Diabetes Care: Closing the Gap between Standards and Practice
Hitchens, Kathy, Drug Topics
Landmark studies completed during the 1990s proved that diabetes complications could be prevented by proper medical care. These findings led to the establishment of standards of medical care for individuals with diabetes. But the first report cardbased on surveys (Third U.S. National Health and Nutrition Examination Survey and the Behavioral Risk Factors Surveillance System) from 1988 and 1995-"found there is a huge gap between the care people with diabetes are getting and the recommended care," said Jinan Saaddine, M.D., division of diabetes translation, National Center for Chronic Disease Control and Health Promotion, Centers for Disease Control & Prevention (see table below).
The study by Saaddine and colleagues found care varied consistently across groups by two factors, health insurance and use of insulin. Not having health insurance was associated with poorer status for several indicators. The use of insulin was associated with better preventive care, perhaps because insulin use is linked to diabetes severity, and providers are more likely to follow recommendations when managing patients with severe disease, according to experts.
Because of its timing (relative to studies documenting the need for "tight control"), results from the period evaluated by Saaddine and colleagues (Annals of Internal Medicine, April 16, 2002) are regarded as a benchmark by many diabetes experts.
But Saaddine noted that the studies showed "we have lots to do." Clinical trials have shown that better adherence to standards would reduce complications. Decreasing hemoglobin Alc (HbAlc) levels by one percentage point would reduce microvascular complications by 25% to 30%. Reducing blood pressure by 10 mm Hg would decrease macrovascular and microvascular complications and mortality rates by 25% to 55% and the risk of death by 43%.
Saaddine remarked that despite what we know about preventing complications, diabetes remains the leading cause of blindness, and of nontraumatic lower limb amputation. "That shouldn't be, because all the trials have proven we can prevent this from happening," she said. To close the gap between the standard of care and current medical practice, "we need to work hard on three very important levels-the patient level, the provider level, and the healthcare system," she added.
Leonard Egede, M.D., Medical University of South Carolina, began studying the attitudes of healthcare providers about diabetes after observing that "there seemed to be a disconnect between the gravity of the diabetes problem and the response of a lot of residents to it."
A recent study, authored by Egede and Yvonne Mitchell, Ph.D., concluded that internists harbor negative attitudes about Type 2 diabetes. As assessed by the standardized test Diabetes Attitude Scale-3, participants in the study scored lower than the standardized mean on the need for special training in teaching, counseling, and behavior change techniques; on understanding the seriousness of Type 2 diabetes and the value attached to tight diabetes control; and on the value attached to patient autonomy regarding daily self-care of their diabetes.
Egede commented, "I don't think it's lack of interest; I think it is several problems." He explained that during training, diabetes is just one of multiple problems residents encounter, so many may not know the guidelines and what needs to be done. "The bigger problem is the time and resources required to deal with the problem in primary care," he said. His research has shown that residents and physicians perceive diabetes as very difficult to treat.
"It takes a lot of time, it takes a lot of resources, and many physicians don't think they have the time nor the resources to provide the quality of care that is required," said Egede. He also noted, "Of course, the third problem is the issue of reimbursement." The 15 to 30 minutes most physicians have available to provide patient care is inadequate to educate diabetes patients about self-management. …