Implementation of AUSDRISK screening for type 2 diabetes in older adults

The research described in this thesis was undertaken in 2014‚Äö-15. At that time, the World Diabetes Federation estimated there were 1.7 million Australians with diabetes (all types) which was predicted to increase to 2.3 million by 2035. A further 2 million Australians were estimated to have pre-diabetes (preDM), which doubles the risk of developing type 2 diabetes mellitus (T2DM). Type 2 diabetes is an age-related condition and life expectancy of the Australian population is increasing. Together they form the perfect storm. In 2014‚Äö-15, the overall prevalence of T2DM in Australia was 4.1% with the prevalence of T2DM in the older age cohort ranging between 9.0% in the 55‚Äö-64 year age group, and rising to 16.0% in the 65‚Äö-74 year age group. In Tasmania, the older age cohort is the most rapidly increasing. Diabetes Tasmania, the peak non-Government body representing individuals with or at risk for diabetes, reported that in calendar year 2014‚Äö-15, 1,471 individuals had been newly diagnosed with T2DM in Tasmania, with 78.5% of those newly diagnosed being over 50 years and over. Of those, 22.3% were first diagnosed in their 70's, 80's and 90's. As of 30 June 2018, 29.0% of newly diagnosed T2DM were over 70 years, reflecting a dramatic increase in this older cohort. In Australia there is no national population screening for early identification of those with, or at high risk (HR) for T2DM, and no systematic T2DM screening in primary care settings by general practitioners (GPs). In 2010, the Australian Type 2 Diabetes Risk Assessment Tool (AUSDRISK) was developed to identify individuals at HR for T2DM, with recommendations for blood glucose testing to confirm glycaemic status. National Health and Medical Guidelines recommend that the AUSDRISK be used as the first step in a 2‚Äö-3 step screening process, but the uptake is limited. In 2015, the Australian National Diabetes Strategy Advisory Group (NDSAG), recommended a wider use of the AUSDRISK assessment in primary health settings, community health and non-health settings and online health services in state and federal health departments to identify individuals at high risk for T2DM. In 2011, prior to the NDSAG recommendation, I conducted a small T2DM screening trial, and found that AUSDRISK could be distributed and completed via community healthcare settings. The objectives of this current study in 2014‚Äö-15 were to verify the procedures and findings of the earlier study with a larger sample size of older adults, by distributing the AUSDRISK via 3 different community settings. The AUSDRISK was presented face-to-face in the 2 community health settings, and indirectly via a statewide mail-out specifically for older adults. The aim was to determine the feasibility, acceptability and effectiveness of using the AUSDRISK as the first step in T2DM screening of community-living older individuals, and to follow those at HR through to biomedical assessment. The purpose of the study is to identify the number of older individuals at High Risk (HR) for T2DM and to determine if there were any differences in participation between a face-to-face presentation of AUSDRISK compared with receiving an AUSDRISK via mail out. The number of HR participants identified, and their baseline characteristics were established for those in each setting/recruitment method (direct/indirect). Differences in gender, age, family history of diabetes, the number and frequency of AUSDRISK HR score levels (HR1, HR2 HR3) were recorded and results were analysed. The major findings of this 2014‚Äö-15 study were that, although local and statewide distribution of AUSDRISK was feasible, older individuals did not find completion of the AUSDRISK to be acceptable. This lack of acceptability was associated with ignorance that older age was a risk factor for T2DM, and therefore the relevance of AUSDRISK was not apparent. There was no statistically significant association between the HR participants' HR score levels (HR1; HR2; HR3) and subsequently assessed glycaemic status. Of those assessed on the AUSDRISK as being at HR, 85.7% (42/49) were found to be normoglycaemic on biomedical assessment and 14.3% HR (7/49) were identified with Elevated Blood Glucose (EBG) frequently referred to as preDM. The participants with EBG had scores spread across all HR levels (HR1‚Äö-HR3). The average risk score of those assessed as having EBG was only 0.95 units higher (p=0.50) than those assessed as normoglycaemic. The older age participants' knowledge of T2DM and AUSDRISK showed that 75.0% had never heard of the AUSDRISK, and 90.0% had never completed an AUSDRISK. Most participants were unaware of the concept of risk, as opposed to diagnosis, and considered being normoglycaemic on biomedical assessment meant they would never get T2DM. This Real-World study demonstrated the limitations of utilizing AUSDRISK in T2DM screening for older age individuals. The results showed that scoring HR on the AUSDRISK had no significant predictive value as a first-step filter in T2DM screening in identifying those older adults who would require a confirmatory blood glucose test from those who did not. The results of this study were compared with other studies using AUSDRISK in a young to mid age population and with international T2DM screening studies using a greater number of biomedical assessments for older age individuals. It is acknowledged that there may be responder bias associated with results in this ultimately small number of HR participants who completed the full screening process. However, the findings in this study were consistent with international studies using Risk Assessment Tools to identify HR for T2DM in the older age cohort. In the light of these findings, and the importance of effective screening, consideration was given for direct implementation of a national system of regular/rolling biomedical glycaemic assessments on a 3‚Äö-5 year basis for all older age individuals from age 60‚Äö-74 years, along the lines of the 5-yearly UK National Health Service Health Check which includes cardiovascular and diabetes components. Implementing regular biomedical assessments would identify a pattern of increasing glycaemic results over time, and interventions, whether lifestyle and/or medication, could be implemented at an earlier stage of dysglycaemia to avert progression to T2DM.