Standard measures of diabetes care in the United States underestimate racial and ethnic disparities when monitoring a patient’s blood sugar and other clinical indicators and could mean management of the disease in the country is actually worsening, according to a new study by University of Chicago Medicine researchers.
National studies of diabetes care often use universal standards of performance for all racial groups. Such studies commonly measure how many patients have a hemoglobin A1C level—a common measure of blood sugar control—below 7 percent. However, the new study, published in the journal Medical Care, found that more Hispanic patients with diabetes would benefit from more aggressive A1C goals than whites or African-Americans. The study’s authors urge physicians to establish individual goals appropriate to a patient’s medical history and personal background, instead of relying on those universal standards.
The researchers also found that when using a comprehensive set of measures of diabetes care, including individualized A1C goals, blood pressure levels, cholesterol levels and smoking status, only 5 percent of African-Americans and 10 percent of Hispanics meet all four targets. These findings contradict other studies based on universal A1C targets, which show diabetes care in the United States is improving overall.
“We should be thinking more about patient’s individual targets if we’re going to comment on quality of care nationally,” said the study’s lead author, Neda Laiteerapong, MD, assistant professor of medicine at the University of Chicago Medicine. “We’re not doing as well as we thought we were doing.”
For this study, Laiteerapong and her colleagues used a nationally representative sample of non-Hispanic white, non-Hispanic African-American and Hispanic adults, who were 20 years or older. Every participant had self-reported diabetes and was included in the National Health and Nutrition Examination Survey (NHANES) from 2007-2010. They calculated individual A1C goals for each patient based on their age, the duration of their diabetes, as well as complications and related conditions. Then the team assigned individual cholesterol goals based on the patients’ cardiovascular history.
Traditionally, patients with diabetes have been advised to keep their A1C levels as low as possible. That’s because the chances of developing complications affecting the eyes, kidneys and cardiovascular system increase the longer a person has diabetes, as the effects of high blood glucose levels accumulate.
However, low blood sugar, or hypoglycemia, can make a person feel disoriented, dizzy and light-headed, or in extreme cases even pass out or go into a coma. Medications for type 2 diabetes can also cause nausea, kidney damage or weight gain.
For younger patients who were recently diagnosed and have no complications, a low A1C level is appropriate. But for older patients with diabetes who may have already developed complications of the disease, the risk of having an extremely low blood sugar and injuring themselves, or suffering from the side effects of medications, outweighs the benefits of more aggressive blood sugar control. Also, the benefits of low A1C levels for patients who’ve already developed complications of diabetes are uncertain.
The National Committee for Quality Assurance (NCQA) provides standard measures of care for diabetes that recommend A1C levels of less than 8 percent for all patients. But the American Diabetes Association (ADA) has endorsed a lower A1C standard of less than 7 percent, and since 2002, has also recommended that physicians and patients set individual goals.
Despite the arguments for individualized goals, Laiteerapong said conflicting messages on performance measurements and confusion over guidelines have made them difficult to implement. The NCQA standards are influential tools for measuring clinical performance, public reporting and insurance reimbursement. Physicians held to these standards may not consider setting A1C goals for patients above or significantly below the standard 8 percent, even if their medical history suggests otherwise. And while the ADA guidelines recommend individual goals, they are emphasized less than the standard 7 percent, and can be difficult to interpret and implement.
Laiteerapong said continuing physician education on setting individual goals for diabetes care is key. This may get a boost as more hospitals adopt electronic medical record software, which could be used to help physicians calculate appropriate goals for patients.
“A lot of this could be automated,” she said. “If we can push the information to doctors in a proactive way without making them jump through the mental hoops during their limited time with patients, it would be a huge improvement for establishing wider adoption of individualized goals.”