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Original Investigation
August 12, 2019

Evaluation of the Cascade of Diabetes Care in the United States, 2005-2016

Author Affiliations
  • 1Medical Practice Evaluation Center, Massachusetts General Hospital, Boston
  • 2Division of General Internal Medicine, Massachusetts General Hospital, Boston
  • 3Harvard Medical School, Boston, Massachusetts
  • 4Division of Infectious Diseases, Massachusetts General Hospital, Boston
  • 5Diabetes Unit, Massachusetts General Hospital, Boston
JAMA Intern Med. 2019;179(10):1376-1385. doi:10.1001/jamainternmed.2019.2396
Key Points

Question  Were there any changes in population-level achievement of diabetes treatment targets in the United States from 2005 to 2016?

Findings  In this population-based study of 2488 individuals, approximately 1 in 4 adults with diagnosed diabetes achieved the composite goal in the United States. No significant improvement in any of the individual targets was observed between 2005 and 2016, and gaps in achieving diabetes care targets, particularly among young (18-44 years), female, and nonwhite adults, persisted during the study period.

Meaning  It appears that advances in diabetes care over the past decade have not translated into meaningful improvement in population-level treatment outcomes.


Importance  Treatment advances in diabetes can meaningfully improve outcomes only if they effectively reach the populations at risk.

Objectives  To evaluate whether the cascade of US diabetes care, defined as diabetes diagnosis, linkage to care, and achievement of individual and combined treatment targets, improved from 2005 to 2016 and to investigate potential disparities in US diabetes care.

Design, Setting, and Participants  Nationally representative, serial cross-sectional studies included in the 2005-2016 National Health and Nutrition Examination Survey were evaluated. Data on nonpregnant US adults (age ≥18 years) with diabetes who had reported fasting for 9 or more hours (n = 1742 diagnosed and 746 undiagnosed) were included. Data analysis was performed from August 1, 2018, to May 10, 2019.

Exposures  Time period (2005-2008, 2009-2012, and 2013-2016), age, sex, race/ethnicity, health insurance, and educational level incorporated into logistic regression models predicting odds of target achievement.

Main Outcomes and Measures  Proportion of participants overall and stratified by age, sex, and race/ethnicity who were linked to diabetes care and met glycemic (hemoglobin A1c <7.0%-8.5%, depending on age and complications), blood pressure (<140/90 mm Hg), cholesterol level (low-density lipoprotein cholesterol <100 mg/dL), and smoking abstinence targets and a composite of all targets.

Results  In 2013-2016, of 1742 US 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, and 57% (95% CI, 51%-62%) met cholesterol level targets; 85% were nonsmokers (95% CI, 82%-88%); and 23% (95% CI, 17%-29%) achieved the composite goal. 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. Compared with middle-aged adults (45-64 years) with diagnosed diabetes, older patients (≥65 years) had higher odds (adjusted odds ratio [aOR], 1.70; 95% CI, 1.17-2.48) and younger adults (18-44 years) had lower odds (aOR, 0.53; 95% CI, 0.29-0.97) of meeting the composite target. Women had lower odds of achieving the composite target than men (aOR, 0.60; 95% CI, 0.45-0.80). Non-Hispanic black individuals vs non-Hispanic white individuals had lower odds of achieving the composite target (aOR, 0.57; 95% CI, 0.39-0.83). Having health insurance was the strongest predictor of linkage to diabetes care (aOR, 3.96; 95% CI, 2.34-6.69).

Conclusions and Relevance  It appears that the diabetes care cascade in the United States has not significantly improved between 2005 and 2016. 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.

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