By Jordan Benadiba
A new study released in the Journal of the American Geriatrics Society (JAGS) shows that diabetes testing practices of Ontario’s long-term care (LTC) residents without diabetes is high and potentially unnecessary. These findings suggest that asymptomatic diabetes testing in LTC may create an unnecessary burden on LTC residents, staff, and the healthcare system.
The study’s lead author, Dr. Iliana Lega, a WCH scientist and endocrinologist, explains the research and its impacts.
Can you provide a general overview of your study?
The goal of our study was to understand diabetes testing practices of Ontario’s LTC residents without diabetes. We looked at all LTC residents in Ontario without diabetes between 2015 and 2018 and measured the number of tests residents had for glycated hemoglobin, A1c, which is a screening test for diabetes, and/or blood glucose over a two-year period. We looked at testing rates overall, and by age, sex and residents who were near the end of life.
We included over 100,000 LTC residents in our study and found that nearly half (46 per cent) had at least one test for diabetes with a A1c during the follow up period, and that among residents that were tested, nearly 20 per cent had four or more tests. Testing rates were similarly high among both sexes, for residents over 80 years and for those who were near the end of life.
Of those tested for diabetes, a little over five per cent were in the diagnostic range for diabetes, of which only 14.7 per cent had started taking diabetes medication. When we used a stricter cutoff for diagnosing diabetes, which is the threshold where glucose levels are more likely to cause symptoms and impact health outcomes and quality of life, less than one per cent of residents met the criteria for diabetes diagnosis.
This showed us that current rates of diabetes testing in LTC homes in Ontario are high and puts into question the utility of such testing given the overall low rates of diabetes that is likely to impact quality of life and long-term outcomes.
Why research asymptomatic diabetes testing of LTC residents?
While screening guidelines for many other chronic conditions, like cholesterol or cervical cancer, have upper age cutoffs after which screening is no longer recommended, no such cutoffs exist for diabetes. In general, the main goal of asymptomatic diabetes screening is to prevent asymptomatic hyperglycemia to reduce the risk of long term microvascular, and potentially macrovascular complications. Given that benefits of treating diabetes to low glucose levels occurs after an average of eight years of treatment and LTC residents have an average life expectancy of 14 to 47 months, there is likely a limited role for detecting and treating asymptomatic hyperglycemia in this population.
In addition, there are potential risks to diabetes treatments including hypoglycemia, as well as the burden it places on LTC nursing staff and the healthcare system. This further puts into question the benefits of identifying and treating asymptomatic diabetes and highlights the need for a more judicious approach to diabetes testing in this setting.
Were you surprised by the study results? And do you think this is likely the case in other provinces?
Given the lack of guidance from Diabetes Canada Clinical Practice Guidelines, as well as other national diabetes guidelines around the world, it is not surprising that there is such a high rate of diabetes testing in LTC homes. While no studies have been done in other provinces in Canada on diabetes testing practices in LTC, unfortunately I do not think our findings in Ontario are unique and we are likely to see frequent testing in other provinces as well. Hopefully our study can help inform guidelines that specifically discuss age cut-offs for diabetes screening in older, frail adults.
Can you share in more detail how unnecessary diabetes testing in LTCs impacts patients, healthcare staff and the health system more broadly?
Unnecessary testing for any condition, not just diabetes, burdens everyone unnecessarily. First and foremost, residents are troubled with laboratory tests which involve needle pokes. As we age, something as simple as finding a vein for a blood test becomes more difficult and can lead to significant discomfort, as well as bleeding and bruising.
In addition, if diabetes medications are started based on the results of diabetes testing, residents may have unpleasant and sometimes even dangerous side effects to diabetes medications, such as hypoglycemia. Diabetes overtreatment, treatments that are unlikely to cause benefits and may cause harm, is already a concern for older adults with diabetes and over-testing further contributes to overtreatment.
Second, laboratory tests are commonly performed by LTC nursing staff who are already incredibly over-stretched due to high-patient ratios and frail and dependent residents who need a lot of care. Reducing unnecessary testing would help reduce the workload of nursing staff and allow them to focus more on resident care and well-being. Lastly, testing and diabetes treatments and monitoring are costly to the healthcare system. If such testing is not needed and could be reduced, there would be significant potential cost savings that could then be diverted to support other important needs in LTC homes.
What steps or recommendations can be drawn from your research? What would you like to see happen on this issue?
Our main goal with this study was to understand current diabetes testing patterns in LTC homes in Ontario and how often this testing leads to a clinically meaningful diagnosis of diabetes that would benefit from treatment. Based on the findings, our study highlights the need for diabetes guidelines to consider an upper age-cutoff for asymptomatic diabetes screening in this population. The next steps in our research are to further understand patterns of diabetes testing by examining regional differences across the province, as well as physician and patient-related factors that may be contributing to diabetes testing rates. Understanding these factors, will allow us to develop targeted strategies to reduce diabetes testing in this population.