Diabetes
Diabetes is a serious disorder that is associated with increased morbidity and mortality, resulting in more than 200,000 deaths annually. It is the sixth-leading cause of death in the United States for all ages and has become one of the most prevalent chronic diseases. Approximately 6.3 percent the population or 18.2 million (13.0 million diagnosed and 5.2 undiagnosed) have the condition. About 90 to 95 percent of people in the United States with diabetes have Type II diabetes.
In 2002, health care costs associated with diabetes were estimated to be as high as $132 billion annually, of which approximately $92 billion (70 percent) were direct medical costs and $40 billion (30 percent) were indirect costs, including disability, work loss and premature mortality. For a person with diabetes, the average yearly health care cost is $13,243, compared with $2,560 for a person without the disease. Although 6 percent of the population has diabetes, 11 percent of the national health care expenditures is represented by diabetes costs with more than one of every 10 health care dollars and one of every four Medicare dollars being attributable to the disorder.
People with diabetes have a high rate of complications related to vascular end-organ disease such as kidney failure, blindness (retinopathy), stroke, arterial insufficiency of limbs, nerve damage and cardiovascular disease. Complications such as these are the main cause of the increased mortality rate. Adults with the condition have heart disease death rates and risk of stroke that are two to four times higher than adults without the disease.
Certain ethnic and racial groups are particularly vulnerable to the development of diabetes. In the National Health And Nutrition Examination Survey (NHANES) I Follow-Up Study, the age-adjusted incidence of diabetes over the course of the study was highest among African-Americans (15 percent among women and 11 percent among men). The incidence rates among Caucasian women and men were 7 percent. The proportion of African Americans with diabetes increases from less than 1 percent in people younger than 20 to as high as 32 percent in those who are 65 to 74 years old.
Compared with Caucasians, African Americans have higher rates of diabetic complications and greater disability due to them. For example, the prevalence of retinopathy among diabetic African Americans is 46 percent higher than among diabetic Caucasians. African Americans with diabetes are three to six times more likely to have kidney disease with over 4,000 new cases of end stage renal disease occurring each year in diabetic African Americans.
Health care professionals working with individuals diagnosed with diabetes can play a major role in improving disease outcomes by providing appropriate medical care and by monitoring and supporting healthy lifestyle choices. The effects of diabetes and its complications can be minimized or delayed by effective management of blood glucose, lipids, and blood pressure. Timely medical follow-up (including eye exams), diet and exercise, and smoking cessation, can all aid in controlling the disease and decreasing morbidity.
The Hemoglobin A1c (HbA1c) test provides an accurate measure of blood glucose control over the past few months. Elevated HbA1c levels are linked to the development of end organ damage, including retinopathy. A reduction of even 1 percent in HbA1c has been shown to reduce the risks of developing microvascular diabetic complications (eye, kidney and nerve diseases) by 40 percent.1
Services to control diabetes and prevent complications are underutilized by the elderly population, particularly by elderly African Americans. A variety of factors contribute to the underutilization of preventive services including lack of awareness of the risk factors for diabetic complications and perceived lack of efficacy of annual or biennial screenings (HbA1c, lipid profiles, retinal eye exams) to prevent complications from diabetes. The African American elderly may face increased challenges in accessing appropriate medical care because they may lack a primary care provider to appropriately oversee diabetes management.
Research indicates that minority populations in urban environments are less likely to have a regular source of care, have higher rates of postponed care and have fewer checkups and other preventive services. They are more likely to be hospitalized for diabetes and other conditions. African Americans are generally in poorer health than their Caucasian counterparts, and are also less likely to seek out healthcare until they are in more advanced stages of disease. African Americans with diabetes are less likely to have HbA1c tests.12
The burden of appropriate and timely care does not fall entirely on the persons with diabetes. Large numbers of physicians do not administer or fail to refer patients for appropriate diabetic screenings. Underutilization of appropriate diabetes screening by healthcare providers may include lack of awareness regarding timetables for appropriate testing, lack of coordination of care with other necessary providers, lack of incentives for performing the services, and difficulty in identifying high risk patients.13,14 Physicians may be unaware of which preventive services are covered under Medicare and the frequency for which they are covered.
The Centers for Medicare & Medicaid Services (CMS) has established three national performance measures for diabetes: biennial retinal eye examinations, biennial lipid testing, and annual HbA1c tests. They are based on performance measures from the Diabetes Quality Improvement Project (DQIP) and were developed by a panel of experts on diabetes, including the American Diabetes Association, the National Committee for Quality Assurance, the Foundation for Accountability on Health Care, and CMS. In addition, Jencks and associates15 have demonstrated that nationally (50 states plus the District of Columbia and Puerto Rico) 30 percent, 26 percent, and 22 percent of Medicare Fee-for-Service (FFS) beneficiaries are not receiving biennial retinal eye exams, biennial lipid profiles, and annual HbA1c tests, respectively--all of which are essential for an appropriate level of care for diabetes management and prevention of disease complications.
For more than two decades, CMS has been working with Quality Improvement Organizations (QIOs) throughout the United States to review and improve the quality of healthcare for Medicare beneficiaries. These priorities include protecting and informing patients, supporting hospital reporting on quality, conducting studies to advance quality of care, and monitoring hospital payment. CMS has augmented these quality improvement activities with major national initiatives to widely disseminate select quality measures for Medicare-certified nursing homes, home health agencies, hospitals and physician offices.
PRONJ, The Healthcare Quality Improvement Organization of New Jersey Inc., is a federally funded and designated QIO for New Jersey and is implementing CMS's national initiatives in the state, including the diabetes national project and reducing healthcare disparities for underserved and rural beneficiaries project.
This article originally appeared in the June 2004 issue of HME Business.