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Cited by 252Diabetes Management and EducationDiabetes Management and ResearchDiabetes, Cardiovascular Risks, and Lipoproteins

Evaluation of the Cascade of Diabetes Care in the United States, 2005-2016

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Kazemian, Pooyan, Shebl, Fatma M., McCann, Nicole, Walensky, Rochelle P., Wexler, Deborah J.·2019·JAMA Internal Medicine
DOI 10.1001/jamainternmed.2019.2396PMC PMC6692836
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Abstract

IMPORTANCE: Treatment advances in diabetes can meaningfully improve outcomes only if they effectively reach the populations at risk. OBJECTIVES: To evaluate whether the cascade of US diabetes care, defined as diabetes diagnosis, linkage to care, and achievement of individual and combined treatment targets, improved from 2005 to 2016 and to investigate potential disparities in US diabetes care. DESIGN, SETTING, AND PARTICIPANTS: Nationally representative, serial cross-sectional studies included in the 2005-2016 National Health and Nutrition Examination Survey were evaluated. Data on nonpregnant US adults (age ≥18 years) with diabetes who had reported fasting for 9 or more hours (n = 1742 diagnosed and 746 undiagnosed) were included. Data analysis was performed from August 1, 2018, to May 10, 2019. EXPOSURES: Time period (2005-2008, 2009-2012, and 2013-2016), age, sex, race/ethnicity, health insurance, and educational level incorporated into logistic regression models predicting odds of target achievement. MAIN OUTCOMES AND MEASURES: Proportion of participants overall and stratified by age, sex, and race/ethnicity who were linked to diabetes care and met glycemic (hemoglobin A1c <7.0%-8.5%, depending on age and complications), blood pressure (<140/90 mm Hg), cholesterol level (low-density lipoprotein cholesterol <100 mg/dL), and smoking abstinence targets and a composite of all targets. RESULTS: In 2013-2016, of 1742 US adults with diagnosed diabetes, 94% (95% CI, 92%-96%) were linked to diabetes care; 64% (95% CI, 58%-69%) met hemoglobin A1c level, 70% (95% CI, 64%-75%) met blood pressure level, and 57% (95% CI, 51%-62%) met cholesterol level targets; 85% were nonsmokers (95% CI, 82%-88%); and 23% (95% CI, 17%-29%) achieved the composite goal. Results were similar in 2005-2008 (composite 23%) and in 2009-2012 (composite 25%). There was no significant improvement in diagnosis or target achievement during the study period. Compared with middle-aged adults (45-64 years) with diagnosed diabetes, older patients (≥65 years) had higher odds (adjusted odds ratio [aOR], 1.70; 95% CI, 1.17-2.48) and younger adults (18-44 years) had lower odds (aOR, 0.53; 95% CI, 0.29-0.97) of meeting the composite target. Women had lower odds of achieving the composite target than men (aOR, 0.60; 95% CI, 0.45-0.80). Non-Hispanic black individuals vs non-Hispanic white individuals had lower odds of achieving the composite target (aOR, 0.57; 95% CI, 0.39-0.83). Having health insurance was the strongest predictor of linkage to diabetes care (aOR, 3.96; 95% CI, 2.34-6.69). CONCLUSIONS AND RELEVANCE: It appears that the diabetes care cascade in the United States has not significantly improved between 2005 and 2016. This study's findings suggest that gaps in diabetes care that were present in 2005, particularly among younger adults (18-44 years), women, and nonwhite individuals, persist.

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  • Cardiovascular risk factors are predicted to increase and only a minority of people with type 2 diabetes achieve recommended risk factor goals and are treated with guideline-recommended therapy.

    “Despite these encouraging opportunities to reduce morbidity and mortality, cardiovascular risk factors are predicted to increase and only a minority of people with type 2 diabetes achieve recommended risk factor goals and are treated with guideline-recommended therapy (7)(8)(9).”

    From 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes—2025 (2025) · cites this paper as [8]

    The Results and Discussion report that only 23% of US adults with diagnosed diabetes met the composite risk-factor goal in 2013–2016. The paper did not distinguish type 1 from type 2 diabetes, did not predict that cardiovascular risk factors would increase, and did not establish that only a minority received guideline-recommended therapy; its Discussion reports statin use in six in ten adults with diagnosed diabetes. Page numbers are unavailable in our copy. (LLM, conf=0.87)

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  • Only a minority of people with type 2 diabetes achieve recommended risk factor goals and are treated with guideline-recommended therapy.

    “only a minority of people with type 2 diabetes achieve recommended risk factor goals and are treated with guideline-recommended therapy (7–9).”

    From 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes—2026 (2026) · cites this paper as [8]

    The Results and Discussion (pages not provided) report that only 23% of US adults with diagnosed diabetes met the combined glycemic, blood-pressure, cholesterol, and nonsmoking goal. The paper does not establish that only a minority received guideline-recommended therapy: it reports that six in ten took a statin, but does not measure receipt of all recommended therapies. Its population is adults with diagnosed diabetes, not specifically type 2 diabetes. (LLM, conf=0.85)

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Authors
Kazemian, P., Shebl, F. M., McCann, N., Walensky, R. P., & Wexler, D. J.
Affiliations
  • Harvard University (US)
  • Massachusetts General Hospital (US)
Corresponding author
Kazemian, Pooyan
ORCID
Venue
JAMA Internal Medicine
Publisher
American Medical Association (AMA)
Published
2019-10-01
Volume
179
Issue
10
Pages
1376
ISSN
2168-6106 (ISSN-L)
DOI
10.1001/jamainternmed.2019.2396
PMC
PMC6692836
OpenAlex
W2968803386
Cited by
252
References
4
Citations by year
2026: 16 · 2025: 27 · 2024: 41 · 2023: 43 · 2022: 32 · 2021: 45 · 2020: 40 · 2019: 8
FWCI
25.35
Type
journal article
Language
en
Open access
Locations
  • JAMA Internal Medicine (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
Funders
National Institute of Diabetes and Digestive and Kidney Diseases (P30DK057521)
Topics
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Education
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes, Cardiovascular Risks, and Lipoproteins
Keywords
diabetes diagnosis, linkage to care, glycemic control, HbA1c, blood pressure control, LDL cholesterol, smoking abstinence, treatment goals, health disparities, racial and ethnic disparities, sex disparities, health insurance, educational attainment, undiagnosed diabetes, NHANES

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