Clinical and Public Health Implications of 2019 Endocrine Society Guidelines for Diagnosis of Diabetes in Older Adults.
Level 4 - case-series / case-control
Cross-sectional analysis and diagnostic cost modeling of survey data
PubMed 32327419 · doi:10.2337/dc19-2467
What was done
Using data from 2,236 adults aged ≥65 years without known diabetes in the 2005–2016 National Health and Nutrition Examination Survey (NHANES), researchers compared the 2019 Endocrine Society diabetes diagnostic approach against standard screening. The Endocrine Society approach tests individuals with prediabetic HbA1c (5.7–6.4%) or fasting plasma glucose (FPG 100–125 mg/dL) using a 2-hour oral glucose tolerance test (OGTT; threshold ≥200 mg/dL), alongside standard cutoffs (HbA1c ≥6.5% or FPG ≥126 mg/dL). Outcomes included estimated national diabetes prevalence, pharmacologic treatment eligibility based on HbA1c thresholds (≥7% to ≥9%), and total implementation cost using Medicare fee schedules.
What was found
The Endocrine Society approach estimated diabetes prevalence at 15.7% (∼5.0 million individuals) compared to 7.3% (∼2.3 million) under the standard approach. Treatment eligibility based on HbA1c cut points ranged from 5.4% down to 0.06% under the Endocrine Society strategy, compared to 11.8% down to 1.3% under standard screening. Cases identified solely by OGTT had HbA1c <6.5%, meaning none qualified for pharmacologic glucose-lowering therapy. Screening the estimated ∼18.3 million older adults with prediabetic values with an OGTT was projected to cost between $737 million and $1.7 billion.
Why it matters
Recommending routine OGTT for older adults with prediabetes more than doubles the diagnosed population and adds up to $1.7 billion in direct testing costs, yet labels individuals who do not meet clinical thresholds for pharmacotherapy.
Limits
The study is a cross-sectional simulation relying on single-day NHANES measurements rather than the repeat confirmatory testing required in clinical practice. The analysis did not evaluate lifestyle intervention outcomes, downstream monitoring costs, or hard cardiovascular and microvascular endpoints.
Cited by
- contradicts Fasting glucose is typically targeted at 90 mg/dL or below, levels over 120 mg/dL classify type 2 diabetes, and values between those define pre-diabetes.