The recent Occupy Wall Street movement brought significant attention to “the other 99%”-- the vast majority of Americans who, as protestors argued, had their voices muted while being victimized by special interests. Veracity of this specific claim aside, Ali, et al., in the April 25, 2013, edition of the New England Journal of Medicine sheds light on a true at-risk majority, the 85.7% of diabetics who do not meet the recommended targets for glycemic control, blood pressure, LDL cholesterol level, and tobacco use.(1) Hopefully, through changing care processes, this majority can be better served, and benefit from quality of life improvements that we know are achievable.
The 22M Americans diagnosed with diabetes(2) spend a total of $301B annually on medical care, of which 57% is directly attributable the disease.(3) This incremental cost represents 1 of every 8 dollars spent on medical care in the US. Numerous studies, including Sharaschamdra et. al., Oglesby et. al., and Menzin et. al., quantify the large savings potential of tighter diabetes control.(4,5,6) Given the dollars involved, we need to do better having merely 14.3% of the indicated population at target control levels. While up from a mere 4.6% of diabetics meeting this standard between 1999 and 2002, the pace of improvement must accelerate.(7) This is not a clinical or public policy opinion— but a fiscal reality.
We have made progress, and we have the will and know-how to do better. As Ali and his colleagues indicated, compliance with glycemic control, blood pressure, and lipid levels all individually improved, 7.9, 11.7, and 20.8 percentage points, respectively, from 1999 to 2010. Other measures, including ACE or ARB usage, daily blood glucose monitoring, and influenza vaccination rates, all saw noticeable increases. At the same time, annual lipid measurements, eye exams, and foot exams exceeded 60% over the study period. Not bad, but there is more to do, and we know some tools to do it with. Specifically, as the NEJM authors contend, “increased integration of care management models into systems of care.”
The 2012 Health Information Network’s Healthcare Benchmarks: Case Management found that 29% of surveyed healthcare professionals said Diabetes is the diagnosis where case management is most effective. Diabetes was followed by a distant “Other”, Behavioral Health, and CHF at 17%, 11%, and 11%, respectively.(8) This interest is already translating to action. The 2013 Staff Salary Survey by Physicians Practice Magazine found more than 1 in 5 physician practices now employ care coordinators.(9) This type of ancillary care gives provider groups new weapons to attack the disease.
Armed with new care coordination resources, we hope to see continued improvement in outcome measures for the diabetic population, driven in part from:
• Improved diabetic education, nutritional counseling, and smoking cessation programs
• Greater use of social work & related services, addressing socio-economic barriers to care
• More aggressive outreach to at-risk patients on the part of providers
• Improvement in monitoring by patients and providers of target metrics, and,
• Better inter-provider coordination and collaboration.
While the Occupy Wall Streeters appeared to have felt alone in their struggle, diabetics have allies— their healthcare providers. Armed with new tools, and new financial incentives, patients and provider alike are more ready than ever to fight. 14.3% down, 85.7% to go.
1. Ali MK. Achievement of Goals in U.S. Diabetes Care, 1999-2010. N Engl J Med 2013; 368:1613-1624
2. American Diabetes Association WWW Site: http://www.diabetes.org/advocate/resources/cost-of-diabetes.html, accessed on May 2, 2013.
3. American Diabetes Assocation. Economic Costs of Diabetes in the U.S. in 2012. Diabetes Care 2013; 36:1033–1046
4. Sharashchandra S. Relationship of Glycemic Control to Total Diabetes-Related Costs for Managed Care Health Plan Members With Type 2 Diabetes. J Manag Care Pharm. 2005;11(7):559-64.
5. Oglesby AK et. al. The association between diabetes related medical costs and glycemic control: a retrospective analysis. Cost Eff Resour Alloc. 2006 Jan 16;4:1.
6. Menzin J et. al. Relationship Between Glycemic Control and Diabetes-Related Hospital Costs in Patients with Type 1 or Type 2 Diabetes Mellitus. J Manag Care Pharm. 2010;16(4):264-75
7. Ali MK. N Engl J Med 2013; 368:1613-1624
8. Health Intelligence Network. 2012 Healthcare Benchmarks – Case Management. May 2012.
9. Boulton G. 1 in 5 physician practices now employ care coordinators, survey shows. Journal Sentinel, Apr 30 2013.