Justification: while the prevalence of T2D in the paediatric population is low, it can reach up to 2.1% in European adolescents, and a worrisome increase is expected due to the epidemic proportions of childhood obesity, which is associated with its development.1 It is well known that the main risk factor for T2D is excess weight. Thus, it would be sensible to develop screening programmes for the obese population.2
Validity: the population under study was well defined, but the sample was limited to four specific clinics. The criteria and risk factors for T2D, while not specified, were those established by the American Diabetes Association. The intervention was clear, and there was a detailed explanation of every step in the computerised system. The outcome measures were clearly defined, but the most relevant finding of the study was the odds ratio (OR) for undergoing screening, which was not defined a priori.
Patients were randomised by clusters based on the clinic they attended, and there were no data regarding the clinicians that participated in the study, which were 29 in total. The authors analysed data to verify that the groups of patients had similar characteristics, and intended to adjust the analyses for race, sex or type of insurance if they found differences between groups. Blinding was not possible due to the characteristics of the software. There were no losses to followup in the final analysis. The analysis was made by intention to treat.
As for external validity, the results of this study cannot be extrapolated to our population due to the ethnic composition of the sample. In our health care centres, we only serve children up to age 14 years, so the yield of screening would probably be even lower.3
Clinical relevance: the usual proportion of patients were identified as being at risk of T2D using CHICA T2D system (approximately 41% of patients in the CG and IG), which suggests that these patients are identified properly under any circumstances. The percentage of patients that completed the workup was 20%, which seems low. However, the likelihood of completing the workup was 4.6 higher in the IG, with a number needed to treat (NNT) of 5*. The final yield for the diagnosis of T2D (1 patient) or prediabetes (18 patients) was higher in the control group, with an OR of 0.6 (95 CI, 0.3 to 1.1). The study did not analyse whether early diagnosis improved long-term outcomes.
There is evidence that suggests that outcomes improve when computerised clinical support systems for clinicians are combined with support for self-guided behaviour change for families.4
In any case, including an additional screen or popup in an application that is used routinely in the care of the paediatric population seems a simple, cheap and risk-free measure that could be beneficial to our patients.
Applicability to clinical practice: at present, when most primary care clinicians work with electronic health record systems, integrated clinical support algorithms offer unquestionable benefits to health professionals as well as patients. However, this study did not seem to find evidence that the use of CHICA T2D offered substantial advantages. Current evidence suggests that primary prevention measures aimed at promoting lifestyle changes may be more cost-effective.2,4
Conflicts of interest: the authors of the commentary have no conflicts of interest to declare.