Reaching Goals of Diabetes Care in the United States

Diabetes mellitus has been diagnosed in an estimated 18.8 million adults in the United States. Patients with diabetes are at increased risk for disabling and life-threatening complications from microvascular diseases (affecting the kidneys, eyes, and limbs) and macrovascular diseases (involving the coronary vascular, cerebrovascular, and peripheral vascular systems).

Twenty years ago, studies demonstrated that microvascular complications and long-term risk of macrovascular complications could be reduced with improved glycemic control. Following the initial studies, trials found that additional reductions in the incidence of vascular diseases and mortality were achieved by lowering blood pressure, reducing cholesterol levels, and avoiding tobacco. Based on those studies, diabetes care guidelines include recommendations to control the identified risk factors and conduct regular screening for complications.

Disease-specific indicators based on the guidelines have been used to measure the quality of care and preventive services for diabetes. Studies conducted from 1988 to 2002 demonstrated improved diabetes care. The studies also showed that there were no incremental cardiovascular benefits of aggressive glycemic control, leading to an emphasis on individualized glycemic targets based on age, coexisting conditions, and time since the diagnosis of diabetes.

Researchers recently conducted an analysis of national surveillance data to (1) examine trends in risk-factor control and adherence to preventive practices among US adults with diabetes, (2) evaluate care based on individualized performance measures, and (3) assess variation in these trends across different clinical and sociodemographic groups. Results of the analysis were reported in the New England Journal of Medicine [2013;368(17):1613-1624].

The researchers utilized data from the National Health and Nutrition Examination Survey (1999-2002, 2003-2006, and 2007-2010) and from the Behavioral Risk Factor Surveillance System survey (2000, 2004, and 2008).

During the study period (1999-2010), the weighted proportion of survey participants who met recommended goals for diabetes care increased by 7.9 percentage points (95% confidence interval [CI], 0.8-15.0) for glycemic control (glycated hemoglobin level <7.0%), 9.4 percentage points (95% CI, 3.0-15.8) for individualized glycemic targets, 11.7 percentage points (95% CI, 5.7-17.7) for blood pressure (target, <130/80 mm Hg), and 20.8 percentage points (95% CI, 11.6-30.0) for lipid levels (target level of low-density lipoprotein [LDL] cholesterol, <100 mg per deciliter [2.6 mmol/L]).

There was no significant change in tobacco use; however, the 10-year probability of coronary heart disease decreased by 2.8 to 3.7 percentage points.

The analysis also found that targets for glycemic control, blood pressure, or LDL cholesterol levels were not being met by 33.4% to 48.7% of persons with diabetes. Only 14.3% met the targets for all 3 measures and tobacco use.

There were no changes in the adherence rates for recommendations for annual eye and dental examinations. Annual lipid-level measurement increased by 5.5 percentage points (95% CI, 1.6-9.4) and foot examination increased by 6.8 percentage points (95% CI, 4.8-8.8). In addition, there was an increase of 4.5 percentage points (95% CI, 0.8-8.2) in the rate of annual influenza vaccination and 6.9 percentage points (95% CI, 3.4-10.4) for pneumococcal vaccination among those ≥65 years of age. Daily glucose monitoring increased by 12.7 percentage points (95% CI, 10.3-15.1).

In summary, the researchers noted that, “Although there were improvements in risk-factor control and adherence to preventive practices from 1999 to 2010, tobacco use remained high, and almost half of US adults with diabetes did not meet the recommended goals for diabetes care.”