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Richard M. Bergenstal, MD
Chief Medical Editor
We can provide cost-effective care for people with diabetes while improving their quality of life. Patients, doctors, diabetes educators, employers and health plan providers should work together to reach scientifically-defined and nationally-accepted goals.
Diabetes is the leading cause of kidney failure and amputations, as well as blindness in working-age adults. It more than doubles the risk of heart attack and stroke. Over 18 million people with diabetes consume $132 billion in health care per year in the United States – the majority is spent on treating complications. These complications can be avoided with early treatment. Diabetes is a multifactorial disease requiring control of glucose, blood pressure, lipids, weight and other clinical variables. It is essential to develop a plan to address all of these factors – we must not become overwhelmed and thereby do nothing.
Many organizations have found that a well-defined plan that establishes and maintains a blood glucose level within a target range is a good place to start. Clinics may be able to handle the logistics and commitment needed to review, accept and implement guidelines for establishing effective diabetes education, glucose monitoring, HbA1c testing and utilization of proven glycemic control clinical decision-making algorithms. When practitioners, educators and administrators in an organization see HbA1c levels improve, confidence, enthusiasm and a spirit of cooperation develop. They can then begin work on similar tools and implementation strategies to improve blood pressure and lipid control, as well as establish consistent approaches to screen and manage micro- and macrovascular complications.
Studies have shown that people with diabetes who reach an HbA1c <7% lower their risk of amputation, blindness and kidney failure. Despite monitoring diabetes control and the therapies proven to control the disease, more than 60% of patients have an HbA1c >7%, according to a recent National Health and Nutrition Examination Survey. We can and must help people avoid disabling and costly complications.
Recently, an important step was taken to address uncontrolled diabetes. In April 2004, the National Committee for Quality Assurance (NCQA), which sets performance standards to gauge the quality of managed care plans and the quality of care delivered in all clinics across the United States, recommended that HbA1c <7% should be the standard. As part of its diabetes physician recognition program, NCQA now recognizes those doctors who help their patients get HbA1c <7% and achieve other quality diabetes measures including good blood pressure and cholesterol levels. I applaud NCQA for making this move to set the HbA1c performance measure at a level that will benefit the most people with diabetes. But we can’t stop there.
It is time to give individuals with diabetes an incentive to get their HbA1c <7%. Donnell Etzwiler, MD, founder of the International Diabetes Center, pointed out the importance of patient-centered team care since people with diabetes provide 99% of their own care.
Patients should look for NCQA diabetes recognized physicians or health care institutions whose majority of patients have an HbA1c <7%, and should engage their health care team to help them find the best treatment plan to reach that goal. For most adults with diabetes, a combination of comprehensive diabetes education and support, regular glucose and HbA1c monitoring, lifestyle changes, oral diabetes medication and insulin are necessary to achieve and maintain HbA1c <7%.
Employers and health insurance providers should educate employees and members about the importance of an HbA1c <7% and direct them to a NCQA-recognized institution. They also should consider incentives for those with good diabetes control. Employers will see the dividend in more productive, healthier and less costly employees.
Society will benefit if the 18 million people with diabetes are able to maintain an HbA1c <7%, blood pressure <130/80 mm Hg and LDL cholesterol <100 mg/dL. We have the tools. We now need broad community awareness leading to determined people with diabetes, health care providers, insurance plans and employers united in an effort to avert this danger of uncontrolled diabetes.
