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Diabet Med. Author manuscript; available in PMC Aug 28, 2012.
Published in final edited form as:
PMCID: PMC3428846
EMSID: UKMS49190

Who attends a UK diabetes screening programme? Findings from the ADDITION-Cambridge study

Abstract

Aims

One of the factors influencing the cost-effectiveness of population screening for type 2 diabetes may be uptake. We examined attendance and practice- and individual-level factors influencing uptake at each stage of a diabetes screening programme in general practice.

Methods

A stepwise screening programme was undertaken among 135,825 people aged 40-69 years without known diabetes in 49 general practices in East England. The programme included a score based on routinely available data (age, sex, BMI and prescribed medication) to identify those at high risk who were offered random capillary blood glucose (RBG) and glycosylated haemoglobin tests. Those screening positive were offered fasting capillary blood glucose (FBG) and confirmatory oral glucose tolerance tests (OGTT).

Results

33,539 high risk individuals were invited for a RBG screening test; 24,654 (74%) attended. 94% attended the follow-up FBG test and 82% the diagnostic OGTT. 70% of individuals completed the screening programme. Practices with higher GP staff complements and those located in more deprived areas had lower uptake for RBG and FBG tests. Male sex and a higher BMI were associated with lower attendance for RBG testing. Older age, prescription of antihypertensive medication and a higher risk score were associated with higher attendance for FBG and RBG tests.

Conclusions

High attendance rates can be achieved by targeted stepwise screening of individuals assessed as high risk by data routinely available in general practice. Different strategies may be required to increase initial attendance, ensure completion of the screening programme, and reduce the risk that screening increases health inequalities.

Keywords: Screening, type 2 diabetes, programme, population, ADDITION

Introduction

Type 2 diabetes meets many of the criteria for suitability for screening. The condition is increasingly common and creates a substantial burden of suffering and health service cost [1]. A growing body of evidence suggests that earlier detection and treatment of hyperglycaemia and related metabolic abnormalities may be beneficial [2, 3]. Screening for diabetes does not appear to be associated with significant psychological harm [4]. However, there is continuing uncertainty concerning feasibility, uptake and the overall benefits and costs of diabetes screening [5-7].

One of the criteria by which a screening programme can be assessed is attendance [8]. Previous studies suggest that the method of diabetes screening may influence uptake, with more invasive methods associated with lower attendance [9-14]. Blood tests may perform better in terms of sensitivity and specificity than, for example, questionnaires [15], but the uptake is lower [10]. Use of non-invasive, routinely available data to stratify a population according to diabetes risk with invitation only to those at highest risk for further assessment might reduce the economic costs and potential psychological harms associated with some screening tests [16]. Evidence from other screening programmes indicates that practice and patient characteristics also influence attendance [12-14, 17]. Identification of factors influencing uptake at these levels might facilitate more appropriate organisation and targeting of screening programmes.

We report results from a cluster-randomised controlled trial of screening for type 2 diabetes in primary care, the ADDITION-Cambridge Study [18]. We aimed to examine (i) attendance in a stepwise screening programme in general practice, and; (ii) the practice- and individual-level factors predicting uptake of screening at each stage in the programme.

Patients and Methods

ADDITION-Cambridge is a primary care-based screening and intervention study for type 2 diabetes. The study has been described in detail elsewhere [18]. In brief, ADDITION-Cambridge consists of two phases: a screening study and a subsequent treatment study. The screening phase examines the feasibility of a stepwise procedure to identify people with undetected diabetes, and the effects of screening on health outcomes at the population level. The treatment study is a pragmatic single blind, cluster-randomised, parallel group trial comparing the effects of intensive multifactorial therapy with routine care (according to national guidelines) in individuals with screen-detected type 2 diabetes. This trial is registered as ISRCTN86769081. Ethical approval was granted by the Eastern Multi-Centre Research Ethics Committee (02/5/54). Written informed consent was obtained from ADDITION-Cambridge participants.

Practices

138 general practices in Eastern England were invited by letter to participate in ADDITION-Cambridge between September 2001 to October 2002; 63 agreed to take part. There was no difference between those practices that participated and those that declined with respect to average practice size, prevalence of known diabetes and deprivation score. Three practices undertook pilot work, five practices were randomly allocated to a no-screening control arm and six practices withdrew from the study before screening commenced, leaving 49 practices in the main study. The electronic medical records of patients aged 40 to 69 years were searched for information that would allow the calculation of the previously validated Cambridge Diabetes Risk Score [19]. The score was based on age, sex, BMI and prescribed steroid and antihypertensive medication. Family history of diabetes and smoking status were excluded from the score as data were not consistently recorded for these variables. The original sensitivity and specificity of the risk score was 77% and 72% respectively for undiagnosed prevalent diabetes, with an area under the receiver-operating characteristic curve of 80% [19]. The same risk score has also been shown to predict undiagnosed hyperglycaemia [20, 21], metabolic syndrome [21], incident diabetes [22], and all-cause mortality [23]. Practices were eligible to take part if they were able to calculate risk scores on at least 70% of their patients aged 40 to 69 years, a criterion fulfilled by all 63 practices that agreed to participate.

Participants

From November 2001 to April 2003, eligible individuals were identified through the application of the risk score to the medical records of 135,825 individuals. Eligible participants were aged 40 to 69 years, not known to have diabetes but with a diabetes risk score ≥ 0.17. This cut-off corresponds to the top 25% of the risk distribution in the participating practices. Where risk score data were missing, for example for BMI, the individual was included on the invitation list if their score exceeded the risk threshold on the basis of the other risk score variables. If having a value for the missing data could not cause the individual to cross the threshold they were not invited. There were, however, cases where missing data, mainly BMI, influenced whether the person would be invited for screening or not. In these cases the patient case notes were tagged so that the practice could measure the patient’s height and weight opportunistically when they attended for another reason and a BMI category of 25 to 27.499 kg/m2 was assumed for this study. Eligible participants deemed unfit for screening by their general practitioner were not invited for biochemical testing. Exclusion criteria included pregnancy, lactation, an illness with a likely prognosis of less than one year to death or a psychiatric illness likely to limit study involvement or preclude informed consent.

Stepwise screening programme

In participating practices, general practitioners wrote to all high-risk patients, enclosing a study information sheet, and inviting them to attend the practice for random capillary blood glucose (RBG) and capillary glycosylated haemoglobin (HbA1c) tests. The letter was sent at least two weeks in advance of the scheduled appointment. Patients were advised to telephone the surgery and arrange an alternative appointment if the original was inconvenient. One reminder letter was sent to non-attendees. Participants gave written informed consent at the appointment. Participants with an RBG of ≥ 11.1 mmol/l were invited for a standard 75 g oral glucose tolerance test (OGTT) at one of four local outpatient facilities. Those with an RBG of 5.5–11.0 mmol/l were invited to return to the practice for a fasting capillary blood glucose (FBG) test. Those with an FBG of ≥ 6.1 mmol/l, or an FBG of 5.5–6.0 mmol/l together with an HbA1c of ≥ 6.1%, were invited for an OGTT. The RBG, FBG and OGTT were conducted on different days. Practices arranged these tests based on a standard screening protocol. Participants with an FBG of 5.5–6.0 mmol/l and an HbA1c of ≥ 6.1% who had a positive OGTT underwent a second confirmatory OGTT on a different day. World Health Organisation criteria were used to diagnose diabetes [24]. Figure 1 summarises the screening algorithm. Random and fasting capillary blood glucose concentrations were assessed on finger prick samples using the Hemocue Glucose Analyser based on the glucose dehydrogenase method and read photochromatically (β-HemoCue AB, Angelholm, Sweden). The stability of the analyser was checked daily and external calibration with the Hemocue quality assurance scheme was undertaken monthly. Venous plasma blood glucose was measured during the OGTT with HemoCue. HbA1c was analysed in capillary blood samples from general practices using the Bio-Rad® system and in venous samples at the time of diagnostic testing by ion-exchange high-performance liquid chromatography (Tosoh Bioscience, Redditch, UK).

Figure 1
ADDITION-Cambridge screening and diagnostic procedure

Screening took place between January 2002 and March 2006. Practice teams were notified of the results of biochemical measures with a clear statement of whether or not the individual met diagnostic criteria for type 2 diabetes. The general practitioner or a practice nurse then informed the patient of the test results.

An eligible participant was defined as being invited for the RBG test if any of the following were recorded: a date of invitation, a scheduled date of appointment, the date a reminder was sent, the date the participant attended the appointment, RBG result or HbA1c result. Attendance for a RBG, FBG or OGTT test was defined if the date of attendance or the test result was recorded. Practice level variables were obtained from the National Primary Care Database for the period 2004-2005 and from the participating practices at the time of recruitment to the study. Practice post codes were used to determine urban or rural status based on criteria by the Countryside Agency. Individual level variables were based on data in participants’ electronic records.

Statistical analysis

We examined variables associated with attendance at different stages of the screening process using generalised linear latent and mixed models in Stata (v10.1) [25], which account for clustering of individuals within general practices. Individual and practice level variables were force included in multivariate models except when they were derived from other variables e.g. models including the risk score did not incorporate its constituent variables such as age and BMI. Blood glucose levels from the previous screening test were included where appropriate e.g. RBG for FBG uptake, and FBG for OGTT uptake.

Results

Risk scores were calculated for 135,825 patients in the 49 screening practices. Practice list sizes ranged from 2,049 to 19,651 patients (median: 7,554). The median prevalence of known diabetes was 3% (range: 1 to 5%). 35,297 (26%) individuals were identified at high risk and were therefore eligible for a RBG test. Table 1 shows the characteristics of screened individuals. Participants eligible for RBG testing were significantly older, had a higher BMI and were more likely to be male, and be prescribed steroids or anti-hypertensive drugs compared with the general population (p<0.001 for all comparisons). This finding reflects the variables included in the risk score. Data on BMI were missing for 34% of the practice population aged 40 – 69 years.

Table 1
Characteristics of screened individuals in the ADDITION-Cambridge study

Invitation

Of those who were eligible on the basis of a high risk score, 33,539 (95%) individuals were invited for RBG testing. The main reason for an invitation not being sent was that the patient had moved away (46%), while other reasons included that the patient had been screened by their practice before, had died, had been advised by their GP not to attend or was too ill to attend.

Screening uptake (Figure 2)

Figure 2
Attendance at each stage of the diabetes screening programme in the ADDITION-Cambridge Study

74% of invited individuals attended the RBG test (95%CI: 73 to 74, practice range: 51% to 90%). Uptake of the subsequent FBG test was 94% (95%CI: 93 to 94, practice range: 79% to 100%). Of the 1,687 individuals who were eligible for an OGTT, 1,389 attended (82%; 95%CI: 80 to 84). After excluding an outlying practice that was geographically distant from the testing centre and arranged their own OGTTs (attendance at outpatient facility for study OGTT: 14%), the practice range was 62% to 100%. An additional 46 OGTTs (3%) were arranged by practice staff in people who were ineligible based on the screening protocol. Of the original 33,539 individuals identified as high risk and invited to participate in the screening programme, 867 (2.6%) were diagnosed with type 2 diabetes and recruited into the intervention study.

Reminders were sent to 8,196 people (24% of those who had been invited) after a median of 42 days (IQR 28 to 68 days). Only 25% of those sent a reminder letter attended, resulting in 124 OGTTs and 64 diagnoses of screen-detected diabetes (7% of all cases). Individuals who attended as a result of a reminder were more likely to be older, female and have been prescribed drugs for hypertension but with a lower mean BMI (30.5 kg/m2, SD: 4.3) compared to those who did not attend (31.1 kg/m2, SD: 4.8) (p<0.001 for all comparisons).

Overall 30% of those who were eligible and invited for screening at various stages dropped out before completing the process, the majority at the initial RBG test. Only 12% refused participation outright.

Variables associated with attendance for RBG, FBG and OGTT testing (Table 2)

Table 2
Association between practice and individual level variables and attendance for screening tests in the ADDITION-Cambridge study; all variables mutually adjusted in a multivariate model (odds ratio, 95% CI), statistically significant results are highlighted ...

In terms of practice characteristics, a large list size, higher prevalence of known diabetes, and a rural location were independently associated with higher uptake of RBG testing, while higher GP WTEs and a higher deprivation score were associated with lower uptake. For patient characteristics, older age and prescription of antihypertensive medication were associated with higher uptake of RBG testing, while male sex and higher BMI were associated with lower uptake. A higher risk score value was independently associated with higher uptake of RGB testing (p<0.001 for trend across quintiles).

Practices with higher GP WTEs and those with the most deprived IMD scores were associated with lower uptake at the FBG test stage, while registration with a training practice was associated with increased attendance. Older age, prescription of antihypertensive medication, and a higher RBG were independently associated with increased attendance for FBG testing. People with higher risk scores were more likely to attend for the FBG test independently of other variables (p=0.02 for trend across quintiles).

At OGTT testing, a higher GP staff complement was independently associated with lower uptake; there was a non-linear association with IMD score. Male sex and younger age were associated with increased attendance for the diagnostic OGTT.

Discussion

It appears to be feasible and acceptable to screen for type 2 diabetes in general practice in the east of England using a risk score to select a high-risk population and capillary glucose measurement as the initial screening test for diabetes. There was a high attendance for each stage of testing: 74% for RBG, 94% for FBG and 82% for the OGTT. Uptake of all steps was 70%. The high response rate for the initial stage of the screening programme may have been influenced by the pre-stratification of the population. We used a score based on routinely available data to identify those at high risk and communicated this risk in the screening invitation letter. The methods used to select participants, invite people for screening and test for diabetes all proved acceptable and practical. However, relatively few participants were diagnosed (2.6%), even in this high risk group. Some groups were hard to reach, with lower uptake in deprived areas and among males and the obese, and attendance at the first screening stage did not ensure completion of the programme.

Screening uptake

Screening uptake was similar to that seen in other screening studies incorporating non-invasive tests at the initial stage of screening [12, 14]. In the ADDITION-Denmark study diabetes risk questionnaires were sent to people identified through primary care. Accompanying instructions advised those with a high risk to attend for an RBG test. The proportion who attended represented 23% of their target population [12]. This was similar to the proportion of the population (26%) that was invited for blood glucose screening on the basis of a risk sore calculated from routinely held data in ADDITION-Cambridge. Studies incorporating a blood test at the initial screening stage tend to have lower uptake [10, 13]. In contrast, a study based on urine testing reported a similar uptake to that found in this study [9]. Although ADDITION-Cambridge is a pragmatic trial and nearly half of the practices approached agreed to take part, response rates in less well resourced practices in other parts of the country may be lower [7]. This is in keeping with relatively low uptake observed in many established screening programmes, such as mammography and screening for colorectal cancer, compared to research studies [17].

Attendance was higher among those offered subsequent confirmatory and diagnostic tests. Studies of cancer screening have suggested that people who attended screening for the same or other cancers were more likely to respond to a subsequent invitation [26, 27]. It may be that those who attended for RBG and were found to be positive and therefore at higher risk had overcome their psychological barriers to screening and were more likely to keep attending. Indeed, a qualitative study embedded in ADDITION-Cambridge found that participants underwent a process of psychological adjustment as they progressed through the screening programme [28]. However, not all individuals identified as high risk at the initial RBG stage completed the programme. Attention to follow-through, as well as first attendance, may be important in optimising screening programmes.

Variables associated with attendance

Practices with higher GP staff complements and those located in more deprived areas had lower uptake for RBG and FBG tests. High GP WTEs were also associated with low attendance for OGTT while the association with area deprivation score was non-linear and less clear. The consistent association of high GP WTEs with decreased attendance at all stages of our study requires explanation. Of note, GP staff levels were associated with increased likelihood of having an invitation sent. Practices with a larger GP staff complement tended to invite a higher proportion of people who were subsequent non-attenders (p<0.001). However, practices with more than 3 full time GPs were also more likely to tell participants not to attend, presumably for medical reasons, than those with 3 or fewer full-time GPs (2.75% versus 0.9%, p<0.001). While individuals with a higher risk score or RBG test result were more likely to attend, attendance was lower in those from more socially deprived areas (inverse care law). This has been shown in other screening programmes where people who attend for screening are more health conscious than those who do not. They are more likely to be taking vitamin supplements and to attend regularly for medical check-ups [26, 27, 29]. Previous studies have reported an association between area of residence [17, 30] as well as GP characteristics [17, 31] and screening uptake.

Prescription of antihypertensive medication predicted higher uptake at the RBG and FBG tests. This may reflect familiarity with the regular consultations and investigations associated with repeat prescribing for blood pressure. A higher BMI was associated with lower attendance for RBG testing. In keeping with similar studies [12-14], the highest uptake of screening for RBG and FBG was among older women, although the reverse was true for the diagnostic OGTT. Men and younger individuals were more likely to attend for OGTT having progressed through the earlier screening tests. The people who progress this far through the screening programme are likely to have very different perceptions of their risk status compared to those at earlier stages. If strategies can be found to encourage younger men and the obese to attend for RBG and FBG testing, these results suggest that they are likely to complete the process. It may be necessary to design different screening approaches to maximise uptake in these groups e.g. testing at worksites, shopping centres, pubs, chemists etc. In addition, more resources may be needed in deprived areas to achieve the same outcomes seen in this study, as well as a range of different strategies for screening e.g. drop-in sessions and opportunistic testing as well as set appointments for screening.

Strengths and limitations

ADDITION-Cambridge is the first large scale investigation of screening for type 2 diabetes in primary care in the UK. The study sample was population-based and similar to the general population of England and Wales for age, sex and BMI as assessed by the Health Survey for England in 1994 [32], though the participants were largely Caucasian. The study population was not completely representative of the background population of the general practices since participants were selected for having complete data for calculating the risk score. The study was limited by the lack of information on individual characteristics that are known to influence screening uptake e.g. ethnicity, education, income, social class and smoking status [17, 30, 31].

The calculation of a risk score, though dependant on having data for the constituent variables in the score, was possible for the majority of the target population despite the high proportion who did not have data on BMI in their general practice notes. BMI was missing in 20% of those whose risk score exceeded the threshold for invitation but 65% of these were eligible on the basis of other risk factors. Furthermore, recording of BMI has improved following the Quality and Outcomes Framework [33]. We used capillary glucose measurements for diabetes screening and diagnosis which are approved by the WHO [34], but used less frequently in clinical practice than venous plasma measurements.

Although the staged nature of the screening programme greatly reduced the number of invasive tests required, practices would need additional resources to carry out this screening approach. Some duplicates, missing results and deviations from the screening protocol occurred. These are potential sources of inefficiency that would need to be managed as part of ongoing quality assurance. A one-off screening programme along the model described in the ADDITION-Cambridge study is feasible but repeated rounds of screening may not be so acceptable to patients and practitioners. Furthermore, our results may not be replicated in areas of greater material deprivation, ethnic diversity and population migration where different approaches may be necessary. There are plans to include blood glucose testing among those at high risk in the UK Department of Health’s “Health Checks” programme [35]. Results from this study may help inform the development of this public health endeavour.

Conclusion

Targeted stepwise screening of individuals assessed as high risk by data routinely available in general practice is feasible and acceptable. Practices will need additional resources to carry out this screening approach. Despite a high attendance for each stage of testing, relatively few participants were diagnosed, even in this high risk group. If screening is shown to be beneficial, different strategies may be required to (i) increase initial uptake in deprived areas and among males and the obese; (ii) ensure completion of the screening programme; and (iii) reduce the risk that screening increases health inequalities. Practice-based computer reminders may be beneficial in targeting patients opportunistically in primary care [36] but more research is needed to determine the best strategies for non-responders in whom reminder letters appear to have marginal benefit [17, 37]. It remains unclear whether early treatment of diabetes can produce sufficient improvement in long-term health outcomes to justify the economic costs of screening. Results from the ADDITION study [38] will help to answer this question.

Acknowledgements

We gratefully acknowledge the contribution of all participants, practice nurses and general practitioners in the ADDITION-Cambridge study (a full list of participating practices is given below). We also acknowledge the contribution of the trial steering committee (Professors Nigel Stott (Chair), John Weinman, Richard Himsworth, and Paul Little). The General Practice and Primary Care Research Unit at the University of Cambridge and the Medical Research Council Epidemiology Unit in Cambridge jointly coordinated the study. Aside from the authors, the ADDITION study team has included Amanda Adler, Sue Boase, Justin B. Echouffo-Tcheugui, Sean Dinneen, Mark Evans, Tom Fanshawe, Francis Finucane, Julie Grant, Wendy Hardeman, Robert Henderson, Richard Parker, Nicola Popplewell, Stephen Sutton, and Fiona Whittle. We thank the Cambridge University Hospitals NHS Foundation Trust Department of Clinical Biochemistry and the NIHR Cambridge Biomedical Research Centre, Core Biochemical Assay Laboratory for carrying out the biochemical assays and the following groups within the MRC Epidemiology Unit: data management (Adam Dickinson), IT (Iain Morrison), technical (Matt Simms) and field epidemiology (Paul Roberts).

ADDITION-Cambridge practices: Acorn Community Health Centre, Arbury Road Surgery, Ashwell Surgery, Birchwood Surgery, Brookfields & Cherry Hinton, Broomfields, Cedar House Surgery, Clarkson Surgery, Cornerstone Practice, Cornford House Surgery, Cottenham Surgery, Cromwell Place Surgery, Dr C Stephens and Partners (Bridge Street), Dr Smith and Partner (Cambridge), Freshwell Health Centre, George Clare Surgery, Great Staughton Surgery, Harston Surgery, Health Centre (Eaton Socon), Hilton House, John Tasker House, Lensfield Medical Practice, Mercheford House, Milton Surgery, Nene Valley Medical Practice, New Roysia Surgery, Northcote House Surgery, Nuffield Medical Centre, Orchard Surgery, Orchard House Surgery, Orton Medical Practice, Park Medical Centre, Paston Health Centre, Petersfield Medical Practice, Priors Field Surgery, Queen Edith’s Medical Practice, Queen Street Surgery, Ramsey Health Centre, Rainbow Surgery, Riverside Practice, Roman Gate Surgery, Rosalind Franklin House, South Street Surgery, The Burwell Surgery, The Health Centre (Upwell), The Health Centre (Woolpit), The Nevells Road Surgery, The Old Exchange, The Surgery (Bourn), The Surgery (Haddenham), The Surgery (Manea), The Surgery (Mayfield), The Surgery (Oundle), The Surgery (Papworth), The Surgery (Thaxted), Trumpington Street Medical Practice, York Street Medical Practice.

The National Primary Care Database is a product of the National Primary Care Research and Development Centre at the University of Manchester. It was devised by Professor Deborah Baker. The database was constructed by Justin Hayes at the Regional Research Laboratory, School of Geography, University of Manchester (Director: Dr Robert Barr); SEE IT consultancy designed and built the map interface. We are grateful to Andrew Wagner, Mark Hann and David Reeves (NPCRDC) for cleaning and validating the data sets. Andrew Wagner is the database manager (ku.ca.nam@rengaw.a).

Funding: ADDITION-Cambridge is supported by the Wellcome Trust (grant reference no: G061895), the Medical Research Council (grant reference no: G0001164), National Health Service R&D support funding and the National Institute for Health Research. ALK, KMW & SJG were members of the National Institute for Health Research (NIHR) School for Primary Care Research. ALK is an NIHR Senior Investigator. The General Practice and Primary Care Research Unit is supported by NIHR Research funds. SJG receives support from the Department of Health NIHR Programme Grant funding scheme [RP-PG-0606-1259]. The views expressed in this publication are those of the authors and not necessarily those of the Department of Health.

Glossary

ADDITION
Anglo-Danish-Dutch Study of Intensive Treatment In People with Screen Detected Diabetes in Primary Care
FBG
Fasting capillary blood glucose
GP
General practice
HbA1c
Glycosylated haemoglobin
IMD
Index of multiple deprivation
OGTT
Oral glucose tolerance test
RBG
Random capillary blood glucose
WTE
Whole time equivalent

Footnotes

Declaration of competing interests: Nothing to declare

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