Screening for Diabetes mellitus: guideline recommendations

Research area: Prevention and screening

Project processing: Thomas Semlitsch, Karl Horvath, Klaus Jeitler, Cornelia Krenn
(all IAMEV)
Duration: April 2019 – July 2019
Language: German
Publication: LBI-HTA Project report No 118: https://eprints.aihta.at/1213/

 

Background:
Diabetes mellitus is a rapidly increasing disease worldwide. In the Austrian Diabetes Report 2017, the number of people with diabetes mellitus in Austria is estimated at about 7 to 11%, with an assumed 30-35% not diagnosed. Diabetes mellitus is basically defined as a group of metabolic diseases characterised by chronic hyperglycaemia, i.e., a chronically elevated blood sugar level. Depending on the cause, a distinction is made between four types – diabetes mellitus type 1, diabetes mellitus type 2, gestational diabetes and other specific diabetes types. Pathophysiologically, diabetes mellitus is based on reduced insulin secretion and/or disturbed insulin action (insulin resistance).

The—individually adapted—treatment of diabetes mellitus therefore aims to achieve freedom from symptoms and to prevent acute complications and serious secondary diseases. Training programmes and the adequate continuous and structured care of patients with diabetes mellitus are helpful for long-term therapeutic success. The Disease Management Programme (DMP) “Therapy Active” has been implemented throughout Austria for patients with diabetes mellitus type 2. Basic therapy options, depending on the type of diabetes mellitus, are lifestyle measures, drug therapies and training. In certain forms of diabetes mellitus, such as type 1 diabetes mellitus, medication with insulin is always indicated.

The term “screening” is used to describe examinations for the systematic recording of diseases in pre- or early stages of disease that are still free of symptoms. They are used to diagnose diseases before symptoms appear so that they can be treated at an early stage with suitable measures. The prerequisites for a meaningful screening for a disease are defined by the following five minimum requirements:

• The disease is an important general health problem.
• The disease is at an early asymptomatic stage.
• There is a suitable screening test.
• A recognised treatment is available.
• Early treatment in the asymptomatic phase improves the long-term outcome.

Although diabetes mellitus appears to meet most of these requirements for general screening in principle, studies have not yet clearly shown that screening and early intervention improve long-term, patient-relevant outcomes. Therefore, the aim of this project is to determine the extent to which general screening or screening for diabetes mellitus restricted to certain populations is recommended in current international evidence-based guidelines.

Project aim and research questions:
The aim of the project is to identify, extract and analyse recommendations for diabetes mellitus screening in current international evidence-based guidelines.

The following questions should be addressed:

1. Is a general screening of the general population for diabetes mellitus recommended in international evidence-based guidelines?
2. Is screening for diabetes mellitus recommended for certain population groups in international evidence-based guidelines? If so, for which groups?
3. If international evidence-based guidelines recommend screening for diabetes mellitus, what screening tests should be used?
4. What is the role of urine strip tests in diabetes screening according to international evidence-based guidelines?

Methods:
Guidelines research: A focused search for current and thematically relevant guidelines is carried out in the following sources:

• Guideline databases: Association of Scientific Medical Societies in Germany (AWMF) and Guidelines International Network (G-I-N)
• Multidisciplinary guideline providers: National Institute for Health and Care Excellence (NICE), Scottish Intercollegiate Guidelines Network (SIGN)
• Bibliographic Database: PubMed
• Internet research via Google

The research is limited to English and German guidelines on the subject of diabetes mellitus.

Selection of relevant guidelines: The guidelines identified within the framework of the search are independently checked for their relevance by 2 reviewers. All inclusion criteria listed in Table 1 below must be fulfilled. Discrepancies in the assessment between reviewers may be resolved by consensus or by a third reviewer.

Inclusion criteria guidelines

Population	Persons of all ages and genders with diabetes mellitus
Contents	The guideline refers specifically to screening for diabetes mellitus or to the prevention and/or treatment of diabetes mellitus in general. Guidelines on individual specific aspects of diabetes care (e.g., therapy of foot complications or medication to lower blood sugar levels) are not considered.
Transferability	Only guidelines whose recommendations are transferable to the Austrian health care system are considered. Therefore, only guidelines from industrial nations according to the classification of states in the World Health Report 2003 of the WHO are included. (Stratum A) [15]
Evidence-based approach and recommendation identification	Only evidence-based guidelines are included and, therefore, guidelines which - make recommendations based on systematic reviews and - indicate Level of Evidence (LoE) and/or Grade of Recommendation (GoR) for recommendations. Recommendations must be clearly identifiable formally as such.
Publication language	English or German
Date of publication / Validity	Publication date from 2014 onwards; the guideline is current and the revision date has not been exceeded.

 

Extraction and comparison of relevant recommendations: All formally recognisable recommendations with reference to a screening for diabetes mellitus or the corresponding screening procedures are extracted from the included guidelines. In addition to the content of the recommendation, the corresponding degree of recommendation (GoR) or level of evidence (LoE) is documented, as far as this can be clearly assigned. If possible and reasonable, the evidence on which the recommendation is based is also collected, as far as information on this is available in the guidelines.

Subsequently, in a structured synthesis of information, the recommendations from the included individual guidelines are compared in terms of content. If there are contradictory recommendations from individual guidelines, these inconsistencies are analysed on the basis of the evidence on which the recommendations are based. If this identifies aspects that can explain the inconsistency in terms of content, these are presented accordingly in the report and discussed if necessary.

Time schedule:
The following schedule contains the work steps that are required for the project. 

Work steps	2019
	May	June	July
Literature search for relevant guidelines
Screening for title, abstract and full text
Extraction of the relevant recommendations
Comparison and descriptive analysis of recommendations
Report generation

Literature:

Guariguata L, Whiting DR, Hambleton I, et al. Global estimates of diabetes prevalence for 2013 and projections for 2035. Diabetes Res Clin Pract. 2014; 103 (2): 137-49.

Klimont J, Baldaszti E. Österreichische Gesundheitsbefragung 2014 - Hauptergebnisse des Austrian Health Interview Survey (ATHIS) und methodische Dokumentation. Available from: http://www.statistik.at/wcm/idc/idcplg?IdcService=GET_NATIVE_FILE&RevisionSelectionMethod=LatestReleased&dDocName=105602 [cited 13.05.2019].

Schmutterer I, Delcour J, Griebler R. Österreichischer Diabetesbericht 2017. Available from: https://jasmin.goeg.at/327 [cited 13.05.2019].

Bundesärztekammer KB, Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften. Nationale VersorgungsLeitlinie: Therapie des Typ-2-Diabetes; Langfassung; Version 4. Available from: https://www.leitlinien.de/mdb/downloads/nvl/diabetes-mellitus/dm-therapie-1aufl-vers4-lang.pdf. [cited 13.05.2019].

American Diabetes A. 2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes-2019. Diabetes Care. 2019; 42 (Suppl 1): S13-S28.

American Diabetes A. 1. Improving Care and Promoting Health in Populations: Standards of Medical Care in Diabetes-2019.

Bundesministerium für Arbeit S, Gesundheit und Konsumentenschutz. Öffentliches Gesundheitsportal Österreichs - Screening. Available from: https://www.gesundheit.gv.at/lexikon/s/lexikon-screening [cited 14.05.2019].

Wilson J, Junger G. Principles and practice of screening for disease. Geneva: World Health Organization; 1968.

McCulloch D, Hayward R. UpToDate: Screening for type 2 diabetes mellitus. Available from: https://www.uptodate.com/contents/screening-for-type-2-diabetes-mellitus?search=screening-for-type-2-diabetes-mell...1&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1 [cited 13.05.2019].

World Health Organization (WHO). The World Health Report 2003: Shaping The Future 2003: Available from: http://www.who.int/whr/2003/en/whr03_en.pdf [cited Access Date].