The diabetes community has been reeling over a recent New York Times article, published in early April 2014, commenting that recent small medical advances can lead to huge jumps in the cost of medical care. There has been so much discussion in regard to this article, written by a New York physician at Montefiore Hospital, that leaders of the diabetes community have written responses to The New York Times not only correcting misinformation, but alluding to all the positive results from advancing technology.
This week, a timely paper entitled “Changes in Diabetes-Related Complications in the United States, 1990-2010” appeared in the prestigious New England Journal of Medicine. The authors—Gregg, Li, Wang, Burrows, Ali, Rolka, Williams, and Geiss—examined trends in the incidence of diabetes-related complications over the years between 1990-2010 (N Engl J Med 2014; 370: 1514-1523/ April 17, 2014.)
What was their source material?
The authors used data from the following surveys:
- National Health Interview Survey
- National Hospital Discharge Survey
- The US Renal Data System
- US National Vital Statistics System
By analyzing the information from these sources, the authors compared the “incidences of lower extremity amputation, end-stage renal disease, myocardial infarction, stroke and death from hyperglycemic crisis between 1990-2010, with age standardized to the US population in the year 2000.”
What were the results?
Based on the above sources, rates of all five complications examined in the paper declined between the 20-year interval, with the largest declines in the rate of heart attacks (decrease of 67.8 percent) and death from hyperglycemia (decrease of 64.4 percent), followed by stroke and amputations (decrease of 50 percent). The smallest decline was in end-stage renal disease (decrease of 28.3 percent). According to the authors, the rates of reductions were larger among adults with diabetes than among adults without diabetes, thus leading to a reduction in the relative risk of complications associated with diabetes.
What may we conclude from these results?
“The rates of diabetes-related complications have declined substantially in the past two decades.” However, the authors were quick to point out that the huge burden of diabetes persists, as shown by the continued increase in the prevalence of diabetes. In the discussion section of the paper, the authors felt that the “findings probably reflect a combination of advances in acute clinical care, improvements in the performance of the health care system, and health promotion efforts directed at patients with diabetes.” They also noted that the decrease in diabetes-related complications are directly related to “ increased emphasis on the integrated management of care for patients with diabetes including enhancements in team-based care, patient education in disease management, and clinical decision-making support that occurred after the 1993 results of the Diabetes Control and Complications Trial.” In addition, the authors noted that “advances in more intensive medical procedures and improvement of hospitals’ management of diabetic ketoacidosis and hyperglycemic hyperosmolar coma, in combination with better patient education in disease management, contributed to the findings as well.”
Several significant limitations of the study must be addressed. These include a lack of data on hypoglycemia and trends for age-related complications of type 2 diabetes, as well as to evaluate trends in the incidence of diabetic retinopathy and determine if these trends in diabetes-related complications differ between persons with type 1 diabetes and type 2 diabetes.
Thus, as a result of the seminal 1993 Diabetes Control and Complications Trial, we may extrapolate that intensive insulin therapy leading to improved blood glucose control decreases complications. Thus, any technology (glucose meters, ketone strips, hb A1c levels, etc.) that may assist in this process would be considered invaluable to many persons with diabetes. Despite the fact that no specific mention was made by the authors regarding the use of advanced technologies including the insulin pump, continuous glucose sensor, and the eventual artificial pancreas, nor was there a mention of the life-saving kidney pancreas transplantation procedures, it is clear that these technologies have played a major role in the decrease of diabetes-related complications.
Money spent wisely?
Ask any person with diabetes…
Published On: May 05, 2014