Improving the Outcomes of Metabolic Conditions: Managing Momentum To Overcome Clinical Inertia

Hypertension, dyslipidemia, and diabetes are highly prevalent, and often concurrent, conditions: 50 million Americans have hypertension (1), 38 million have high-risk cholesterol levels (2), and 20.8 million have diabetes (3). The direct (medical services) and indirect (disability and premature death) costs of treating diabetes alone exceed $130 billion per year (4). Amputations, renal failure, visual loss, stroke, heart attack, and premature death reduce the length of life of patients and the quality of life for them and their families.

In the last decade or so, several remarkable clinical trials have shown that better control of glycemia, blood pressure, and low-density lipoprotein (LDL) cholesterol level leads to better outcomes (1-3). We now know that surveillance for nephropathy, neuropathy, and retinopathy enables early identification and treatment of diabetes-related complications (5). Guidelines have incorporated the new evidence very quickly. National public education programs and professional societies have disseminated these evidence-based recommendations to the public and to professionals. The new evidence likewise influenced national voluntary consensus standards for performance measurement, which are widely used for accreditation (6) and quality improvement (7).

Has this unprecedented momentum created by publicizing evidence and measuring outcomes resulted in translation of evidence into practice? And if not, why? Two studies in this issue (8, 9) provide us with a progress report from both the public health and managed health care plan perspectives.

Saaddine and colleagues (8) evaluate changes in the quality of diabetes care from the 1990s to the early 2000s. They measured care by comparing patient-level findings on nationally representative, federally sponsored surveys to standardized national consensus measures for diabetes care. The news is mixed. Encouragingly, the number of individuals with hemoglobin A_1c levels between 6% and 8% increased by about 13% to 47%, the proportion of individuals with LDL …