AHRQ Research on Diabetes Care
Translating Research Into Practice
Diabetes—a disease that causes problems with insulin production or utilization—affects about 16 million Americans and accounts for an estimated $98 billion in annual health care costs. Without enough insulin, sugar levels in the blood become too high, which can lead to permanent damage to the blood vessels and associated complications, such as heart disease and stroke. As a result, diabetics spend over 3 million days in the hospital and make over 15 million visits to health care providers each year. Type 1 diabetes, usually diagnosed in childhood, is less common than Type 2, which is most often diagnosed in middle age. Type 2 accounts for 9 in 10 diabetes cases, and 650,000 new cases occur every year. Both types tend to run in families although Type 2 usually requires another factor, such as obesity, to stimulate the onset.
The Agency for Healthcare Research and Quality (AHRQ, formerly known as the Agency for Health Care Policy and Research) sponsors research that focuses on how patients and providers together can better manage diabetes to improve quality of life and reduce risk of complications. Results of this research have contributed to a better understanding of how to measure quality and outcomes of diabetes care.
AHRQ research has revealed that:
- Screening Type 2 diabetics under age 65 for eye disease could save the Government alone $472 million.
- Over 4 in 10 Type 1 diabetics and 3 in 10 Type 2 diabetics failed to receive a routine monitoring test recommended by the American Diabetes Association.
- Tight control of blood sugar levels by Type 1 diabetics reduces their risk of kidney disease by two-thirds and eye disease by one-half.
- African-American diabetics are 7 times more likely to have amputations and develop kidney failure than white diabetics.
Controlling blood sugar levels. AHRQ-funded research on diabetes treatment has confirmed that complications are less likely with tighter control of blood sugar levels. For Type 1 diabetics, tight control achieved with either continuous infusion or small, frequent doses of insulin over the long term reduces the risk of eye disease by almost a half and kidney disease by two-thirds. However, this type of intensive therapy requires very close monitoring due to the risk of blood sugar crisis or other short-term problems.
For Type 2 diabetics, AHRQ research has shown that:
- Bringing poorly controlled sugar levels under more strict control can reduce the risk of blindness, particularly in those under age 50. Insulin therapy can also help bring high blood sugar levels into the moderate range.
- With stricter management, those already in moderate control have fewer symptoms, better quality of life, and less time lost from work but they are not likely to further reduce their risk of complications. Insulin therapy rarely helps this group reach near normal levels, even with additional doctor visits and home glucose monitoring.
Patient monitoring and treatment. AHRQ research on the extent of routine testing and treatment of diabetic patients has revealed important findings about the ways patients are monitored. For example:
- Fewer than one in five diabetics receives the minimum number of a routine monitoring test recommended by the American Diabetes Association as an indicator of the longer term effects of blood sugar control. Over the course of a 1-year study, more than 40 percent of Type 1 patients and more than 30 percent of Type 2 patients did not receive this test.
- Another AHRQ study estimated that, if all Type 2 diabetics under age 65 received recommended screening for eye disease to prevent blindness, net savings to the government would be more than $472 million.
- Severe foot infections in diabetics sometimes lead to amputations. AHRQ-supported researchers found that foot infections in diabetics were most effectively treated by surgical removal of dead tissue followed by a long course of antibiotics. Expensive diagnostic imaging was shown to add little benefit.
Care for Vulnerable Populations
Risk assessment. The incidence of Type 2 diabetes is much higher for nearly all minority groups than for whites, and certain groups have higher rates of diabetes-related complications and death. AHRQ-funded research has shown, for example, that African-American diabetics are seven times more likely than white diabetics to have amputations and develop kidney failure. Diabetes-related blindness is more prevalent in African Americans, Hispanics, and Native Americans than in whites.
Barriers to care. To understand some of the problems that may be preventing better diabetes care, AHRQ-sponsored researchers have begun studying the barriers to self-care and treatment that exist for these groups. Findings have shown that Hispanic diabetics often face economic barriers to treatment and are reluctant to place their own medical needs over needs of family members. Other common barriers include a distrust of insulin therapy, a preference for more familiar traditional remedies, and a fatalistic acceptance of the course of the disease. Strategies to prevent the onset of diabetes through diet and lifestyle changes require interventions that are culturally sensitive and population specific.
Family support for frail elderly. AHRQ-sponsored research has shown that frail elderly diabetics whose family members were involved in their treatment regimen were more likely to take prescribed medicines and follow proper diets than were elderly patients without involved family members.
AHRQ-supported researchers have developed a number of tools that measure quality and outcomes of diabetes care.
Total Illness Burden Index. This composite measure of symptoms, diagnoses, and disease manifestations helps clinicians assess severity of illness for a particular patient. It can also be used to determine the severity mix of patients in a clinician's caseload, thereby enabling important comparisons of cost and outcomes.
'Hassles' Diabetes-Specific Health Status Measure. This measure helps patients and clinicians differentiate among the effects of different treatments on a patient's ability to carry out important daily activities.
VF-14 Index of Visual Functioning. This measure, which was originally developed by AHRQ-funded researchers to assess visual functioning in people with cataracts, can also help detect impairments due to diabetic eye disease.
Patient reports of foot exams. Routinely checking feet of diabetic patients for sores can substantially lessen the likelihood of severe foot infections that can lead to amputations. Asking patients whether they removed their shoes during an office or clinic visit helps assess whether physicians are following recommended practices for diabetic patients.
Current AHRQ studies continue to address the need for better disease management and improved quality of life for diabetics in at-risk populations and in managed care:
- Primary care providers are collaborating with endocrinologists in Atlanta to see if they can improve care and prevent complications in indigent urban African Americans with Type 2 disease who are in poor control of their blood sugar.
- A study of financial arrangements for providers, care strategies, and cost sharing by patients is being conducted in three health plans in the Twin Cities.
- The impact of a number of managed care features on changes in vision and general health is being investigated in working-age patients with diabetic eye disease and glaucoma.
- Nine managed care organizations, as part of Florida's Healthy Kids Program, are being studied to determine which organizational features have the greatest impact on care coordination and access to pediatricians and specialists for children with diabetes, asthma, and other special care needs.
Research in Practice
AHRQ research findings are providing core input to the Diabetes Quality Improvement Project (DQIP), a national public-private effort to establish performance and outcome measures for use by patients, providers, and purchasers in making decisions about the quality of diabetes care. The Project's provisional questionnaire uses the 'Hassles' health status measure, the Total Illness Burden Index, and patients' reports of foot exams that were developed with AHRQ support.