Development and validation of a patient self-assessment score for diabetes risk

Abstract

Background: National guidelines disagree on who should be screened for undiagnosed diabetes. No existing diabetes risk score is highly generalizable or widely followed.

Objective: To develop a new diabetes screening score and compare it with other available screening instruments (Centers for Disease Control and Prevention, American Diabetes Association, and U.S. Preventive Services Task Force guidelines; 2 American Diabetes Association risk questionnaires; and the Rotterdam model).

Design: Cross-sectional data.

Setting: NHANES (National Health and Nutrition Examination Survey) 1999 to 2004 for model development and 2005 to 2006, plus a combined cohort of 2 community studies, ARIC (Atherosclerosis Risk in Communities) Study and CHS (Cardiovascular Health Study), for validation.

Participants: U.S. adults aged 20 years or older.

Measurements: A risk-scoring algorithm for undiagnosed diabetes, defined as fasting plasma glucose level of 7.0 mmol/L (126 mg/dL) or greater without known diabetes, was developed in the development data set. Logistic regression was used to determine which participant characteristics were independently associated with undiagnosed diabetes. The new algorithm and other methods were evaluated by standard diagnostic and feasibility measures.

Results: Age, sex, family history of diabetes, history of hypertension, obesity, and physical activity were associated with undiagnosed diabetes. In NHANES (ARIC/CHS), the cut-point of 5 or more points selected 35% (40%) of persons for diabetes screening and yielded a sensitivity of 79% (72%), specificity of 67% (62%), positive predictive value of 10% (10%), and positive likelihood ratio of 2.39 (1.89). In contrast, the comparison scores yielded a sensitivity of 44% to 100%, specificity of 10% to 73%, positive predictive value of 5% to 8%, and positive likelihood ratio of 1.11 to 1.98.

Limitation: Data during pregnancy were not available.

Conclusion: This easy-to-implement diabetes screening score seems to demonstrate improvements over existing methods. Studies are needed to evaluate it in diverse populations in real-world settings.

Primary funding source: Clinical and Translational Science Center at Weill Cornell Medical College.

Figure 1. The estimated prevalence of undiagnosed diabetes by screening score

NHANES 1999–2006 has N=6,898 and ARIC/CHS has N=19,728. Proportions of individuals for scores of (−1,0,1,2,3,4,5,6,7,8,9) correspond to (1%,4%,10%,14%,16%,17%,16%,13%,7%,2%,0.1%) in NHANES and (2%,5%,11%,19%,24%,22%,13%,4%,0.4%,0.01%) in ARIC/CHS. ARIC = Atherosclerosis Risk in Communities; CHS = Cardiovascular Health Study; NHANES = National Health and Nutrition Examination Survey. Label of Y-axis: Prevalence, % Label of X-axis: Total Screening Score

Figure 2. Self-assessment screening score for undiagnosed diabetes or pre-diabetes