Winning the Battle
Declines in Rate of Complications Among People With Diabetes
Although diabetes (90–95% of which is type 2) remains a daunting public health problem, affecting 29.1 million individuals and costing $245 billion in the U.S.,[1] there have been impressive improvements in outcomes among people with diabetes in the country over the past two decades[2] (Fig. 1). Mortality rates among both men and women with diabetes in the U.S. have declined substantially between 1997 and 2006.[3] Furthermore, rates of several diabetes complications have also declined between 1990 and 2010, including the incidence of acute myocardial infarction by 67.8%, death from hyperglycemic crisis by 64.4%, stroke by 52.7%, amputation by 51.4%, and end-stage renal disease by 28.3%.[2] Such improvements are not limited to the U.S., as improvements in outcomes among people with diabetes have also been observed in other high-income countries.[4,5]
These improvements in diabetes complications are likely due to several factors; however, there are three that deserve special mention: investments in science, institutional orientation toward translation and implementation, and quality-of-care benchmarking efforts. First, investments in science leading to the development of new knowledge about the disease, better diagnostics, and a widening array of treatment options are all paying off. Namely, large clinical trials such as the Diabetes Control and Complications Trial (DCCT), the UK Prospective Diabetes Study (UKPDS), the Steno-2 study, and their successor mega-trials have helped to shape our understanding of diabetes management, treatment intensity and targets, and clinical practice. Second, there has been an increased emphasis on the implementation of proven interventions into clinical and public health practice and policy. Specifically, attention has been given to translational research to facilitate the implementation of proven interventions by the Centers for Disease Control and Prevention (CDC), the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), and the American Diabetes Association (ADA).[6–8] Large multicenter translational studies, such as the Translating Research Into Action for Diabetes (TRIAD), funded by the CDC, NIDDK, and the Department of Veterans Affairs, have generated valuable information around key factors to improve quality of care.[9] Factors at the level of the health systems (i.e., financing, electronic record systems), disease management strategies (i.e., care coordination, diabetes teams, physician–patient communication), physician reimbursement (i.e., incentivizing quality as opposed to volume of services), and the patient (i.e., reducing out-of-pocket expenses, patient education and empowerment) each positively impact quality of care.[10–14] Third, the measurement of quality of care, led by the national Diabetes Quality Improvement Project (DQIP), working through a coalition of influential private and public national organizations, and later to become the National Diabetes Quality Improvement Alliance (NDQIA), has helped to focus attention on implementation. The NDQIA develops, maintains, and promotes the use of an updated standardized measurement set (the NDQIA measures) for quality of diabetes care. Monitoring and reporting of quality of care among people with diabetes nationally by the CDC and NIDDK have focused attention on gaps and documented significant improvements in diabetes processes and intermediate outcomes.[15–17] For example, such documentation has revealed that control of vascular risk factors, HbA1c, blood pressure, and LDL cholesterol among people with diabetes have all improved in the period 1999–2000.[17]
Diabetes Care. 2016;39(5):653-663. © 2016 American Diabetes Association, Inc.
