A Direct-to-Patient Alert for Glycated Hemoglobin Screening Using Prediction Modeling and Mobile Health (mHealth) (North Carolina)

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Using Direct-to-Patient Technology and Clinical Decision Support to Increase Type 2 Diabetes Screening


A low-cost, novel direct-to-patient CDS tool that identifies patients at high risk of type 2 diabetes and offers them a screening test could increase the number of patients screened and save physicians’ time.

Identifying patients with elevated blood glucose levels

Type 2 diabetes (T2D) and pre-diabetes are significant public health problems. Characterized by elevated blood glucose levels, T2D and pre-diabetes, with the resulting complications that occur when untreated, can result in significant medical costs. Those at risk for T2D may be screened with serum hemoglobin A1C (HbA1c) testing, which reflects a patient’s average blood glucose level over the prior 3 months. Despite current screening guidelines, many high-risk patients do not get screened, contributing to approximately a quarter of T2D cases going undiagnosed. To assist physicians in identifying patients at risk, Dr. Brian Wells and his Wake Forest research team previously developed an HbA1c risk calculator for predicting which patients without previous symptoms of diabetes or hyperglycemia would have an elevated HbA1c. One method to increase screening is to alert providers when patients are at risk as identified by the risk calculator.

"In primary care, one of the best things that we can do to improve patient outcomes is identify and manage chronic conditions early.”
- Dr. Wells

Offering screening to patients through text messaging

However, as a family physician Dr. Wells understands that busy PCPs may experience “alert fatigue” from alerts such as these. As such, he and his research team are developing a direct-to-patient CDS tool to identify at-risk patients and directly offer them screening. The tool will access patient data in the EHR and identify patients at risk using characteristics validated in the calculator. Once a patient is identified, they will receive a text message offering them testing through their primary care physician’s office. If the patient agrees to the screening, a lab order will be automatically placed. Results from the screening will be sent to both the patient and the patient’s physician.

Changing the way services are delivered

Using direct-to-patient technology is a novel strategy for reaching patients for screening recommendations. Dr. Wells thinks that by bypassing the clinician, more patients with be screened; those identified as hyperglycemic will be offered earlier treatment and thus better outcomes. Dr. Wells hopes that by “going directly to the patient and empowering them to get screened” the tool will help reconnect high-risk patients to the healthcare system. This low-cost, low-risk tool has the potential to be adapted for use with other chronic health conditions.

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A low-cost, novel direct-to-patient CDS tool that identifies patients at high risk of type 2 diabetes and offers them a screening test could increase the number of patients screened and save physicians’ time.

Project Details - Ongoing


Type 2 diabetes (T2D) is a pervasive public health issue in the United States. Studies have shown that 36.5 percent of adults have pre-diabetes, and 12.3 percent of adults have T2D diabetes. Of those adults with T2D, approximately a quarter of cases are undiagnosed. Onset can be difficult to predict due to a lack of symptoms early in the disease course. Hyperglycemia--elevated blood sugar--is the defining characteristic of T2D and can be present for years before a diagnosis. Screening, diagnosis, and management of T2D may be done via hemoglobin A1c (HbA1c), a blood test that is reflective of an individual’s average blood sugar over 3 months. It is thus an easy and accurate method for determining if a patient has experienced hyperglycemia regularly, possibly indicating T2D.

In a previous study, the researchers created a clinical decision support (CDS) tool to identify patients at risk of elevated HbA1c. In the current study, the researchers will implement this existing CDS tool in the electronic health record (EHR) of the Department of Family Medicine at Wake Forest University Health Systems to identify patients at high risk for elevated HbA1c levels. High-risk patients will be contacted via text message and offered HbA1c testing. Patients will then have the ability to accept or decline the testing. If a patient accepts, an order for testing will automatically be placed. Feedback from focus groups will initially guide message content and features. For this pilot study, the CDS will be applied to 500 high-risk patients. Surveys will determine potential factors influencing a patient’s decision to accept or decline HbA1c testing.

The specific aims of the research are as follows:

  • Develop a mobile (mHealth) text message intervention to improve the early identification of patients with hyperglycemia. 
  • Evaluate the impact of a text message mHealth HbA1c screening program in the Department of Family Medicine. 
  • Perform telephonic surveys on 100 patients: 50 who completed screening and 50 who did not complete screening. 

This targeted screening has the potential to improve the cost-effectiveness and efficiency of screening for abnormal HbA1c. Recognizing provider alert fatigue, the HbA1c screening offer will bypass the provider, removing steps to screening, and empower patients to take ownership of their health. Results from this and future studies may demonstrate the viability of texting as a tool for preventive medicine and encourage more studies to leverage direct patient interventions based on personalized recommendations. Results from this project will inform the development of a larger trial.