Original Title: Dépistage du diabète de type 2 et évaluation du risque cardiovasculaire. Rapport en soutien au protocole médical national et au modèle d’ordonnance collective

Authors' objectives: Diabetes and cardiovascular disease remain among the leading causes of potentially avoidable premature death, the prevention of which depends on early detection and prompt, appropriate management. These two pathologies are often interrelated, since: 1) obesity and age are important and common risk factors; 2) diabetes is a risk factor for cardiovascular disease; and 3) optimizing lifestyle habits is the basis of recommended preventive approaches for both conditions. Screening for type 2 diabetes and cardiovascular risk assessment are currently being conducted in Quebec on an opportunistic basis and are not part of a recruitment strategy involving systematic invitations to a targeted population. Access to these services also depends on the prescription of laboratory tests by a physician or specialized nurse practitioner (SNP). Given the large number of people who do not have a family doctor or who do not have access to regular medical follow-up, measures enabling nurses or other authorized professionals to initiate laboratory tests for type 2 diabetes screening or cardiovascular risk assessment could contribute to greater participation by the targeted population, in order to promote rapid and appropriate management of the risk factors associated with these conditions, as well as the prevention of related complications. To this end, the Ministère de la Santé et des Services sociaux (MSSS) has asked the Institut national d'excellence en santé et en services sociaux (INESSS) to develop tools that will not only facilitate access to type 2 diabetes screening and cardiovascular risk assessment, but also support front-line professionals in various settings, while promoting harmonized practice across the province.

Authors' results and conclusions: RESULTS (#1 ELIGIBILITY CRITERIA BASED ON AGE AND ESSENTIAL FACTORS TO BETTER TARGET AT-RISK INDIVIDUALS): Risk assessment for type 2 diabetes and the development of cardiovascular disease should only be considered for people over the age of 18 since age is a very important risk factor in the development of these conditions. Furthermore, as an individualized risk-benefit assessment is required for people aged 75 and over, they were excluded from the present protocol. (#2 ADEQUATE, EASY-TO-PLAN LABORATORY TESTS FOR THE TARGET CLIENTELE AND THE CARE NETWORK): The recommended test for assessing the risk associated with the development of cardiovascular disease in primary prevention is the fasting lipid profile (including total cholesterol [TC], high-density lipoprotein cholesterol [HDL], low-density lipoprotein cholesterol [LDL] and triglycerides [TG]). This test should be repeated every 5 years, if there is no major change in risk factors, or if the result is normal. Although other laboratory tests (e.g., a once-in-a-lifetime lipoprotein (a) test, or apolipoprotein B) test have been recommended in some clinical practice guidelines, the lack of evidence showing a clinical benefit from these tests, as well as an applicability issue concerning the lipoprotein (a) test, have prevented their inclusion in the protocol. (#3 CRITERIA FOR PERSONALIZED MEDICAL MONITORING - ESPECIALLY OF THOSE MOST AT RISK): Lipid profile results should be integrated into a risk calculation tool that takes into account the main cardiovascular risk factors. For this purpose, the INESSS CVR calculator based on the FRS (Framingham Risk Score) prediction model, which has been validated in the Canadian population, was chosen. Thus, people at high risk (FRS greater than or equal to 20%) or moderate risk (FRS between 10 and 19%, but with LDL cholesterol greater than or equal to 3.5 mmol/l or non-HDL cholesterol ≥ 4.2 mmol/l if LDL cholesterol is not available), who may therefore require lipid-lowering drug treatment, should be referred for case-by-case assessment by a physician or SNP. Regardless of the calculated risk level, people with elevated LDL cholesterol levels of 5 mmol/l or more, or fasting triglycerides of 5.7 mmol/l or more, also require case-by-case assessment to determine the need for lipid-lowering treatment. CONCLUSION: The development of this national medical protocol and the group prescription model on the introduction of laboratory tests for type 2 diabetes screening and cardiovascular risk assessment is the result of clinical practice recommendations that have been enhanced by the perspective of various stakeholders as well as contextual aspects. While not a substitute for clinical judgment, the recommendations should encourage more targeted participation of the at-risk population in these interventions, including those without a family physician, and standardize clinical practice in type 2 diabetes screening and cardiovascular risk assessment across the province. The changes in practice that could result from this work will depend, however, on the adoption of these tools by front-line care teams (e.g., primary care access point - GAP, family medicine groups - GMF, local community service centres - CLSC) and the adoption of the recommendations by the healthcare professionals concerned. A dissemination strategy, and the production of an information tutorial for front-line clinicians will be implemented to facilitate the adoption and use of these tools. Finally, it is important to emphasize that all the recommendations and clinical information detailed in the present work concern type 2 diabetes screening and cardiovascular risk assessment in an opportunistic strategy context, and that the relevance of systematic screening has not been addressed.

Authors' methods: Data integrated and gathered from a rapid review of the literature on best clinical practices, contextual information from health and social services establishments, and the experiential knowledge of clinicians from various specialties and areas of expertise, enabled us to identify the findings that served as the basis for the recommendations and clinical tools developed. The scientific quality, acceptability, and applicability of the work were assessed by external readers specializing in the field of interest, as well as future users who had not participated in the work.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/depistage-du-diabete-de-type-2-et-evaluation-du-risque-cardiovasculaire.html

Year Published: 2024

URL for published report: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/depistage-du-diabete-de-type-2-et-evaluation-du-risque-cardiovasculaire.html

English language abstract: An English language summary is available

Publication Type: Other

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: L'Institut national d'excellence en sante et en services sociaux (INESSS)