First-trimester preexisting diabetes screening in Medicaid beneficiaries

Patients with public insurance have higher rates of pregestational diabetes mellitus (DM) and are less likely to receive preconception care than those with private insurance. First trimester DM screening rates among high-risk publicly insured pregnant individuals in the United States are unknown. This study assessed first-trimester DM screening rates in this population. We hypothesized that less than half of publicly insured pregnant patients with at least one DM risk factor were screened in the first trimester. We also examined the utilization of different DM screening tests and pregnancy outcomes between those who did and did not receive early screening.

This retrospective cohort study used US claims-based data from January 2020 to December 2022. Publicly insured individuals with a viable intrauterine pregnancy, who presented for care before 14 weeks, and had no history of DM were included. International classification of diseases 10th revision codes identified patients who had at least one risk factor for DM. Current procedural terminology codes identified DM screening tests. Chi-square test compared categorical variables, and two-sample t-test compared continuous variables. Logistic regression assessed risk factors associated with early DM screening.

A total of 240,109 individuals met inclusion criteria. Among them, 64,230 patients had at least one DM risk factor of which 27,059 (42%) underwent early screening and 37,171 (58%) did not. Insulin resistance (adjusted odds ratio [aOR] 9.47, 95% confidence interval [CI] 8.58-10.47), history of gestational diabetes (aOR 5.89, 95% CI 5.4-6.43), family history of DM (aOR 3.34, 95% CI 3-3.71), prepregnancy obesity (aOR 3.17, 95% CI 3.04-3.31), and hyperlipidemia (aOR 1.59, 95% CI 1.41-1.8) were most strongly associated with early DM screening. Compared to high-risk patients who were not screened, those who were screened had higher rates of gestational hypertension (21.2% vs. 19.7%, p < 0.001), preeclampsia (17.4% vs. 15.6%, p < 0.001), and gestational diabetes (22.8% vs. 12.9%, p < 0.001). Hemoglobin A1c and 1-h oral glucose tolerance test were the most used screening tests (50.0% and 29.4%, respectively).

More than 50% of publicly insured individuals with at least one DM risk factor did not undergo first trimester DM screening, highlighting a potential missed opportunity for screening a high risk population.