Preoperative Glucose Testing and USPSTF Diabetes Screening Guideline Adherence in Patients With Gynecologic Cancer on an Enhanced Recovery Pathway

Katherine Chaves, MD, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, discusses a study that evaluated adherence to both preoperative glucose testing and U.S. Preventive Services Task Force (USPSTF) diabetes mellitus screening guidelines, and aimed to identify the prevalence of impaired glucose metabolism in unscreened patients with gynecologic cancer.

This study was presented at the SGO 2022 Annual Meeting on Women’s Cancers.

Transcript: 

I'm Kate Chaves. I am a second year minimally invasive gynecology surgery fellow at Vanderbilt and I'll be discussing our work today that was presented at SGO 2022 and it's entitled Compliance With Preoperative Glucose Testing and USPSTF Diabetes Screening Guidelines and Gynecologic Oncology Patients On An Enhanced Recovery Pathway.

So really initially what prompted this research was that we implemented in 2019 an enhanced recovery pathway for our gynecologic oncology surgery patients, and part of this pathway includes having a day of surgery glucose checked. As anybody familiar with the rollout of these programs, often compliance is an issue. So we kind of first and foremost just wanted to see how are we doing our patients having their glucose checked the day of surgery?

But then kind of the bigger question is what is this day of surgery glucose suggesting about a patient's glucose metabolism? So there's evidence that up to 40% of patients with diabetes don't know that they have it. So really an underdiagnosed condition and that even in the primary care population that only about half of patients are appropriately screened. So seeing if we could shed some light on using the perioperative time period to help screen patients for this underdiagnosed condition.

So we looked at patients who were having surgery with a gynecologic oncologist at Vanderbilt on an enhanced recovery pathway, and we covered about a three and a half year period. Our primary outcome was just yes or no, did they have a glucose checked the day of surgery? Then we looked at patients to see if they met criteria for USPSTF diabetes screening. So that's patients who are age 40 to 70 and who are overweight or obese. So we basically reviewed Vanderbilt records and any screened or scanned outside records to see if they had a diabetes screen test on file.

Then in patients who had not been screened, we looked at their day of surgery glucose to see what that suggested. By that, I mean, we looked to see if it was between 100 and 125 mgs per deciliter, which suggests impaired fasting glucose or greater than are equal to 126 mgs per deciliter, suggesting diabetes. I say suggest because our patients are not strictly fasting. They consume a small carbohydrate load, which is varied a little bit, but in general, less than 10 gram carbohydrate load prior to their surgery. So we can't use this value to definitively diagnose it, but instead to just kind of suggest that maybe there is an issue going on.

So we identified 664 patients who met our inclusion criteria and we did not do a great job. About half or 53% of our patients actually had a blood sugar check the day of surgery. There were 530 non-diabetic patients and of those 530 non-diabetic patients about half met those diabetes screening criteria. So focusing on that group that met criteria for screening, we looked to see if they a documented screening and the vast majority did not. Or 80% of patients who needed screening did not have documented screening in the three years proceeding surgery.

Then finally, when we looked at those patients and it was about 107 patients who did not have documented screening and had a blood glucose the day of surgery. So basically these are patients that we've missed an opportunity to screen them. What is their blood sugar the day of surgery showing, and half, 50%, had a blood glucose greater than or equal to 100 mgs per deciliter. So again, potentially suggesting impaired fasting glucose or Frank diabetes.

So I think the key limitation of our study, as I've alluded to a little bit, is that it is not a strictly fasting glucose. So again, we cannot use this to definitively say that 50% of our patients have impaired glucose metabolism, but it kind of opens the door to future questions and future research about using the perioperative time period to help make sure that patients are screened appropriately for diabetes.

So I think that was kind of the big takeaway for us was that working on utilizing this perioperative time to not just focus kind of on the acute surgical considerations, but that making sure that patients are up to date on other medical needs. In this case, routine diabetes screening. Kind of the next steps that we're working on are looking in the more acute setting that even in non-diabetic patients does preoperative hyperglycemia have any associations with complications after gynecologic surgery? Most of that evidence comes from the trauma literature or colorectal surgery, which can be a pretty different population than ours. Thank you so much for learning more about our study and I look forward to hearing out any other ideas that people have.