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Medical News & Perspectives
November 6, 2019

Study Identifies Primary Care Knowledge Gaps and Barriers in Type 2 Diabetes Prevention

JAMA. Published online November 6, 2019. doi:https://doi.org/10.1001/jama.2019.18024

With an interest in improving disease prevention in primary care, Eva Tseng, MD, MPH, chose a condition ripe for progress: prediabetes. “This is one of the areas where we have an opportunity to prevent a bad illness from happening,” said Tseng, an assistant professor in the Division of General Internal Medicine at the Johns Hopkins School of Medicine.

Even so, a question looms: How well-equipped are primary care physicians and the US health system to manage patients with prediabetes? In a recent study, Tseng and her colleagues surveyed nearly 300 primary care physicians to find out. They uncovered some critical deficiencies in physicians’ knowledge about prediabetes as well as serious system-level barriers that challenge their ability to provide optimal care.

“There were some clear gaps that were identified,” said Eric Johnson, MD, chair of the American Diabetes Association’s Primary Care Advisory Group, who wasn’t involved in the study. “Some of it was knowledge of risk factors; some of it was using evidence-based recommendations.” And some of it is the health care infrastructure in which physicians work, Tseng said.

“I think the larger barriers really come from [the lack of] resources that are available for physicians to manage these patients,” she noted. Considering that 90% of the 84 million US adults with prediabetes aren’t aware they have it, filling the knowledge gaps and removing barriers are central issues in preventing type 2 diabetes.

Measuring the Gaps

Tseng and her colleagues surveyed 1000 primary care physicians selected randomly from the American Medical Association (AMA) Physician Masterfile. Of the 888 who were eligible to participate, 298 (33%) responded to questions asking about prediabetes risk factors, diagnostic criteria, guidelines recommendations, and clinical management as well as barriers to and interventions for improving prediabetes management.

On average, the physicians surveyed chose only 10 of 15 correct risk factors for prediabetes. The risk factors they most often missed were being of African American or American Indian race. Many physicians also weren’t familiar with prediabetes diagnostic criteria, which Johnson found surprising. Of those surveyed, 42% knew the correct range for fasting glucose levels and only 31% knew the accurate hemoglobin A1c (HbA1c) range.

“Those numbers have been pretty well publicized for the last decade or so,” said Johnson, also an associate professor of family and community medicine at the University of North Dakota School of Medicine and Health Sciences. “I work in a diabetes center on my clinic side, and I know that we’re certainly aware of those, and we do everything we can to promote those to our health care system.”

Without knowledge of risk factors and diagnostic criteria, misdiagnoses occur. “We found that 25% of [primary care physicians] may be identifying patients as having prediabetes when they actually have diabetes,” Tseng said. “That’s definitely an issue if people aren’t recognizing what are the criteria and how to appropriately manage those patients depending on whether they fall into the prediabetes range or diabetes range.”

”Eye-opening” Lack of Referrals

Guidelines from the American Diabetes Association point to strong evidence supporting a structured lifestyle intervention to prevent people with prediabetes from developing type 2 diabetes. Findings published in 2002 by the Diabetes Prevention Program (DPP) Research Group showed that intensive lifestyle changes that lead to at least a 7% weight loss and 150 minutes weekly of physical activity can reduce the incidence of diabetes by 58% in people at high risk of the disease.

Yet, only 36% of physicians in Tseng’s study said referral to an intensive lifestyle change program like the DPP would be their initial approach, even though 93% said diet and physical activity counseling would be their first step in managing prediabetes. Only 8% correctly identified 7% as the recommended amount of weight loss—a more achievable goal for patients than the 10% weight loss that most physicians in the study said they recommended for their patients.

“It’s been 17 years since that first [DPP] study was published, and it’s been redone in a number of different settings,” noted Megha Shah, MD, MSc, an assistant professor in the Department of Family and Preventive Medicine at the Emory University School of Medicine. “So, it’s very eye-opening that a lot of what people have studied and published in the literature hasn’t really made it to people practicing in community settings.” If she were to give physicians in the survey a grade, Shah said it would be a C+.

But some findings were encouraging. In the DPP study, metformin reduced the incidence of diabetes by 31%. In Tseng’s study, 43% of the physicians said they discussed starting metformin for prediabetes and 57% said they prescribe the drug for up to 25% of their patients. Fifteen percent of physicians in the survey said they never prescribe metformin for prediabetes.

Kate Kirley, MD, MS, director of chronic disease prevention at the AMA, said the metformin numbers were higher than she expected, reflecting greater physician awareness of treatment options for prediabetes. “Nevertheless, it’s still a minority of physicians who are aware of these evidence-based treatment options,” she added.

Barriers Block Physicians’ Efforts

Despite the knowledge gaps, Tseng said primary care physicians recognize that it’s important to manage prediabetes and that the condition can increase their patients’ risk of developing type 2 diabetes. However, the study revealed substantial systemic barriers that physicians said interfere with prediabetes management.

Basic resources for improved nutrition and physical activity such as grocery stores that sell healthy foods and safe community spaces for physical activity are scarce in some areas. Insurance coverage for diabetes prevention programs often is inadequate and technology is needed to help streamline the clinical workflow for physicians.

“Tools that could facilitate automatic ordering of follow-up labs and referral of these patients to diabetes prevention programs” could minimize some of the barriers physicians face, Tseng said. “If electronic health records are not appropriately flagging prediabetes, busy practices and busy clinicians might just miss that,” Shah noted.

The system Shah works with at Emory flags patients with an HbA1c of 5.7% or greater. At Johns Hopkins, Tseng said laboratories flag patients’ test results that are in the prediabetes range. She and her colleagues can then use the Maryland Department of Health website to connect patients who have prediabetes with diabetes prevention programs. “I think some of these connections are starting to form and we will definitely see many things coming up in the next couple of years,” Tseng said.

Johnson noted that his employer, the University of North Dakota, now offers a diabetes prevention program for its employees. “That’s been very well received,” he said. Nearly 2000 organizations now offer evidence-based programs that meet Centers for Disease Control and Prevention (CDC) standards. Their individual locations in every state and Puerto Rico are on the CDC website.

But national availability doesn’t always add up to easy accessibility for patients. The programs are structured, with a set number of visits over a specified period with specific weight loss and physical activity goals. “Sometimes in a rural area, just getting enough patients together to start a group and get them going together…it’s hard to do this,” Johnson said.

In Georgia, where Shah practices, 40% of her patients have Medicaid coverage, but Medicaid doesn’t cover the diabetes prevention programs. Some that are offered through a CDC-YMCA partnership may have a reduced cost, “but that’s still a barrier to a lot of patients,” she said.

What’s more, Shah noted, those community-based diabetes prevention programs encourage people to participate but they overlook physicians. “A lot of their advertising and targeting doesn’t really focus on getting physicians to refer patients,” she observed.

Campaigns Raise Awareness

In response to the growing body of evidence about prediabetes and diabetes prevention, some professional organizations developed new guidelines and others launched awareness campaigns for physicians and patients. The CDC and AMA partnered to support both.

“The CDC takes the lead on expanding the availability of the diabetes prevention programs and we take the lead on connecting with physicians and health care teams to solve some of the system challenges that came up in [Tseng’s] article,” said the AMA’s Kirley. As an example, she cited a program in which the AMA worked with Henry Ford Macomb Hospital near Detroit to integrate more clinical decision-making tools into its electronic health record. The modifications helped physicians to more effectively identify patients with prediabetes and refer them to diabetes prevention programs.

“They saw several hundred referrals to the diabetes prevention program generated in the first several months of that project and it continues to grow almost exponentially,” Kirley said.

In addition to guidelines, the American Diabetes Association publishes an abridged version of its Standards of Medical Care in Diabetes that contains evidence-based recommendations most applicable to primary care settings. “That would include some prediabetes materials,” said Johnson, who works on the abridged standards.

At its scientific sessions, the diabetes association also sponsors Diabetes Is Primary, a dedicated day for primary care physicians. The program is presented on its own in various locations throughout the year and it’s made available in podcasts.

“[There] seems to be a general shift toward more awareness than we used to have,” Kirley said. “It’s encouraging…but we still have a long way to go.”

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