Why NYU Langone screens its ER patients for diabetes

A patient entering the ER with a sprained ankle may be surprised if the attending physician asks to screen them for Type 2 diabetes. But at NYU Langone Health, it’s been the norm since 2019—and as a result, the system has tested more than 10,000 patients for the disease, diagnosing 20% of them with prediabetes and 2.5% with diabetes.

The health system, which runs the screening initiative at four emergency rooms located in Manhattan and Brooklyn, as well as on Long Island, started giving a blood test for Type 2 diabetes (at no additional cost to the patient) to people who meet criteria set out by the US Preventive Services Task Force.

The diabetes screening initiative is the first of its kind in New York City. Reed Caldwell, the health system’s EMS medical director, said he instituted the policy because it would lower morbidity and mortality rates for these patients while also decreasing healthcare costs.

How it works

The ER was the perfect spot to do the screening because many people only seek care there, Caldwell said.

The inexpensive tests, which check hemoglobin A1C levels, can quickly indicate whether a patient has diabetes. So by the time they’re getting sent home with care directions for that ankle injury, a primary care appointment can be scheduled for diabetes management, said Caldwell. 

Depending on the severity of the person’s disease, diabetes management could simply be increasing exercise and making dietary changes. Other interventions include oral medications and insulin, as well as regular checkups for kidney function, eye health, and foot care, Caldwell said.

“My goal was to do the most we can for people’s health…during the time that they’re with us,” Caldwell said. “By moving upstream, we can do some reduction in the risk of some of the other disease processes, like stroke and heart attack, that can have devastating consequences.”

The cost-saving benefit of screening

Roughly 10% of Americans have diabetes, and 90%–95% of those people have Type 2 diabetes, a chronic condition with symptoms that can be reversed by eating healthier and living a more active lifestyle.

The disease is extremely expensive to treat. The CDC estimates that a quarter of annual US healthcare dollars ($4.3 trillion in 2021) is spent on treating the condition, with $237 billion spent per year on direct medical costs and $90 billion lost in reduced productivity.

One way to reduce the economic burden of diabetes is early screening and treatment, like NYU Langone has done. It’s estimated that 7.3 million adults have Type 2 diabetes and don’t know it. On average, it can take five years before a person gets diagnosed, according to Kevin Pantalone, the director of diabetes initiatives at Cleveland Clinic.

Caldwell said NYU Langone has been tracking the results of the screening initiative, but doesn’t yet have any publicly available data on how much money the initiative may have saved the health system.

Other systems might also struggle to quantify the financial impact if they adopted NYU Langone’s policy, said Christian Dankers, a principal and the associate chief medical and quality officer at healthcare consulting firm Chartis.

“When you are thinking about it from a cost-benefit perspective, the benefit of catching diabetes earlier is ideally…[that] you’re actively managing the condition to avoid future complications,” Dankers said.

One way the healthcare industry does cost-benefit analyses of medical interventions or treatments is through a “quality-adjusted life year,” or QALY, said Dankers.

Medical professionals will look at how long a certain intervention or treatment—like a diabetes test—could lengthen a person’s life, and the quality of life they’d have during that time. Generally, interventions that cost less than $50,000 per QALY are considered cost-effective, according to the CDC.

The data for diabetes is “a little bit mixed,” according to Dankers, but experts generally agree that it is cost effective to screen for diabetes.

A screening initiative like NYU Langone’s is likely to save costs in the long-term by improving the overall health of the community.

“It’s really more like on a population health level,” said Dankers. “Are we doing the right thing for our patients today, with the expectation that these things down the road will have a benefit for the patient, benefit for the health system, and benefit for society?”