Although many individuals eligible for diabetes screening go untested, little is known about the contribution of patient, provider, and clinic level factors to variation in screening in clinical practice. We used electronic health record (EHR) data from an integrated safety net health system to create a retrospective cohort of non-pregnant, primary care patients age 18-64 years without diagnosed diabetes who completed ≥ 2 primary care visits from 2010-2015 across 12 clinics. Hierarchical nested 3-level and cross-classified models were used to evaluate multilevel variation in screening at the patient (age, sex, race, insurance, family history, BMI, HTN, HLD, CVD etc.), provider (attending, physician in training, advanced practitioner), and clinic (teaching vs. non-teaching) level. Of 56,818 patients, 70.4% completed screening over 3 years of follow-up with nearly two-fold variation across clinics (51-92%; p<0.001). Of those meeting ADA (69%) and U.S. Preventive Services Task Force (36%) screening criteria, three-quarters were screened (73%,74%) with almost two-fold variation across clinics (ADA 53-92%; USPSTF 49-93%). Nearly 70% of patients not eligible for guideline-based screening were also tested. Overall yield of guideline-indicated screening was similar between USPSTF and ADA guidelines for diabetes (11% vs. 9%) and prediabetes (38% vs. 36%). Among those not meeting screening criteria, the USPSTF guideline missed more cases of diabetes (6% vs. 3%) and prediabetes (26% vs. 19%) than ADA. Even after adjustment for patient, provider, and clinic factors and accounting for clustering, there was unexplained two-fold variation in screening by clinic (Median OR 1.97; intra-class correlation 0.13). Screening rates vary widely in an integrated health system and are not fully accounted for by patient, provider, and clinic factors available in the EHR. Clinical decision support and other system level interventions are needed to optimize screening practices across clinics.
U.C. Obinwa: None. I. Lingvay: Advisory Panel; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Eli Lilly and Company, Intarcia Therapeutics, Inc., MannKind Corporation. Consultant; Self; AstraZeneca, Novo Nordisk Inc., Sanofi, TARGET PharmaSolutions, Valeritas, Inc. Research Support; Self; Merck & Co., Inc., Mylan, Novo Nordisk Inc., Pfizer Inc. Other Relationship; Self; AstraZeneca, Boehringer Ingelheim Pharmaceuticals, Inc., Novo Nordisk Inc., Sanofi. L. Meneghini: Advisory Panel; Self; AstraZeneca, Novo Nordisk Inc., Sanofi-Aventis. Consultant; Self; Sanofi-Aventis. Other Relationship; Self; American Diabetes Association. E. Halm: None. M.E. Bowen: None.
National Institutes of Health (DK104065)