Are We Meeting the Goals for Diabetes Care?   (April 29, 2013)

A recent diabetes report, Achievement of Goals in U.S. Diabetes Care 1999–2010, examined how people with diabetes said they are doing. The participants had been enrolled in two big U.S. surveys, the National Health and Nutrition Examination Survey and the Behavioral Risk Factor Surveillance System, and who had self-reported that they had diabetes. (Unfortunately, whether the participants had type 1 or type 2 diabetes was not ascertained).

The researchers looked at a huge amount of data relating to diabetes, such as daily glucose monitoring, A1C levels, blood pressure, LDL cholesterol, tobacco use, coronary artery disease, eye, dental, and foot exams, flu shots, and pneumococcal vaccinations, and compared the results to various guidelines for diabetes care goals established by the ADA or the National Quality Forum.

The goals the authors used were variable, depending on what the researchers were examining. Exact target numbers for some of the tests were defined: for instance, the A1C goal was to be at or below 7.0% if age 18-44 with complications (other A1C levels were defined for different age or complication status combinations), blood pressure was to be <130/80 mm Hg, LDL cholesterol, <100 mg/dl. The researchers assumed that the goal for many of the preventive practices they evaluated (including lipid measurement, eye, dental, and foot exams, urine screening, and flu shots) was simply that  the specified intervention should be done annually.  For smoking, the goal was “non smoking status achieved.” For home glucose monitoring, the goal was testing one or more times daily.

All sorts of believable but totally useless statements can be generated from the data. I think one of the most bizarre was the following:  “In the 2007–2010 surveys, more than 70% of participants reported undergoing annual eye examinations (73.4%), foot examinations (71.4%), and lipid checks (88.2%) and performing self-monitoring of glucose levels (70.9%), whereas 49 to 60% reported receiving vaccinations and 54.6% reported receiving diabetes education.” (To me, that’s as useless as saying that 73.4% of fruit salads contain grapes, 71.4% of Waldorf salads contain apples, 88.2% of Greek salads contain cheese, while 49-60% of chefs have been screened for staph and 54.6% have had culinary education.) Sure, one could conclude that not everyone had met every criterion, but that’s about all.

Despite my nit-picking about such statements, the authors’ overall conclusions are indeed very important: the United States is not doing very well in meeting goals for diabetes care. They conclude that “Although there were improvements in risk-factor control and adherence to preventive practices from 1999 to 2010, tobacco use remained high, and almost half of U.S. adults with diabetes did not meet the recommended goals for diabetes care.” The situation would inevitably be even worse if one were to somehow able to include those individuals who don’t know that they have diabetes: remember, this survey only included self-reported diabetes patients. If you didn’t know you had diabetes, it would seem very likely that you most likely didn’t have annual eye or foot exams or diabetes education, and would drag down the statistics even more.

That’s looking at the bad side of how the US is doing; the flip side is that things are better than they had been. The lead author of the study is quoted as saying "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 we still have a long way to go.