A Procter&Gamble Health Care Publication

The News that Matters to Pharmacists

Volume 14. Issue 2. Summer 2008

pharmacist di est

The June 2008 issue of U.S. Pharmacist includesan overview of probiotics titled “Probiotics: ACloser Look.” The article seeks to inform healthcare professionals about these increasingly populardietary supplements by reviewing the history,health benefits, and risks of probiotics. The articlealso discusses the differences between prebioticsand probiotics and provides detailed informationabout Lactobacillus and Bifidobacterium species(the most widely used probiotic bacteria).

As the author explains, the World HealthOrganization/Food Agricultural Organizationdefines probiotics as “live microorganisms whichwhen administered in adequate amounts providea health benefit on the host.” Probiotics help tocorrect imbalances in the body’s naturally occurringgut flora that may result from use of antibioticsor other drugs, certain diseases, stress, exposureto toxic substances, or other factors. In simpleterms, probiotics replace harmful bacteria withuseful bacteria. Probiotics also exhibitimmunomodulatory activity, such as improveddisease resistance and diminished risk of allergies.

Some key points from the article aresummarized below.

�Most probiotics are nonpathogenic bacteriasimilar to those found naturally in the humangut, particularly in the gut of breast-fedinfants (who have natural protection againstmany diseases). Some yeasts, such as

Saccharomyces boulardii, also are usedas probiotics.

� Probiotics may be ingested as foods(e.g., yogurt, fermented milk, miso, tempeh)or as capsules, tablets, powders, or other oraldosage forms.

� Probiotics are used to prevent and treatcertain illnesses as well as to supportgeneral wellness.

� The safety and efficacy of probioticsare unique to specific strains and can varywidely, even among similar bacteria species.Thus, not all species will necessarilyhave the same therapeutic potential in aparticular condition.

� In recent studies, the probiotic Bifidobacteriuminfantis 35624 was found to specifically relievemany of the symptoms of irritable bowelsyndrome. This symptomatic response wasassociated with normalization of the ratio ofan anti-inflammatory to a proinflammatorycytokine, suggesting an immune-modulating role.

� Before recommending products to patients,pharmacists must know what strain theproduct contains and what evidence backsthat strain. Pharmacists also should be awarethat some probiotic products have beenassociated with quality concerns, includingcontamination with strains not includedon the label.

* Pharmacy Times Annual Over-the-CounterProduct Survey, June, 2008

Inside This Issue:Pharmacy Practice� Patients Rewarded forSwitching to OTCs

� Health Care Work ForceUnprepared for Baby Boomers

This Season� Heart & Diabetes Patients Benefitfrom Pharmacist Care

� Student Programs Educate Patients

Treatment & Prevention� New Studies on Medicare Part D

� Risk Associated with Dual Use of NSAIDs

� New Guidelines for Hip &Knee Osteoarthritis

P&GNews

Taking a Closer Look at ProbioticsUS Pharm. 2008;33(6):40-44. http://tinyurl.com/5etmp3

Helpful Lists for Pharmacists

P&GBrandsReceiveHighestHonorPharmacy Times OTC RecommendationsSurvey, 2008; www.pharmacytimes.com

Procter & Gamble brands ineight categories received thedistinction of “#1 PharmacistRecommended” according toPharmacy Times’ annualsurvey of over-the-counter products.

The International Drug Information Centerof the Arnold & Marie Schwartz College ofPharmacy and Health Sciences in Brooklyn,New York, recently compiled a list of light-sensitive and moisture-sensitive prescriptionoral solid dosage forms. Of the 300 medicationson the list, 233 are sensitive to light and 146 aresensitive to moisture (some are sensitive to both).The list was published in the May 12, 2008,issue of Drug Topics and can be accessed atthe following URL:http://drugtopics.modernmedicine.com/drugtopics/data/articlestandard//drugtopics/252008/524496/article.pdf.

An article in the June 2008 issue of theAmerican Journal of Geriatric Pharmacotherapyincludes a list of prescription drugs that aremost likely to contribute to falls in olderpatients. The list of more than 90 medicationsevolved from an ongoing study by researchersat the University of North Carolina at ChapelHill Eshelman School of Pharmacy; theyare evaluting a falls-prevention program forpatients aged 65 and older that is designed tobe implemented by pharmacists. The list canbe accessed at the following URL:http://uncnews.unc.edu/images/stories/news/health/2008/drugslist.pdf

Products Pharmacy TimesSurvey Categories

NyQuil Adult Cold – Nighttime

Prilosec OTC Antacids/Heartburn

Metamucil Fiber Laxatives

Metamucil Bulk Type Laxatives

ThermaCareHeatWraps Thermal Care

Crest Whitestrips Teeth Whiteners

Tampax Tampons

Duracell Hearing Aid Batteries

pharmacist digest Summer 2008 3

Pharmacy Practice

Patients Rewarded for Switching To Nonprescription Drugshttp://tinyurl.com/48q9ab

In a recently completed year-long pilotprogram, more than 4,600 members ofBlue Cross and Blue Shield of Rhode Island(BCBSRI) saved $260,000 in copaymentsby using nonprescription loratadine (or aloratadine-pseudoephedrine combinationproduct) in place of costlier prescriptionmedications. The program was intended tointroduce members to cost-saving nonpre-scription alternatives to prescription drugs.

Under the OTC Options Program—designed by pharmacy benefit managerWellPoint NextRx—BCBSRI members hadthe option of receiving the nonprescriptionmedications at no charge as an alternative

to prescription medications. The programwas so successful that BCBSRI is consideringexpanding it to include conditions suchas heartburn, allergic conjunctivitis,and acne.

BCBSRI is not the first insurer toprovide financial incentives for usingnonprescription medications. For example,in recent years, Blue Cross and Blue Shieldcompanies in California, Georgia, andVirginia provided coupons to members toencourage use of Prilosec OTC in placeof higher-priced prescription proton pumpinhibitors. Aetna also has provided couponsfor several nonprescription medications.

PHARMAssist HelpsConsumers Select OTCshttp://tinyurl.com/498zaj andhttp://tinyurl.com/3knb47

Consumers who visit any of more than 100Longs Drugs stores are able to get targetedrecommendations for nonprescription medicationsfrom an interactive kiosk developed byCalifornia startup Evincii.

PHARMAssist, as the kiosk is called, drawsfrom a comprehensive “Knowledge Web” thatincludes the symptoms, conditions, and treatmentsfor more than 2,000 diseases. Consumers whouse PHARMAssist are guided through a simpleseries of questions about their symptoms, allergies,medical conditions, and preferences. Based onthe responses, PHARMAssist provides a list ofsuitable products sorted according to popularityand whether or not the companies paid Evinciifor the listing. It also provides video ads andmaps showing where the products are locatedin the store.

According to Evincii, PHARMAssist wasdeveloped “to engage and guide consumerswho may not be computer savvy.” The kiosksalready have provided more than 1 millionuser recommendation sessions.

FDAUpdate

Omeprazole Approved for Use in Children1 to 2 Years of Agewww.fda.gov/cder/foi/label/2008/022056lbl.pdf

Omeprazole delayed-release capsules anddelayed-release oral suspension, previouslyapproved for use in patients 2 years of ageor older, were recently approved for thefollowing indications in pediatric patients1 to 2 years of age:� Treatment of heartburn and other symptomsassociated with gastroesophagealreflux disease.

� Short-term treatment (4-8 weeks)of erosive esophagitis.

�Maintenance of healing oferosive esophagitis.

The recommended daily dose ofomeprazole for pediatric patients is basedon weight. For patients who weigh 5 kg(11 lb) to less than 10 kg (22 lb), the dailydose is 5 mg; for patients who weigh 10 kgto less than 20 kg (44 lb), the daily dose is10 mg. Children who weigh 20 lb or morereceive the usual adult dose of 20 mg. On aper-kilogram basis, the doses of omeprazolerequired to heal erosive esophagitis inpediatric patients are greater than thosefor adults.

Health Care Work Force Unprepared for Aging Baby BoomersInstitute of Medicine of the National Academy of Sciences, April 14, 2008. www.iom.edu/agingamerica and http://tinyurl.com/43sopg

As America’s 78 million baby boomersbegin to reach age 65 in the year 2011, theywill face a health care work force that istoo small and woefully unprepared to meettheir complex health needs, warns a recentreport from the Institute of Medicine titled“Retooling for an Aging America: Buildingthe Health Care Workforce.”

The report represents the work of an adhoc committee that was charged with deter-mining the health care needs of older adultsand assessing those needs through an analysisof the forces that shape the health carework force. These forces include education

and training, models of care, and publicand private programs. The committeeconcluded that bold initiatives are neededimmediately to achieve the followingimportant goals:

� Boost recruitment and retention of geriatricspecialists and health care aides.

� Expand the duties and responsibilitiesof workers at various levels of training.

� Better prepare informal caregivers totend to the needs of aging family membersand friends.

The committee also stated that new modelsof health care delivery and payment willbe needed as existing programs such asMedicare prove to be too ineffectiveand inefficient.

By the year 2030, one in five Americanswill be 65 years of age or older. Thereport notes that this group will be the mostdiverse the nation has ever seen, with moreeducation, increased longevity, widelydispersed families, and more racial andethnic diversity. Because of these factors,their health care needs will be much differentthan those of previous generations.

4 pharmacist digest Summer 2008

Treatment & Prevention

A pair of studies in the April 23, 2008, issue ofJAMA raises important concerns about theMedicare Part D program.

The first study sought to determine theimpact of Medicare Part D on cost-related med-ication nonadherence. The authors revieweddata from the more than 24,000 community-dwelling Medicare enrollees who participatedin the Medicare Current Beneficiary Survey(MCBS) during the fall seasons of 2004, 2005,and 2006. The MCBS incorporates three measuresof cost-related nonadherence (“decided not tofill or refill a prescription because it was tooexpensive,” “skipped doses to make the medicinelast longer,” and “took smaller doses of a medi-cine to make the medicine last longer”), as wellas a related measure of spending less on basicneeds (“spent less money on food, heat, orother basic needs so that you would havemoney for medicine”).

The results revealed a small but significantoverall decrease in cost-related nonadherenceand forgoing basic needs following the imple-mentation of Medicare Part D. The unadjustedprevalence of cost-related nonadherence was15.2% in 2004, 14.1% in 2005, and 11.5% in

2006 (the year during which Medicare Part Dwas implemented). The unadjusted prevalenceof spending less on basic needs was 10.6% in2004, 11.1% in 2005, and 7.6% in 2006.However, no significant changes in cost-relatedmedication nonadherence were detected amongthe sickest beneficiaries—patients who weredisabled, had fair to poor health, or reportedfour or more morbidities.

The second study investigated beneficiaries'knowledge of their Medicare Part D benefitstructures, including their awareness of thecoverage gap, after their first full year in theprogram. The authors conducted telephoneinterviews with more than 1,000 members ofKaiser Permanente-Northern California’sMedicare Advantage Prescription Drug Planwho were at least 65 years of age and had agap in coverage if they exceeded $2250 intotal Part D drug costs. Participants were askedabout their awareness of the coverage gap, gapstart and end thresholds, and drug cost sharingbefore, during, and after the gap; they also werequestioned about cost-coping behaviors (e.g.,switching to lower-cost medications), reducedadherence (e.g., not refilling prescriptions), and

financial burden (e.g., going without necessities).

Approximately 60% of the beneficiaries wereunaware that their drug plan included a coveragegap. The 40% of beneficiaries who were awareof the gap demonstrated limited knowledge ofdetails on their cost sharing. For example, onlyhalf of the beneficiaries could identify their gapstart amount within $250, and only one fifth ofthe beneficiaries could identify their gap endamount within $400. Participants who hadentered the coverage gap during the year weremore knowledgeable than other participants.Beneficiaries with greater 2006 drug costs weremore likely to report cost-coping behaviors,reduced adherence, or financial burden.

Studies Provide New Information, Raise Concerns About Medicare Part DJAMA. 2008;299(16):1922-8 and 1929-36. http://jama.ama-assn.org

Counseling ResourcesFor information and resources to helpseniors plan ahead to delay or avoid thecoverage gap, visit www.ManagePartD.com.Also, request free copies of the brochure,“Plan Ahead for 2008 Medicare Part D,”online at www.prilosecotc-hcp.com.

Use of More Than One NSAID Associated withPoorer Health-Related Quality of LifeArthritis Rheum. 2008;59(2):227-33. http://tinyurl.com/4r2sx7

Patients who take more than one nonsteroidalanti-inflammatory drug (NSAID) may have apoorer health-related quality of life, accordingto a study that appeared in the February 2008issued of Arthritis Care & Research.

The 138 study participants—all members ofa managed care organization in Alabama—hadfilled at least one prescription for an NSAID(nonselective or cyclooxygenase-2 selectiveinhibitor) between February 2002 and August2002. Information about their use of prescriptionand nonprescription NSAIDs and responsesto the 12-Item Short Form Health Survey(a well-validated instrument that includesmeasures of physical and mental health) werecollected via telephone. Participants wereclassified as “dual users” of NSAIDs if anyof the following criteria were met:

� They were taking a prescription NSAIDfor arthritis and/or joint pain and also tooka nonprescription NSAID for arthritisand/or joint pain daily or a few times perweek during the past month.

� They reported taking at least two nonpre-scription NSAIDs for arthritis and/or jointpain daily or a few times per week overthe past month.

Of the 138 participants, 36 (26%) were dualusers; most (81%) were using a nonprescriptionNSAID in conjunction with a prescription agent.Dual users had significantly lower PhysicalComponent Summary scores on the Short FormHealth Survey than non-dual users did (P = 0.05).The authors speculated that dual users may takemultiple NSAIDs to reduce their pain, and mayknowingly or unknowingly do this despite theassociated safety risks. The authors alsoconcluded that providers most likely wereunaware of patients’ risk, because use ofnonprescription medications often is notdiscussed during clinic visits.

*Pharmacy Times, OTC Supplement, June 2008

P&GNews

SameRelief – NowEasier To OpenBlister Card

Patients may knowinglyor unknowingly takemultiple NSAIDs,despite safety risks

Prilosec OTC is now available in anew easier to open package. In responseto requests from you and your patients,Prilosec OTC designed a convenientpush-through blister pack, making the#1 pharmacist recommended OTC antacids/heartburn medicine* easier to take thanever. Tell your patients to look for thenew package on store shelves today.

pharmacist digest Spring 2007 5

Treatment & Prevention

pharmacist digest Summer 2008 5

The Osteoarthritis Research Society International(OARSI) has released a set of 25 evidence-based,expert-consensus treatment recommendationsfor hip and knee arthritis. The treatmentrecommendations appear in the February2008 issue of Osteoarthritis and Cartilage.

The first recommendation states that optimalmanagement of osteoarthritis requires a combi-nation of nonpharmacologic and pharmacologicmodalities. The remaining recommendations

address the use of 12 nonpharmacologicmodalities, 8 pharmacologic modalities, and5 surgical modalities.

The pharmacologic treatmentrecommendations include the following:

� Acetaminophen in doses up to 4 g/day isrecognized as an effective initial oral analgesicfor treatment of mild to moderate pain inpatients with knee or hip osteoarthritis.

� Nonsteroidal anti-inflammatory drugs(NSAIDs) also are considered to be effective;however, because they are associated withmore adverse effects than acetaminophen,the recommendations advise using the lowesteffective dose and avoiding long-term useif possible.

� Patients at increased risk of gastrointestinaladverse events should be treated either witha cyclooxygenase-2 selective agent or witha nonselective NSAID in combination witha proton pump inhibitor or misoprostolfor gastroprotection.

� All NSAIDs (including cyclooxygenase-2selective agents) should be used withcaution in patients with cardiovascularrisk factors.

New Treatment Recommendations forHip and Knee OsteoarthritisOsteoarthritis Cartilage. 2008;16(2):137-62. http://tinyurl.com/3ztard

High-Dose Vitamin E May Help Alzheimer’s PatientsAmerican Academy of Neurology, April 5, 2008. http://tinyurl.com/4qjecp

ThermaCareArthritis ProvidesAll-Day Pain Reliefwww.thermacare.com

Updated InfluenzaGuidelines ReleasedMMWR 2008;57:1-60.http://tinyurl.com/5ukb44

In a study presented at the AmericanAcademy of Neurology 60th AnnualMeeting in Chicago, patients with Alzheimer’sdisease who took large doses of vitamin E(2,000 IU/day) had a 26% lower mortalityrate than patients who did not take vitamin E.

The researchers analyzed the survivalhistory of 847 patients with probable ormixed Alzheimer’s disease who werefollowed for an average of 5 years.Approximately two thirds of the patientstook vitamin E with a cholinesteraseinhibitor; fewer than 10% took vitamin Ealone. The remaining patients (approximately

15% of the cohort) did not take anyantidementia medication.

The adjusted hazard ratio associated withvitamin E, with or without a cholinesteraseinhibitor, was 0.74 (95% CI, 0.59-0.92;p = 0.008). The adjusted hazard ratio associatedwith cholinesterase inhibitor use, with orwithout vitamin E, was 0.91 (95% CI,0.72-1.14; p = 0.393). Analyzing mutuallyexclusive treatment categories suggestedthat the combination of vitamin E plus acholinesterase inhibitor was more beneficialthan either agent alone.

The 2008 recommendations from the Centersfor Disease Control and Prevention’s AdvisoryCommittee on Immunization Practices regardingthe use of influenza vaccine and antiviralagents were published online on July 17,2008, in advance of being printed in MMWRMorbidity and Mortality Weekly Report.A key change from previous years is therecommendation that all children aged 5 to18 years receive annual vaccination beginningin the 2008–2009 influenza season, if feasible,but no later than the 2009–2010 season.

1Data on file, P&G.

P&GNews

Experts discouragelong-term use of NSAIDsdue to associated risks

ThermaCare Arthritis® HeatWraps arespecifically designed to provide 12 hoursof continuous heat to common arthritispain sites: hand & wrist, knee & elbow,and neck & shoulders. Heat therapy isclinically proven to provide greater painrelief than acetaminophen and greaterflexibility than ibuprofen in patients withosteoarthritis of the knee1. RecommendThermaCare Arthritis HeatWraps to yourpatients who suffer from minor osteoarthritispain or occasional arthritis flare-ups, andvisit www.thermacare.com to learn more.

Hip

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This season

Pharmacist Care Reduces Risk of Hospitalizationin Patients with Heart FailureArch Intern Med. 2008;168(7):687-94. http://tinyurl.com/3w6jmz

A systematic review of randomized trialspublished in the April 14, 2008, issue ofArchives of Internal Medicine showed thatpharmacist care in the treatment of patientswith heart failure reduces the risk of all-causeand heart failure hospitalizations by almost 33%.

The review included 12 trials involvingmore than 2,000 patients. Seven of the trialscompared pharmacist-directed interventionswith usual care; five trials compared pharmacistcollaborative care with usual care.Pharmacist-specific interventions typicallyinvolved education on heart failure and itstreatment, including self-monitoring, medicationmanagement, and facilitation of compliance.

Pooled data from the 12 trials showed anonsignificant reduction in mortality for phar-macist care compared with control (OR, 0.84;95% CI, 0.61-1.15; I2 , 19%). In contrast,pharmacist care yielded significant reductionsin all-cause hospitalization rates (OR, 0.71;95% CI, 0.54-0.94; I2, 50%) and heart failurehospitalization rates (OR, 0.69; 95% CI, 0.51-0.94; I2, 40%), although there was someheterogeneity in these results.

The authors concluded that including apharmacist in the care of patients with heartfailure, particularly within a multidisciplinaryteam, is beneficial and should be stronglyconsidered by health policy makers.

Coronary Heart Disease Three-Question QuizHeart. 2008;94:482-6. http://tinyurl.com/3v4mbd

As part of a community outreach program,students from the University of PittsburghSchool of Pharmacy recently helped patientsin the waiting area of a large hospital outpatientpharmacy learn about nonprescriptionmedications.

The student pharmacists and a pharmacistsupervisor set up a display near the outpatientpharmacy on two consecutive Thursdayafternoons. The display included a large

poster of the new Drug Facts label, which thestudents used as a teaching tool for 73 patients.Patients were provided with printed copies ofthe Drug Facts label that showed where tolocate key pieces of information. Of 40patients surveyed, fewer than half (45%)reported always reading the Drug Facts labelbefore taking a nonprescription medication.

Patients were counseled about the impor-tance of speaking with their physician or

pharmacist prior to using a nonprescriptionmedication. They were invited to pick upbrochures containing information aboutnonprescription medications, the pharmacy'smedication therapy management program,and blood pressure/medication cards. Atthe end of the program, most patientsreported being more likely to speak withtheir pharmacist prior to future nonprescriptionmedication use.

6 pharmacist digest Summer 2008

Pittsburgh Students Promote Safe Use of OTCsDrug Topics, April 21, 2008. http://tinyurl.com/4te44d

Missouri StudentsWin National AwardAmerican Pharmacists Association.http://tinyurl.com/5xoc5m

The American Pharmacists AssociationAcademy of Student Pharmacists(APhA-ASP) recently awarded theUniversity of Missouri Kansas City firstplace in the 2007 Heartburn AwarenessChallenge national competition. TheKansas City student pharmacistslaunched a state-wide campaign usingpublic service announcements in localmovie theaters and on television thatreached nearly one million viewers.

The Heartburn Awareness Challengeprogram is a partnership of the NationalHeartburn Alliance, Procter & Gambleand APhA-ASP in which students developprograms to educate patients aboutheartburn and provide personal consultationfor heartburn sufferers. For more information,including free heartburn education tools,visit www.heartburnalliance.org.

P&GNews

A short version of the World HealthOrganization Rose Angina Questionnaire,which has been used for decades as anindicator of cardiovascular health, mayhelp to detect undiagnosed coronary heartdisease (CHD) in both men and women intheir 40s, based on the results of aNorwegian study that included more than32,000 patients.

The three-item questionnaire poses thefollowing questions:

1 Do you get pain or discomfort in yourchest when walking up hills, stairs, orhurrying on level ground?

2 If you get pain or discomfort in thechest when walking, do you usually stop?

Slow down? Carry on at the same pace?

3 If you stop or slow down, does the paindisappear after less than 10 minutes?Or after 10 minutes or more?

Answers of “yes” to the first question,“stop” or “slow down” to the secondquestion, and “less than 10 minutes”to the third question indicate thepresence of angina symptoms.

In the study, the presence of anginasymptoms among men and women ages 40to 49 years was associated with an elevatedrisk of premature CHD death. The adjustedhazard ratios were 1.50 (95% CI, 1.16to 1.93) in men and 1.98 (95% CI, 1.30to 3.02) in women.

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This season

Diabetes Program Shows Benefit of Pharmacist CareJ Am Pharm Assoc. 2008;48(2):181-90. http://tinyurl.com/4vnqjt

The Diabetes Ten City Challenge is anemployer-funded, collaborative healthmanagement program in 10 geographic areasof the United States that incorporates community-based pharmacist coaches, evidence-baseddiabetes care guidelines, and self-managementstrategies designed to keep patients with diabeteshealthy and productive. In its initial year ofoperation, the program demonstrated measurableimprovements in clinical indicators of diabetesmanagement, higher rates of self-managementgoal setting, and increased satisfaction withdiabetes care.

The interim study results that appear in theMarch/April 2008 issue of the Journal of theAmerican Pharmacists Association reflectdata from 914 patients who received pharmacistcare for 3 months or more. (The mean ± SDduration of enrollment was 10.2 ± 3.7months.) When beginning measures werecompared with ending measures, meanglycosylated hemoglobin decreased from7.6% to 7.2%, low-density lipoprotein cholesteroldecreased from 96.3 to 93.3 mg/dL, and systolicblood pressure decreased from 131.3 to 128.7mm Hg. All of these changes were significant(P <0.001). The percentage of patients with

current influenza vaccine increased from 43%to 61%, current eye examinations from 60%to 77%, and current foot examinations from38% to 68%.

Fewer than 25% of patients had individualself-management goals for nutrition, exercise,or weight at the beginning of the program.Over the course of the study period, these

percentages increased to 66% for nutrition,72% for exercise, and 64% for weight. Thepercentage of patients who rated their diabetescare as excellent increased from 39% atbaseline to 87% at follow-up. In addition,most patients (97.5%) reported being satisfiedor very satisfied with the care provided bythe pharmacists.

New Tool: Diabetes Risk CalculatorDiabetes Care. 2008;31(5):1040-5. http://tinyurl.com/6rftsb

A study in the May issue of DiabetesCare describes a simple, paper-basedtool that was designed and validated to detectundiagnosed diabetes and prediabetes in theU.S. population.

The Diabetes Risk Calculator is formattedas a decision tree that includes questionsabout age, waist circumference, gestationaldiabetes, height, race/ethnicity, hypertension,family history, and exercise. Patients’ yes/noresponses to these questions lead to 14 dif-ferent terminal nodes; each terminal node

specifies the probabilities of diabetes andprediabetes. For example, a patient whoreplies “no” to “Age <44” and “yes”to “Waist >38.4 inches” has a 15.8%probability of diabetes and a 47.8%probability of prediabetes.

The authors conclude that use of thisscreening tool “enables the identificationof individuals who might benefit fromconfirmatory tests and treatment to delayor prevent the onset of type 2 diabetesand its complications.”