NIHR: People with diabetes with a low risk of developing foot ulcers can be screened less often

NIHR | January 2021 | People with diabetes with a low risk of developing foot ulcers can be screened less often

Current NICE guidance recommends that people with diabetes have their feet screened annually to identify those most at risk of developing foot ulcers.  Now a new NIHR- funded study suggests that annual foot checks could be reduced. It found that people at low risk of developing ulcers do not need yearly reviews, as 1 in 20 patients at low risk of a foot ulcer progressed to medium risk level over a two year period.

The researchers analysed the data of over 10 000 patients in Scotland diagnosed with diabetes, who attended their first screening session in the period from 2009 to 2017. From this they identified each individual’s risk of foot ulceration according to standard risk factors of insensitivity, previous ulcers, and whether pulses in the foot could be felt. They looked at the change over time – from low to moderate risk. They cross-referenced this information with data on ulceration, amputation and death.

The results showed:

  • People with diabetes changed from low to moderate risk slowly
  • Around one in ten changed from low to moderate risk after five years (9.9 %) and eight years (11.3%)
  • Most changes in risk status (94%) were down to nerve damage in the feet (peripheral neuropathy)
  • One in 250 (0.4%) in the low-risk group developed ulcers after two-years; one in a thousand (0.1%) had an amputation (Source: NIHR).

Read the full NIHR Alert

Primary paper is available from Diabetic Medicine

Rapid Review: Diabetic retinopathy screening during the COVID-19 pandemic

Ahmad, E., Davies, M.J. & Khunti, K. | Centre for Evidence-Based Medicine| May 2020 | Diabetic retinopathy screening during the COVID-19 pandemic

A new rapid review from tbeCentre for Evidence-Based Medicine considers the question

People with diabetes (PWD) are included in the group at increased risk of severe illness from coronavirus (COVID-19) and have been advised to observe stringent social distancing measures.(1)  This creates a difficult situation for PWD and their Health Care Providers (HCP) as PWD require an annual review including retinal screening as part of their screening for complications, which involves a physical visit to a community or hospital facility or an eye clinic.

  • How can we help stratify annual retinal screening programmes for people with diabetes (PWD) during the COVID-19 pandemic?
  • Can we do remote retinal review for PWD?
  • What can we do to control the risk factors for development or progression of diabetic retinopathy during the COVID-19 pandemic?
  • Is hydroxycholoroquine safe to use in individuals with diabetic retinopathy?

Rapid Review: Diabetic retinopathy screening during the COVID-19 pandemic



Breast, cervical and colorectal cancer screening in adults with diabetes: a systematic review and meta-analysis

Bhatia, D., Lega, I. C., Wu, W., & Lipscombe, L. L. |2019| Breast, cervical and colorectal cancer screening in adults with diabetes: a systematic review and meta-analysis| Diabetologia| 1-15.

Individuals  with diabetes are at an increased risk of developing cancer.A new study published in the journal Diabetologica has quantified an association between association between diabetes and participation in breast, cervical and colorectal cancer screening.




Individuals with diabetes are at increased risk of developing and dying from cancer. Evidence-based guidelines recommend universal screening for breast, cervical and colorectal cancer; however, evidence on the uptake of these tests in individuals with diabetes is mixed. We conducted a meta-analysis to quantify the association between diabetes and participation in breast, cervical and colorectal cancer screening.



MEDLINE, EMBASE and CINAHL were searched systematically for publications between 1 January 1997 and 18 July 2018. The search was supplemented by handsearching of reference lists of the included studies and known literature reviews. Abstracts and full texts were assessed in duplicate according to the following eligibility criteria: study conducted in the general population; diabetes included as a predictor vs a comparison group without diabetes; and breast (mammography), cervical (Papanicolaou smear) or colorectal (faecal and endoscopic tests) cancer screening uptake included as an outcome. Random-effects meta-analyses were performed using the most-adjusted estimates for each cancer site.



Thirty-seven studies (25 cross-sectional, 12 cohorts) were included, with 27 studies on breast, 19 on cervical and 18 on colorectal cancer screening. Having diabetes was associated with significantly lower likelihood of breast and cervical  cancer screening, relative to not having diabetes. Colorectal cancer screening was comparable across groups with and without diabetes ; however, women with diabetes were less likely to receive a colorectal cancer screening test than women without diabetes.



Our findings suggest that women with diabetes have suboptimal breast, cervical and colorectal cancer screening rates, compared with women without diabetes, although the absolute differences might be modest. Given the increased risk of cancer in this population, higher quality prospective evidence is necessary to evaluate the contribution of diabetes to cancer screening disparities in relation to other patient-, provider- and system-level factors. (Source: Bhatia, Lega, Wu & Lipscombe, 2019)

If you are Rotherham NHS staff and interested in reading the full article, why not request it from the Library ?

In the news: Cancer screening rates lower among women with diabetes

Type 2 Diabetes screening in community pharmacies could increase early diagnosis

University of East Anglia | March 2019 | Type 2 Diabetes screening in community pharmacies could increase early diagnosis

Research undertaken by the University of East Anglia in conjunction with high street pharmacy Boots, identifies community pharmacies as being well positioned to screen patients for type 2 diabetes.  

Researchers studied the cost effectiveness of a pilot in community pharmacies in Surrey and Leicester; with data collected from 328 participants during a six month period in 2014. The experts found that the cost of each test and the pilot’s identification statistics in patients were similar to those in medical practices for type 2. The team reduced the number of tests needed through a risk screening questionnaire.


The authors suggest providing a targeted screening service at a community service in an area with suspected high prevalence of type 2 diabetes  could increase the proportion of patients who follow pharmacist advice to visit their GP- which would reduce the cost-effectiveness of the screening service.

Prof David Wright, from UEA’s School of Pharmacy, said: “This study shows that screening though community pharmacies is no more costly or less effective than undertaken through other routes. For such services to be cost-effective however, we also need to intervene in those identified as ‘high risk’ to prevent progression to diabetes.

“This is a natural addition to the diabetes screening process and, with appropriate funding, is something which community pharmacists can effectively do to contribute to the public health agenda.” (Source: University of East Anglia)

Read the full press release at University of East Anglia 

The paper has been published in the journal Pharmacy 

The article can also be accessed in full here 

Full reference: Wright, D., Little, R., Turner, D., & Thornley, T. |2019| Diabetes Screening Through Community Pharmacies in England: A Cost-Effectiveness Study| Pharmacy| 7| 1| 30.


Community pharmacies are commonly used to screen for patients with diabetes. The aim of this paper is to estimate the cost per test and cost per appropriately referred patient from a pharmacy perspective using a one-year decision tree model. One-way sensitivity analysis was performed to estimate the effect of geographical location and patient self-referral rate. Data was used from 164 patients screened and located in an area with average social deprivation and largely white European inhabitants and 172 patients in an area with higher social deprivation (lower than average ability to access society’s resources) and a mixed ethnicity population in England. The diabetes screening consisted of initial risk assessment via questionnaire followed by HbA1c test for those identified as high risk. The cost per person screened was estimated as £28.65. The cost per appropriately referred patient with type 2 diabetes was estimated to range from £7638 to £11,297 in deprived mixed ethnicity and non-deprived areas respectively. This increased to £12,730 and £18,828, respectively, if only 60% of patients referred chose to inform their general practitioner (GP). The cost per test and identification rates through community pharmacies was similar to that reported through medical practices. Locating services in areas of suspected greater diabetes prevalence and increasing the proportion of patients who follow pharmacist advice to attend their medical practice improves cost-effectiveness.

Barnsley and Rotherham: diabetic eye screening programme

Public Health England | March 2019 | Barnsley and Rotherham: diabetic eye screening programme

Public Health England (PHE) has now published an Executive summary of quality assurance (QA) visit to Barnsley and Rotherham held on 18 October 2018. 

Quality assurance (QA) visits are carried out by the Public Health England screening quality assurance service (SQAS)


The evidence for this report comes from:

  • routine monitoring of data collected by the NHS screening programmes
  • data and reports from external organisations
  • evidence submitted by the provider(s), commissioner and external organisations
  • information collected during pre-review visits
  • information shared with SQAS (North) as part of the visit process

Full details from Public Health England

Screening Quality Assurance visit report NHS Diabetic Eye Screening Programme
Barnsley and Rotherham

Diabetic eye screening: cohort management

Public Health England | February 2019 | Diabetic eye screening: cohort management

This guidance explains the management of the cohort (people on the programme register) for the NHS diabetic eye screening (DES) programme.

pexels-photo.jpgThis document explains the management of the cohort for diabetic eye screening (DES).

It includes:

  • exclusions
  • suspensions
  • people who are ineligible or off-register
  • situations that require special consideration
  • rarer forms of diabetes
    (Source: Public Health England)

Diabetic eye screening: cohort management

Diabetic eye screening: cohort management

Public Health England| August 2018 | Diabetic eye screening: cohort management

Updated guidance from Department of Health and Social Care (DHSC) has been released to cover diabetic eye screening, it covers the management of people on the programme register of their local diabetic eye screening, known as the ‘screening cohort’.


The full guidance is available from Public Health England

Potential cost savings for early detection and treatment of type 2 diabetes

Large study finds that for individuals diagnosed with diabetes, screening is associated with a reduction in healthcare costs due to fewer admissions and doctor’s visits and a reduction in prescribed medicationDiabetologia | via ScienceDaily

Between 2001 and 2006, a population-based cardiovascular and diabetes screening programme was introduced in five out of sixteen Danish counties. Over 150,000 individuals registered with 181 practices participating in the ADDITION-Denmark study were sent a diabetes risk score questionnaire, and if their score indicated moderate to high risk they were invited to attend for a diabetes test and cardiovascular risk assessment with their family doctor.

More than 27,000 attended for screening, and 1533 were diagnosed with diabetes during screening. A further 1,760,000 individuals were identified for a matched no-screening control group. Participants were followed for approximately six years following diagnosis until 31 December 2012, when national registers were searched for healthcare usage and healthcare cost.

The researchers found that those individuals with clinically-diagnosed diabetes were identified on average 2.2 years later than individuals whose diabetes was detected in the screening practices. Healthcare costs were significantly lower in the screening group compared with the no-screening control group, with an average annual difference in healthcare costs of €889 per individual with diabetes. The results have just been published in the scientific journal Diabetologia.

Full article:  Sortsø C et al |  Effect of screening for type 2 diabetes on healthcare costs: a register-based study among 139,075 individuals diagnosed with diabetes in Denmark between 2001 and 2009 | Diabetologia |  March 2018