Boston—A plethora of advances in diabetes care has occurred in the last decade or so in the United States, according to a new study, but achievement of treatment targets has not improved during that time period.

That was especially the case with younger adults aged 18 to 44 years, women, and nonwhite patients, according to the article published online by JAMA Internal Medicine.

Researchers from Massachusetts General Hospital and Harvard Medical School used 2005-2016 nationally representative survey and examination data from the CDC. They determined that more than a quarter of U.S. adults with diabetes were not diagnosed, and nearly a third of patients were not receiving appropriate care for diabetes in the study period.

“Fewer than one in four American adults with diagnosed diabetes achieve a controlled level of blood sugar, blood pressure and cholesterol and do not smoke tobacco,” explained lead author Pooyan Kazemian, PhD, of the MGH Medical Practice Evaluation Center, and instructor in medicine at Harvard Medical School. “Our results suggest that, despite major advances in diabetes drug discovery and movement to develop innovative care delivery models over the past two decades, achievement of diabetes care targets has not improved in the United States since 2005.”

The article emphasizes that treatment advances in diabetes can meaningfully improve outcomes only if they effectively reach the populations at risk.

The study included 1,742 people diagnosed with diabetes, and 746 who were undiagnosed. Data analysis was performed from August 1, 2018, to May 10, 2019.The focus was on the proportion of participants overall and stratified by age, sex, and race/ethnicity who were linked to diabetes care and met glycemic goals, defined as hemoglobin A1c less than 7.0% to 8.5%, depending on age and complications; blood pressure less than 140/90 mmHg; cholesterol level (low-density lipoprotein cholesterol less than 100 mg/dL), and smoking abstinence, as well as a composite of all targets.

Results indicated that, in 2013-2016, of 1,742 U.S. adults with diagnosed diabetes:
• 94% (95% CI, 92%-96%) were linked to diabetes care
• 64% (95% CI, 58%-69%) met hemoglobin A1c level
• 70% (95% CI, 64%-75%) met blood pressure level
• 57% (95% CI, 51%-62%) met cholesterol level targets
• 85% were nonsmokers (95% CI, 82%-88%)

Only 23% (95% CI, 17%-29%) achieved the composite goal, according to the report.

Researchers point out that results were similar in 2005-2008 (composite 23%) and in 2009-2012 (composite 25%).

“There was no significant improvement in diagnosis or target achievement during the study period,” the authors write.

The study also found that, compared with middle-aged adults (45-64 years) with diagnosed diabetes, older patients (aged 65 years) had higher odds (adjusted odds ratio [aOR], 1.70; 95% CI, 1.17-2.48) and younger adults (aged 18-44 years) had lower odds (aOR, 0.53; 95% CI, 0.29-0.97) of meeting the composite target. In addition, women had lower odds of achieving the composite target than men (aOR, 0.60; 95% CI, 0.45-0.80).

In terms of racial disparities, non-Hispanic black persons had lower odds of achieving the composite target (aOR,0.57; 95% CI, 0.39-0.83) than non-Hispanic white individuals.

Overall, having health insurance was the strongest predictor of linkage to diabetes care (aOR, 3.96; 95% CI, 2.34-6.69), according to the study.

“It appears that the diabetes care cascade in the United States has not significantly improved between 2005 and 2016,” researchers conclude. “This study’s findings suggest that gaps in diabetes care that were present in 2005, particularly among younger adults (18-44 years), women, and nonwhite individuals, persist.”

“Barriers accessing health care, including lack of health insurance and high drug costs, remain major factors that have not been adequately addressed on a population level,” explained senior author Deborah J. Wexler, MD, MSc, of the MGH Diabetes Unit, and associate professor in Medicine at HMS.

“Treatment advances in diabetes mellitus can meaningfully improve outcomes only if they effectively reach the populations at risk. Our findings suggest this is not the case in the U.S. and indicate an immediate need for better approaches to diabetes care delivery including a continued focus on reaching underserved populations with persistent disparities in care.”

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