Evaluation of the Cascade of Diabetes Care in the United States


Posted Oct 17 , 2019 04:31 AM

Evaluation of the Cascade of Diabetes Care in the United States, 2005-2016.
Kazemian P, et al. JAMA Internal Medicine 2019_Online Aug 12

Institute Summary (excerpted from the abstract)

The purpose of this study was to evaluate whether the cascade of US diabetes care, defined as diabetes diagnosis, linkage to care, and achievement of individual and combined treatment targets, improved from 2005 to 2016 and to investigate potential disparities in US diabetes care. Nationally representative, serial cross-sectional studies included in the 2005-2016 National Health and Nutrition Examination Survey were evaluated. Data on nonpregnant US adults (age18 years) with diabetes who had reported fasting for 9 or more hours (n = 1742 diagnosed and 746 undiagnosed) were included. Data analysis was performed from August 1, 2018, to May 10, 2019. Data were collected representing 2005-2008, 2009-2012, and 2013-2016 regarding age, sex, race/ethnicity, health insurance, and educational level incorporated into logistic regression models predicting odds of diabetes target achievement. The proportion of participants were reviewed overall and stratified by age, sex, and race/ethnicity who were linked to diabetes care and met glycemic (hemoglobin A1c <7.0%-8.5%, depending on age and complications), blood pressure (<140/90mmHg), cholesterol level (low-density lipoprotein cholesterol <100mg/dL), and smoking abstinence targets and a composite of all targets. In 2013-2016, of 1742 US adults with diagnosed diabetes, 94% were linked to diabetes care; 64% met hemoglobin A1c level targets, 70% met blood pressure level, and 57% met cholesterol level targets; 85% were nonsmokers; and 23% achieved the composite goal. Results were similar in 2005-2008 (composite 23%) and in 2009-2012 (composite 25%). There was no significant improvement in diagnosis or target achievement during the study period. Compared with middle-aged adults (45-64 years) with diagnosed diabetes, older patients (>65 years) had higher odds (adjusted odds ratio (aOR=, 1.70) and younger adults (18-44 years) had lower odds (aOR=0.53) of meeting the composite target. Women had lower odds of achieving the composite target than men (aOR= 0.60). Non-Hispanic black individuals vs non-Hispanic white individuals had lower odds of achieving the composite target (aOR=0.57). Having health insurance was the strongest predictor of linkage to diabetes care (aOR=3.96).

Why is this important?

It appears that the diabetes care cascade in the United States has not significantly improved between 2005 and 2016. This study’s findings suggest that gaps in diabetes care that were present in 2005, particularly among younger adults (18-44 years), women, and nonwhite individuals, persist. This should come as a surprise to many that with the development of new classes of antidiabetes therapies since 2005, including incretin-based drugs and sodium–glucose cotransporter 2 inhibitors (SGLT2i), the paradigm of therapy options for patients with highly heterogeneous glycemic and cardiovascular risk factors has changed significantly (Montvida O, et al. Diabetes Care 2018;41:69-78). Implementation of these newer antidiabetic drug options has lagged in real world practice, and issues such as clinical inertia (not advancing therapy when current therapy is failing to achieve glucose targets). Clinical inertia is not only a problem with glucose control but plagues the variety of targets studied in this report. Advancing therapy, especially with the newer antidiabetes medications should be a priority! Let’s all work to achieve the level of control our patients need!

Concluding Thought: The times they are a changin’… the results, not so much

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