Adopting a ‘Cascade of Care’ Approach to Diabetes

Researchers say it is time to combat the diabetes epidemic in the United States by adopting a treatment model used to combat the AIDS epidemic. Specifically, researchers at Emory University are suggesting adopting a “cascade of care” model.

A cascade of care model involves identifying how many patients are living with a certain condition and how many are receiving the care and treatment that they need to manage their condition. This model has been successful at identifying gaps in HIV care. Now, it is theorized that this approach could significantly help identify those patients with type 2 diabetes who are undiagnosed.

“In HIV, they used it to know how many people have HIV and which ones had been tested and knew their stats. It includes which patients take their medications and which ones have better outcomes. We did the same thing with diabetes. You don’t know you have it unless you have been tested for blood sugar,” said lead study author Mohammed Ali, MBChB, MSc, MBA, who is an assistant professor in the department of Global Health at Emory University in Atlanta. 

In the Annals of Internal Medicine, Dr. Ali and his colleagues reported that three in 10 adults with diabetes appear to be undiagnosed.¹

In their study, the researchers analyzed data from the National Health and Nutrition Examination Survey (NHANES) and created a cascade of care for diabetes. Using this model, they found that 11.8% of the population (28.4 million adults) over a 5-year study period had diabetes. However, 7.9 million were unaware that they had diabetes even though 85% of them had a usual care provider and 66.5% had visited their usual care provider at least twice during the preceding year.

“As we move into consumer-driven health care, everyone should know their risks,” Dr. Ali said in an interview with Endocrinology Advisor. “All the previous national report cards have been on the diagnosed population.” 

He said the cascade-of-care concept may be an ideal tool for visualizing gaps and disparities across various populations. He and his colleagues believe that this model can serve as a guidepost to monitor the clinical, organizational and public health response to the diabetes epidemic.

Problem of Underdiagnosis

Another recent analysis also supports the notion that there are many undiagnosed patients who need to be screened and treated.  Researchers from the United Kingdom and the United States looked at electronic medical records (EMRs) for 11.5 million patients at more than 9,000 primary care clinics across the U.S. and found serious gaps in care.² 

As part of this investigation, the researchers analyzed diabetes coding in the EMRs and biochemical data using an algorithm. They also measured the quality of diabetes care. Of the 1,174,018 people with diabetes, 63,620 (5.4%) had undiagnosed diabetes. The study suggested that the rates of undiagnosed patients were higher in parts of Arizona, North Dakota, Minnesota, South Carolina and Indiana.

“Undiagnosed diabetes is a common problem in all health systems, but in the presence of biochemical evidence, raised blood glucose or HbA1c results in electronic health records, it becomes a significant clinical error, potentially delaying the commencement of interventions likely to improve clinical outcomes,” said study co-author Tim Holt, MD, of the Nuffield Department of Primary Care Health Sciences at University of Oxford in the United Kingdom.

The study showed that in some areas of the country, 12.0% to 15.9% of the overall diabetes population was undiagnosed. Although this is less than the 27.8% believed to have undiagnosed diabetes, Dr. Holt said these individuals were immediately identifiable through simple searches of EMRs from primary care practices.