Organizations (ACOs), who primarily focus on comprehensively maintaining the health of the patient. Care coordination and education between providers and patients, as well as an overall restructuring of care delivery in the healthcare system, may improve the health status of the population and reduce health expenditures in the long run. Keywords: Chronic disease, Type II Diabetes Mellitus, Accountable Care Organizations, Social determinants, Care management
Introduction of Chronic Diseases
According to the Center for Medicare and Medicaid Services (CMS), the United States spent $2.7 trillion dollars on healthcare in 2011, which made up 17.9% of the GDP (Squires, 2012). One of the most pressing issues affecting a high amount of Americans while contributing a significant amount to health expenditures are chronic conditions, which account for more than 75% of healthcare expenditures at approximately $2.025 trillion. Chronic conditions are prolonged in duration, do not resolve spontaneously, and are rarely cured completely (CDC, 2013). All chronic illnesses have the potential to limit the functional status, productivity, and quality of life of those affected (IOM, 2012). According to The Center for Disease Control and Prevention (CDC), 133 million Americans suffer from chronic conditions, which cause 7 out of 10 deaths each year in the United States (CDC, 2013). Chronic disease accounts for more than 75% of healthcare expenditures, which is approximately $2.025 trillion. TheInstitute of Medicine (IOM) asserts, “All chronic illnesses hold the potential to worsen the overall health of our nation by limiting an individual’s capacity to live well,” and has defined a list of nine chronic conditions that affect the most people and dominate health expenditures in the United States (IOM, 2012).
The chronic condition from which the fourth-most Americans suffer, Type II Diabetes Mellitus (T2D), could in many cases have been prevented through a change in the delivery of care (Table 1). T2D is the sixth leading cause of death in the United States (2010 National, 2010). Many of the known risk factors have implications on the healthcare system. For example, as of 2007, the U.S. has spent approximately $174 billion on care related to T2D (AHRQ, 2012).
An Overview of Type II Diabetes Mellitus
Approximately 8.3% of the United States population is affected by diabetes. There are 25.8 million people in the United States with diabetes, 18.8 million of which who have been diagnosed with diabetes, and an estimated 7.0 million people who have diabetes but have not been diagnosed (National Diabetes, 2011). Diabetes is a chronic disease caused by the body’s inability to make or process insulin, which is required to convert glucose into energy (Mayo Clinic, 2003). Diabetes Mellitus Type I, occurs when the pancreas is unable to produce insulin. This is typically a congenital disease, and it can be managed through insulin injections (Mayo Clinic, 2003).
Insulin-resistant diabetes mellitus, commonly referred to as T2D, is the most common form of diabetes, affecting 95% of people with diabetes (American Diabetes Association, 2014). In T2D, the fat, liver, and muscles of the body are unable to properly respond to insulin, which allows high levels of sugar to build up in the blood, resulting in hyperglycemia (NIH, 2013). Early symptoms of T2D are fatigue, hunger, increased thirst, increased urination, and bladder, kidney, skin, or other infections that are more frequent or take longer to heal (NIH, 2013). There is currently no cure for T2D. However, treatments include blood sugar monitoring, healthy eating, regular exercise, and some forms of diabetes medication or insulin therapy (Mayo Clinic, 2013).
There are many risk factors associated with T2D, some of which include: obesity, hypertension, a family history of diabetes, a prior history of gestational diabetes, high cholesterol levels, or physical inactivity (CDC, 2013). These risk factors are more commonly found in older populations as one’s health status continues to decline with age, leading to a higher rate of risk factors of T2D. Figure 1A demonstrates the positive correlation between T2D incidence and age, demonstrating that older age categories had higher rates of incidence of T2D. Due to the current declining health of the population of a whole in the United States, including higher rates of obesity and related co-morbidities, general incidence of T2D has also increased (Fig 1B). The risk factors mentioned above, such as being overweight or obese, having high blood pressure, and abnormal cholesterol levels are three factors that are most prevalent in African American, American Indian, Asian American, Pacific Islander, andHispanic American/Latino communities. Thus, many diagnosed with T2D in the United States fall into the aforementioned ethnic communities, which highlights the possible issue of health disparities. Figure 1C demonstrates the higher rate of diagnosed diabetes in groups of African Americans and Asians than in groups of Caucasians. Moreover, studies have shown that minorities for the most part have high complication rates when it comes to T2D, indicating possible discrepancies in treatment and management (Fig 3). Furthermore, the rate of diabetic end stage renal disease (ESRD) is 2.6 times higher among African Americans than Caucasians, which may be attributed to the interaction between hypertension and T2D (AHRQ, 2013).
Figure 1: Statistics of Noninstitutionalized Population with Diagnosed Diabetes, United States, 1980-2011. A. Percentage of civilians affected by age: increased incidence of diagnosis of T2D over a 30 year span in all age groups, with a significant increase in the 65-74 and 75+ age groups. B. Number (in millions) of civilians affected by age: increased incidence and steadily increasing prevalence of T2D in the United States population over a 30 year span, possibly demonstrating changes in the health of the population. C. Age-specific percentage of civilians by age, race and sex: higher prevalence of T2D among African Americans and Asian Americans in comparison to Caucasian Americans and increased prevalence of T2D with increased age for all represented groups. D. Age-adjusted percentage of civilians affected by education: those who did not graduate high school consistently had a higher incidence of T2D between 1980 and 2011 while those who finished high school or completed education ata higher level than high school maintained a similar incidence between 1980 and 1988; but those who had only completed high school had a higher incidence of T2D starting in 1988 (CDC, 2013).
The Challenges of Managing Type II Diabetes in the Current Environment There are many challenges associated with managing T2D because of the difficulty in addressing the root issues. Changing the root problems would revolve around a lifestyle change of factors that are often beyond the scope of control of the person affected by diabetes. The risk factors associated with T2D are highly associated with the social determinants of health, which can be defined as the circumstances in which people are born, grow up, live, work, and age, and the systems put in place to deal with illness, which are in turn shaped by a wider set of forces: economics, social policies, and politics (Social determinants, 2013). Being unable to afford or have access to healthy foods, which help to prevent obesity, hypertension, and high cholesterol, may affect the intake of proper nutrients and increase the intake of unhealthy foods. Additionally, safety and community issues may play a role in the amount ofphysical activity one can get. Health disparities influenced by these social determinants perpetuate risky health behaviors that can increase the chances of developing T2D. The differences in prevalence between different levels of education have increased between 1980 and 2011 (Fig 1D). This may be due to the same socioeconomic factors that affect various ethnic/racial groups that contribute to risky health behaviors. This, again, could possibly be linked to health disparities and the impact of the social determinants of health. Social determinants are difficult to overcome, especially if one is in a socioeconomic position in which he or she cannot address certain recommendations for lifestyle changes. This leads to poor health behaviors that lead to negative health outcomes later in life, such as T2D. Poor health behaviors, such as unhealthy diet and lack of exercise, are perpetuated throughout the lives of the individuals and by individuals in the community, which may lead toobesity, hypertension, and high cholesterol levels, all of which can lead to T2D. Once an individual is diagnosed with T2D, it is just as difficult to manage because the same social determinants that helped perpetuate the development of T2D are in place. The individual may still not have access to healthy foods, may still not be able to pursue an increase in physical activity, and may still not be able to take control of their own health. Managing T2D brings up one of the major issues that inherently plague the United States healthcare system, which is addressing acute, episodic care, instead of practicing comprehensive and preventative care. Currently, the reimbursement system pays more for procedures and acute episodes of care, such as heart attack and stroke, the rates of which are increased by the same risk factors that lead to T2D. Instead of receiving consistent, preventative treatment, people continue to practice bad health behaviors until they develop T2D. Although treatmentfor diagnosed T2D can be covered by insurance, actions taken to prevent T2D are not covered or addressed by the system. The current system of payment does not address the root causes of diabetes, which tend to be the social determinants of health. This perpetuates the development of diabetes, significantly increasing the health expenditures in the U.S. healthcare system as it continues to pay for the management of T2D. Currently, the Affordable Care Act (ACA) is expanding coverage through the health insurance exchange and Medicaid expansion. While this will be beneficial to those who previously could not afford insurance, this still does not address the problems associated with T2D, but is simply enabling more people to receive care for T2D. Although this is beneficial for the population, it does little to reverse the current pattern, and simply perpetuates the increase in prevalence. Another issue that makes T2D difficult to manage is the actual clinical management. It requiresconstant monitoring of blood sugar levels, as well as consistent adherence to prescribed medication. The National Diabetes Education Program has developed a four-step approach to managing T2D: Learn about diabetes, know your diabetes ABCs, learn how to live with diabetes, and get routine care to stay healthy (4 Steps, 2012). It is often up to the patient to seek out information to fully understand diabetes. Although the physician may explain diabetes, they can feel rushed and may not be able to fully explain management of T2D in a way that the patient understands due to health literacy barriers or language barriers (Marvel, 1999). While the Internet may be filled with information to adequately address diabetes concerns, many people are not able to access the correct information to learn about their diabetes. This brings up issues in the delivery of care and reimbursement system as well. Because reimbursements are higher for more complicated, acute procedures, physicians get reimbursedvery little to explain diabetes management to a patient (Green, 2013). Additionally, the hospitals make more money over time by treating diabetes, whether through the actual management, or through critical acute issues that may arise from the same risk factors of T2D, such as heart attacks and strokes. Overall, the current healthcare reimbursement system simply makes not preventing diabetes and not educating about diabetes more economically favorable (Green, 2013). The National Diabetes Program asserts that the patient must know their “Diabetes ABCs,” which are different health indicators that must be managed to lower the chances of having heart attacks, strokes, or other diabetes-related problems. “A” stands for the A1C test, which measures the average blood level over the past three months. If the blood level is too elevated, the heart, blood vessels, kidneys, and feet could be negatively affected. “B” stands for blood pressure, which must be measured to prevent the heart fromoverworking, which could result in heart attack or stroke. “C” stands for cholesterol. Low density lipoprotein (LDL) cholesterol buildup can result in heart attack or stroke, whereas HDL helps remove LDL cholesterol from blood vessels. Although the three ABC tests can monitor the chance of heart attack and stroke, studies have shown that there is still discrepancy in the delivery of these tests. The National Health Disparities report demonstrated that there were disparities between different races/ethnicities that had their hemoglobin (Hb) A1c levels, their total cholesterol, and blood pressure under control. (2010 National, 2010). The Agency for Healthcare Research and Quality (AHRQ) found a low rate of adults age 40 and over with diagnosed diabetes who had reported receiving the four recommended services. The highest percentage that received all four recommended services was the 60 and up age range at 30% (Fig 2). The four recommended services for diabetes include two or more HbA1ctests, a foot exam, a dilated eye exam, and a flu shot (AHRQ, 2012). Learning to live with diabetes and getting into a routine is highly influenced by the social determinants of health, especially in regards to economic resources. While the actual medications and tests may be paid for by insurance, the lifestyle change required for a diabetic may still be out of financial reach. Keeping track of blood sugar and checking blood pressure may also be difficult for many patients and many might not adhere to the medical recommendations. The National Diabetes Education Program also suggests seeing a healthcare provider at least twice a year for a blood pressure, foot, and weight exam, in addition to an A1C Test. It is recommended that once a year patients have a cholesterol test, a triglyceride test, a complete foot exam, a dental exam, a dilated eye exam, a flu shot, and a urine test (NDEP, 2013). It is clear from the study above that not all people with diabetes are receiving this processof care. The current healthcare system lacks a consistent primary care provider gatekeeper who would help facilitate to make sure these tests were performed in order to maintain the health of the patient. The lack of primary care provider (PCP) also brings up an issue in diagnoses. As mentioned above, it is estimated that approximately 7.0 million people do not know that they have diabetes (National Diabetes, 2011). Without consistent check-ups with a PCP, it is very difficult to determine whether or not one is suffering from diabetes, since the symptoms are not extremely obvious and become more evident over time. The Institute of Healthcare Improvement (IHI) has introduced the triple aim of healthcare would require developing three dimensions: improving the patient experience of care, improving the health of populations, and reducing the per capita cost of healthcare (IHI, 2013). Currently, the healthcare system is not achieving these aims for diabetes. Overall, the main issues indealing with T2D are that the current delivery system is not focused on coordinated care or preventative care, the current reimbursement system is not focused on patient-centeredness, and the root causes of T2D are difficult to address. Figure 2: Adults age 40 and over with diagnosed diabetes who reported receiving four recommended services for diabetes in the calendar year (2+ hemoglobin A1c tests, foot exam, dilated eye exam, and flu shot), by age and residence location, 2008-2009 (AHRQ, 2012).
Best Practices for Management of Type II Diabetes
In order to facilitate optimal outcomes in diabetes management, several guidelines have been established outlining best practices. These best practices, once fully explored, can eventually be implemented as a standard process of managing chronic disease in an effort to increase the standardized, evidence-based practice that can lead to better health outcomes overall. The following are best practices in the clinical aspect of T2D care and the standards of self-management of diabetes.
could potentially be a significant decrease in incidence of T2D, as more established processes of prevention and management are developed. This could lead to better outcomes of the United States population overall, by not only reducing the prevalence of T2D and its associated health risks, such as heart attack and stroke, but also by reducing risk factors associated with T2D, such as hypertension, obesity, and high cholesterol levels. This can lead to both a healthier nation and a decrease in health expenditures in the future. References 2012 National Healthcare Quality Report. (2013, May). Retrieved from
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