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Jackson SL, Olson DE, Wilson P, Venkat Narayan KM, Weaver J, Michaels JA, Varughese R, Jasien C, Byrd-Sellers J, Phillips LS. Screening Detects Highly Prevalent Undiagnosed Diabetes and Prediabetes in Veterans Receiving Primary Care, but A1c Misclassifies Patients. Paper presented at: American Diabetes Association Annual Scientific Session; 2011 Jun 24; San Diego, CA.
Screening to detect unrecognized dysglycemia is recommended, but the best methods to use and "real world" yield from screening in primary care are unknown. Since the quality of primary care in the VA is high, we examined the use of A1c for opportunistic screening at VA primary care visits. Screening was offered to patients meeting NIDDK/ADA guidelines: without known diabetes, and with age > 45 yr or BMI > 25 kg/m2 with another risk factor. An OGTT identified hyperglycemia classified by ADA criteria, and A1c findings were evaluated according to International Expert Committee (IEC, prediabetes 6.0-6.4%, diabetes > 6.5%), ADA (5.7-6.4% and > 6.5%), and new VA/Dept of Defense (VA, 5.7-6.9% and > 7.0%) guidelines. The 680 subjects were 96% male, 73% black, and 26% white, with average age 58 yr and BMI 30. By OGTT, 11% had diabetes (DIAB) and 41% prediabetes (PRE). In patients with DIAB by OGTT, A1c classification was incorrect in 76% by IEC criteria, 76% by ADA, and 87% by VA. With PRE by OGTT, A1c classification was incorrect in 66% by IEC, 41% by ADA, and 36% by VA. With NL by OGTT, A1c classification was incorrect in 21% by IEC, 56% ADA, and 57% VA. Weighted misclassification with A1c testing (DIAB*2 + PRE*1 + NL*0.5) averaged 56% with IEC, 54% ADA, and 54% VA.
