A new "diabetes report card" chronicling how the United States is faring in terms of management of the condition in adults, based on data to 2010, shows that there has been improvement, but there are still large gaps in terms of the control of 2 important risk factors, smoking and hypertension.
The data "provide a nationally representative snapshot of risk-factor control and preventive practices" with regard to both type 1 and type 2 diabetes, say the researchers in their article in the April 25 issue of the New England Journal of Medicine.
"The take-home for me is that we are doing better," lead author Mohammed K. Ali, MB, ChB, from the Centers for Disease Control and Prevention, Atlanta, Georgia, told Medscape Medical News. "The improvements, especially for glucose and cholesterol control, are pretty evident, and we are also getting more and more people to come back for their preventive-care visits — for annual eye exams, flu vaccinations, and such."
But "the big gaping hole that we are not really doing a good job with is blood-pressure control and tobacco," he added. "One in 5 Americans with diabetes still smokes, and that's high, and there has literally been no change in the past 12 years, and that's quite disappointing. We are not doing enough to counsel patients in terms of quitting smoking."
The researchers assessed data from adults with self-reported type 1 or type 2 diabetes from the National Health and Nutrition Examination Survey (NHANES) and the Behavioral Risk Factor Surveillance System to examine risk-factor control, preventive practices, and risk scores for coronary heart disease from 1999 to 2010.
Over this time period, the weighted proportion of survey participants who met recommended goals for diabetes care increased by 7.9 percentage points for glycemic control (HbA1c < 7.0%), 9.4 percentage points for individualized glycemic targets, 11.7 percentage points for blood pressure (< 130/80 mm Hg), and 20.8 percentage points for lipid levels (LDL cholesterol < 100 mg/dL [2.6 mmol/L]).
The changes in numbers of people reaching glycemic control and cholesterol goals were significant (P = .009 and < .001, respectively), but for the blood-pressure target, this was not the case (P = .08).
Tobacco use did not change significantly, either (P = .96), but the 10-year probability of coronary heart disease decreased by 2.8 to 3.7 percentage points.
Still, almost 30% to 50% of adults with diabetes did not meet targets for glycemic control, BP, or lipid control, and only 14.3% met the targets for all 3 of these measures and for tobacco use, the authors note.
However, Dr. Ali said that when they assessed people in terms of individualized HbA1c targets, "something there has been a renewed emphasis on, from all of the major diabetes organizations, such as the American Diabetes Association and European Association for the Study of Diabetes, it wasn't just 50% now meeting the goal of an HbA1c under 7, it was something like two thirds of all adults with diabetes actually meeting their respective [individualized] goals.
"The key for us now is that this is just a start," he stressed. "We've tried to lay a foundation of saying this is probably what's going on in terms of control. Now what's needed is more research, where you actually follow those same people into the future, with a really well-designed study, to see whether those different levels of control for different risk groups actually result in fewer heart attacks and strokes" and other outcomes of interest such as retinopathy and chronic kidney disease, he said.
In an accompanying editorial, Graham T. McMahon, MD, MMSc, and Robert G. Dluhy, MD, from the division of endocrinology, diabetes, and hypertension, Brigham and Women's Hospital, Boston, Massachusetts, call the gains reported by Dr. Ali and colleagues "modest" and point out "there's a long way to go to deliver the quality of diabetes care that truly meets our patients' needs." To achieve this, there needs to be a move from "episodic care" for diabetes to a chronic care model, they stress.
Dr. Ali concurs. "Team-based care for chronic diseases is really the way we should be moving into the future," he told Medscape Medical News. Doctors, he said, don't always have the time to address behavioral change like smoking cessation and also "may not always have the best skills to deal with something that is behavioral and requires so much counseling." Allied healthcare professionals such as nurse practitioners can be hugely beneficial in this instance, "because they can spend much more time with a patient to achieve a behavior change like tobacco control," he explained.
Drs. McMahon and Dluhy add that patients too need to become collaborators in this model of care for chronic diseases, "and physicians need to become comfortable with sharing responsibility" with other healthcare providers. Curricular changes across the continuum of training "are helping new physicians to develop the skills required to facilitate these changes in practice," they observe.
And such change is needed, not least because diabetes costs the economy so much, Dr. Ali added. "The gaps we are not attaining, they are really costly. Diabetes is one of the biggest contributors to healthcare costs in the US. If we could work on these very preventable causes of mortality, the tobacco and the blood-pressure control, it's likely we will see large reductions in spending."
Dr. Ali and coauthors have reported no relevant financial relationships. Dr. McMahon is the medical education editor and Dr. Dluhy is an associate editor for the New England Journal of Medicine.
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