Memorandum

JAMA Investigation of US Diabetes Care: 94% of Adults Diagnosed with Diabetes Linked to Diabetes Care, 64% Hit Target A1c in 2013-2016; No Improvement Since 2005 – August 21, 2019

Women 40% less likely, younger adults half as likely to hit A1c, blood pressure, cholesterol targets; Coverage is strongest predictor for getting diabetes care

Using NHANES survey data, researchers from Massachusetts General Hospital have found that the rate of adults with diabetes achieving A1c, blood pressure, and cholesterol targets has not improved significantly since 2005. These findings were just published in JAMA.

From 2013-2016, the study (n=634) found that 94% of adults diagnosed with diabetes were linked to diabetes care (defined as seeing a provider for diabetes in the past year, taking “diabetic pills,” taking insulin, or seeing a specialist in the past two years). In the same period, 64% met individualized A1c targets (ranging from 7%-8.5% based on patient age and presence of complications), 70% met blood pressure targets (less than 140/90 mm Hg), and just 57% met LDL-cholesterol targets (<100 mg/dL). Perhaps most importantly, the 2013-2016 numbers were no better than those from 2009-2012 (n=603) or 2005-2008 (n=505), and in the case of reaching A1c targets, may have actually gotten worse.

While it’s clear that there have been significant advances in diabetes drugs, technology, clinical guidelines, and models of care since 2005, this study is a troubling reminder that the most challenging advances to make in diabetes may be in access. In fact, having health insurance was a strong predictor of linkage to diabetes care and statistically improved likelihood of achieving A1c targets (see Table 1 below).

The MGH authors conclude that more frequent diabetes screenings, expanded access to care and health insurance, and interventions to improve patients’ medication adherence and to reduce therapeutic inertia are needed.

  • The study also found major disparities across age and sex. Compared to middle-age adults (45-64 years), younger adults were one-third as likely to be linked to diabetes care and females were significantly less likely than males to be linked to diabetes care. Unfortunately, it’s challenging from a behavioral perspective to get younger adults engaged in any chronic disease management, since the symptoms and negative health consequences of a condition like diabetes only appear over time. To this end, we support any incentive for earlier diagnosis and intervention, including $0 co-pays for primary care appointments and workplace wellness programs that reward healthy behavior.

  • In 2013, a similar NEJM article concluded that improvements in meeting A1c, blood pressure, and LDL cholesterol goals had been made from 1999-2002 to 2003-2006, but concluded that “we have reached a plateau” in the 2007-2010 period. Considering the major advances made in diabetes care since the early 2000s (e.g. GLP-1s, SGLT-2s, DPP-4s, CGMs), the lack of notable improvement in three major clinical outcomes in the US population at large represents an enormous disappointment. The sad reality is that sulfonylureas remain the most-prescribed second-line diabetes drug, simply because they are cheap. We can’t emphasize enough: access to advanced diabetes therapy is critical if we want to raise the number of patients meeting glycemic, blood pressure, and cholesterol goals. We would note also that technologies like CGM, automated insulin delivery, and digital coaching have greatly improved and become much more affordable since 2016, and certainly have the potential to help more people reach their targets.

Table 1. Adjusted odds ratios for achieving diabetes care targets from 2005-2016 (n=1742). Yellow highlight indicates statistical significance.

Characteristic

Linkage to Diabetes Care

A1c

Blood Pressure

Cholesterol

Period

 

 

 

 

2005-2008

1 [Reference]

1 [Reference]

1 [Reference]

1 [Reference]

2009-2012

0.71

0.72

1.42

0.87

2013-2016

0.62

0.63

0.97

0.73

Age group

 

 

 

 

18-44

0.34

0.79

1.40

0.75

45-64

1 [Reference]

1 [Reference]

1 [Reference]

1 [Reference]

≥65

0.85

3.75

0.37

1.70

Sex

 

 

 

 

Male

1 [Reference]

1 [Reference]

1 [Reference]

1 [Reference]

Female

0.53

1.25

1.04

0.66

Race/ethnicity

 

 

 

 

Non-Hispanic white

1 [Reference]

1 [Reference]

1 [Reference]

1 [Reference]

Non-Hispanic black

1.30

0.88

0.42

0.62

Hispanic

0.43

0.66

0.83

0.60

Health insurance

 

 

 

 

No

1 [Reference]

1 [Reference]

1 [Reference]

1 [Reference]

Yes

3.96

1.61

1.35

1.32

Close Concerns Questions

Q: Have rates of diabetes complications improved since 2005? As diabetes complications often take time to develop, will the apparent inability to improve achievement of targets from 2005-2016 stall rates of complications in the future?

Q: What changed in 2005-2007 to cause this plateau in percentage of people reaching A1c targets?

Q: How do the rising costs of insulin – and the subsequent rising proportion of patients who ration insulin – correlate with the results presented in this study?

Q: Can interventions designed to reduce therapeutic inertia help patients better achieve goals?

Q: Has there been increasing investment in diabetes prevention?

Q: What percentage of people have A1c targets over 7% and how has this changed?

Q: How much variability is there by ZIP code and can this be tracked? Variability by access to good nutrition?

Q: How much variability is there for those on insulin by type of insulin?

Q: Could achievement of time-in-range targets have changed since 2005, given that CGM is now standard of care for anyone on insulin, including type 1 and type 2?

Q: What role can pharmaceutical manufacturers play in expanding access to the most effective diabetes therapies available?

Q: What is the correlation between being on a high-deductible health plan (HDHP) and reaching A1c, blood pressure, and LDL goal? How do these numbers vary for patients on Medicare, Medicaid, employer-sponsored insurance, and within the ACA exchanges?

 

--by William Newton, Albert Cai, Martin Kurian, Payal Marathe, and Kelly Close