America is Losing Ground on Dire Diabetes Complications: Let's Turn It Around
Jun 5, 2019
Epidemiologic and statistical experts from the diabetes division of the Center for Disease Control and Prevention (CDC) wrote an important article on the surge of diabetes complications between 2010 and 2015, largely due to lifestyle modifiable factors in the May 21, 2019 issue of JAMA. The article is a dire warning about young (age 18-44) and middle-aged (age 45-64) adults who disproportionately represented the resurgence in diabetes complications.
While work needs to continue to better understand the demographics and behaviors of subsets in these age groups, the message is that we have to do more to prevent diabetes and reach diabetic individuals who are on a collision course with serious maladies.
We are able to make a marked difference for our clients’ populations because we can use Advanced Plan for Health’s (APH) Poindexter analytics to find these individuals, use motivational interviewing to collaboratively set goals with them, and measure progress (or the lack thereof) in helping them to be more compliant with their physician’s treatment plan and able to modify their lifestyle.
APH is dedicated to reversing this untoward trend – and has done so for many clients – but there is more work to do.
Positive progress, then a resurgence in diabetes-related complications
JAMA published a summary of diabetes-related trends from the early 1990s through 2015. A summary of that follows. In the early 1990s, diabetic individuals had complications that shortened their lives and had more serious systemic problems than individuals without diabetes in the following areas:
Lower extremity amputation (LEA)
Acute myocardial infarction
Higher risk of cardiac events (which caused the most deaths)
Then, from 1990 – 2010, a collaborative, multi-focal full-court press in the management of risk factors, education, support, integrated care and improvements in self-care resulted in a reduction of complications that ranged from 28% to 68% in diabetic individuals.
Unexpectedly, in the five years following this positive progress, experts identified increased diabetic complications. Between 2009 and 2015, emergency department visits skyrocketed from 16.2 to 19.4 visits per 1,000 diabetics. Hospitalizations soared from 15.3 to 26.6 admissions per 1,000 diabetics. These dire complications from diabetic complications caused deaths to rise from 15.7 to 24.2 per 1,000 diabetics. Likewise, the progress in reducing end stage renal disease (ESRD), AMI and strokes was status quo in 2010.
It is troubling to note that national statistics revealed that young (18-44 years) and middle- aged (45 to 64 years) adults were the groups most heavily impacted by the hyperglycemic crisis, AMI and strokes with increases in each group of more than 25% in just 5 years. Risk reductions in older adults simply plateaued.
More worrisome is that improvements in AMI and strokes were at a standstill for the general population and the incidence of cardiovascular disease mortality in younger adults actually increased in most counties in the USA.
What caused this setback? Trends in coding practices, the difficulty of getting adequate diagnoses and procedure codes from claims data to do statistical reporting, and various provider incentives and trends for performing, or not performing, certain procedures were discussed as undocumented factors.
The CDC experts were able to identify four modifiable trends from these data:
First, they identified a changing profile for the population of new diabetes diagnoses. New diabetics in the millennial generation, born between 1980 and 2000, seem to have poor lifestyle habits with higher BMIs, higher levels of tobacco use, as well as poor lipid and blood pressure management in comparison to older adults. In middle aged and especially older adults, the combination of increased longevity coupled with the increased incidence of diabetes means that individuals have diabetes for a longer portion of their lives than diabetics did in the past. Because they have more time with diabetes, individuals may be experiencing an increased risk of long-term diabetes-related complications.
Second, diabetes preventive care was at a standstill in the 2011-2014 timeframe – particularly in young adults. When comparing 1990-2010 with 2011-2014, individual hemoglobin A1c levels increased by 6 percentage points in the total population, but by 10 percentage points in young adults. According to the article authors, some of this increase may be due to providers personalizing diabetic management goals with an emphasis on preventing hypoglycemia. The unintended consequence could be relaxed attitudes toward glycemic control in younger adults, resulting in suboptimal glycemic control.
Third, broad policies have changed the health insurance industry since 2010 – bringing higher insured levels, but higher consumer responsibility for costs in High Deductible Health Plans. Higher consumer out of pocket costs may be driving less preventive care and the downstream impact of complications in areas such as diabetes.
Fourth, vulnerable populations may have been adversely affected by social and economic trends. The recession that began in 2008-2009 has been blamed for increasing the death rate of middle age adults. At first it was thought to be the higher rate of opioid overdoses, suicide and social disadvantages driving this statistic. Other studies pointed to the additional factor of increased mortality rate due to metabolic causes related to economic hard times, job loss, and financial hardships that seemed to have hit the communities hardest which had the highest rate of diabetics.
A Perplexing Twist in the Current Trend
According to a recently released article from STAT - currently, the number of new diabetes diagnoses among adults in the U.S. are declining despite climbing obesity rates.
New federal data from the journal BMJ Open Diabetes Research & Care released in May of 2019 shows that the number of new diabetes diagnoses fell from 1.7 million in 2009 to 1.3 million in 2017. This trend is not cause for celebration though as the cause of the reduction is not yet identified according to the CDC. Though there are possibilities that changes in testing and efforts to change people’s behavior prior to them becoming diabetic are contributing factors.
Doctors have increasingly begun to utilize a newer blood test (hemoglobin A1C test) to diagnose diabetes as recommended by the American Diabetes Association starting in 2010. Since this is an easier test to do, the expectation was that it would lead to more diabetes diagnoses. But, the concern is that it may be missing a large percentage of early diagnoses where people are not showing symptoms and are not tested.
Another potential contributing factor is the increased diagnosis of “prediabetes” – where blood sugar levels are of concern, but not yet at the level of diabetes. This diagnosis has triggered interventions by doctors and other clinical professionals earlier. Resulting in concerted efforts by doctors, employers, insurers and others to provide support to improve these individuals’ health through diet and exercise to avoid a downstream diabetes diagnosis.
To assist in identifying members with pre-diabetes, apart from a formal diagnosis of prediabetes or Metabolic Syndrome, APH has developed functionality in Poindexter that automatically identifies the number of indicators present for these individuals when biometrics are in the system.
What to do to Turn Around These Shifting Trends
Despite all of this research related to trends shifting, the American Diabetes Association cites that in 2015, 30.3 million Americans, or 9.4% of the population, had diabetes. Of the 30.3 million adults with diabetes, 23.1 million were diagnosed, and 7.2 million were undiagnosed, and 1.5 million Americans are diagnosed with diabetes every year.
How do we work together to turn around these trends? One strong target is to focus on the 84.1 million Americans age 18 and older who have prediabetes in addition to getting support to those who have already been diagnosed.
We believe that the next frontier is to capture factors in the data that drive individual behaviors with regard to disease occurrence, progression, compliance with best practices and self-care. Quantifying these factors will enhance the ability to identify those at-risk so we may continue to offer early intervention and prevention.
APH and our clients have the Poindexter analytics platform that we utilize today to find vulnerable individuals, assess them, set a baseline and then measure the effectiveness of customized collaborative, ongoing interventions for those with chronic health conditions. The APH approach emphasizes the need to find effective strategies that improve bottom line financial and clinical outcomes, and the lives of those affected by diabetes and other serious chronic health conditions.
APH is also proactive in identifying the “next wave” of individuals where active intervention can help to change their lifestyle behaviors and guide them to better manage ongoing chronic health conditions to avoid serious health consequences – including avoidable Plan costs. APH delivers Emergency Department and Inpatient Admission member targeting support to identify those with avoidable visits and preventable diagnoses where early intervention can make a difference. We also include a simple cost savings tool to capture financial results from action – both clinical and at the Plan or vendor level.
If you’d like to learn more about our analytics and our proven analytics-powered clinical programs, contact us here and we will setup some time with you.
We have also assembled a task force of experts to determine how to gain more insight from various Social Determinants of Health to drive even more informed analytics output and clinical intervention. We will share more on our progress in this area over time.