Health Care Access And Detection of Diabetes Mellitus
The September 2008 issue of Diabetes Care had a very interesting article that is quite relevant to both diabetes specifically, and to health care delivery in general. The article was entitled “The missed patient with diabetes: how access to health care affects the detection of diabetes” and was written by Xuanping Zhang at colleagues at the Centers for Disease Control (CDC) in Atlanta, Georgia (Diabetes Care 2008;31:1748-53).
Background information
If you’ve read some of my earlier postings, you surely know that the prevalence of diabetes mellitus word-wide has been increasing at an alarming rate over the past 20-30 years; in the U.S. alone it is estimated that 20-25 million people have the disease with 6-7 million of those undetected. On top of those depressing statistics, studies have shown that the average duration of diabetes before it is detected is about 9 years; many people with diabetes first learn they have diabetes when they develop symptoms from some diabetes complication. None of this would really matter much except that we now know that diabetes complications are preventable with early detection and appropriate treatment (check out some of my earlier posts about the Diabetes Control and Complications Trial, or DCCT, The Epidemiology of Diabetes Interventions and Complications Trial, or EDIC, and the United Kingdom Prospective Diabetes Study, or UKPDS).
The study design
The investigators analyzed data from the 1999-2004 National Health and Nutrition Examination Survey or NHANES. I need to explain that one good thing done with your tax dollars (assuming you live in the U.S. and pay your taxes) is that every 8 years or so, the CDC carries out a 6-year studies to assess the health status of people living in the U.S. They have been at this for quite a number of years and over the years, the data gleaned from these studies have been incredibly important and useful. I know quite a bit about the NHANES since my laboratory carried out most of the diabetes-related laboratory analyses (plasma glucose, hemoglobin A1c, serum C-peptide, and serum insulin) between 1987-2004. I’ll vouch for the accuracy of the data.
Zhang and colleagues picked through the NHANES 199-2004 data in an effort to answer the following question: does access to health care affect the detection of diabetes (I guess you’d figure that out from the article title). The question of access to health care is a rather complex subject with a number of components. For their study, Zhang and colleagues focused on health insurance status and utilization of health services (i.e., number of health care visits during the previous 12 months) as their measures of access (some other components to access include availability, organization, and satisfaction). The investigators analyzed data from approximately 5500 people ages 18-64 years. They identified 110 people who met criteria for diagnosis of diabetes yet had not been previously diagnosed, 704 who had been previously diagnosed, and 4782 who did not have diabetes. Thus, 110/5486 people had been “missed.” What turned out to be so interesting, but not so surprising, was that those people undiagnosed with diabetes had the least favorable profile of access to care of the three groups (missed, previously diagnosed, and no diabetes. The differences were very large; taking all diabetic people (missed and previously diagnoses), the percentage of people with no health insurance was much greater in the missed group than in the previously diagnosed group. Continuity of coverage was also important; people with no insurance for > 1 year were much more likely to be in the missed group than in the previously diagnosed group. Level of education and income were far less important than health care access in determining risk for undetected diabetes. The investigators concluded that given the data showing undetected diabetes is a serious risk factor for adverse health outcomes, timely detection of diabetes is difficult without access to health care.
So?
These data are just one more piece of evidence that if we want to provide optimal medical care to people with diabetes, we can not do it without providing adequate access (code word for quality health insurance) to appropriate medical care. It doesn’t matter how skillful the physician and how motivated the patient if the diabetes goes undetected for years and years before it is diagnosed. Remember, the lion’s share of diabetes health care costs are for the treatment of preventable diabetes complications. And who actually pays for treating diabetes complications? The answer is that we all pay. If I had to bet or die, I’d say the situation is very similar for other chronic diseases such as heart disease and cancer, but here in a study of diabetes, Zhang and colleagues have made their case very persuasively.