Diabetes care has improved but still falls short

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Reason to celebrate, but a long way to go

There is reason to celebrate the improvements in achieving glycemic, blood-pressure, and lipid targets documented in the study by Dr. Ali and his colleagues, but the data also show "there’s a long way to go to deliver the quality of diabetes care that truly meets our patients’ needs," according to Dr. Graham T. McMahon and Dr. Robert G. Dluhy.

"The next wave of improvement in the delivery of diabetes care will probably come through intensive quality improvement and a movement away from episodic care toward the chronic care model and panel management," they predicted.

Incentive systems for clinicians that reward incremental improvement, not just the achievement of target goals, would be helpful. Such incentives may be financial, but others, such as public profiling "or the provision of credits in a program that allows continuous maintenance of certification, may also be motivational," they added.

Dr. McMahon and Dr. Dluhy are in the division of endocrinology, diabetes, and hypertension at Brigham and Women’s Hospital, Boston. Dr. McMahon is the medical education editor at the New England Journal of Medicine, and Dr. Dluhy is an associate editor at the journal. They reported no other financial conflicts of interest. These remarks were taken from their editorial accompanying Dr. Ali’s report (N. Engl. J. Med. 2013;368:1650-1).



Adults with diabetes made substantial gains since 1999 in adherence to preventive practices and in control of risk factors for diabetic complications, according to a report published online April 25 in the New England Journal of Medicine.

However, up to half of these patients still failed to meet targets for glycemic control, blood pressure, and lipid control, and approximately half reported that they never received diabetes education, usually neglected getting the recommended yearly vaccinations, and failed to get the recommended annual dental and eye examinations, said Dr. Mohammed K. Ali of the Centers for Disease Control and Prevention, Atlanta, and his associates (N. Engl. J. Med. 2013;368:1613-24).


According to a recent report, adults with diabetes have made substantial gains in controlling risk factors for diabetic complications.

The investigators examined changes over time in diabetes care by analyzing data from a series of National Health and Nutrition Examination Surveys (NHANES 1999-2002, 2003-2006, and 2007-2010) and Behavioral Risk Factor Surveillance System surveys (2000, 2004, and 2008). Both sets of surveys include nationally representative samples of the population, and both also rely on self-reports of health-related behavior.

For this study, Dr. Ali and his colleagues included data from 3,355 NHANES participants and 97,310 BRFSS participants who reported having diabetes.

Between the earliest (1999-2002) and the most recent (2007-2010) survey, the proportion of patients with poor glycemic control decreased by 5.8 percentage points, while the proportion who met recommended targets for glycated hemoglobin level, blood pressure, and LDL cholesterol levels rose substantially (by 7.9, 11.7, and 20.8 percentage points, respectively).

Similarly, the population distributions of glycated hemoglobin levels, LDL cholesterol levels, and blood pressure levels all improved significantly over time. The mean glycated hemoglobin levels dropped by 0.4 percentage points, and the mean LDL cholesterol level declined by 17.7 mg/dL, to 99.5 mg/dL. The mean blood pressure decreased by 4/2 mm Hg, to 130/68 mm Hg.

At the same time, the proportion of adults with diabetes who were free of microalbuminuria rose by 4.0 percentage points, and the 10-year risk of coronary heart disease dropped significantly by 2.8 percentage points.

However, up to half of the diabetes patients in the most recent surveys still failed to meet targets for glycated hemoglobin level, blood pressure, or LDL cholesterol levels, and more than 22% still smoked. Only 14.3% of the survey participants met the targets for all four risk factors, the investigators said.

Only 22.4% of the respondents got their annual flu vaccines, annual eye exams, and annual foot exams as recommended.

When the data were analyzed by patient age, younger adults with diabetes (those aged 44 years and younger) showed no improvements in meeting their treatment goals or in following preventive recommendations. The reason for this lack of improvement isn’t clear, but the finding "suggests that younger adults with diabetes need further attention," Dr. Ali and his associates said.

Respondents with limited access to health care and those of lower socioeconomic status were more likely than others to have suboptimal control of risk factors throughout the study period.

"Our findings concur with previous reports: Health insurance coverage was significantly and consistently associated with better, more improved risk-factor profiles and preventive practices during the 12 years examined in our study," the investigators noted.

"Unfortunately, the proportion of persons with diabetes who do not have health insurance has remained the same, despite increases in mean income and educational level over the study period," they concluded.

No financial conflicts of interest were reported.

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