Promoting early diagnosis and treatment of type 2 diabetes: the National Diabetes Education Program.

Abstract

DIABETES MELLITUS EXACTS AN ENORMOUS TOLL IN the United States by decreasing quality of life and causing death and disability, all at a huge economic cost. Yet simple diagnostic criteria and effective treatment choices that prevent or delay the onset of costly diabetes complications are readily available to health care professionals. It is time for health care professionals and patients with diabetes to take action together to reduce premature morbidity and mortality from diabetes-caused disease. The National Diabetes Education Program is the first joint diabetes initiative of the National Institutes of Health and the Centers for Disease Control and Prevention and involves public and private partnerships to promote early diagnosis and improve the treatment and outcomes for patients with type 1 and type 2 diabetes mellitus. It is estimated that in the United States, type 2 diabetes can be present for up to 9 to 12 years before initial clinical diagnosis. Microvasculardiseaseprogressesduringthis time,causing 15% to 20% of patients to have retinopathy and 5% to 10%tohaveproteinuriaat the timeofdiagnosis. Patientswith type 2 diabetes have high rates of hypertension, dyslipidemia, and obesity, major reasons for their 2to 4-fold higher rates ofcardiovasculardisease. Type2diabetes isoccurring increasingly in younger people. Although every patient can be expected to benefit from any increment in improved glycemic control, blood glucose control is more effective in preventing the initial development of microvascular complications than inpreventing theprogressionofcomplicationsonce theyhave become established. This finding underscores the need for aggressive treatment as soon as type 2 diabetes is diagnosed. Diabetes accounts for almost $100 billion in direct medical costs and indirect expenditures attributable to diabetes each year. Further, while patients with diabetes represented 4.5% of the US population in 1992, they accounted for 15% of total US health care expenditures and 27% of Medicare expenditures. There is a marked correlation between glycemic control of diabetes as measured by glycosylated hemoglobin (HbA1c) testing and the cost of medical care. Medical care charges increase significantly for every 1% increase in HbA1c level above 7%. In 1994, excess expenditures for patients with diabetes in a managed care setting totaled $282.7 million or $3494 per person—2.4 times the cost for control subjects. Nearly 38% of the total excess was spent treating the long-term complications of diabetes, predominantly coronary heart disease and end-stage renal disease. Because of its high and increasing prevalence, type 2 diabetes contributes a significant portion of these costs. There is substantial evidence that the human and economic burden of diabetes can be reduced significantly by early, aggressive therapeutic intervention. The Diabetes Control and Complications Trial and the United Kingdom Prospective Diabetes Study (UKPDS) demonstrated that intensive blood glucose control for patients with type 1 and type 2 diabetes significantly reduced the risk for retinopathy, nephropathy, and neuropathy. Lowering blood pressure in a subset of UKPDS patients to a mean of 144/82 mm Hg reduced the risk of strokes, diabetes-related deaths, heart failure, microvascular complications, and vision loss