Miriam E. Tucker
August 12, 2019
There have been few improvements in diabetes diagnosis, linkage of patients to care, or achievement of treatment targets in the United States since 2005 despite advances in care, new research suggests.
The findings, from 2488 participants in the National Health and Nutrition Examination Survey (NHANES) cycles covering 2005 to 2016, were published online August 12 in JAMA Internal Medicine by Pooyan Kazemian, PhD, of the Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, and colleagues.
The data suggest that gaps in the diabetes care "cascade," defined as the sequence of diagnosis, linkage to care, and achievement of treatment targets, essentially remained the same from 2005 through 2016. For example, one quarter of patients who meet blood glucose criteria for diabetes remain undiagnosed, and roughly the same proportion with diabetes meet all recommended targets for blood glucose, blood pressure, cholesterol, and nonsmoking.
The deficiencies are particularly striking among younger adults (age 18-44 years), women, and nonwhite individuals.
"It appears that advances in diabetes care over the past decade have not translated into meaningful improvement in population-level treatment outcomes," Kazemian and colleagues write.
Kazemian told Medscape Medical News, "While there are often reasons why individuals may not achieve care goals, on a population level, we are not where we need to be for a variety of reasons ... as most clinicians readily appreciate."
He advised that clinicians "should continue to pay close attention to the ABCs of diabetes, namely blood sugar, blood pressure, and cholesterol level, monitor these measures often, and take action if their patients do not meet the guideline-recommended thresholds." However, he acknowledged, "this is easier said than done, as our study demonstrates."
Kazemian advised that health systems and insurers continue to support practice infrastructure and pharmacy benefit design to favor goal attainment, along with strategies such as "more frequent diabetes screening, expanded access to care and health insurance, and interventions to improve patients' adherence to medication and reduce clinical inertia."
In an accompanying editorial, Mohammed K. Ali, MD, and Megha K. Shah, MD, both of the Department of Family and Preventive Medicine, Emory University, Atlanta, Georgia, write, "Given this report's clear message of persistent and deep disparities in diabetes care, local-level innovations alone will likely be insufficient. In our view, without policy-level initiatives to address socioeconomic disparities, we will not be able to move the needle on diabetes care nationally ... We need to boldly find ways to align the economic and health motivations of the key stakeholders in our society to revolutionize care for chronic conditions in America."
'Cascade' Gaps Persist Over 14-Year Period
Kazemian and colleagues examined NHANES data over three 4-year intervals: 2005-2008, 2009-2012, and 2013-2016. During those periods, a total of 1742 participants had diagnosed diabetes and another 746 had undiagnosed diabetes (determined by either fasting plasma glucose or HbA1c as part of the NHANES examination).
In 2013-2016, 94% of those diagnosed with diabetes were linked to diabetes care. During that time, 64% met individualized HbA1c targets per American Diabetes Association (ADA) recommendations (7.0%-8.5%, depending on age and clinical status), 70% achieved blood pressure control (< 140/90 mmHg, again per ADA), 57% had low-density lipoprotein cholesterol (LDL-C) < 100 mg/dL, and 85% were nonsmokers (self-reported via survey).
However, only 41% met both blood pressure and cholesterol (BC) goals, 25% met HbA1c, blood pressure, and cholesterol (ABC) targets, and just 23% met ABC plus nonsmoking (ABCN) status. These levels were not statistically different from those in 2005-2008 and 2009-2012 (proportions meeting ABCN composite were 23% and 25%, respectively).
Compared with middle-aged adults (45-64 years), the proportions achieving ABCN composite targets were significantly greater for those aged 65 years and older (adjusted odds ratio [aOR], 1.70) and significantly lower for adults younger than 45 years (aOR, 0.53). Younger adults were also less likely than middle-aged adults to be linked to diabetes care (aOR, 0.34).
In 2013-2016, 30% of older adults with diabetes achieved the combined ABCN targets, whereas only 20% of middle-aged adults and 12% of young adults with diabetes did.
Women were significantly less likely than men to achieve the combined ABCN target (aOR, 0.60), primarily because of lower achievement of the LDL-C target (aOR, 0.66). Women were also less likely to be linked to care (aOR, 0.53).
Compared with white participants, those who were black were less likely to achieve the combined ABCN target (aOR, 0.57). Hispanic participants were less likely to be linked to care (aOR, 0.43) and achieve ABC control (aOR, 0.60).
In 2013-2016, the proportions achieving the combined ABCN targets among white, black, and Hispanic participants were 25%, 14%, and 18%, respectively.
Again, results by age, sex, and race/ethnicity were similar across the year cycles.
'People Are Still Getting Left Behind'
In their editorial, Ali and Shah discuss several factors possibly contributing to the lack of improvement and persistent disparities in "cascade" care since 2005.
For one, the 2010 ADA recommendation for use of HbA1c of 6.5% as diagnostic criteria for diabetes could have altered the diagnosed population in unpredictable ways. In addition, the Affordable Care Act's expansion of health insurance access may have "added adults with different sociodemographic and clinical characteristics in latter survey cycles."
The availability of newer glucose-lowering medications such as dipeptidyl peptidase-4 inhibitors, glucagon-like peptide-1 agonists, and sodium-glucose cotransporter-2 inhibitors probably had minimal effect as they had lower penetration at the time of the surveys, in part because of high cost and low reimbursement. But at the same time, the skyrocketing cost of insulin may well have presented a barrier, they note.
Ali and Shah also say that lack of access isn't the only factor in maintaining care gaps, but rather "a confluence of patient-level, healthcare professional-level, and system-level barriers of varying degrees," as well as "the fragmentation of care and payment in America, which often disrupts continuity of care."
The editorialists conclude, "The message of this report is clear: people are still getting left behind; we need to act now or they will slip (further) through the cracks."
Commenting on the editorial, Kazemian told Medscape Medical News that he "cannot agree more with the points discussed." In particular, he said, "policy-level initiatives to address socioeconomic disparities are essential to revolutionizing care for patients with diabetes in the United States."
"Developing new drugs and technologies are critical, but we should make sure they effectively reach the population at risk. Making healthcare more affordable, accessible, and efficient can be an important step toward improving diabetes outcomes in the United States."
The study was supported by the Boston Area Diabetes Endocrinology Research Center and Steve and Deborah Gorlin MGH Research Scholar Award. Kazemian, Ali, and Shah have reported no relevant financial relationships.