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Introduction

The problem​

Diabetes is a serious, common, and costly chronic disease that affects 29.1 million people, or 9.3 percent of the U.S. population. About 1.7 million new cases are diagnosed annually amont adults aged 20 years or older.[1] Diabetes disproportionately affects African Americans, Hispanic Americans, American Indians, Asian and Pacific Islanders, and older Americans. Complications from the disease include cardiovascular disease, vision loss, kidney failure, nerve damage, and lower-extremity amputations. These complications can subsequently result in higher rates of disability, increases in the use of health care services, lost days from work, unemployment, illness, an​d premature death.

Type 1 and type 2 diabetes

Type 1 diabetes usually strikes children and young adults, although disease onset can occur at any age. In adults, type 1 diabetes accounts for 5 to 10 percent of all diagnosed cases of diabetes.[1] About 90 to 95 percent of people with diabetes have type 2 diabetes, which more commonly occurs in adults older than age 45 who are obese and have a family history of the disease. Overweight and obese children are at increased risk for developing type 2 diabetes during adolescence and later in life. This increased incidence of type 2 diabetes in youths is a first consequence of the obesity epidemic among young people and a significant and growing public health problem.[2]

Intensive versus standard therapy​

Investigators in the Diabetes Control and Complications Trial (DCCT), a large clinical trial of intensive versus standard therapy for adults with type 1 diabetes, reported in 1993 that intensive glucose control reduced eye, nerve, and kidney damage. Findings reported in 2005 from the Epidemiology of Diabetes Interventions and Complications[3] (DCCT follow-up) study and in 2008 from the 10-year follow-up of the United Kingdom Prospective Diabetes Study (UKPDS)[4], show that intensive glucose control (A1C* goal <7 percent) in newly diagnosed people with either type of diabetes not only has benefits during the period of intensive therapy but also has a “legacy effect” in which micro- and macro-vascular benefits are realized years later.

Cost of diabetes​

The estimated diabetes cost in the United States in 2012 was $245 billion, including $176 billion for direct medical costs and $69 billion in indirect costs, such as disability, time lost from work, and premature death.[5]

Computer modeling has shown that compared to standard treatment, early, effective diabetes management can reduce treatment costs for diabetes complications of the eye, kidney, and extremities.[6] There is a marked correlation between glycemic control and the cost of medical care, with medical charges increasing significantly for every 1 percent increase in A1C above 7 percent.[7] The increase in medical charges accelerates as the A1C value increases.

Prevention or delay of diabetes onset​

Eighty-six million American adults have prediabetes and are likely to develop type 2 diabetes within 10 years, unless they take steps to prevent or delay diabetes. Prediabetes occurs when a person’s blood glucose is higher than normal but not high enough for a diagnosis of diabetes. The Diabetes Prevention Program (DPP), a large prevention study of people at high risk for diabetes, showed in 2002 that lifestyle intervention reduced the incidence of diabetes by an average of 58 percent over 3 years (by 71 percent among adults age 60 or older); diabetes incidence was reduced by 31 percent in those taking metformin.[8] A cost-effectiveness model estimated in 2005 that the DPP lifestyle intervention would cost society about $8,800 per quality-adjusted life-year saved (within a typically acceptable range). Metformin would cost about $29,900 per quality-adjusted life-year saved and was considered not cost-effective after age 65.[9]

In 2009, a 10-year follow-up study of DPP participants, the Diabetes Prevention Program Outcomes Study, found that diabetes incidence was reduced by 34 percent in the lifestyle group and 18 percent in the metformin group compared with placebo. These results show that prevention or delay of diabetes with lifestyle intervention or metformin can persist for at least 10 years.[10] Interventions to prevent or delay type 2 diabetes in people with prediabetes are feasible and could be cost-effective.

Models for better diabetes care​​

The Chronic Care model[11, 12], the Medical Home model[13], and the Healthy Learner model[14] provide frameworks for effective care of diabetes and other chronic diseases. All incorporate team care as a vital component of delivery system design. These models will likely guide health care reform initiatives that incorporate an integrated health care delivery system.

This publication, Redesigning the Health Care Team: Diabetes Prevention and Lifetime Management, provides the following

  • an overview of the evidence that supports team care as a component of effective diabetes management
  • practical information to help health care professionals and organizations incorporate team care into practice in a variety of settings
  • tables with steps for forming and maintaining a successful team
  • eight case studies that demonstrate real-world team care in several different settings

* NDEP and its partners have adopted the simple name “A1C” for the hemoglobin A1C test. A1C is a standardized blood test that indicates the average blood glucose over the previous 8 to 12 weeks. A1C values and self-monitoring of blood glucose can be used to guide therapy to achieve glycemic targets. People with diabetes need to know their own A1C values and whether they are reaching their targets.

February 2013

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