A Time-To-Event Analysis to Conceptualize and Predict Delay in Type 2 Diabetes Diagnosis in Primary Care

A Time-To-Event Analysis to Conceptualize and Predict Delay in Type 2 Diabetes Diagnosis in Primary Care | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A Time-To-Event Analysis to Conceptualize and Predict Delay in Type 2 Diabetes Diagnosis in Primary Care Parisa Lotfibgha, Kristen Miller, William J. Gallagher, Elizabeth B. Selden, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7357893/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 10 You are reading this latest preprint version Abstract Background: Delayed diagnosis of Type 2 diabetes (T2D) contributes to the development of diabetes-related health complications. Although signs of T2D are commonly identified in primary care, delays in diagnosis remain a significant challenge. The relationship between patient-level factors (e.g., demographics and healthcare utilization patterns), practice-related factors (e.g., primary care location), and the time to T2D diagnosis represents a critical, yet understudied, research area. Methods: We conducted a retrospective observational cohort study of 736 adults who received care from two primary care clinics within an integrated healthcare system in the mid-Atlantic region of the United States (2017--2023). Kaplan--Meier survival analysis and Cox proportional hazards models quantified diagnostic delays from the first elevated hemoglobin A1c (HgA1c \((\ge)\) 5.7% [39\,mmol/mol]) to documented T2D diagnosis. Patient features, primary care location, continuity of care and visit regularity were evaluated in multivariate models as potential contributors to diagnostic delay. A Markov cohort state-transition model characterized diagnostic pathways over one year following the initial abnormal HgA1c measurement. Results: Median time to formal T2D diagnosis varied significantly between the two primary care locations (10 months vs. 6.6 months) which highlighted practice-specific gaps in timely diagnosis. High continuity and regularity of primary care visits were significantly associated with shorter time to diagnosis. Markov cohort model revealed that 60.6% of individuals remained undiagnosed one year after the initial abnormal HgA1c. Conclusion: Our study highlights the role of clinical practice influencing diagnostic delay in T2D within primary care. Improved continuity and regularity of care accelerate the T2D diagnosis, while location-specific diagnostic disparities persist. These findings underscore the urgent need for targeted clinical and policy interventions aimed at improving patient engagement, strengthening continuity of care, and facilitating earlier diagnosis. Type 2 diabetes Diagnostic delay Continuity of care Survival analysis Full Text Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 03 Jan, 2026 Reviews received at journal 17 Dec, 2025 Reviews received at journal 03 Dec, 2025 Reviewers agreed at journal 02 Dec, 2025 Reviewers agreed at journal 24 Nov, 2025 Reviewers invited by journal 16 Sep, 2025 Editor invited by journal 18 Aug, 2025 Editor assigned by journal 14 Aug, 2025 Submission checks completed at journal 14 Aug, 2025 First submitted to journal 12 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7357893","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":516054230,"identity":"0d48e995-75a0-4af1-8b8d-bdd8017207a8","order_by":0,"name":"Parisa Lotfibgha","email":"","orcid":"","institution":"University of Massachusetts Amherst","correspondingAuthor":false,"prefix":"","firstName":"Parisa","middleName":"","lastName":"Lotfibgha","suffix":""},{"id":516054232,"identity":"703b1b2f-b107-40e1-a728-97cc12d301bd","order_by":1,"name":"Kristen Miller","email":"","orcid":"","institution":"MedStar Health Research Institute","correspondingAuthor":false,"prefix":"","firstName":"Kristen","middleName":"","lastName":"Miller","suffix":""},{"id":516054234,"identity":"0e675594-bad4-43fd-9b83-e55a2a15ccb3","order_by":2,"name":"William J. 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Care","fulltext":[],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":true,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":true,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Type 2 diabetes, Diagnostic delay, Continuity of care, Survival analysis","lastPublishedDoi":"10.21203/rs.3.rs-7357893/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7357893/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e\u003cp\u003eDelayed diagnosis of Type 2 diabetes (T2D) contributes to the development of diabetes-related health complications. Although signs of T2D are commonly identified in primary care, delays in diagnosis remain a significant challenge. The relationship between patient-level factors (e.g., demographics and healthcare utilization patterns), practice-related factors (e.g., primary care location), and the time to T2D diagnosis represents a critical, yet understudied, research area.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e\u003cp\u003e We conducted a retrospective observational cohort study of 736 adults who received care from two primary care clinics within an integrated healthcare system in the mid-Atlantic region of the United States (2017--2023). Kaplan--Meier survival analysis and Cox proportional hazards models quantified diagnostic delays from the first elevated hemoglobin A1c (HgA1c \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\((\\ge)\\)\u003c/span\u003e\u003c/span\u003e5.7% [39\\,mmol/mol]) to documented T2D diagnosis. Patient features, primary care location, continuity of care and visit regularity were evaluated in multivariate models as potential contributors to diagnostic delay. A Markov cohort state-transition model characterized diagnostic pathways over one year following the initial abnormal HgA1c measurement.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003eMedian time to formal T2D diagnosis varied significantly between the two primary care locations (10 months vs. 6.6 months) which highlighted practice-specific gaps in timely diagnosis. High continuity and regularity of primary care visits were significantly associated with shorter time to diagnosis. Markov cohort model revealed that 60.6% of individuals remained undiagnosed one year after the initial abnormal HgA1c.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e\u003cp\u003eOur study highlights the role of clinical practice influencing diagnostic delay in T2D within primary care. Improved continuity and regularity of care accelerate the T2D diagnosis, while location-specific diagnostic disparities persist. These findings underscore the urgent need for targeted clinical and policy interventions aimed at improving patient engagement, strengthening continuity of care, and facilitating earlier diagnosis.\u003c/p\u003e","manuscriptTitle":"A Time-To-Event Analysis to Conceptualize and Predict Delay in Type 2 Diabetes Diagnosis in Primary Care","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-25 10:57:13","doi":"10.21203/rs.3.rs-7357893/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-03T12:41:37+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-17T05:22:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-03T18:32:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"175913216600821178600551509379467217903","date":"2025-12-02T17:39:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"75307501855927270257027779176204865389","date":"2025-11-24T16:14:20+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-16T13:43:19+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-18T06:17:38+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-14T23:39:51+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-14T23:37:51+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Primary Care","date":"2025-08-12T16:35:37+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a15b22cf-caa4-495a-a678-c2999e41b68a","owner":[],"postedDate":"September 25th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-21T00:53:51+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-25 10:57:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7357893","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7357893","identity":"rs-7357893","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}