<p><strong>BACKGROUND: </strong>Risk-based screening for type 2 diabetes (T2D) in youth with overweight/obesity is recommended, but rates remain low in practice. Identification of factors impacting provider ordering and patient completion of testing may guide strategies to improve screening.</p>

<p><strong>OBJECTIVE: </strong>To evaluate predictors of hemoglobin A1c (A1c)-based T2D screening in pediatric primary care.</p>

<p><strong>METHODS: </strong>This retrospective cohort study included 10 to 18 year-old patients with overweight/obesity (body mass index [BMI] Z-score ≥1.04) followed in a large academic-affiliated pediatric primary care network, 2009 to 2018. Percentages of patients with ordered and completed A1c were determined, and multivariable Cox proportional hazards regression was used to evaluate independent predictors of screening.</p>

<p><strong>RESULTS: </strong>34 927 (48.0% female; 52.5% with BMI Z-score ≥1.64) youth followed for a median of 3.0 years were included. 21% (7457) of patients had screening ordered and 14% (4966) completed screening during follow-up. In multivariable regression, after controlling for race/ethnicity, BMI, family history of diabetes and age, males were significantly less likely to have ordered screening, but were equally or more likely to complete screening if ordered.</p>

<p><strong>CONCLUSIONS: </strong>Male adolescents were less likely to undergo A1c-based T2D screening due to differential ordering practices. The source of this differential practice should be pursued to avoid under-recognition of cardiometabolic risk in at-risk male youth.</p>