and economic burden of diabetes, and improve the diabetes mellitus could potentially overwhelm existing health care systems. …
Midcourse Review
Diabetes
Co-Lead Agencies:
CentersforDiseaseControlandPrevention NationalInstitutesofHealth
5
Contents
Goal 53 Introduction 53 ModificationstoObjectivesandSubobjectives 54 ProgressTowardHealthyPeople2010Targets 54 ProgressTowardEliminationofHealthDisparities 55 OpportunitiesandChallenges 56 EmergingIssues 57 ProgressQuotientChart 59 DisparitiesTable 511 ObjectivesandSubobjectives 513 References
521 RelatedObjectivesFromOtherFocusAreas 523
Goal: Through prevention programs, reduce the disease and economic burden of diabetes, and improve the quality of life for all persons who have or are at risk for diabetes
Introduction
Diabetes mellitus continues to increase in both new and total cases, not only in the United States but throughout the world1, 2 Because of the increase in the number of persons with diabetes and the earlier onset of both type 1 and type 2 diabetes in many populations, concern is growing about the possibility of substantial increases in diabetes-related complications3 The increases in the number of persons with diabetes mellitus could potentially overwhelm existing health care systems Accordingly, the translation of emerging diabetes management research results into clinical practice needs to be expedited This strategy must be complemented by a greater emphasis on primary prevention of diabetes Opportunities to reduce the health and economic burden of diabetes during the course of the disease are primarily located at four transition points The first transition point is
primary prevention, which, when successful, stops the development of diabetes Screening/early diagnosis, when a patient moves from unrecognized to recognized diabetes, is the second transition point Access to care presents the third transition point when the receipt of diabetes-specific care commences Finally, improved quality of care moves from inadequate care to the standard of care Progress has been mixed for these four transition points in recent years Greater progress in each of these four transition points will be one of the most effective methods for ensuring further improvement in quality of life and elimination of disparities Quality of care, the fourth transition point, is improving4, 5 Because fewer people in the United States possess health insurance,6, 7 access to care for persons with diabetes mellitus is worsening8, 9 The second transition point, early diagnosis, is being supported by greater knowledge and efforts such as the Diabetes Detection Initiative,10 which combines public health strategies with health marketing and health communication techniques to improve risk assessment11 Finally, important scientific and economic evidence supports the critical nature of
primary prevention, the first transition point12, 13 Preventive behaviors–among persons with diabetes mellitus and their health providers–are increasing The degree to which preventive behaviors and both intermediate- and long-term outcomes have improved varies by objective14 Despite advances in care, several issues regarding continued progress must be addressed First, the majority of progress may have occurred with early adopters–that segment of a population that includes opinion leaders and experimenters who are critical to the spread of innovation Subsequent positive movement may require new strategies15
Unless otherwise noted, data referenced in this focus area come from Healthy People 2010 and can be located at http://wondercdcgov/data2010 See the section on DATA2010 in the Technical Appendix for more information
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Modifications to Objectives and Subobjectives
The following discussion highlights the modifications, including changes, additions, and deletions, to this focus areas objectives and subobjectives as a result of the midcourse review As stated in Healthy People 2010: Most developmental objectives have a potential data source with a reasonable
expectation of data points by the year 2004 to facilitate setting 2010 targets in the mid-decade review Developmental objectives with no baseline at the midcourse will be dropped Accordingly, at the midcourse review some developmental objectives and subobjectives were deleted because they lacked a data source However, the US Department of Health and Human Services HHS and the agencies that serve as the leads for the Healthy People 2010 initiative will consider ways to ensure these public health issues retain prominence despite their current lack of data Two objectives–decrease the proportion of women with gestational diabetes 5-8 and reduce the frequency of foot ulcers in persons with diabetes 5-9–were deleted from Healthy People 2010 due to the lack of an adequate, nationally representative data source The developmental objective for annual urinary microalbumin measurements among adults with diabetes 5-11 became measurable The objective was changed to track adults in keeping with the data collected by the new data source, the US Renal Data System developed and maintained by the National Institutes of Health
Progress Toward Healthy People 2010 Targets
The following discussion
highlights objectives that met or exceeded their 2010 targets; moved toward the targets, demonstrated no change, or moved away from the targets; and those that lacked data to assess progress Progress is illustrated in the Progress Quotient bar chart see Figure 5-1, which displays the percent of targeted change achieved for objectives and subobjectives with sufficient data to assess progress All but 1 of the 15 objectives remaining at the time of the midcourse review were measurable Three objectives met or exceeded the targets, six moved toward targets, four moved away from targets, and one showed no movement Objectives that met or exceeded their targets Three objectives exceeded their targets: diabetesrelated deaths among persons with diabetes 5-6, cardiovascular deaths in persons with diabetes 5-7, and annual urinary microalbumin measurements in persons aged 65 years and older with diabetes 5-11 Regarding the objectives for diabetes-related deaths and diabetes-related cardiovascular deaths, progress reflected the increasing attention now paid to cardiovascular risk factors, including blood lipid levels, high blood pressure, aspirin use, and heart attack treatments among those with
diabetes A collaboration between the American Cancer Society, American Heart Association, and American Diabetes Association was initiated in June 2004 The collaboration creates a national commitment to the prevention and early detection of cancer, cardiovascular disease, and diabetes and reflects the increased emphasis on prevention of these diseases16
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Objectives that moved toward their targets Six objectives moved toward their targets: diabetes education for persons aged 18 years and older 5-1, diagnosis of diabetes in persons aged 20 years and older 5-4, lower extremity amputations for persons with diabetes 5-10, hemoglobin A1c testing for persons aged 18 years and older with diabetes 5-12, annual dilated eye exams 5-13, and daily selfblood-glucose-monitoring 5-17 Several of these objectives fell under the transitional point of improved quality of care Individual and collective efforts of the public, private, academic, and professional communities contributed to this progress Along with academic and industry developments, the National Diabetes Quality Improvement Alliance Alliance, founded in 1997 as the Diabetes Quality Improvement
Project, worked toward influencing change The Alliance established a comprehensive set of national measures for assessing the quality of diabetes care, which have been incorporated into the Health Plan Employer Data and Information Set, the American Diabetes Association Provider Recognition Program, the American Medical Association Diabetes Measures Group, and the US Department of Veteran Affairs performance monitoring program Other programs working to improve the quality of diabetes care are longstanding and include the National Diabetes Education Program NDEP, the National High Blood Pressure Education Program, and the National Cholesterol Education Program17 Objectives that demonstrated no change Annual foot examinations in persons aged 18 years and older with diabetes 5-14 neither moved toward its target nor regressed from it Objectives that moved away from their targets Four objectives moved away from their targets: new cases of diabetes in persons aged 18 to 84 years 5-2, overall cases of diagnosed diabetes 5-3, diabetes-related deaths 5-5, and annual dental exams for people aged 2 years and older with diabetes 5-15 For new and overall cases of diabetes 5-2 and 5-3, the
movement away from the targets was a reflection of improved disease identification and diagnosis by health care providers, demographic changes,1 and greater obesity18 This trend will continue unless primary prevention programs can be widely implemented and companion efforts to improve care are sustained for persons already affected Factors associated with the decrease in yearly dental examinations 5-15 are not clear NDEP has specifically targeted dental care and dental professionals for better diabetes management19 Objectives that could not be assessed Tracking data were not available to measure progress for aspirin therapy in persons with diabetes 5-16 Additional data to assess the trend are anticipated by the end of the decade
Progress Toward Elimination of Health Disparities
The following discussion highlights progress toward the elimination of health disparities The disparities are illustrated in the Disparities Table see Figure 5-2, which displays information about disparities among select populations for which data were available for assessment Progress was made toward Healthy People 2010s two overarching goals to increase quality and years of healthy life and eliminate
health disparities In general, the white non-Hispanic population, females, and persons with higher education levels were identified as having the best group rates Exceptions, however, existed; for example, the Asian or Pacific Islander population had the best group rate for diabetes-related deaths among the general population 5-5, and the Hispanic population had the best group rate for cardiovascular deaths in persons with diabetes 5-7
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Large disparities exist in rates of diabetes The American Indian or Alaska Native populations number of overall cases of diabetes 5-3 was twice that observed in the white non-Hispanic population Persons with less than a high school education experienced twice the rate for new cases of diabetes 5-2 as did persons with at least some college Rates for new cases and overall cases of diabetes 5-2 and 5-3 among persons with disabilities were three times the rates among persons without disabilities The diabetes-related death rate 5-5 was more than twice as high in the black non-Hispanic population as in the Asian or Pacific Islander population Similarly, persons with less than a high school education and high school graduates experienced
diabetes-related death at more than twice the rate of persons with at least some college The rate for lower extremity amputation among males with diabetes was twice that observed among females with diabetes 5-10 Between 1997 and 2003, disparity in overall cases of diabetes 5-3 decreased between persons with a high school education or less and persons with at least some college best population Disparity also decreased between the Hispanic and the white non-Hispanic best populations However, between 1997 and 2003, each of these populations had an increase in new cases of diabetes Thus, the declines in disparity resulted because the best populations moved away from the target at a faster pace than the other populations Disparities among various populations were largely unchanged from baseline assessments A few positive trends were evident: disparities in receiving an annual dilated eye exam 5-13 and disparities between high school graduates and persons with at least some college decreased by 10 to 49 percentage points Diabetes-related deaths 5-5 showed a 10 to 49 percentage point decrease in the disparity gap between the American Indian or Alaska Native and the Asian or Pacific
Islander populations Finally, both the white non-Hispanic population and persons with less than a high school education had reductions in disparities for cardiovascular deaths related to diabetes 5-7 New cases of diabetes 5-3 demonstrated a 50 to 99 percentage point decrease in disparity between persons with less than a high school education and those with at least some college For the same objective 5-3, a 10 to 49 percentage point decrease occurred in the disparities between the Hispanic and white non-Hispanic populations and persons with a high school education and those with at least some college Of concern were increases in disparities tied to education The disparities for the proportion of persons diagnosed with diabetes 5-4 rather than total cases and the rate for diabetes-related deaths 5-5 increased among persons with a high school education and the best populations High school graduates also showed an increase in disparity from the best group in obtaining annual dental exams 5-15 Finally, the disparity in cardiovascular deaths in persons with diabetes 5-7 between the black nonHispanic and Hispanic best populations widened by 10 to 49 percentage points This result was
particularly alarming because of the greater rate for co-morbidities, like high blood pressure, among the black non-Hispanic population affected by diabetes mellitus
Opportunities and Challenges
Improvements in diabetes management are now being documented in health care settings on a national scale However, since aspects of diabetes management are not improving at similar rates, overall progress is slow Moreover, broader, systemic changes in US health care are needed for further improvement20 Individual efforts by health professionals and patients may have reached maximal impact21
Page 56 Healthy People 2010 Midcourse Review
With an increasing rate for type 2 diabetes mellitus cases occurring throughout the world, including 70 percent of new cases of diabetes mellitus in developing countries,22 health system capacities face a challenge The gradual benefits that have occurred in the management of diabetes mellitus may be reversed as more people require care23 Yet, studies indicate that with modest behavioral changes, persons with prediabetes can reduce the likelihood of progression to type 2 diabetes mellitus by approximately 50 percent These efforts are cost effective since they
avoid the chronic care costs associated with the development of diabetes mellitus and thus save money over the long term13 Therefore, additional progress in this focus area will require commitment to primary prevention of type 2 diabetes mellitus and improved diabetes management practices
Emerging Issues
Major challenges exist to both the public health and clinical implementation of lifestyle intervention for preventing type 2 diabetes For a serious commitment to primary prevention, four areas need to be addressed: identification of candidates for diabetes prevention, delivery of lifestyle interventions, economics, and ethics Although an estimated 54 million people have prediabetes in the United States, how best to identify persons at high risk for diabetes is not clear24 One approach is to identify candidates for primary prevention in the clinical care system at an opportunistic encounter that is, during a visit by patients to their health care providers for conditions unrelated to diabetes prevention Limitations to opportunistic screening exist because persons with limited or no access to health care will be overlooked Persons who have health insurance and persons who are more
likely to use the health care system will be preferentially identified Screening for diabetes outside of the opportunistic clinical setting raises the issues of how programs can ensure that persons with positive results are referred and receive the necessary clinical care and how patients will receive access to appropriate interventions if prediabetes or diabetes is diagnosed The responsibility of clinical followup is equally challenging At present, evidence is not clear whether lifestyle intervention from the Diabetes Prevention Program DPP can be delivered with similar efficacy through integration into health care systems or in the community Physicians may not have the means to deliver these interventions and may have little or no resources necessary to support them It is also unclear whether other practicing professionals will be able to match the success of the DPP interventionists who were trained in counseling on nutrition, exercise, and behavior modification22 Furthermore, it is not certain who will be responsible for the administration of lifestyle interventions, how quality will be assessed and ensured, or how these services will be covered Economic studies may help to
address these issues For example, the DPP included a prospective economic evaluation to address two issues about the interventions to prevent type 2 diabetes: the cost of interventions to prevent type 2 diabetes and whether these interventions are a good value According to the results, on balance, primary prevention is a good investment for health insurers and society25 While health insurers may be primarily responsible for reimbursement of the interventions direct medical costs, including the costs of delivering the interventions and the costs of treating adverse effects of the interventions, other sectors of society will be responsible for the patient-specific direct medical costs, including deductibles and copayments, direct nonmedical costs, and time off from work
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The ethical implications of translating diabetes prevention by lifestyle interventions into public health and clinical practice are complex and challenging According to results of the DPP, some experts assert that the health promotion activities and drug interventions should be widely applied because the results are obviously beneficial and without substantial adverse effect Diabetes prevention
science has evolved over the past two decades, with major breakthroughs in controlling complications and now in preventing the diseases onset Continuing efforts are needed as more Americans develop type 2 diabetes and spend increasing periods of time living with the complications of the disease
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Figure 5-1 Progress Quotient Chart for Focus Area 5: Diabetes
Moved away from target
Moved toward target
Met target
5-1
Diabetes education: 18 years 1998, 1999 New cases of diabetes: 18-64 years 199799, 200002 Overall cases of diabetes 1997, 2003 Diagnosed diabetes: 20 years 198894, 19992000 Diabetes-related deaths 1999, 2002 Diabetes-related deaths: persons with diabetes 1999, 2002 Cardiovascular deaths: persons with diabetes 1999, 2002
67
5-2
-82
5-3
-60
5-4
43
5-5
-3
5-6
110
5-7
188
5-10 Lower extremity amputation: persons with diabetes 199799, 200103 5-11 Annual urinary microalbumin measurement: 65 years with diabetes 2000, 2002 -100 -75 -50 -25 0
49
189
350 25 50 75 100
Percent of targeted change achieved
See notes at end of chart continued
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Figure 5-1 continued
Moved away from target
5-12 A1c test
at least 2 times a year: 18 years with diabetes 2000, 2003 5-13 Annual dilated eye examination: 18 years with diabetes 1998, 1999 5-14 Annual foot examination: 18 years with diabetes 1998, 2003 5-15 Annual dental examination: 2 years with diabetes 1997, 2003 5-17 Daily self-blood-glucose-monitoring: 18 years with diabetes 1998, 2003
Moved toward target
Met target
83
44
0
-27
89 -50 -25 0 25 50 75 100
-100 -75
Percent of targeted change achieved Notes: Tracking data for objective 5-16 are unavailable Objectives 5-8 and 5-9 were deleted at the midcourse Years in parentheses represent the baseline data year and the most recent data year used to compute the percent of Healthy People 2010 target achieved Percent of targeted change achieved recent value baseline value —————————- Most 2010 target baseline value Year
X 100
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Figure 5-2 Disparities Table for Focus Area 5: Diabetes Disparities from the best group rate for each characteristic at the most recent data point and changes in disparity from the baseline to the most recent data point
continued
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Figure 5-2 continued
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People 2010 Midcourse Review
Objectives and Subobjectives for Focus Area 5: Diabetes
Goal: Through prevention programs, reduce the disease and economic burden of diabetes, and improve the quality of life for all persons who have or are at risk for diabetes As a result of the Healthy People 2010 Midcourse Review, changes were made to the Healthy People 2010 objectives and subobjectives These changes are specific to the following situations:
Changes in the wording of an objective to more accurately describe what is being measured Changes to reflect a different data source or new science Changes resulting from the establishment of a baseline and a target that is, when a formerly developmental objective or subobjective became measurable Deletion of an objective or subobjective that lacked a data source Correction of errors and omissions in Healthy People 2010
Revised baselines and targets for measurable objectives and subobjectives do not fall into any of the above categories and, thus, are not considered a midcourse review change1 When changes were made to an objective, three sections are displayed: 1 In the Original Objective section, the objective as published in Healthy
People 2010 in 2000 is shown 2 In the Objective With Revisions section, strikethrough indicates text deleted, and underlining is used to show new text 3 In the Revised Objective section, the objective appears as revised as a result of the midcourse review Details of the objectives and subobjectives in this focus area, including any changes made at the midcourse, appear on the following pages
1
See Technical Appendix for more information on baseline and target revisions
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NO CHANGE IN OBJECTIVE
5-1 Increase the proportion of persons with diabetes who receive formal diabetes education Target: 60 percent Baseline: 45 percent of persons aged 18 years and older with diabetes received formal diabetes education in 1998 age adjusted to the year 2000 standard population Target setting method: Better than the best Data source: National Health Interview Survey NHIS, CDC, NCHS
NO CHANGE IN OBJECTIVE Data updated and footnoted
5-2 Prevent diabetes Target: 381 new cases per 1,000 population per year Baseline: 552 new cases of diabetes per 1,000 population aged 18 to 84 years 3-year average occurred in 1997992 age adjusted to the year 2000 standard population Target setting
method: Better than the best retain year 2000 target Data source: National Health Interview Survey NHIS, CDC, NCHS
1 2
Target revised from 25 because of baseline revision after November 2000 publication Baseline and baseline year revised from 35 and 199496 after November 2000 publication
NO CHANGE IN OBJECTIVE
5-3 Reduce the overall rate of diabetes that is clinically diagnosed Target: 25 overall cases per 1,000 population Baseline: 40 overall cases including new and existing cases of diabetes per 1,000 population occurred in 1997 age adjusted to the year 2000 standard population Target setting method: Better than the best retain year 2000 target Data source: National Health Interview Survey NHIS, CDC, NCHS
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NO CHANGE IN OBJECTIVE Data updated and footnoted
5-4 Increase the proportion of adults with diabetes whose condition has been diagnosed Target: 781 percent Baseline: 642 percent of adults aged 20 years and older with diabetes had been diagnosed in 198894 age adjusted to the year 2000 standard population Target setting method: Better than the best Data source: National Health and Nutrition Examination Survey NHANES, CDC, NCHS
1
2
Target revised from 80 because of baseline revision after November 2000 publication Baseline revised from 68 after November 2000 publication
NO CHANGE IN OBJECTIVE Data updated and footnoted
5-5 Reduce the diabetes death rate Target: 461 deaths per 100,000 population Baseline: 772 deaths per 100,000 population were related to diabetes in 19992 age adjusted to the year 2000 standard population Target setting method: 43 percent improvement Data source: National Vital Statistics System NVSS, CDC, NCHS
1 2
Target revised from 45 because of baseline revision after November 2000 publication Baseline and baseline year revised from 75 and 1997 after November 2000 publication
NO CHANGE IN OBJECTIVE Data updated and footnoted
5-6 Reduce diabetes-related deaths among persons with diabetes Target: 78 deaths per 1,000 persons with diabetes Baseline: 88 deaths per 1,000 persons with diabetes listed anywhere on the death certificate occurred in 19991 age adjusted to the year 2000 standard population Target setting method: 11 percent improvement
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NO CHANGE IN OBJECTIVE continued Data updated and footnoted
Data sources: National Vital Statistics System NVSS, CDC, NCHS;
National Health Interview Survey NHIS, CDC, NCHS
1
Baseline year revised from 1997 after November 2000 publication
NO CHANGE IN OBJECTIVE Data updated and footnoted
5-7 Reduce deaths from cardiovascular disease in persons with diabetes Target: 2991 deaths per 100,000 persons with diabetes Baseline: 3322 deaths from cardiovascular disease per 100,000 persons with diabetes occurred in 19992 age adjusted to the year 2000 standard population Target setting method: 10 percent improvement Data sources: National Vital Statistics System NVSS, CDC, NCHS; National Health Interview Survey NHIS, CDC, NCHS
1 2
Target revised from 309 because of baseline revision after November 2000 publication Baseline and baseline year revised from 343 and 1997 after November 2000 publication
OBJECTIVE DELETED
5-8 Objective deleted due to lack of data source Developmental Decrease the proportion of pregnant women with gestational diabetes
OBJECTIVE DELETED
5-9 Objective deleted due to lack of data source Developmental Reduce the frequency of foot ulcers in persons with diabetes
NO CHANGE IN OBJECTIVE Data updated and footnoted
5-10 Reduce the rate of lower extremity amputations in persons with diabetes
Target: 291 lower extremity amputations per 1,000 persons with diabetes per year Baseline: 662 lower extremity amputations per 1,000 persons with diabetes occurred in 1997992 age adjusted to the year 2000 standard population
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NO CHANGE IN OBJECTIVE continued Data updated and footnoted
Target setting method: 55 percent improvement Data sources: National Hospital Discharge Survey NHDS, CDC, NCHS; National Health Interview Survey NHIS, CDC, NCHS
1 2
Target revised from 18 because of baseline revision after November 2000 publication Baseline and baseline year revised from 41 and 1997 after November 2000 publication
ORIGINAL OBJECTIVE
5-11 Developmental Increase the proportion of persons with diabetes who obtain an annual urinary microalbumin measurement Potential data source: Behavioral Risk Factor Surveillance System BRFSS, CDC, NCCDPHP
OBJECTIVE WITH REVISIONS
5-11 Developmental Increase the proportion of persons adults with diabetes who obtain an annual urinary microalbumin measurement Target: 14 percent Baseline: 12 percent of adults aged 65 years and older with diabetes obtained an annual urinary microalbumin measurement in 2000
Target setting method: Better than the best Potential dData source: Behavioral Risk Factor Surveillance System BRFSS, CDC, NCCDPHPUS Renal Data System USRDS, NIH, NIDDK
REVISED OBJECTIVE
5-11 Increase the proportion of adults with diabetes who obtain an annual urinary microalbumin measurement Target: 14 percent Baseline: 12 percent of adults aged 65 years and older with diabetes obtained an annual urinary microalbumin measurement in 2000 Target setting method: Better than the best Data source: US Renal Data System USRDS, NIH, NIDDK
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NO CHANGE IN OBJECTIVE Data updated and footnoted
5-12 Increase the proportion of adults with diabetes who have a glycosylated hemoglobin measurement at least once a year Target: 651 percent Baseline: 592 percent of adults aged 18 years and older with diabetes had a glycosylated hemoglobin measurement at least once a year mean of data from 39 States in 20002; age adjusted to the year 2000 standard population Target setting method: Better than the best Data source: Behavioral Risk Factor Surveillance System BRFSS, CDC, NCCDPHP
1 2
Target revised from 50 because of baseline revision after November 2000 publication Baseline and
baseline year revised from 24 and 1998 after November 2000 publication
NO CHANGE IN OBJECTIVE Data updated and footnoted
5-13 Increase the proportion of adults with diabetes who have an annual dilated eye examination Target: 761 percent Baseline: 492 percent of adults aged 18 years and older with diabetes had an annual dilated eye examination in 1998 age adjusted to the year 2000 standard population Target setting method: Better than the best Data source: National Health Interview Survey NHIS, CDC, NCHS
1 2
Target revised from 75 because of baseline revision after November 2000 publication Baseline revised from 47 after November 2000 publication
NO CHANGE IN OBJECTIVE Data updated and footnoted
5-14 Increase the proportion of adults with diabetes who have at least an annual foot examination Target: 911 percent Baseline: 682 percent of adults aged 18 years and older with diabetes had at least one annual foot examination mean value of data from 39 States in 1998; age adjusted to the year 2000 standard population
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NO CHANGE IN OBJECTIVE continued Data updated and footnoted
Target setting method: Better than the best Data source:
Behavioral Risk Factor Surveillance System BRFSS, CDC, NCCDPHP
1 2
Target revised from 75 because of baseline revision after November 2000 publication Baseline revised from 55 after November 2000 publication
NO CHANGE IN OBJECTIVE Data updated and footnoted
5-15 Increase the proportion of persons with diabetes who have at least an annual dental examination Target: 711 percent Baseline: 562 percent of persons aged 2 years and older with diagnosed diabetes saw a dentist at least once within the preceding 12 months in 1997 age adjusted to the year 2000 standard population Target setting method: Better than the best Data source: National Health Interview Survey NHIS, CDC, NCHS
1 2
Target revised from 75 because of baseline revision after November 2000 publication Baseline revised from 58 after November 2000 publication
NO CHANGE IN OBJECTIVE
5-16 Increase the proportion of adults with diabetes who take aspirin at least 15 times per month Target: 30 percent Baseline: 20 percent of adults aged 40 years and older with diabetes took aspirin at least 15 times per month in 198894 age adjusted to the year 2000 standard population Target setting method: Better than the best Data source:
National Health and Nutrition Examination Survey NHANES, CDC, NCHS
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NO CHANGE IN OBJECTIVE Data updated and footnoted
5-17 Increase the proportion of adults with diabetes who perform self-blood-glucosemonitoring at least once daily Target: 611 percent Baseline: 432 percent of adults aged 18 years and older with diabetes performed self-blood-glucose-monitoring at least once daily mean of data from 39 States in 1998; age adjusted to the year 2000 standard population Target setting method: Better than the best Data source: Behavioral Risk Factor Surveillance System BRFSS, CDC, NCCDPHP
1 2
Target revised from 60 because of baseline revision after November 2000 publication Baseline revised from 42 after November 2000 publication
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References
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Boyle, P, et al Projection of diabetes burden through 2050 Diabetes Care 24:19361940, 2001 Wild, S, et al Global prevalence of diabetes: Estimates for the year 2000 and projections for 2030 Diabetes Care 27:10471053, 2004 Engelgau, M, et al The evolving diabetes burden in the United States Annals of Internal Medicine 140:945949, 2004 Geiss, L, et al A national progress report on
diabetes: Successes and challenges Diabetes Technology Therapeutics 7:198203, 2005 Saaddine, J, et al A diabetes report card for the US: Quality of care in the 1990s Annals of Internal Medicine 136:565574, 2002 More information available at wwwcmwforg/surveys/surveys_showhtm?doc_id367929; accessed October 31, 2006 More information available at wwwcmwforg/usr_doc/Collins_gapshltins_920pdf; accessed October 31, 2006 Nelson, KM, et al The association between health insurance coverage and diabetes care; data from the 2000 Behavioral Risk Factor Surveillance System Health Services Research 402:361372, 2005 Oladele, CR, and Barnett, E Racial/ethnic and social class differences in preventive care practices among persons with diabetes BMC Public Health 6259:18, 2006 More information available at http//ndepnihgov/ddi/; accessed October 31, 2006 US Department of Health and Human Services HHS HHS launches new effort to reach people with diabetes who are undiagnosed [HHS press release] November 3, 2003 Diabetes Prevention Program Research Group Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin New England Journal of Medicine 346:393403, 2002 Zhang, P, et
al Application of economic analysis to diabetes and diabetes care Annals of Internal Medicine 140:972977, 2004 Improvements have occurred in lipid measurements and control, frequency of hemoglobin A1c testing, proper vaccination rates, and eye examinations More limited progress has been demonstrated in absolute values of hemoglobin A1c levels and control of blood pressure Berwick, D Disseminating innovations in health care Journal of the American Medical Association 289:19691975, 2003
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Eyre, H, et al American Cancer Society, American Diabetes Association, and American Heart Association Preventing cancer, cardiovascular disease, and diabetes: A common agenda for the American Cancer Society, the American Diabetes Association, and the American Heart Association Circulation 10925:32443255, 2004 Saaddine, J, et al Improvements in diabetes processes of care and intermediate outcomes: United States, 19882002 Annals of Internal Medicine 1447:465475, 2002 Gregg, E, et al Trends in the ratio of diagnosed to undiagnosed diabetes according to obesity levels in the US Diabetes Care 27:28062812, 2004 More information
available at wwwndepnihgov/; accessed October 31, 2006 Wagner, E Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice 1:24, 1998 Bodenheimer, T High and rising health care costs Part 3: The role of health care providers Annals of Internal Medicine 142:9961002, 2005 Knowler, W, and Barrett-Conner, E Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin New England Journal of Medicine 346:393403, 2002 Brown, A, et al Socioeconomic position and health among persons with diabetes mellitus: A conceptual framework and review of the literature Epidemiologic Reviews 26:6377, 2004 Cowie, C, et al Prevalence of diabetes and impaired fasting glucose in adults in the US population: National Health and Nutrition Examination Survey 19992002 Diabetes Care 29:12631268, 2006 Diabetes Prevention Program Research Group Costs associated with the primary prevention of type 2 diabetes mellitus in the Diabetes Prevention Program Diabetes Care 26:3647, 2003
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Related Objectives From Other Focus Areas
1 Access to Quality Health
Services 1-1 Persons with health insurance 1-3 Counseling about health behaviors 4 Chronic Kidney Disease 4-1 End-stage renal disease 4-2 Cardiovascular disease deaths in persons with chronic kidney failure 4-7 Kidney failure due to diabetes 4-8 Medical evaluation and treatment for persons with diabetes and chronic kidney disease 9 Family Planning 9-3 Contraceptive use 9-11 Reproductive health education 12 Heart Disease and Stroke 12-1 Coronary heart disease CHD deaths 12-2 Knowledge of symptoms of heart attack and importance of calling 911 12-7 Stroke deaths 12-8 Knowledge of early warning symptoms of stroke 12-9 High blood pressure 12-10 High blood pressure control 12-11 Action to help control blood pressure 12-12 Blood pressure monitoring 12-13 Mean total cholesterol levels 12-14 High blood cholesterol levels 12-15 Blood cholesterol screening 12-16 LDL-cholesterol level in CHD patients 14 Immunization and Infectious Diseases 14-5 Invasive pneumococcal infections 14-29 Influenza and pneumococcal vaccination of high-risk adults 16 Maternal, Infant, and Child Health 16-6 Prenatal care 16-10 Low birth weight and very low birth weight 16-19 Breastfeeding 19 Nutrition and Overweight
19-1 Healthy weight in adults 19-2 Obesity in adults 19-3 Overweight or obesity in children and adolescents 19-16 Worksite promotion of nutrition education and weight management 19-17 Nutrition counseling for medical conditions
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22 Physical Activity and Fitness 22-1 No leisure-time physical activity 22-2 Moderate physical activity 22-3 Vigorous physical activity 22-6 Moderate physical activity in adolescents 22-7 Vigorous physical activity in adolescents 28 Vision and Hearing 28-1 Dilated eye examinations 28-5 Impairment due to diabetic retinopathy 28-10 Vision rehabilitation services and devices
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Source:kff.org
