Many patients at risk for T2D in clinical practice remain unscreened. Scalable, EHR-driven strategies are needed to assess glycemic risk and improve screening in health systems.

We developed and implemented an automated, EHR risk score linked to clinical decision support (CDS) to detect undiagnosed dysglycemia (PDM+T2D). The risk score (random glucose, age, race, BMI, hypertension) was linked to an Epic reporting workbench (RWB) and used by clinic nurses to bulk-order screening HbA1cs and notify patients. We deployed 2 patient outreach strategies in 2 clinics: 1) population health, inviting high-risk patients for screening with letters, regardless of scheduled appointments; 2) pre-visit labs with text notification 2 weeks before scheduled clinic appointments.

Using mixed-methods, we report patient response rates, case-finding yields, and acceptability. Over 6 months, 754 patients (mean age 55; 80% female; 49% Hispanic, 32% non-Hispanic Black; mean BMI 32) had screening tests ordered. Patient response rates were similar for the population health (N=404) and pre-visit lab (N=350) strategies (40% vs. 34%; p=0.12). Of those screened with the population health strategy (N=162), 45% had PDM and 3.7% had T2D. Of those screened with the pre-visit lab strategy (N=120), 48% had PDM and 5% had T2D. In surveys, stakeholders (N=16) reported the intervention was appealing (75%), easy to use (68%), and not time consuming (100%). One interviewee said, “It’s not a time-eating monster,” and noted, “It’s very user friendly, and the end result is something happens without me having to put a lot of labor into it⋯it can find something that changes a person’s life.”

Automated CDS for T2D screening and patient outreach is feasible in real-world primary care using existing resources. Population health and pre-visit outreach strategies had similar response rates with case yields reflecting the rates of undiagnosed PDM and T2D in the U.S. population.


P.M. Chen: None. R.T. Higashi: None. S.J.C. Lee: None. I. Lingvay: Consultant; Self; AstraZeneca, Boehringer Ingelheim Pharmaceuticals, Inc., Eli Lilly and Company, Intarcia Therapeutics, Janssen Pharmaceuticals, Inc., MannKind Corporation, Novo Nordisk A/S, Sanofi, TARGET PharmaSolutions, Valeritas, Inc. Other Relationship; Self; Novo Nordisk A/S. L. Meneghini: Advisory Panel; Self; Novo Nordisk Inc., Sanofi US. Consultant; Self; Applied Therapeutics, Sanofi US. E. Obialo: None. S. Kassa: None. E. Halm: None. M.E. Bowen: None.


National Institute of Diabetes and Digestive and Kidney Diseases (DK104065)

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