The impact of population-level HbA(1c) screening on reducing diabetes diagnostic delay in middle-aged adults: a UK Biobank analysis

Abstract

AIMS/HYPOTHESIS: Screening programmes can detect cases of undiagnosed diabetes earlier than symptomatic or incidental diagnosis. However, the improvement in time to diagnosis achieved by screening programmes compared with routine clinical care is unclear. We aimed to use the UK Biobank population-based study to provide the first population-based estimate of the reduction in time to diabetes diagnosis that could be achieved by HbA(1c)-based screening in middle-aged adults. METHODS: We studied UK Biobank participants aged 40-70 years with HbA(1c) measured at enrolment (but not fed back to participants/clinicians) and linked primary and secondary healthcare data (n=179,923) and identified those with a pre-existing diabetes diagnosis (n=13,077, 7.3%). Among the remaining participants (n=166,846) without a diabetes diagnosis, we used an elevated enrolment HbA(1c) level (≥48 mmol/mol [≥6.5%]) to identify those with undiagnosed diabetes. For this group, we used Kaplan-Meier analysis to assess the time between enrolment HbA(1c) measurement and subsequent clinical diabetes diagnosis up to 10 years, and Cox regression to identify clinical factors associated with delayed diabetes diagnosis. RESULTS: In total, 1.0% (1703/166,846) of participants without a diabetes diagnosis had undiagnosed diabetes based on calibrated HbA(1c) levels at UK Biobank enrolment, with a median HbA(1c) level of 51.3 mmol/mol (IQR 49.1-57.2) (6.8% [6.6-7.4]). These participants represented an additional 13.0% of diabetes cases in the study population relative to the 13,077 participants with a diabetes diagnosis. The median time to clinical diagnosis for those with undiagnosed diabetes was 2.2 years, with a median HbA(1c) at clinical diagnosis of 58.2 mmol/mol (IQR 51.0-80.0) (7.5% [6.8-9.5]). Female participants with lower HbA(1c) and BMI measurements at enrolment experienced the longest delay to clinical diagnosis. CONCLUSIONS/INTERPRETATION: Our population-based study shows that HbA(1c) screening in adults aged 40-70 years can reduce the time to diabetes diagnosis by a median of 2.2 years compared with routine clinical care. The findings support the use of HbA(1c) screening to reduce the time for which individuals are living with undiagnosed diabetes.