A “cascade-of-care” model that has been successfully used in improving HIV and AIDS care may similarly improve diabetes care, especially in patients who are unaware of their condition.

New research has found that almost one-third of American adults with diabetes remain undiagnosed despite the fact that many of them have regular access to care. Researchers believe that looking at the big picture with a “cascade-of-care” model, similar to one that has been used successfully to find gaps in HIV/AIDS care, can increase awareness of the diagnosis, engagement, and treatment of diabetes.

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Published in the Annals of Internal Medicine, the study looks at data from 2007 to 2012 from the National Health and Nutrition Examination Survey (NHANES).

They found that in 2012, an estimated 28.4 million U.S. adults had diabetes. Roughly 30 percent of them — or almost 8 million Americans — were unaware they had it.

Among diagnosed adults, 95 percent had a usual care provider and 92 percent saw their doctor two or more times in the past year. In contrast, among undiagnosed adults, 85 percent had a usual care provider and 67 percent reported two or more visits in the past year.

Study co-author Mohammed K. Ali of Emory University told Healthline that a cascade-of-care model is a visual diagram that maps out the entire care continuum. This helps doctors see where people’s care falls in relation to other people with a particular condition, such as diabetes.

“Are they getting the care they should receive at every point in the care continuum? It is a way of identifying who knows they have the disease, who is engaged in care, and how well are they doing,” Ali said. “If you can spot where the gaps are happening, that’s where you are going to intervene the most. Providers can show patients the data and say, here’s where you are doing well. You have the blood pressure thing down, but your blood glucose, sugar, and cholesterol are not well controlled. What can we do together to make that better?”

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The researchers also found that undiagnosed people don’t engage in their care as much as people who are diagnosed.

“There’s a big missed opportunity in our care system to really care for people better had we known about their diabetes status and they had been tested for their cholesterol levels and actually been treated,” Ali said.

Between 60 and 65 percent of people with diagnosed diabetes have their sugar or blood pressure level controlled, but only about 20 to 25 percent control all three risk factors ― blood glucose, blood pressure, and cholesterol.

“The science in the past few years has shown us that those that have all three controlled are the ones that are going to do the best in terms of preventing heart disease, kidney disease, and eye disease. Those were the big gaps we saw,” Ali said.

If 80 percent of undiagnosed people are linked to a care provider and about two-thirds have been to a care provider twice in the past year, why do they remain undiagnosed?

Patient motivation and whether or not they have insurance coverage may be to blame. “It may also be those patients with undiagnosed disease may have been coming to the doctor for a cold or because their back hurts. It may not ring a bell in physician’s ear, I should test them for diabetes,” said Ali.

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The study found that undiagnosed diabetes was more common in men and young adults 18 to 44 years old.

Young adults may not perceive themselves to be at high risk for diabetes so they may not go for a screening or visit a provider regularly, or they may not buy health insurance immediately after their parent’s health insurance coverage ends. The researchers also found that younger adults with diabetes didn’t fare as well as other groups when it came to meeting care goals.

As far as the future of diabetes care, although the cascade can be a simple hand drawing, Ali envisions doctors integrating the visual representation into their electronic medical records. “A cascade of care can really help them see where their patients are falling off and help them continue to improve,” Ali concluded. “This is how we can get patients to do better at managing their own health.”

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