Clinical and Public Health Implications of 2019 Endocrine Society Guidelines for Diagnosis of Diabetes in Older Adults.

Objective: Screening for diabetes is typically done using hemoglobin A (HbA) or fasting plasma glucose (FPG). The 2019 Endocrine Society guidelines recommend further testing using an oral glucose tolerance test (OGTT) in older adults with prediabetic HbA or FPG. We evaluated the impact of this recommendation on diabetes prevalence, eligibility for glucose-lowering treatment, and estimated cost of implementation in a nationally representative sample.

Research Design And Methods: We included 2,236 adults aged ≥65 years without known diabetes from the 2005-2016 National Health and Nutrition Examination Survey. Diabetes was defined using: ) the Endocrine Society approach (HbA ≥6.5%, FPG ≥126 mg/dL, or 2-h plasma glucose ≥200 mg/dL among those with HbA 5.7-6.4% or FPG 100-125 mg/dL); and ) a standard approach (HbA ≥6.5% or FPG ≥126 mg/dL). Treatment eligibility was defined using HbA cut points (≥7% to ≥9%). OGTT screening costs were estimated using Medicare fee schedules.

Results: Diabetes prevalence was 15.7% (∼5.0 million) using the Endocrine Society's approach and 7.3% (∼2.3 million) using the standard approach. Treatment eligibility ranged from 5.4% to 0.06% and 11.8% to 1.3% for diabetes cases identified through the Endocrine Society or standard approach, respectively. By definition, diabetes identified exclusively through the Endocrine Society approach had HbA1 <6.5% and would not be recommended for glucose-lowering treatment. Screening all older adults with prediabetic HbA/FPG (∼18.3 million) with OGTT could cost between $737 million and $1.7 billion.

Conclusions: Adopting the 2019 Endocrine Society guidelines would substantially increase the number of older adults classified as having diabetes, require significant financial resources, but likely offer limited benefits.