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J Am Soc Nephrol 14:S88-S91, 2003
© 2003 American Society of Nephrology

Supplement Article

Addressing the Burden of Diabetes in the 21st Century: Better Care and Primary Prevention

Michael M. Engelgau, K. M. Venkat Narayan, Jinan B. Saaddine and Frank Vinicor

Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.

Correspondence to Dr. Michael M. Engelgau, 4770 Buford Hwy NE, Atlanta, GA 30341. Phone: 770-488-5024; Fax: 770-488-1148;


   Abstract
Top
 Abstract
Introduction
 Conclusion
 References
 
ABSTRACT. By the end of the 20th century, the worldwide diabetes pandemic had affected an estimated 151 million persons. Strategies to mitigate both the human and economic burden are urgently needed. Efficacious treatments are currently available but the quality of diabetes care being delivered is suboptimal in both developed and developing countries. Some progress to improve quality has been made thought national strategies. These efforts need two elements: "translation" research that will establish the methods needed to assure that clinical research findings are delivered effectively in every day practice settings; and development and implementation of quality improvement measures that will reliably track progress. New interventions that prevent diabetes among those at high risk also now hold much promise and need to be implemented. E-mail: mxe1@cdc.gov


   Introduction
Top
 Abstract
 Introduction
Conclusion
 References
 
By the end of the 20th century the worldwide diabetes pandemic had affected an estimated 151 million persons, distributed among both developed and developing countries (1,2). In Asia alone an estimated 85 million were affected; this continent had both the highest proportion of current cases and the greatest projected increases for the future. Why are these trends alarming? Because diabetes is a major cause of blindness, kidney failure, amputations, and cardiovascular disease, and its complications results in major reductions in both length and quality of life (3–5). In addition, the burden on individuals and on society extends past human suffering to include staggering economic costs, lost productivity, and social capital (6,7). Strategies to mitigate both the human and economic burden are urgently needed. Here we examine the availability of efficacious diabetes treatments, the level at which quality of diabetes care is currently being delivered, the challenges associated with improving care, and the future role of diabetes prevention.

Efficacious Treatments Exist
Several efficacious treatments that can substantially reduce or prevent diabetes-related complications have been established. These treatments include glycemic and BP control to reduce microvascular (retinopathy and nephropathy) complications (8,9); eye examinations with timely follow-up, and laser treatment to prevent vision loss (10); foot care to decrease serious foot disease (11); BP, lipid control, and aspirin use to prevent cardiovascular disease (9,12,13); angiotensin-converting enzymes inhibitors to reduce nephropathy and cardiovascular disease (14,15); and influenza and pneumococcal vaccines in the elderly to reduce hospitalizations, respiratory conditions, and death (16).

Therefore, today’s challenges do not arise from a lack of efficacious diabetes treatments. Rather, these challenges lie with effectively implementing them across the population. Numerous barriers to implementation are located at several levels including the societal, health care system, provider, and patient levels (17). Most health care systems that have evolved to address acute disease often display limitations in delivering care for chronic diseases like diabetes. These systems are often constrained in allowing patient encounters for comprehensive care, and these may compete with treatment of other diseases and conditions that may require more urgent attention than diabetes. Although the provider may make decisions about treating chronic diseases with or without patient involvement, successful implementation of these decisions often resides within the domain of the overall health care system and the patient. Understanding the importance of comprehensive care is diminished because the seriousness of diabetes is underappreciated; early diabetes is relatively asymptomatic or unrecognized, and much of diabetes care relies on behavior modification and self-care. Thus, the complexities and intricacies of providing quality diabetes care are challenging.

Quality of Diabetes Care
Quality, "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with the current professional knowledge" (18), links treatment advances to the extent of their implementation in populations that will benefit from such treatments. In general, the quality of diabetes care remains suboptimal worldwide regardless of the country’s level of development, health care system, or population characteristics. Many ongoing efforts to assess the quality of diabetes care have met challenges. However, some progress in this area has been made over the last decade. For example, in the United States during the 1990s, several major health agencies and other interests formed the Diabetes Quality Improvement Project (DQIP) and developed a standard set of quality performance measures designed for universal use among health care delivery systems (19) (Table 1). These measures retrospectively assess the level of care delivered across the diabetic population in a uniform and systematic fashion. The essential criteria for DQIP measures are: (1) firm scientific and evidence-based links between the process being measured and important clinical outcomes; (2) the feasibility, reliability, and suitability for uniform application across health care systems; and (3) variation across the populations so that improvement can be monitored.


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  		Table 1. Diabetes Quality Improvement Project (DQIP) measures set
 
On the basis of DQIP measures applied to the US population, a major gap was found between recommended diabetes care and the care that patients actually receive (20). As shown by the results from population-based national surveys among adults conducted in the 1990s, 29% had a HbA1c test, 63% a dilated eye exam, and 55% a foot examination within the last year. Although the median HbA1c level was 7.5%, 18% had poor glycemic control (HbA1c >9.5%). Lipid testing was performed for 85% of the population within the previous 2 yr, but only 42% had an LDL level in good control (<3.4 mmol/L). Only 66% had a BP of less than 140/90 mmHg.

Other countries and regions that have examined the quality of diabetes care have reported similar findings. In Asia, the Diabcare-Asia project, modeled after a project conducted in Europe, was designed to provide large-scale, yet simple, standardized information about patient characteristics and care received from numerous centers across each country. The results, collected using similar methods during the same time frame from Singapore, India, and Taiwan, showed that one-third to one-half of the diabetic population had poor glycemic control and that lipid control was suboptimal (21–23) (Table 2).


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  		Table 2. Studies of the quality of diabetes care in selected Asian countriesa
 
Future Challenges
Two important activities are needed to improve the level of care such that it will achieve better outcomes. First, research efforts are needed to translate clinical and public health interventions into those that can be delivered uniformly in typical clinical settings (24). Translating research-based efficacious interventions into effective practice patterns that are broadly implemented is not trivial. Biological, social, educational, geographic (urban/rural), cultural, and psychologic influences on the patient, provider, health care system, and society may present barriers to effective treatments. However, many effective interventions do exist in the face of these challenges (25–29). These include patient-centered interventions such as diabetes self-management education delivered in clinical or community settings (26–29), multifaceted health care provider- or health system-based interventions to improve process of care and in some cases outcomes of care (27,28), and community-based interventions (26).

Second, the assessment of progress using standardized evidence-based performance measures, such as the DQIP quality measures, is needed. Feeding this information back to the health care systems, providers, and patients facilitates the identification of both successes and failures. The ultimate goal is that these assessments will further enhance uptake of research into practice and lead to improved diabetes care and clinical outcomes.

Many recent high-quality clinical trials in several populations around the world have attempted to prevent or delay the progression to type 2 diabetes among persons at high risk. These studies, which lasted approximately 3 to 6 yr, have found a robust benefit in using various lifestyle and drug interventions (30–34). Participants had prediabetes (impaired glucose tolerance [IGT]), and most were obese and sedentary. Some participants had a history of gestational diabetes or diabetes in their families. As these interventions are translated into routine clinical and public health practice, issues such as the population to target, methods to identify those who will benefit from prevention efforts, the best method of delivering prevention treatments, and the economic and health policy implications need to be resolved. Future efforts in developing and implementing standard measures for quality of care will need to include a number of dimensions for primary prevention of diabetes.


   Conclusion
Top
 Abstract
 Introduction
 Conclusion
References
 
The current diabetes pandemic threatens to be a rapidly expanding burden in the future for both developed and developing countries (2). By the year 2025 the number of persons with diabetes is expected to increase in developed countries by 41%, from 51 to 72 million, and by 170% in developing countries, from 84 to 228 million. Several interventions now exist that can vastly improve diabetes care and reduce needless human suffering. New interventions that prevent diabetes among those at high risk also now hold much promise and need to be implemented. Despite this promise, suboptimal diabetes care is common throughout the world, and considerable health benefit is needlessly foregone. Development and implementation of standard diabetes care quality measures will help track progress and guide improvement efforts. The ongoing diabetes epidemic is a worldwide problem that will benefit greatly from worldwide efforts to collaborate and improve the quality of diabetes care.


   References
Top
 Abstract
 Introduction
 Conclusion
 References
 

  1. Zimmet P, Alberti KGMM, Shaw J: Global and societal implications of the diabetes epidemic. Nature 414: 782–787, 2001[CrossRef][Medline]
  2. King H, Aubert RE, Herman WH: Global burden of diabetes, 1995-2025: Prevalence, numerical estimates, and projections. Diabetes Care 21: 1414–1431, 1998[Abstract]
  3. Klein R, Klein BEK, Moss SE: Visual impairment in diabetes. Ophthalmology 91: 1–9, 1984[Medline]
  4. Wetterhall SF, Olson DR, DeStefano F, Stevenson JM, Ford ES, German RR, Will JC, Newman JM, Sepe SJ, Vinicor F: Trends in diabetes and diabetic complications, 1980–1987. Diabetes Care 15: 960–967, 1992[Abstract]
  5. Geiss LS, Engelgau M, Frazier E, Tierney E: Diabetes Surveillance, 1997, Atlanta GA, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, 1997
  6. Diabetes Health Economics Study Group: The Economics of Diabetes and Diabetes Care, Edited by Gruber W, Lander T, Leese B, Songer T, Williams R, International Diabetes Federation, 1997, http://www.pitt.edu/tjs/diabecon.html
  7. American Diabetes Association: Economic consequences of diabetes mellitus in the U.S. in 1997. Diabetes Care 21: 296–309, 1998[Abstract]
  8. UK Prospective Diabetes Study Group: Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 352: 837–853, 1998[CrossRef][Medline]
  9. The UK Prospective Diabetes Study Group: Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes (UKPDS 38). BMJ 317: 703–713, 1998[Abstract/Free Full Text]
  10. Early Treatment Diabetic Retinopathy Study Research Group: Early photocoagulation for diabetic retinopathy:ETDRS 9. Ophthalmology 98 [Suppl 5]: 767–785, 1991
  11. Littzelman DK, Slemenda CW, Langefeld CD, Hays LM, Welch MA, Bild DE, Ford ES, Vinicor F: Reduction of lower extremity clinical abnormalities in patients with non-insulin-dependent diabetes mellitus: A randomized controlled trial. Ann Inter Med 119: 36–41, 1993[Abstract/Free Full Text]
  12. Pyorala K, Pedersen TR, Kjekshus J, Faergeman O, Olsson AG, Thorgeirsson G: Cholesterol lowering with simvastatin improves prognosis of diabetic patients with coronary heart disease. A subgroup analysis of the Scandinavian Simvastatin Survival Study (4S). Diabetes Care 20: 614–620, 1997[Abstract]
  13. ETDRS Investigators: Aspirin effects on mortality and morbidity in patients with diabetes mellitus. Early Treatment Diabetic Retinopathy Study Report 14. JAMA 268: 1292–1300, 1992[Abstract]
  14. Ravid M, Lang R, Rachmani R, Lishner M: Long-term renoprotective effects of angiotensin-converting enzyme inhibition in non-insulin-dependent diabetes mellitus: A 7-year follow-up study. Arch Intern Med 156: 286–289, 1996[Abstract]
  15. Heart Outcomes Prevention Evaluation (HOPE) Study Investigators: Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and MICRO-HOPE substudy. Lancet 355: 253–259, 2000[CrossRef][Medline]
  16. Nichol KL, Wuorenma J, Von Sternberg T: Benefits of influenza vaccination for low-intermediate- and high-risk senior citizens. Arch Intern Med 158: 1769–1776, 1998[Abstract/Free Full Text]
  17. Blonde L, Dey J, Testa MA, Gutherie RD: Defining and measuring quality of diabetes care. Primary Care 26: 841–855, 1999[Medline]
  18. Lohr KN, Schroeder SA: A strategy for quality assurance in Medicare. N Engl J Med 322: 707–712, 1990[Medline]
  19. Fleming BB, Greenfield S, Engelgau MM, Pogach LM, Clauser SB, Parrott MA: The Diabetes Quality Improvement Project. Moving science into health policy to gain an edge on the diabetes epidemic. Diabetes Care 24: 1815–1819, 2001[Free Full Text]
  20. Saaddine JB, Engelgau MM, Beckles GL, Gregg EW, Thompson TJ, Narayan KMV: A diabetes report care for the United States: Quality of care in the 1990. Ann Intern Med 136: 565–574, 2002[Abstract/Free Full Text]
  21. Lee WRW, Lim HS, Thai AC, Chew WLS, Emmanuel S, Goh LG, Lau HC, Lee HC, Soon PC, Tambyah JA, Tan YT, Jorgensen LN, Chua A, Yeo JP: A window on the current status of diabetes mellitus in Singapore - the Diabcare-Singapore 1998 study. Singapore Med J 42: 501507, 2001
  22. Raheja BS, Kapur A, Bhoraskar A, Sathe SR, Jorgensen LN, Moorthi SR, Pendsey S, Sahay BK: DiabCare Asia: India study: Diabetes care in India: Current status. J Assoc Physicians India 49: 717–722, 2001[Medline]
  23. Chuang LM, Tsai ST, Huang BY, Tai TY: The current state of diabetes management in Taiwan. Diabetes Res Clin Prac 54 [Suppl]1: S55–S65, 2001
  24. Narayan KMV, Gregg EW, Engelgau MM, Moore B, Thompson TJ, Williamson DF, Vinicor FV: Translation research for chronic disease: The case of diabetes. Diabetes Care 23: 1794–1798, 2000[Free Full Text]
  25. Peterson KA, Vinicor F: Strategies to improve diabetes care delivery. J Fam Prac 47 [Suppl]: S55–S62, 1998[Medline]
  26. Norris SL, Messina PJ, Caspersen CJ, Engelgau MM, Jack L, Riccio KM, Briss PA, Isham GJ, Glasgow RE, Garfield S, McCulloch D: Strategies for reducing morbidity and mortality from diabetes through health-care system interventions and diabetes self-management education in community settings. A report on recommendations of the task force on community preventive services. Mor Mort Wkly Rep 50 [RR-16]: 1–16, 2001
  27. Renders CM, Valk GD, Griffin SJ, Wagner EH, van Eijk JT, Assendelft WJ: Interventions to improve the management of diabetes in primary care, outpatient, and community settings. Diabetes Care 24: 1821–1833, 2001[Abstract/Free Full Text]
  28. Renders CM, Valk GD, Franse LV, Schellevis FG, van Eijk JT, van de Wal G: Long-term effectiveness of a quality improvement program for patients with type 2 diabetes in general practice. Diabetes Care 24: 1365–1370, 2001[Abstract/Free Full Text]
  29. Norris SL, Lau J, Smith SJ, Schmid CH, Engelgau MM: Self-management education for adults with type 2 diabetes. A meta-analysis of the effect on glycemic control. Diabetes Care 25: 1159–1171, 2002[Abstract/Free Full Text]
  30. Narayan KMV, Bowman BA, Engelgau MM: Prevention of type 2 diabetes. BMJ 323: 63–64, 2001[Free Full Text]
  31. Tuomilehto J, Knowler WC, Zimmet P: Primary prevention of non-insulin-dependent diabetes mellitus. Diabetes Metab Rev 8: 339–353, 1992[Medline]
  32. Pan X, Li G, Hu Y, Wang J, Yang W, An Z, Hu Z, Lin J, Xiao J, Cao H, Liu P, Jiang X, Jiang Y, Wang J, Zheng H, Zhang H, Bennett PH, Howard BV: Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance: the Da Qing IGT and Diabetes Study. Diabetes Care 20: 537–544, 1997[Abstract]
  33. Tuomilehto J, Lindstrom J, Eriksson JG, Valle TT, Hamalainein H, Ilanne-Parikka P, Keinanen-Kiukaanniemi S, Laakso M, Louheranta A, Rastas M, Salminen V,and Ussitupa M, for the Finnish Diabetes Prevention Study Group: Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med 344: 1343–1350, 2001[Abstract/Free Full Text]
  34. The Diabetes Prevention Program Research Group: The Diabetes Prevention Program. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. New Engl J Med 346: 393–403, 2002[Abstract/Free Full Text]



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