"The Benefits of Tight Control: No End in Sight", Wayne Clark, Diabetes Self-Management, May/June 2006.
This article presciently reviews what we know about tight control - how many people with diabetes in the U.S. are getting there, and what it means for complications. Clark recounts the details of the Diabetes Control and Complications Trial (DCCT), which proved the hypothesis that tight glucose management reduces the risk of complications. The study also famously proved that there is no glycemic threshold, or point below which a lower HbA1c does not yield additional benefit. The follow-up study to the DCCT, the Epidemiology of Diabetes Interventions and Complications (EDIC) trial, found that even years after the DCCT, when the A1c's of the two patient groups converged, patients from the intensive management cohort still had fewer complications. A similar study, the United Kingdom Prospective Diabetes Study (UKPDS) published in 1998, found that intensive control in type 2 diabetes reduced microvascular complications by 25%.
Despite these impressive studies - which collectively followed more than 6,500 patients - data show that less than one-third of patients today are reaching glucose targets. In the article, Clark reviews some barriers to tight control, including lack of insurance coverage, the progressive nature of type 2 diabetes, and the way in which medical care is delivered. On this last point, MaineHealth in Portland, Maine, has implemented a Chronic Care Model that tackles diabetes using electronic registries, automated reminders and notices, and multidisciplinary treatment teams. As part of this program, nurse specialists called Chronic Illness Care Managers are incorporated into primary care practices to provide patients with more intensive education and motivational support. The model has been successful; the percentage of people with A1c values under 7% jumped from 41% to 49%, while the percentage of people with an A1c higher than 8% decreased from 31% to 24%.
The bottom line: Despite the poor outcomes for many diabetic patients, the Chronic Care Model used in Maine shows that enlightened, rigorous treatment can benefit many people with the disease. The challenge is how to spread these efforts to other parts of the country.
(The site is www.diabetesselfmanagement.com, but the article itself is not available online.)