Outcomes of the 2003 Defeat Diabetes Screening Project

Project Goal: to provide free diabetes screening and access to diabetes care targeting Washoe County’s Hispanic community. This goal supports the Healthy People 2010 Goal " Increase the proportion of adults and children with diabetes whose condition has been diagnosed."

Original Objectives for CY 2003 were to:

· Provide an additional diabetes screen targeting the Hispanic community (making a total of 4)

· Screen 500 individuals

· Follow-up and encourage those referred with a positive screening test and/or risk factors to seek and obtain appropriate follow-up diagnostic testing

· Develop a master database of those screened and referred for diagnostic testing to determine project's outcomes

Revised Objectives for CY 2003:

• Provide three community-based screenings targeting the Hispanic community (due to limited manpower and funding)
• Screen no more than 200 individuals per screening event (based on limited supplies)
• Follow-up and encourage those referred with a positive screening test and/or risk factors to seek and obtain appropriate follow-up diagnostic testing
• Develop a master database of those screened and referred for diagnostic testing to determine project's outcomes (supported by $1000.00 granted by The Alliance for the Washoe Medical Society).

Project's team players and contributors:

· Abbott Labs

· HAWC

· Nevada Diabetes Association for Children and Adults

· Reno Host Lions Club

· Sac & Sav

· Saint Mary’s Health Network (St. Mary's Foundation, Take-Care-a- Van, and Community Outreach and Neighborhood Clinics)

· St. Therese Little Flower Church

· Volunteers: Mariarita Perez, Jackie Juarez, Margie Varela Salas

· Washoe County District Health Department

· Washoe Enhancement Services, Diabetes Wellness Program

Three free diabetes community-based screenings were offered in March, June and September 2003. March and June were the most successful in terms of numbers screened (see Table 1). The March screen was advertised in St. Therese's Church bulletin (Spanish and English) and announced during the Masses two consecutive weeks before the screening date. Flyers were put on the church's entrance doors the day of the screening. The screening was held in the church's community hall and after most of the morning Masses including one in Spanish. St. Mary's Take-Care-a-Van was situated outside the same door people entered to start the screen.

For the June screen, a press release followed by a phone call was faxed to Spanish-speaking radio and TV stations and one newspaper. The Ahora-Spanish English News did a write-up and a reporter from one of the TV stations came to the screen. A week after the screen, KUVR 68, Aztexa American, interviewed three Health department staff that has diabetes or a family member with diabetes for a 30-minute show. All screening stations except for seeing the nurse were performed inside Sak & Sav. Folks were escorted after their finger stick glucose to the van to see the nurse. The van was situated at the front of the store.

The smaller number screened in September was due to several factors. All screening stations (except for seeing the nurse) were set up outside the van not inside the store. The van was hidden in the corner of the parking lot, which was a significant distance from Sak and Sav's front doors. Another major factor that hindered the success of this screen was it had to compete with the store's special event celebration. The celebration with music and food began at noon whereas the screening started at 10 a.m. and ended at 2 p.m. In spite of staff's onsite efforts to inform folks about the screen, the poor location of the van, the walking distance to the van, and timing of the screen proved to be major barriers.

Table 1. Total Number Screened for 2003

Date 2003	Number Screened	Location	Female	Male	Unknown
March 20	124	St.Therese Little Flower Church, Reno	73	50	1
June 28	151	Sac & Sav, Sparks	102	49
Sept 20	73	Sac & Sav, Reno, celebration	47	25	1
Total	348		222	124	2

Description of the Screening Process

Please see Attachment A, Manpower Requirements which outlines the steps of the screening process. The Informed Consent and the Authorization to Disclose Information forms and the Diabetes Screening Worksheet were available in Spanish and English. Two bilingual staff explained the purpose of these forms and assisted individuals in answering questions in Steps 1 and 2 of the Diabetes Screening Worksheet (see Attachment B).

Parameters for taking blood pressure measurements were established after the March screen to streamline the screening process. Persons age 10 and older were offered the full screen. Persons less than 10 years of age with a family concern or family history of diabetes, only a finger stick glucose was taken. If a digital blood pressure reading was high, the blood pressure was rechecked manually and recorded on the worksheet.

Another improvement made after the March screen was providing a bilingual interpreter for each nurse. An interpreter per nurse enhanced the nurse's consultation and time with the participants and expedited the flow of the screening process.

A copy of the completed worksheet was given to those who were referred/encouraged to see their primary care provider (PCP) or to go to HAWC or St. Mary's Clinic for further diagnostic testing. The participating clinics also received worksheet copies for those referred to their clinic to initiate the follow-up. Only 11 with an established primary care provider were called after the March screening to ascertain if they had made an appointment to see their doctor or if they intended to call their doctor. Due to a lack of manpower and phone numbers obtained, this time-consuming effort to follow-up with those with PCPs was not pursued.

The majority of those referred to one of the clinics or to a PCP received some health education from the nurses during the screening. The most common teaching points were: eat smaller more frequent meals throughout the day, increase water intake, stay active, increase exercise, to have annual checkups, get screened yearly and stop smoking. The nurses provided one educational handout written in English and Spanish that contained three messages: know your diabetes risk, eat less fat and fewer calories (pass up the extra helping) and start walking. Try to walk at least five times per week (Small Steps…Big Rewards Campaign).

Demographics of Participants Screened

Tables 2 and 3 describe who participated in all three screens in terms of ethnicity and age. The majority (71%) of those screened were Hispanic. Sixty percent of those screened were between ages 30 and 59.

Table 2. Ethnicity of Participants

	Total	%	Female	Male
Hispanic	248	71	163	84
Pacific Islander	8	2	4	4
African American	8	2	4	4
American Indian	8	2	7	1
Asian American	15	4	9	6
Caucasian	26	8	13	13
Other	3	1	1	2
No answer	32*	10	22	10

*31 of the "no answers" were from the March screen. The most likely reason for those who did not answer the ethnicity question is due to the question's format and location on the worksheet. The screening worksheet was reformatted after the March screen to enhance its readability and the collection of information.

Table 3. Age of Participants

Age in years	Number screened
< 10	12
10-19	25
20-29	30
30-39	76
40-49	85
50-59	48
60-69	38
70-79	25
80-89	5
90+	1
Not given	3
Total	348

Self-report of Participants' Risk Factors

Family History (parent, sister or brother) of diabetes

Response	% (N=346)
No	53 (n=184)
Yes	41 (n=143)
Unknown	5 (n=19)
No answer	1 (n=2)

Diabetes

Response	% (N=216)
No	81 (n=180)
Yes	14 (n=31)
Unknown	2 (n=5)
No answer	3 (n=7)

History of High Cholesterol

Note: 48 of the 79 Yes responses (61%) were Hispanics; 29 were female, 19 male

29 of the 46 (63%) Unknown responses were Hispanic

Response	% (N=341)
No	63 (n=216)
Yes	23 (n=79)
Unknown	13 (n=46)
No answer	1 (n=7)

History of High Blood Pressure

Response	% (N=338)
No	75 (n=255)
Yes	13 (n=44)
Unknown	11 (n=39)
No answer	1 (n=10)

Who were the smokers?

Ethnicity	% who smoke (n=38)	Age in Years
		10-19	20-29	30-39	40-49	50-59	60-69	70-79	Unknown
Hispanic	49 (n=18)	1	2	6	2	4	2	0	1
Caucasian	30 (n=12)		1		4	2	2	3
All Others	21 (n=8)			1	3	1	2	1

Of the 18 Hispanics who said they currently smoked, 11 were male, 6 female and one did not disclose their age or sex. Three Hispanics had a systolic pressure greater than 130. No one had a diastolic pressure greater than 85.

Description of Participants' Screening Measurements

Blood Pressure

According to the JNC VII ( Claude: please spell out this reference for me, and include the year of the newest guidelines), normal blood pressure is defined as 120/75 (120=systolic and 75= diastolic). For the diabetes screens, a blood pressure of at least 130/85 was considered abnormal.

Systolic Pressure > 130 (37%, N=339)

Systolic	Number
131-135	22
136-140	41
141-146	11
147-152	10
153-158	10
159-164	12
165-170	6
171-176	5
177-182	3
183-204*	5
Total	125

Diastolic Pressure >85 (17%, N=339)

Diastolic	Number
86-88	15
89-91	22
92-94	4
95-97	3
98-100	8
101-103	1
104-106	1
107-108*	2
Total	56

*Highest value

Participants with Systolic Pressure >130 AND Diastolic Pressure >85 (13%, N=339) Compared to Their Reported History of High Blood Pressure

Reported History of High Blood Pressure	Number
Yes	22
No	19
No answer	2
Unknown	1
Total	44

Waist Circumference

In addition to being an abnormal condition associated with metabolic syndrome, a wide waist circumference is considered an independent risk factor for serious diseases, similar to factors such as weighing too much and high blood pressure. According to Dr. George Blackburn, associate director of the division of nutrition at Harvard Medical School, waist circumference is "an absolute vital sign in determining your health." People with wide girths are more likely to have large amounts of deep-hidden belly fat around their organs, which is linked to high cholesterol, high insulin, high triglycerides and high blood pressure.

The clinics used Body Mass Index (BMI) which is a measure of your weight relative to your height. Combining both waist circumference and BMI with information about the person's additional risk factors gives the health care provider a more accurate picture of the person's risk for developing obesity-associated diseases. The table below describes the BMI scores that are valid for both men and women.

Seventy percent of the 214 females measured had a waist circumference greater than 34 inches. Twenty-six percent of the 118 males measured had a waist circumference greater than 40 inches.

Female Participants with Waist circumference >34 inches

(N= 214 females measured)

Circumference (Inches)	Number of Females
35-37	42
38-40	38
41-43	33
44-46	19
47-49	11
50-52	4
55-58	2
Total	149

Male Participants with Waist Circumference >40 inches

(N= 118 males measured)

Circumference (Inches)	Number of Males
41-42	14
43-44	9
45	2
48	4
55	1
59	1
Total	31

Finger stick glucose

A finger stick glucose reading greater than 126 mg/dL was considered abnormal. Sixteen percent of all participants (N=348) had a finger stick glucose greater than (>) 126. Forty-nine of the 57 with a finger stick glucose greater than 126 were Hispanic and were from the September screen.

Gender and Ethnicity of Participants with a Finger Stick Glucose > 126

Screen date 2003	Total	Female	Male	Ethnicity
				H	AA	AI	C	Unknown
March 30 St. Therese	5	5			1			4
June 28 Sak & Sav	3	2	1			2	1
Sep 20 Sak & Sav Celebration	49	38	11	49
Total	57 (16%)	45	12	49	1	2	1	4

Of the 57 who had a screening blood sugar >126, what percentage reported a history of high blood sugar?

Response	History of High Blood Sugar (%)
No	49 (n=28)
Yes	40 (n=23)
Unknown	5 (n=5)
No answer	5 (n=5)

Description of Protocol for Diabetes Screening Referrals

The protocol used to make appropriate referrals for diagnostic testing is based on a group of abnormalities associated with metabolic syndrome. Three or more of the abnormalities listed below puts a person at increased risk of developing diabetes mellitus and cardiovascular disease.

Abnormalities of Metabolic Syndrome

The nurses made a referral for further diagnostic testing if the person had a combination of three or more of the risk factors listed below:

· Family history of diabetes

· Abnormal waist circumference

· History of high blood cholesterol and/or blood sugar and/or take medication for either condition

· Finger stick glucose > 126 mg/dL

· Belong to ethnic group (Hispanic, Native American, African-Americans, Asian/South Pacific Islanders)

The following tables provide the percentage of participants not referred and referred as well as the referrals per referral site.

March screen, N=124	%	Referrals per site (%)
		St. Mary's	HAWC	PCP
Not referred	55 (n=68)
Referred	45 (n=56)	43 (n=24)	16 (n=9)	41 (n=23)

June screen, N=151	%	Referrals per site (%)
		St. Mary's	HAWC	PCP
Not referred	64 (n=97)
Referred	36 (n=54)	24 (n=13)	22 (n=12)	54 (n=29)

Sept screen, N=73	%	Referrals per site (%)
		St. Mary's	HAWC	PCP
Not referred	63 (n=46)
Referred	37 (n=27)	37 (n=10)	30 (n=8)	33 (n=9)

Several inconsistencies were noted in the nurse's referral process during the review of the screening worksheets and the development of the master database. Several participants had three or more risk factors and indicated they had a PCP but were not referred (Y or N was not circled in Step C of the worksheet). For the purpose of data analysis, these folks were registered in the database as a PCP referral because in most cases the nurses wrote in the PCP's name. However, about 45 participants had three or more risk factors and no PCP but were not referred. One possible reason the nurses did not make a referral may have been due to the person indicating they were an established patient with HAWC or St. Mary's clinic. However, the more likely reason for not making the referrals was due to an oversight of not highlighting ethnicity as a risk factor. In other words, when the nurse reviewed the person's screening worksheet, she would highlight an abnormal blood pressure or finger stick glucose and a yes answer to one of the risk factors but did not count a person's ethnicity as a risk factor. Based on this observation, the protocol for referral needs to be reviewed and modified for future diabetes screenings that target a specific ethnic population.

Description of the Follow-up Process

A major difference exists between the two clinics. HAWC is a federally funded community health center where anyone is eligible for and receives care when they walk through the door. Payment of services is based on the client's ability to pay (sliding scale). Before an individual is able to make a clinic appointment to see a health care provider, St. Mary's requires the individual (a new patient) to set up an appointment to establish their eligibility status. St. Mary's staff assists persons to establish and receive some type of health care reimbursement (i.e., Medicaid, Medicare). Unfortunately, this additional clinic appointment to establish eligibility was an extra hurdle for some. Consequently, a health care provider did not see those who did not establish eligibility. (See Tables 4 and 5)

However, when one looked at the time lag between the screening date and the date of the first clinic appointment with a health care provider, both clinics had similar time periods. For HAWC, most clinic appointments were made one month after the screen date. For St. Mary's Clinic, appointments were made one to two months after the screen date. Both clinics made an additional effort to call some of the referrals two months after the screen date.

Table 4. HAWC's Referrals (N=28)

	March 20 n=9	June 28 n=11	Sep 20 n=8
Appts Made	5*	4
No Show	3	0
Refused appt	2	3
No phone	1	2
Unable to contact	0	2
New Patient	2	1
Established Patient	2	4

*Appointment was not made for one of the established patients

who was previously diagnosed with pre-diabetes.

Table 5. St. Mary's Referrals (N=47)

	March 20 n=24	June 28 n=13	Sep 20 n=10
Appts Made	6	6
No Show	0	0
Refused appt	0	0
Pt undecided	1	0
Eligibility unconfirmed	5	6
No phone	0	0
Unable to contact	11	1
Worksheet not given	1	0
New Patient	5	3
Established Patient	2	3

Outcomes for New and Established Patients

HAWC and St. Mary's Neighborhood Health Clinics basically followed the same American Diabetic Association protocol for diagnostic testing. The first clinic visit included a review and confirmation of the person's risk factors based on the screening worksheet, measurement of blood pressure and height/weight (to calculate Body Mass Index) and finger stick glucose and a tentative diagnosis. In most cases, the client's second visit was to an outpatient lab to have fasting lab work drawn for a fasting blood sugar and lipid profile. The client's third clinic visit included a review of the lab work and a diagnosis. Unfortunately, multiple barriers kept many clients from following through with this protocol. (See Tables 6 and 7 for Outcome of New and Established Patients).

Lessons Learned

1. Having the same bilingual interpreters (from the Health Department) and nurses (from St. Mary's and Washoe Enhancement Services) provided continuity from one screen to the next. However, a review of the screening process and referral protocol with the staff prior to each screen would enhance continuity even more.

2. Nurses added credibility to the screening and referral process by providing assessment and health education. Their contributed to the project's planning phase and process improvements.

3. The project achieved its goal of providing diabetes screening to its targeted population by holding them in locations where the Hispanic population frequently visited (Sak & Sav grocery caters to the Hispanic population and most Hispanics are Catholic).

4. A screen should not compete with other special events.

5. Use of St. Mary's Take-Care-a-Van added significant credibility to the screening project. "On the road" in Reno/Sparks since 1995, it is a highly visible, well-known symbol of accessible and reliable health care, health information and referrals.

6. To obtain buy-in and to enhance the follow-up of clinic referrals and data retrieval, one must be knowledgeable about the clinics' protocol and include key clinical staff in the planning and evaluation phases of the project.

7. Having two staff direct and oversee the flow of the screening process and escort participants from the finger stick glucose station to the nurse in the van ensured that every participant saw the nurse. Only one person out of 348 did not see the nurse.

8. Most staff wore a T-shirt that indicated their affiliation with a particular community-based organization. If nothing else, it was a subtle way of showing the team players and the community the collaboration involved in this effort.

Conclusions and Implications

The Defeat Diabetes Screening Project is a secondary prevention effort to identify persons with high risk for unrecognized, asymptomatic diabetes and provide early diagnosis and treatment to prevent or delay complications and improve health outcomes. It is one of many diabetes screening programs that would be evaluated on its ability to detect undiagnosed cases. Defeat Diabetes is an example of selective screening where a high-risk group, the Hispanic population, was targeted. Yields for selective screening have ranged from 5 to 40% compared to yields for population screening of 4-72%. Defeat Diabetes detected 6 new cases of diabetes, a 1.7% yield. (348 divided by 6).

Evidence for and against screening asymptomatic adults for diabetes has been reviewed (Engelgau, Michael M., K.M. Venkat Narayan and William H Herman. Screening for Type 2 Diabetes, Diabetes Care, Volume 23, 2000, pp. 1563-1580). A debate on the costs versus benefits of screening is a major issue. A major cost of selective community screenings, such as Defeat Diabetes, is the considerable resources needed. Another significant cost is the burden on the health care system, i.e., HAWC and St. Mary's Clinics, in terms of patient load in addition to an "opportunity cost" in taking on a new activity (screening).

The National Diabetes Detection Initiative, launched in November 2003 by the Department of Health and Human Services and Centers for Disease Control and Prevention, will be pilot testing selective screening in specific states using an organized health communications approach and coordination of health systems and community intervention. Hopefully, this initiative will provide more concrete evidence on the costs and benefits of selective screening and identify a more cost-effective approach to community screening. The success of this initiative would potentiate the likelihood of federal funding and resources for communities, such as Washoe County, to perform screenings. No doubt, the Defeat Diabetes Screening Project strengthens Nevada's statewide Diabetes Control and Prevention Program.

Table 6. Outcomes for St. Mary's New & Established Patients

(V1= first clinic visit, L2= lab visit, V3= second clinic visit)

Patient Status	V1 BS	V1 systolic	V1 diastolic	V1 BMI	L1 Diagnosis	L2 FBS	L2 Tchol	L2 HDL	L2 LDL	V3 Diagnosis
New	109	180	110	39	Morbid obesity		201	39	135	Has not f/u
New	97	120	58		Osteoarthritis		195	87	108	Has not f/u
New	227	172	82	30	Diabetes	202
New	152	132	70	28	Diabetes	166	207	50	134	Diabetes, leg pain
New	166	150	84	32	Diabetes	196	220	43	149	Diabetes
New	244	150	80	26	Diabetes & hypertension	276	212	37	139	Seen by dietitian 8/20
New	346	104	60		Uncontrolled diabetes	345	247	40	182	Diabetes
New		140	86	40	Post menopause	93	220	43	160	10/23 visit for strep throat
New		90	60	28	Adult exam	90	162	51	100	Depression
Established	215	160	100	36	Diabetes improved control, B/p variable but overall better		268	41	41
Established		100	80		Bronchitis					Cervical strain
Established		104	56	19	5yr well child clinic	97				depression
Established		90	60		Epigastric pain, GERD

Table 7. Outcomes for HAWC's New & Established Patients

(V1= first clinic visit, V2= lab visit, V3= second clinic visit)

Patient Status	V1 BS	V1 systolic	V1 diastolic	V1 BMI	V1 Diagnosis	L2 FBS	L2 Tchol	L2 HDL	L2 LDL	V3 Diagnosis
New	171	130	80	29	HTN, hypercholesterolemia	171	277	37	400
New	87	110	80	31	FHx of diabetes	87	177	50	106
New	348	110	70	28	Diabetes	174	227	55	137	Diabetes
Established	94	130	90	45	Prediabetic		166	41	92
Established	94	110	70	28	Glaucoma	94	199	60	129	Glaucoma/depression
Established					Hypothyroid
Established	219				Diabetes					Diabetic