That sounds like an excellent system! How do you handle labs not ordered by the PCP? Do you already know who the PCP is for all patients?


  3. Ben,

    We have an advantage of having a hospital where all providers are employed by the hospital itself. This gives us the ability to focus on labs for those patients "owned" in our data system by one of our providers. All of our providers use our lab for tests that can be done here.

    In theory, I could provide the same data to local private practices that use our lab for testing, but then I'd be competing against Vermedx, rather than focusing on primary care within our hospital.

    I do pull all labs that we do here in our hospital, but I miss labs performed at other hospitals. So, if one of our diabetic patients gets DM care at the VA or at DHMC or at FAHC, I have to mark them as "cared for elsewhere" in our system. Their provider still double-checks that other visits are ongoing, but the lab tests are not available to me.

    The sharing of those tests in some sort of HIE network is my dream for the future.

    Right now, I'm also doing a similar project for cancer screening, but many of our patients have had mammos and colonoscopies done elsewhere. I have no access to those results at present, and it's up to the patient to provide the doctor with the information, which is then passed to me thirdhand.


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