identifying and managing pre-diabetes: a systematic review of screening and intervention studies
TRANSCRIPT
IDENTIFYING AND MANAGING PRE-DIABETES: A SYSTEMATIC REVIEW OF
SCREENING AND INTERVENTION STUDIES
Dr Eleanor Barry, Dr Samatha Roberts, Dr Shanti Vijayaraghavan, Dr Jason Oke and Professor Trisha Greenhalgh
Project Aims
• Estimate and map at risk population
• Systematic Review• Identification & Interventions • Engagement• Cost-effectiveness and affordability
• Pilot Intervention
• Evaluate intervention
Newham
• Poverty• Unemployment• Overcrowding• Ethnic makeup • Diabetes and GDM
Systematic Review
Embase/Medline search
Abstract extraction
and full paper review
Meta-analysis
Three Systematic
Reviews
• 2853 abstracts• 49 test papers• 49 intervention trials
Test Accuracy
Studies using HbA1c as index test and OGTT as reference standard.
Sensitivity 0.49 (CI 0.40-0.58)Specificity 0.79 (CI 0.73- 0.84AUROC 0.71Partial AUROC 0.59
Test Accuracy
Studies using FPG as index test and IGT as reference standard.
Sensitivity 0.25 (CI 0.19 to 0.32)Specificity 0.94 (CI 0.04 to 0.08)AUROC 0.72Partial AUROC 0.422
Test PrevalenceAnalysis of Pre-Diabetes Prevalence by Diagnostic Test using WHO and IEC criteria in UK population.
Data extracted from Mostafa et al doi:10.1016/j.diabres.2010.06.008
HbA1c IGT
IFG
Of those who had an abnormal test:-Isolated IFG- 4.7%Isolated IGT- 24.4%Isolated HbA1c- 47.8%IFG+IGT -2.9%IFG +HbA1c -4.1%IGT +HbA1c -12.2%IGT+IFG+Hba1c -3.9%
N= 8696, Prevalence 27.2%
Test selection
Why is this important?
• Each test reflects a different underlying process.
• Different rates of progression.
• Behave differently.
• Commissioning implications.
• Trials still use OGTT/IGT as gold standard in patient selection.
Lifestyle InterventionsForrest Plot 1: Relative risk reduction at the end of the trial
Lifestyle Interventions
Forrest Plot 2: Relative risk reduction at follow up post intervention
Real World Applicability
Pre-Diabetes population
71% Eligible RCT
33% Randomised
27% Completed trial
Qualitative review
Extracted from Greenhalgh et al DOI: 10.1186/s12916-015-0360-1
Newham Strategies
38,940 people QDS
>20%NHS DPP and LES
Population based approach
Gestational Diabetes
Conclusions• Who is most at risk?• HbA1c correctly identifies half of people at high risk of
DM• HbA1c abnormal in twice as many people
• Individualised interventions• Intervention at least 2-3 years in length and intensive at
onset• Surrogate outcomes do not equal diabetes incidence
reduction• What about everyone else?
• Disconnect between literature
• Explore underlying complexity of condition.
