Regional Variation in the Management of Diabetes in the United States

Cardiovascular disease risk and diabetes management vary in patients with diabetes by geographic region in the United States, according to study results published in the Journal of Diabetes and Its Complications.

Using data from the Diabetes Collaborative Registry (DCR), researchers investigated geographic differences in the management of cardiovascular disease risk in patients with diabetes. Demographic and clinical characteristics of the DCR cohort were also compared against data from the National Health and Nutrition Examination Survey (NHANES) to evaluate the extent to which the results may be considered representative of the US population.

A total of 67,433 adults (48% women) with diabetes (98% type 2 diabetes) were included in the analysis from the DCR cohort. Patients were restricted to those from 212 primary care sites and classified based on their geographic region (Northeast, Midwest, South, and West). The majority of patients (62%) were treated in the South, followed by the Northeast (18%), Midwest (17%), and West (3%). Approximately 21.5 million people with diabetes were included from the NHANES database.

Compared with the NHANES cohort, the DCR cohort was older (61±10 years vs 57±12 years), less ethnically diverse (83% vs 76% non-Hispanic white), and had a higher percentage of patients with insurance (99.7% vs 91.0%).

For both cohorts, the average body mass index was in the obese range and mean hemoglobin A1c (HbA1c) and percentage of individuals with blood pressure <140/90 mm Hg were similar. Dyslipidemia was more prevalent in the DCR cohort (83%) than the NHANES cohort (63%). A higher percentage of patients in the DCR cohort achieved diabetes control compared with the NHANES cohort (18.8% vs 6.0%).

Within the DCR cohort, patients treated in the West were oldest (P <.0001). Non-Hispanic white patients were the majority in all geographic regions, with the largest percentage of non-Hispanic black patients observed in the South (P <.0001). The percentage of patients with obesity, mean HbA1c levels, and tobacco use were highest in the Midwest, and the South had the lowest percentage of patients who achieved blood pressure <140/90 mm Hg (P <.0001 for all). The South and Northeast had the lowest percentage of individuals who achieved low-density lipoprotein levels <2.59 mmol/L (both 58%). Diabetes control was highest in the Northeast (21%), followed by the South (20%), West (19%), and Midwest (14%).

Rates of use of insulin (18% vs 27%), oral hypoglycemic agents (56% vs 71%), and antihypertensive medications (79% vs 95%) were lower in the DRC cohort than the NHANES cohort. However, among individuals with HbA1c >9%, use of diabetes medications was similar between groups. Use of cholesterol-lowering medications was similar between groups, but patients in the DCR cohort were less likely than NHANES patients to receive lipid-lowering therapy in the context of dyslipidemia (78% vs 90%) or low-density lipoprotein levels ≥2.59 mmol/L (60% vs 77%).

The highest rates of use of diabetes medications, antihypertensive medications, and cholesterol-lowering medications in the DCR cohort were in the West.

The researchers noted that medical conditions were diagnosed differently in the DCR and NHANES cohorts, which may have limited the comparisons made between the groups.

“Significant regional differences in diabetes care delivery and outcomes were identified,” the study authors concluded. “These analyses can support health policy initiatives and efforts to cost-effectively manage the diabetes epidemic confronting the [United States].”

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Reference

Tinsley LJ, Wong ND, Reusch JEB, et al. Regional differences in the management of cardiovascular risk factors among adults with diabetes: an evaluation of the diabetes collaborative registry [published online April 21, 2020]. J Diabetes Complicat. doi:10.1016/j.jdiacomp.2020.107591