The “cascade of care” concept is a relatively new approach to disease management in that it shows in visual form the number of people living with a condition and gaps in care for that disease. It has been hypothesized that diabetes care could be a viable candidate for applying a cascade of care concept to visualize gaps in awareness of diabetes status, engagement in care, and treatment outcomes. For a study published in Annals of Internal Medicine, Mohammed K. Ali, MBChB, MSc, MBA, and colleagues used 2007 to 2012 survey data from a nationally representative sample of Americans to identify non-pregnant adults with either diagnosed or undiagnosed diabetes. “We used the cascade to map out where gaps occur along the continuum of care,” says Dr. Ali.
Dr. Ali and colleagues determined that about 8 million of the more than 28 million people with diabetes in the United States remain undiagnosed (Figure). “That gap needs to be closed by improving awareness and with appropriate screening,” says Dr. Ali. “Clinicians should be alert and attentive to guidelines and actively screen for diabetes in those who are eligible.”
The researchers also found that large proportions of patients with diabetes—regardless of whether they had diagnosed or undiagnosed disease—were not meeting care goals. In particular, they had difficulty controlling A1C, blood pressure, and cholesterol levels as well as quitting smoking, all of which are key components to preventing costly and disabling diabetes complications. “For A1C, blood pressure, and cholesterol, only about half of patients were meeting each goal,” explains Dr. Ali. “In addition, about 20% still smoked cigarettes or tobacco.”
When the investigators looked deeper into the available data, they found that men and young adults were at highest risk for remaining undiagnosed with diabetes. “Physicians should be attentive to the risk factors for diabetes among young adults, including being overweight or obese, being a minority race or ethnicity, having high blood pressure, or having previous gestational diabetes,” says Dr. Ali. Young adults and Hispanic Americans were among the patient groups at highest risk for not meeting care goals, regardless of whether they had diagnosed or undiagnosed diabetes.
From Concept to Practice
Dr. Ali explains that the cascade of care concept can be used as a quality improvement tool in healthcare settings. “Applying it to a case series of patients with diabetes could provide a clear visualization of where improvements are needed and stimulate physicians and healthcare systems to act,” he says. “The cascade could also help build pride among teams that successfully close gaps in care.”
Help confirm diabetes risk in your patients by accessing the American Diabetes Association’s Type 2 Diabetes Risk Test.
Readings & Resources (click to view)
Ali M, Bullard K, Gregg E, del Rio C. A Cascade of Care for Diabetes in the United States: Visualizing the Gaps. Ann Intern Med. 2014;161:681-689. Available at http://annals.org/article.aspx?articleid=1935052.
Holt T, Gunnarsson C, Cload P, Ross S. Identification of undiagnosed diabetes and quality of diabetes care in the United States: cross-sectional study of 11.5 million primary care electronic records. CMAJ Open. 2014;2:E248-E255.
Dall T, Yang W, Halder P, et al. The economic burden of elevated blood glucose levels in 2012: diagnosed and undiagnosed diabetes, gestational diabetes mellitus, and prediabetes. Diabetes Care. 2014;37:3172-3179.