This article is more than 5 years old. Information may no longer be current.
'Cascade-of-care' displays gaps in US diabetes diagnosis, treatment
Click Here to Manage Email Alerts
Using a cascade model to visualize the gaps in awareness of diabetes diagnosis, engagement in care and treatment in the United States, researchers found three of 10 adults with the condition remain undiagnosed, according to research published in the Annals of Internal Medicine.
“We know that of the 28.4 million people with diabetes in the United States, adults largely, one-quarter remain undiagnosed, and we were really curious to see what sorts of missed opportunities were there in terms of caring for them,” Mohammed K. Ali, MBChB, MSc, MBA, of the Rollins School of Public Health of Emory University, told Endocrine Today. “Undiagnosed individuals with diabetes were less likely to be engaged with a care provider, less likely to go for regular visits and far less likely to be given lipid-lowering therapies for their elevated levels of cholesterol.”
Mohammed K. Ali
Ali, along with colleagues from Emory and the CDC, looked at National Health and Nutrition Examination Surveys between 2007 and 2012 to develop a “cascade-of-care concept” similar to that which addressed implementation gaps in HIV care.
“The cascade concept is a visual report of whether people with a certain condition are getting the type of care they need at every point in the continuum of care,” Ali said. “It has its roots in HIV management and has been really useful in that particular paradigm to promote accountability among providers and also among patients.”
The records, from nonpregnant women and men aged at least 18 years, contained standardized collected data and laboratory procedures. The researchers benchmarked diabetes care against recent diabetes and cardiovascular risk reduction guidelines.
In 2012, an estimated 28.4 million (11.8%) adults in the United States had diabetes, with 20.5 million (72.2%) aware of their diagnosis. Among those diagnosed, 95.3% had a usual care provider and 91.7% made at least two visits in the year preceding. Among undiagnosed adults, 84.5% had a usual care provider and 66.5% reported at least two visits in the past year.
Among diagnosed adults, 63.7% met individualized HbA1c targets, 65.5% met BP target (<140 mm Hg/80 mm Hg), 56.6% met lipid target (LDL cholesterol <2.6 mmol/L, or <100 mg/dL) and 80.6% met nonsmoking goals. Further, 26.7% met combined ABC (HbA1c, BP and LDL cholesterol) targets and 21.3% met combined ABC targets and did not smoke.
Among undiagnosed adults, 77% met their HbA1c targets, 57.9% BP target, 36% lipid target and 77.9% and nonsmoking goals, with 22.1% reaching combined ABC targets and 18.8% combined ABC targets and not smoking.
“Clearly, with the proportion of people that remain undiagnosed, both providers and patients can do better,” Ali said.
It is critical clinicians offer glucose tests to patients meeting the clinical profile for weight, age and hypertension and minority status set forth by guidelines, and that patients use tools at their disposal including risk tests on the American Diabetes Association and CDC websites, he noted.
With the absolute number of people with diabetes continuing to increase, and the chronic condition among the biggest drivers of health care costs, Ali highlighted the potential in using the cascade design.
“My hope is clinicians will embrace the concept of the cascade, and see it as a way of constantly checking in and seeing how their whole population of patients is doing compared with what the guidelines are suggesting,” Ali said.
An algorithm could integrate cascade into electronic health records and generate reports for health care providers or systems on a weekly or monthly basis, he said, offering continuous opportunities for evaluation and follow-up with patients not meeting care goals.
“In the grand scheme, if we do that, we’re going to lower a whole lot of diabetes morbidity and a whole lot of costs for our health care system,” Ali said. – by Allegra Tiver
For more information:
Mohammed K. Ali, MBChB, MSc, MBA, can be reached at 1518 Clifton Road NE, CNR Building Room 7041, Atlanta, GA 30322; email: mkali@emory.edu.
Disclosure: The researchers reports no relevant financial disclosures.
Perspective
Back to Top
Gerald Bernstein, MD, FACP
This article looks to the care given to adults with diabetes diagnosed in a variety of ways, but more important looks to the gaps in the continuity of treatment as well as those undiagnosed. Obviously, to lower the risk for complications, you need to know who carries that risk. The authors quote a figure that some 11% of the US adult population has diabetes. Looking at the future, I believe that it is imperative that the entire adult population must be screened for pre-diabetes and preventative treatment instituted. According to the CDC, this would now extend the population at risk to 42.3% of adults over the age of 20 years. Identifying this population will help reduce the number of gaps in treatment and improve the “cascade of care.”
Click Here to Manage Email Alerts