Remote Screening for Pediatric Diabetes Gets Closer

Researchers sought to determine if the use of a computerized system would virtually allow for improved identification of pediatric patients at high risk for prediabetes and type 2 diabetes

With Tamara S. Hannon MD and Elena Christofides MD

Remote web-based screening improves screening for diabetes in children.

Given the rising prevalence of diabetes in the pediatric population and the recent rise of telemedicine, the value of a remote screening method to foster an earlier, more consistent diagnosis is being pursued with the aim of improving clinical outcomes.

Tamara S. Hannon MD, associate professor of pediatrics at Indiana University School of Medicine in Indianapolis, Indiana and her colleagues sought to employ the Child Health Improvement Through Computer Automation (CHICA), a computerized clinical decision support system, to decrease screening barriers and improve rates of diagnosis and follow-up for prediabetes and type 2 diabetes (T2D) in children in a the study recently published in JAMA Pediatrics.

The findings indicate that the proportion of children meeting the outcomes criteria for T2D was an astonishing 41.3%.

Based on the authors’ literature review, they had expected greater than 20% of their patients 10 years or older would have at least 3 risk factors for T2D.

While the CHICA analysis did not increase the proportion of youths identified with diabetes risk factors, it more than quadrupled the rate of screenings and demonstrated greater compliance in follow-up visits.

Can digital tools reduce barriers to screening with better rates of diagnosis?

“Computer decision support is going to be utilized for screening in the future,” Dr. Hannon, the study’s primary author, told Endocrine Web when discussing the clinical implications of this study. “Healthcare providers can be pointed quickly to conditions that individuals may be at risk for, helping clinicians to be more effective in implementing a care plan when in-person office visits are not possible."

Similar research results suggested that web-based and computer decision support systems may be the evolution in medical diagnosis and treatment, as the data can be accessed readily by clinicians from remote locations and reduces potential errors in patient analysis.

However, despite the ease of ordering HbA1c and fasting blood glucose, the authors found a low rate of actual overall screening, even for children having at least 3 risk factors for diabetes. The researchers noted 3 common barriers to screening:

  • Time constraints during virtual office visits
  • Lack of effective treatment methods and resources
  • Scarcity of family-inclusive, comprehensive programs 

CHICA is perfect for a problem that has evidence-based guidelines that can be partially automated to make the workflow smoother," said Dr. Hannon. The goal is to facilitate the process so physicians will follow the screening guidelines more closely.

The results were so positive, that the researchers are implementing the use of the CHICA-T2D module in all of the control clinics used in their study.

Looking at the study process

This study was performed in 4 primary care practices in the Eskenazi Health Center Primary Care system for three years. The patients, 10 – 16 years old, had a median age of 13. The study design was a cluster-randomized clinical trial in which 283 patients and an equal number were followed as controls.

The American Diabetes Association guidelines for T2D in the pediatric setting were applied to the CHICA-T2D and paired with an electronic medical record (EMR) to produce a prescreening form containing 20 questions directed at parents. CHICA-related questions covered family history, race or ethnicity, and maternal gestational diabetes while the EMR module inserted diagnostic information such as codes, laboratory data, prescriptions, and physician orders.

The intervention groups used the CHICA system that incorporated the T2D module while the control groups used a generic CHICA model without the inclusion of diabetes guidelines or EMR data.

Relevance to clinical practice challenged

From a private practice perspective, Elena Christofides MD, chief executive officer at Endocrinology Associates, Inc., in Columbus, Ohio, felt that the study questions were not as useful as they initially appeared.

While acknowledging that CHICA-T2D improved screening, Dr. Christofides felt that spending more money on screening methods would not necessarily help physicians diagnose patients more effectively.

 “The control group, which was basically physician judgment, had a better return on investment of time and energy spent on screening these patients because they had a higher diagnosis rate,” said Dr. Christofides. She indicated that she always is looking for a return on investment and cost-effective implementation. From that standpoint, her assessment was that the computer decision support systems present the illusion of being cost-effective but were actually money that she couldn't justify spending for this technology at this point.

Offering a counter perspective, Dr. Hannon’s hope lies in integrating the CHICA module into other health care systems programs to make it more widely available, which ultimately would put more pediatric endocrinologists on a level playing field to help screen and diagnosis many more children with prediabetes or T2D. And, in this way, would foster preventive strategies and improved outcomes.

Continue Reading:
Diabetes Prevention Program Outcomes Study (DPPOS) Highlights
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