Finding Diabetes Mellitus Among Veterans
Condition: Diabetes Mellitus
MeSH terms: Diabetes Mellitus
Study type: Observational

Summary: 
      Population-based screening for diabetes mellitus in non-pregnant adults remains
      controversial. For a screening strategy to be successful, patients identified by surveillance
      will have to have better outcomes than if they had been diagnosed at a later, more
      symptomatic phase of disease. However, little is known about the fate of patients diagnosed
      with diabetes by screening. Additionally, while about half of the cases of diabetes among the
      general population at any given time are undiagnosed, the prevalence of undiagnosed diabetes
      among veterans is unknown. The annual incidence of diabetes among veterans is also unknown.

      Assessing risk factors prior to blood testing will improve the specificity, with little cost
      in sensitivity, of screening for diabetes in a medical center setting. The target population
      which optimizes the potential value of diabetes screening is patients with at least 1 of the
      above 3 risk factors for diabetes (obesity, hypertension, family history). Hypertension is
      strongly associated with unrecognized diabetes in veterans. VA and other health care
      providers considering whether to perform systematic screening for diabetes should use known
      risk factors to identify an appropriate target population for screening.
    

Detailed description: 
      Primary Objectives: To measure the prevalence of undiagnosed Diabetes Mellitus (DM) and the
      annual incidence of new cases of DM among veterans between the ages of 45 and 64 and to
      compare the health-related quality of life (HRQoL) of veterans with undiagnosed DM to those
      without DM but who are at comparable risk for DM, both at baseline and over three years of
      follow-up.

      Secondary Objectives: To describe the clinical state of veterans with diabetes newly
      diagnosed by screening and to describe the process of usual care for veterans with diabetes
      newly diagnosed by screening.

      Primary Outcomes: The primary outcomes are: 1) prevalence of undiagnosed
      non-insulin-dependent diabetes mellitus (NIDDM); 2) HRQoL as measured by SF-36; 3) glycemic
      control as measured by HbA1C; and 4) calculation of the 3-year direct utilization-related
      cost, from the perspective of the VA, associated with early diagnosis of DM, and comparison
      of this to the 3-year direct utilization-related cost for veterans who are screened for
      diabetes but do not have diabetes.

      Intervention: N/A

      Study Abstract: Population-based screening for diabetes mellitus in non-pregnant adults
      remains controversial. For a screening strategy to be successful, patients identified by
      surveillance will have to have better outcomes than if they had been diagnosed at a later,
      more symptomatic phase of disease. However, little is known about the fate of patients
      diagnosed with diabetes by screening. Additionally, while about half of the cases of diabetes
      among the general population at any given time are undiagnosed, the prevalence of undiagnosed
      diabetes among veterans is unknown. The annual incidence of diabetes among veterans is also
      unknown.

      A mail-out survey for this study was completed with 10,350 surveys mailed and 4,500 surveys
      returned (43%). Enrollment concluded 7/31/99 with 1,253 new subjects enrolled. Follow-up of
      the enrolled subjects is ongoing. Some descriptive analyses of the data revealed the
      prevalence of undiagnosed diabetes was 4.5%. Factors associated with unrecognized diabetes
      were the diagnosis of hypertension and history of a parent or sibling with diabetes. Having a
      primary care provider did not raise or lower the risk for unrecognized diabetes. Based on the
      new diagnosis, most patients found to have diabetes required a change in treatment either of
      their blood sugar or comorbid hypertension or hyperlipidemia in order to achieve targets
      recommended in published treatment guidelines. Patients reporting a primary care provider
      were no less likely to require a change in treatment.

      Conclusions: If diabetes screening is an effective intervention, opportunistic screening for
      diabetes may be the preferred method for screening, as there is substantial potential for
      case-finding in a medical center outpatient setting. A majority of patients with diabetes
      diagnosed at opportunistic screening will require a change in treatment of blood sugar, blood
      pressure, or lipids to receive optimal care.
    

Keywords: Diabetes Mellitus,DM,glycemic control