Abstract
We surveyed state diabetes programs to determine whether they develop and disseminate diabetes guidelines. We found they largely disseminate clinical practice guidelines developed from subspecialty organizations, do not prioritize among the many recommendations contained in diabetes guidelines, and have not adapted guidelines to focus on population rather than individual health. An opportunity exists for state diabetes control programs to better align guidelines with public health goals.
Clinical practice guidelines wield a strong influence over chronic disease care. Many health care organizations issue clinical practice guidelines, and the strength of evidence underlying the recommendations varies.1 Some guidelines emanate from a strong basis in medical evidence, whereas others reflect expert opinion.2,3 Although many have criticized guidelines for lack of transparency and potential for conflicts of interest,4–6 they remain a cornerstone of chronic disease care. Most guidelines are intended to optimize the treatment of individual patients and largely do not address population health.7
Guidelines are particularly important to diabetes care because managing type 2 diabetes is a major challenge for health systems, practitioners, and patients.8 Because diabetes is a multisystem disease, relevant guidelines have many individual recommendations that differ in their relative effects on health and their cost-effectiveness.9,10 Because of diabetes’ public health importance, each US state and territory has a federally funded diabetes prevention and control program (DPCP) within its public health department intended to mitigate the public health burden of diabetes in the community. These programs are well positioned to guide prioritization of clinical services to maximize population health within existing resource constraints.
We explored public health DPCPs’ perceptions about and use of diabetes practice guidelines. We were interested in learning (1) whether state DPCPs have adapted clinical practice guidelines to align with population-based public health goals, (2) how DPCPs perceive the public health value of specific guideline recommendations, and (3) whether DPCPs prioritize individual recommendations within practice guidelines over others.
We conducted an independent survey of Centers for Disease Control and Prevention–funded state DPCPs. We solicited information from all 50 states and the 7 US territories and island jurisdictions operating DPCPs as of August 2009, drawn from a publicly available list.11 We invited DPCP directors and program managers and designees to participate via an in-person announcement at their annual meeting and via e-mail, directing consenting individuals to the Web-based survey administered between August and October 2009. We sent 2 reminder e-mails to nonresponders, contacted them by telephone, and mailed them paper surveys.
The survey addressed (1) extent of guideline dissemination, (2) use of various organizations’ guidelines, (3) resource availability to deliver guideline-concordant care, (4) prioritization and perceived cost-effectiveness of individual recommendations within guidelines, and (5) safety concerns about aggressive glycemic control. We present summary statistics for items for each outcome using a complete data–only approach.
Of 57 federally funded state and territory diabetes programs, 52 completed the survey (response rate 91%). Of the 52, 40 (77%) reported disseminating diabetes guidelines. Of these, 60% (24/40) reported directly adopting other organizations’ recommendations, most frequently citing the American Diabetes Association (23/24, 96%) and the American Association of Clinical Endocrinologists (13/24, 54%). The remainder of the programs that disseminate guidelines (14/40, 35%) reported using a committee process to adapt published guidelines (2/40 missing responses). We examined the resulting 14 state-issued guidelines; none mentions cost-effectiveness, and 1 mentions tailoring for vulnerable populations in the context of social barriers to adherence.
The majority (35/49, 71%) of DPCPs reported that their state lacked the capacity to deliver guideline-concordant care. Nevertheless, of the 49 programs, 29 (59%) reported that their guidelines do not respond to the state's lack of resources, and only 1 explicitly prioritized among domains of diabetes care within their guidelines. This program's guidelines prioritized glycemic control as most important, followed by blood pressure control, and then lipid control.
In terms of perceived public health importance among individual guideline recommendations, DPCPs ranked optimizing glycemic control as most important, followed by blood pressure, and then lipid control (Table 1). For perceived cost-effectiveness (Figure 1), respondents most often perceived glycemic control, blood pressure control, and lipid control as cost saving. All guideline recommendations were perceived as either cost saving or cost-effective.
TABLE 1— Perceived Public Health Importance of Diabetes Care Domains: Survey of Centers for Disease Control and Prevention–Funded State Diabetes Prevention and Control Programs, United States, 2009
| Diabetes Care Domain | Rank (pooled) |
| Optimal glycemic control (HbA1c < 7%) | 1 |
| Optimal blood pressure control (BP < 130/80) | 2 |
| Optimal lipid management (LDL < 100) | 3 |
| Diabetes education from certified practitioner | 5 |
| Annual dilated retinal examinations | 5 |
| Annual foot inspection and monofilament examination | 5 |
Note. BP = blood pressure; HbA1c = marker of glycemic control or a form of hemoglobin which is measured primarily to identify the average plasma glucose concentration over prolonged periods of time; LDL = low-density lipoprotein. Ranking: most important = 1; least important = 10. The sample size was n = 49.
FIGURE 1— Perceived cost-effectiveness of diabetes interventions: survey of Centers for Disease Control and Prevention–Funded state diabetes prevention and control programs, United States, 2009.
Note. BP = blood pressure; HbA1c = marker of glycemic control or a form of hemoglobin which is measured primarily to identify the average plasma glucose concentration over prolonged periods of time; LDL = low-density lipoprotein. The sample size was n = 49.
Of 52 programs, 6 (12%) reported that they disseminated their interpretation of recent findings that tight glycemic control was associated with increased mortality in recent trials. Two suggested raising glycemic targets for special populations, and 1 de-emphasized tight glucose control.
The traditional roles of state health departments include improving population health at low cost, promoting public safety, and working with safety net health systems to promote health for the most vulnerable populations.12 State DPCPs can play a critical role in furthering these objectives for diabetes. Although most DPCPs disseminate guidelines, these guidelines are focused on individual-level risk factor optimization rather than population health. The sources for guidelines are most likely to be subspecialty organizations, such as medical subspecialty societies or single-disease associations, rather than public health or primary care entities.
Although most DPCPs reported that their states do not have the resources or capacity to deliver guideline-concordant care in all domains, most DPCPs do not prioritize among the many individual recommendations contained in diabetes clinical practice guidelines to enable planners and to maximize use of resources to improve population health. Finally, our finding that only 6 DPCPs have communicated possible risks associated with tight glycemic control is surprising, given that informing, educating, and empowering people about health issues is an essential public health function.13
The DPCP respondents perceived glycemic control to be of greater public health importance than is blood pressure or lipid control in diabetes. Optimal diabetes management indeed requires simultaneous control of blood glucose, blood pressure, blood lipid levels, tobacco cessation or avoidance, and access to other preventive services to prevent complications for people with diabetes.14 Although cost-effectiveness is only 1 metric to help determine prioritization and public health importance, abundant evidence exists that controlling blood pressure is the most cost-effective means to reduce morbidity and mortality in diabetes.15
Participants overestimated the cost-effectiveness of achieving recommended glycemic targets. In contrast to respondents’ perceptions, glycemic control is not cost saving. Although it is known that glycemic control is important for preventing microvascular complications,16,17 it is far more costly per quality-adjusted life year than are blood pressure and lipid control18,19 and retinal screening.20
Our study has numerous limitations. We did not conduct preparatory qualitative work to develop the questionnaire but instead relied on our own DPCP experience. We did not explicitly define the terms “cost-effective” and “cost saving,” which may have led to imprecision in our assessment of DPCPs’ perceptions of individual recommendations. We did not distinguish between type 1 and type 2 diabetes in the survey, although approximately 95% of cases in the United States reflect type 2 diabetes and, among the DPCP guidelines we evaluated, all related to type 2 diabetes. Finally, we acknowledge the recent controversy regarding optimal targets for blood pressure control21–23 and the lack of scientific consensus regarding the risks versus benefits of intensive glycemic control,24–26 although the risks of hypoglycemia in vulnerable subgroups is now well established.27,28
State DPCPs play a vital role in advancing public health objectives related to diabetes in the United States. DPCPs often employ the model of influence29,30 in a context of multifaceted quality improvement efforts involving multiple systems, partners, and strategies to build capacity for high quality diabetes care. We believe that DPCPs have the potential to provide a unique perspective on how individual recommendations can affect population health and how allocation of health resources can foster achievement of public health goals in diabetes. With respect to diabetes guidelines, our findings suggest that DPCPs have an unmet need for guidance regarding the relative values of diabetes care recommendations on improving population health, particularly in the context of resource constraints, and our studies have identified a novel area for public health research, capacity building, and leadership.31
Acknowledgments
The Agency for Health Care Research and Quality (K08 HS017594 to U. S.), a National Institutes of Health Clinical and Translational Science award (ULRR024131 to D. S.), and the National Center for Research Resources (KL2RR024130 to U. S.) funded this study.
Note. None of the funders had any role in study design; collection, analysis, and interpretation of data; writing the article; or the decision to submit the article for publication.
Human Participant Protection
The committee on human research at the University of California, San Francisco approved the study protocol.
