Close Concerns about the Diabetes Epidemic
Close Concerns attended the ADA's 66th Annual Scientific Sessions in Washington, D.C. in June, where there were over 100 oral presentations, 1,600 posters (a poster is where researchers show the highlights of their work – people walk around and read them in an area that looks like a football field), and 15,000 attendees (doctors, nurses, scientists, businesspeople, journalists, and others).
Some of the most exciting presentations revealed the latest on Byetta and other GLP-1-based therapies (see the May column for more details on this most exciting new therapy), inhaled insulin, and continuous glucose sensing, among other topics.
Dr. Robert Rizza, current ADA President, delivered the "President, Medicine, and Science Address", giving a dramatic, effective, highly-applauded address on the need for the U.S. to fully commit to finding a cure for diabetes and improving diabetes care. Dr. Rizza spoke on some of the same themes that we saw in the notable January New York Times series on diabetes—the phenomenal return on investment that quality diabetes care will give to both individuals with diabetes and to the healthcare system. (If you haven't read the NYT "Bad Blood" series, we highly recommend it.) Dr. Rizza underscored the devastation that diabetes is inflicting on our country, and he showed that optimal diabetes care for all could save millions of lives and billions of dollars.
The statistics are stunning. More than 20 million people in the United States have diabetes, and more than 40 million have prediabetes. It is projected that one in three children born today will develop diabetes. In 2002 alone, diabetes costs in the US totaled $132 billion. Costs of complications from diabetes are prodigious. Diabetes is the number one cause of new blindness in adults 20-74 years of age, of kidney failure, and of non-traumatic lower-limb amputations.
In emphasizing the great threat diabetes poses to our population and the problem with governmental inaction on this front, Dr. Rizza compared diabetes to a "biologic weapon." Clearly our government would take swift action if an enemy used biological warfare against our nation, so why not for diabetes? To illustrate his point, Rizza used an evidence-based healthcare model called Archimedes to quantify the predicted benefits of a cure for diabetes and optimal diabetes care. Archimedes is a robust mathematical model of physiology and health care delivery, created for Kaiser Permanente in the early 1990s by David Eddy, MD, PhD, and Leonard Schlessinger, PhD. Equations simulate metabolic pathways and processes leading to diabetes complications, and the model creates virtual people. (As for its validity, Archimedes has independently predicted the results of randomized controlled trials that were not used in the model, including accurate prediction of Diabetes Prevention Program results before they were even published.)
Archimedes estimates that over the next 30 years, diabetes will lead to 57 million deaths and 127 million serious adverse events, including heart attacks, strokes, and amputations. The model predicts that it will cost $6.6 trillion over the next 30 years to treat the complications of people alive today with diabetes. On the other hand, it predicts that if diabetes were cured tomorrow, over the next 30 years there would be a 45% reduction in serious complications. The predicted cost savings over the next thirty years would be a whopping $700 billion.
While it's nice to consider, diabetes is not going to be cured tomorrow. Dr. Rizza quantified the predicted benefits of treating 100% of diabetes patients with optimal care. Optimal care was defined by ADA recommended goals: A1C less than 7%, blood pressure less than130/80 mmHg, LDL less than100 mg/dL and statin therapy for LDL.-lowering, HDL exceeding 40 mg/dL in men and 50 mg/dL in women, triglycerides under150 mg/dL, no smoking, and daily aspirin therapy. If all patients received optimal diabetes care, Archimedes predicts that over the next thirty years there would be a staggering drop in serious diabetes complications: 57% reduction in the risk of diabetes complications and a $325 billion reduction in medical costs.
What if 80% of patients met ADA goals? Rizza termed this idea "committed care." Without the smoking cessation requirement, if 80% of patients achieved ADA goals, Archimedes predicts 11 million fewer serious diabetes complications and a cost savings of $150 billion over the next thirty years. Rizza presented cost analysis: Lowering A1C to less than 7% while lowering blood pressure to less than 130/80 saves money. Meeting A1C, blood pressure, LDL, HDL, and triglyceride goals, along with aspirin therapy is cost neutral. We would save lives and reduce complications without even spending more money!
Lastly, Dr. Rizza raised the idea of giving a polypill (all in one pill) containing metformin, a low-dose aspirin, a generic statin, and a generic ACE-inhibitor to diabetes patients. The cost would be about $100 per patient per year and would result in a dramatic decrease in complications. Cost savings would begin to accrue after 5 years and would increase each year thereafter. One pill containing all of these medications would improve what some people call "compliance" – this means taking all your medicine on time!
Dr. Rizza pointed out that it costs less to treat diabetes than it costs to treat the complications of diabetes that result from not treating the disease in the first place. Treating diabetes is a wise investment. Dr. Rizza stressed the need for the United States to invest more in diabetes research. He eloquently stated that the size of this investment should be commensurate with the risk diabetes poses to our society. Right now, it's not even close.
What's amazing is that there is no cost-benefit analysis to be performed here—excellent care, healthy, long lives for people with diabetes, and huge savings to the government and healthcare system all are aligned. Which means that individuals with diabetes like you should advocate for the absolute best care and for reaching or beating the ADA treatment goals above. As you may know, while the ADA target for A1c is 7%, other organizations like the American Association of Endocrinologists and many physicians recommend an A1c lower than 6.5% or even 6.0%. If your healthcare team isn't independently motivated to bring you there, remind them – loudly, if you need to - that you want an A1c, blood pressure, and cholesterol readings in the recommended ranges.
NOTE: The information is not intended to be a replacement or substitute for consultation with a qualified medical professional or for professional medical advice related to diabetes or another medical condition. Please contact your physician or medical professional with any questions and concerns about your medical condition.
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