Why has progress in diabetes outcomes stalled?

Despite advances in medications and care delivery models, the U.S. has made little progress towards improving outcomes for patients with diabetes in recent years, a new study finds.

            The study in JAMA Internal Medicine looks at what the authors call the “cascade of diabetes care”-defined as whether the patient had been diagnosed with diabetes, whether they were getting some form of care if diagnosed, and their success in  achieving goals in four target areas-from 2005 to 2016. The target areas included hemoglobin A1C and low-density lipoprotein cholesterol levels, blood pressure and smoking cessation. 

            To conduct the study, the authors analyzed data on 1,742 nonpregnant people age 18 and older who had been diagnosed with diabetes and had participated in the National Health and Nutrition Examination Survey between 2005 and 2016. They constructed a cascade of diabetes care for three periods-2005-2008, 2009-2012 and 2013-2016-and investigated whether care had improved between periods and over the entire 11-year span.

            They found that during the 2013-2016 period, 94 percent of those in the study were receiving some form of diabetes care, 64 percent had met target hemoglobin A1C levels, 70 percent met target blood pressure, 57 percent met cholesterol level targets, 85 percent were nonsmokers and 23 percent achieved goal in all four areas.

            These results were close, and in some cases virtually identical, to those of the 2005-2008 period, leading the authors to observe that “there was no significant improvement in diagnosis or target achievement during the study period.”

            In analyzing the data by the age, sex and race/ethnicity of the participants, the authors found significant differences. For example, in 2013-2016, 30 percent of those 65 and older achieved control in all four target areas, or “composite control,” compared with 20 percent of those age 45-64 and 12 percent of those 18-44.

            Similarly, in 2013-2016, 25 percent of those identifying as non-Hispanic white achieved composite control, whereas 14 percent of those identifying as non-Hispanic black and 18 percent of those reporting Hispanic ethnicity achieved the composite. Regardless of category, however, having health insurance was found to be the strongest indicator for the likelihood of being diagnosed, linked to care and achieving composite control in the four target areas. 

            The authors conclude that more frequent screening for diabetes, expanded access to care and healthcare insurance and interventions aimed at improving patients’ medication adherence should be the key strategies in improving diabetes outcomes.

            The study, “Evaluation of the Cascade of Diabetes Care in the United States, 2005-2016” is online at the JAMA Internal Medicine website.