Data Collection and Diabetes Screening, Management Needs Improvement

A new study published in Population Health Metrics showed the differences in detection and management of type 2 diabetes among insured and uninsured adults in the United States.

In 2012, an estimated 28.9 million adults in the United States have diabetes, including 8.1 million whose diabetes was undiagnosed. National statistics suggest a significant proportion of cases are undiagnosed, untreated, not under optimal control, and at high-risk for complications and associated medical and indirect costs.

The investigators sought to address key questions by state and insurance types: how many insured adults in 2012 had diagnosed and undiagnosed type 2 diabetes; among diagnosed type 2 diabetes cases, how many received diabetes mediation and recommended exams; among patients who received diabetes medication, how many had poorly controlled diabetes as indicated by ICD-9 diagnosis codes; and how the prevalence of diabetes complications and annual medical expenditures differed by diabetes control status.

For the study, the investigators conducted a combined analysis of survey data with medical claims for the commercially insured, Medicare, and Medicaid populations, to estimate the number of adults diagnosed with type 2 diabetes and undiagnosed diabetes by insurance type, age, and gender.

The investigators analyzed medical and pharmacy claims from 2011 to 2012 for commercially insured adults using the OptumInsight de-identified Normative Health Information database, the 2011 Medicare Standard Analytical File 5% sample for the Medicare population, and the 2008 Mini-Max file for the Medicaid population. All analyses were conducted by state, age, and gender.

Patients with diabetes were identified if the patient had at least 1 emergency department visit or hospitalization, had 2 separate ambulatory visits with a diabetes diagnosis submitted during the year, or if the patient used insulin or other diabetes-related medications.

The results of the study showed that of insured adults in 2012, approximately 16.9 million had type 2 diabetes, 1.45 million had type 1 diabetes, and 6.9 million were undiagnosed. Of the patients diagnosed with type 2 diabetes, approximately 13 million received diabetes medication ranging from 70% in New Jersey to 82% in Utah. Suboptimal percentages had claims indicating that recommended exams were performed, according to the study.

Forty-three percent of patients receiving diabetes medication had least 1 medical claim that indicated poorly-controlled diabetes, ranging from 18% with poor control in Minnesota and Iowa to 53% in Texas.

The prevalence of neurological conditions was +14% among the uncontrolled diabetes computation compared with the population that had no indication of uncontrolled diabetes. Among the uncontrolled population, there was a +14% higher prevalence of renal failure, and +13% for “other” complications. Peripheral vascular complications were +11% higher, and endocrine/metabolic complications +10%.

Patients with uncontrolled diabetes had higher annual health care expenditures, averaging $4150 per type 2 diabetes patient. The average expenditure differences between controlled and uncontrolled diabetes were found to be highest among the commercially insured population ($6680), followed by the Medicaid population ($4360), and Medicare population ($3430).

Limitations in the study were as follows: analysis of medical claims were restricted to a fee-for-service population, as medical claims are often incomplete for patients in capitated managed care plans; uncontrolled status was determined by diagnosis code, rather than independent lab results; medical claims were unavailable for care provided through the Veterans Health Administration, Indian Health Services, and other providers; although the OptumInsight dNHI claims data were nationally representative of the privately insured patient population, it may not be representative of states where UnitedHealthcare and other insurers have smaller market shares; the analysis partially relied on self-reported data collected through surveys; and some data sources were combined from multiple years between 2008 and 2012 to increase sample size.

The results of the study showed a large number of patients with undiagnosed diabetes, and large numbers of diabetes patients who are not receiving medication or monitoring exams, which indicates the need for a greater commitment from providers to closely monitor patients, and to be more aggressive in following standards of medical care, according to the authors.

Furthermore, the study highlights gaps in the quality of diabetes care among patients with diagnosed diabetes, and corresponding poorly controlled diabetes. The authors concluded that there is a need for improved data collection, and diabetes screening and management, as well as policies that support these improvements.