https://diabetes.acponline.org/archives/2014/12/12/2.htm

Care gaps identified in U.S. diabetic adults

Among U.S. adults with diabetes, 3 in 10 are undiagnosed, possibly due to limited access to care, a study recently reported.


Among U.S. adults with diabetes, 3 in 10 are undiagnosed, possibly due to limited access to care, a study recently reported.

Researchers used National Health and Nutrition Examination Survey (NHANES) data from 2007 to 2012 to develop a “cascade of care” concept, defined as “a way of showing, in visual form, the numbers of persons living with a condition who are receiving the care and treatment they need.” The goal was to determine gaps in diagnosis, engagement, and treatment of diabetes in U.S. adults 18 years of age and older. NHANES data were benchmarked against the most recent available guidelines for reduction in cardiac risk, including the Eighth Joint National Committee guidelines for hypertension and the American College of Cardiology/American Heart Association 2014 lipid treatment guidelines. The study results were published in the Nov. 18 Annals of Internal Medicine.

Overall, 28.4 million U.S. adults (11.8%) had diabetes in 2012, and of these, 20.5 million (72.2%) were aware of this diagnosis. In adults who had a diabetes diagnosis, 95.3% had a usual clinician they visited and 91.7% had visited their clinician at least twice in the past year, compared with 84.5% and 66.5% of undiagnosed adults, respectively. Goals for individualized HbA1c, blood pressure (<140/80 mm Hg), lipids (LDL cholesterol <100 mg/dL [2.6 mmol/L]), and nonsmoking were met by 63.7%, 65.5%, 56.6%, and 80.6% of diagnosed adults, respectively, compared with 77.0%, 57.9%, 36.0%, and 77.9% of undiagnosed adults. In addition, among diagnosed adults, 26.7% met combined ABC (HbA1c, blood pressure, and LDL cholesterol) targets and 21.3% met these targets and did not smoke, compared with 22.1% and 18.8% of undiagnosed adults.

The authors noted that NHANES data do not include persons living in institutions or noncivilians and that some of the diabetes data were based on self-reports, among other study limitations. However, they concluded that approximately 30% of U.S. adults with diabetes do not have a diabetes diagnosis and that this may be related to access to care. “Compared with diagnosed adults, undiagnosed adults have less elevated hemoglobin A1c levels, less lipid treatment and worse control, and similarly poor [blood pressure] and combined [HbA1c, blood pressure, and cholesterol] control regardless of smoking status,” they wrote. “Addressing these care gaps in both groups would prevent long-term complications.”

A study published by MMWR on Nov. 21 also addressed gaps in care, specifically the use of diabetes self-management education and training (DSMT) in patients with newly diagnosed diabetes. Researchers used data from the Marketscan Commercial Claims and Encounters database from 2009 to 2012 to determine how many privately insured adults age 18 to 64 with new diabetes diagnoses participated in DMST during the first year after diagnosis, as the American Diabetes Association recommends. Patients were considered to have new diagnoses if they had diabetes in 2011 but not in 2009 or 2010 and were considered to have participated in DSMT if at least 1 DSMT claim was filed within 12 months of diabetes diagnosis.

Overall, 95,555 patients with new diabetes diagnoses were identified, and of these, 6.8% participated in timely DSMT. DSMT participation was slightly more common among patients age 45 to 64 years than among patients age 18 to 44 years (7.2% vs. 5.9%; P<0.001), as well as among patients prescribed insulin compared to patients on oral agents only and compared to patients not prescribed any antiglycemic medication (14.2% vs. 6.7% and 14.2% vs. 5.1%; P<0.001 for both comparisons).

The authors noted that their findings might not be generalizable to other populations and that some patients might have received DSMT that was not captured by insurance claims, among other limitations. However, they concluded that DMST participation is uncommon among U.S. adults with newly diagnosed diabetes. “The finding of low rates of participation in DSMT among privately insured adults with newly diagnosed diabetes underscores the need to identify specific barriers to access and participation in DSMT along with strategies to overcome these barriers,” the authors wrote. They noted that the CDC is working with state health departments to try to increase DSMT use.