A survey of federally funded diabetes prevention and control programs in 57 U.S. states and territories has highlighted the need for better diabetes treatment guidelines that are specifically adapted to different populations. Such guidelines do not currently exist.
The survey, conducted by researchers at the University of California, San Francisco (UCSF), San Francisco General Hospital and Trauma Center (SFGH) and the California Department of Public Health, looked at how state programs disseminate diabetes treatment guidelines to doctors. Usually, it found, state programs distribute clinical practice guidelines obtained from national clinical specialty organizations.
As described in the American Journal of Public Health, these national guidelines are geared toward managing diabetes in individuals, not planning care for populations — and may not be designed to operate optimally within a given state’s resources. But officials who oversee these programs do not have enough scientific evidence to adapt these guidelines to their needs and resources, the survey revealed.
If more specific guidelines did exist, each state might be able to better maximize its resources and more effectively confront the pressing problem of diabetes, which affects about one in 10 Americans and costs taxpayers more than $200 billion annually.
“In order to improve diabetes health for populations, rather than individuals, we need to know how to maximize health and quality of life with the limited resources that are available,” Urmimala Sarkar, MD, MPH, an assistant professor at UCSF Division of General Internal Medicine and the Center for Vulnerable Populations at San Francisco General Hospital, who led the study, stated in a press release.
Diabetes in California provides a snapshot of the national diabetes epidemic: it is a serious problem that is getting worse. An estimated 4 million people in the state (one in seven adults) already have diabetes and millions of others are at risk of developing the disease. Cases of diabetes have soared by more than a third over the last decade, and statewide costs related to the disease are estimated at over $24 billion a year.
According to the new survey, officials in California and most other states promote public health in part by publicizing best practice guidelines for treating people with the disease. These guidelines are set at the national level by professional societies like the American Diabetes Association and the American College of Endocrinology, which generally convenes working groups of clinical experts to review the latest available clinical data and set the guidelines, often based on an idealized health care system and patient.
These guidelines outline when patients should be started on insulin, for instance, how often they should have their blood sugar levels tested, how often they should go in for eye exams and so forth. But the guidelines do not consider the cost of delivering the care, the comparative effectiveness of each intervention, the ease of implementation and the points at which most public health benefits can be gained.
This advice is informed by evidence showing how effective aggressive glucose control can be in clinical trials. But these trials usually involve patients with few secondary health problems who are not very diverse in terms of gender, ethnicity or age, according to Sarkar.
Diabetes control programs need to have better data to determine how to best prioritize these guidelines and weigh optimal versus “good enough” care. Not enough is known about how interventions compare, or whether public health guidelines that depart from national standards for aggressive treatment would enable more people to benefit from interventions to prevent complications. Lacking these data, states may be missing an opportunity to better promote public health, according to Sarkar.
