As a medical resident in primary care over the past three years, I cared for a large number of diabetic patients, and each one seemed to present a unique challenge. For instance, Walter, who was legally blind, lived alone, and required daily treatment with insulin. After numerous discussions with our clinic pharmacist and social worker, we devised a plan so that Walter could use an insulin pen that was pre-filled with medication. Walter could dial the pen and listen to the number of clicks to determine the insulin dosage. Then there was Roberta, a strong-willed woman who was resistant to the idea of taking any medication for her diabetes. However, once we enlisted the support of her family members, she agreed to take her pills (most of the time). Finally, Larry’s hemoglobin A1c never dropped below 12 despite the efforts of our entire clinic staff. Eventually, after many unanswered phone calls and fruitless outreach efforts, we learned that Larry was homeless and could not focus on addressing his diabetes until he had secured permanent housing.
These experiences taught me that successful diabetes treatment is much more challenging than simply prescribing medications based on treatment algorithms. In general, I found that working with a multidisciplinary team of care providers helped patients to achieve the best results. Yet, with my singular perspective it was difficult to say for certain how much better off my diabetic patients were doing as a whole. While some patients achieved great control over their diabetes, others just never seemed to make any progress at all.
This week’s NEJM features a special article by Ali et al. which asks an important question: How are we doing at managing diabetes at the population level here in the United States? The authors of this study analyzed data from large national surveys and medical exams to paint a picture of how we as a nation are doing with regards to meeting target care goals for patients with diabetes.
Some of the results are encouraging. More adults with diabetes are achieving recommended targets for hemoglobin A1c, blood pressure, and LDL cholesterol. Cardiovascular risk overall decreased amongst diabetics. More patients are receiving influenza and pneumococcal vaccinations, getting their lipids checked, undergoing annual foot exams, and are self-monitoring their blood glucose.
Yet, there are also discouraging findings in this report. Large numbers of diabetics have not reached clinical targets: 13% had a hemoglobin A1c greater than nine, 49% had a blood pressure greater than 130/80, and 43% had an LDL cholesterol greater than 100. Smoking in the presence of diabetes leads to even greater risk for vascular events, yet still 22% of diabetics were smoking in 2010. Finally, only 14% of diabetics met all four targets for hemoglobin A1c, blood pressure, LDL cholesterol and not smoking.
How should we interpret the results of this report? In an accompanying editorial, Graham McMahon and Robert Dluhy help put these data into perspective. They write, “While there is reason to celebrate the modest improvement in performance suggested by these data, there’s a long way to go to deliver the quality diabetes care that truly meets our patients’ needs.” In particular, McMahon and Dluhy provide suggestions for how we as a society can better meet the care needs of our growing population of diabetics. First, we will need to embrace the Chronic Care Model, in which care for our diabetics is reorganized into care teams involving both physicians and other care professionals working together and sharing responsibility for achieving desired outcomes. Next, curricular changes will need to be implemented to give physicians and allied health providers the skills necessary to work collaboratively in care teams. We must create an incentive structure for providers that rewards improvement in outcomes rather than just achievement of thresholds. And finally, we need to ensure that the measures we track are not just those that are of interest to clinicians, but are actually patient-centric and include such variables as reported well-being and access to care.
There are approximately 19 million diabetics in the United States today. This report by Ali et al. gives us a benchmark for how we are doing as a healthcare system in managing these patients and also serves as a reminder that we must improve our systems of care delivery to better meet the needs of these patients. The challenge is daunting, but the opportunities for innovation are also exciting to those of us who care for diabetic patients. After reading this report, I look forward to spending some time with my own practice colleagues to think about how we can better work collaboratively to improve care for patients with diabetes.
Connect with Dr. Colbert on Twitter: @jcolbertMD