Jim Poggi
Physician Office Lab
By Jim Poggi
A word of caution regarding this month’s lab article: it’s about diabetes, and the statistics are not pretty. So, if you’re squeamish, or you think we are doing a great job diagnosing and monitoring diabetes, or just believe “it can’t happen here”, turn the page. But, if you believe we have all the right tools to diagnose and monitor diabetes, believe we need to do better work with the healthcare community and think your personal involvement can make a difference, read on. There is plenty of work to do.
What are we up against?
With some of the biggest lab companies in the world offering multiple testing methods to screen for and monitor diabetes – not to mention the abundance of diabetes meters available – you’d think diabetes in the United States would be well on its way to eradication. In addition, there are a growing number of new diabetes medications for both type 1 and type 2 diabetes. At the same time, you would expect that every primary care practice in the United States would have an effective diabetes screening and management program in place and a high patient compliance rate. So, there would be “nothing to see here, right”?
While the death rate for diabetes is decreasing, the total number of diagnosed and undiagnosed diabetics is increasing. It is currently estimated that there are 23 million diagnosed diabetics and over 7 million remaining to be diagnosed. In 2015, 1.5 million new diabetics were diagnosed.
The picture for pre-diabetes (defined as A1c of 5.7 to 6.4 percent or fasting glucose in the 100-125 mg/dL range) is worse. The incidence is over 84 million Americans, or more than 33 percent of the U.S. population. If you total the number of diabetics and prediabetics, the number is over 115 million, nearly one of two Americans. Diabetes is most prevalent in the south and Appalachian states, among people with less than a high school education and among people in their middle years (45-64). A last sobering statistic: diabetes is the seventh leading cause of death in the United States, taking more than 76,000 lives in 2014, but it is implicated in over 250,000 deaths or more than 9.6 percent of all deaths in 2014.
What are the risk factors for diabetes?
Among adults over 18, the key risk factors are listed below. While we can’t control our genetics, we can choose healthy habits. In many ways, the risk factors are related to personal health habits and lifestyle choices.
- Smoking
- Overweight and obesity
- Physical inactivity
- High blood pressure
- High cholesterol
- High blood glucose or A1c
We have the tools to do the job
For diagnosis of diabetes or pre-diabetes, we have an excellent combination of vital signs metrics and lab diagnostic tools. For monitoring, we also have the right tools for the job. While A1c tests have been cleared for monitoring for several years, recently a waived A1c test has been cleared for diagnosis also, and joins several large chemistry system assays cleared for diagnosis of diabetes.
| Risk Factor | Diagnostic tool(s) | Diagnosis/monitoring/both |
| Smoking | History, cotinine test | Both |
| Overweight/obesity | Office scale, waist measurements | Both |
| Physical activity | History, patient dialogue | Both |
| High blood pressure | Blood pressure cuff | Both |
| High cholesterol | Cholesterol, HDL and triglycerides tests | Both |
| High blood glucose or A1c | Glucose and A1c tests | Both |
| Kidney co-morbidity | Albumin, creatinine, A/C ratio | Monitoring |
MACRA wants to help
There are a large number of advocacy groups dedicated to diagnosis and effective treatment of diabetes, including the American Diabetes Association. Most communities also have support groups and most primary care physician practices have a list of local resources to assist their diabetic patients with life style changes, smoking cessation and peer support.
With the advent of MACRA, Medicare has also added important “Quality” and “Improvement Activities” that are tracked as part of the Merit-based Incentive Payment System (MIPS). Quality measures include tracking A1c over 9 percent, eye exams for known diabetics and foot exams and care to prevent diabetic foot ulceration. Improvement Activities include glycemic screening, implementation of a glycemic management program and chronic conditions plans. MACRA broadly supports diabetic diagnosis and management initiatives for Medicare patients. Your key diabetic vital signs and lab diagnosis partners have all the details and can provide you with even more information.
How can we help?
First of all, let me acknowledge two things. Number one, this article is a bit more of a call to action than my typical “hey, I have a few lab nuggets to share” article. Number two, I am not asking you to drop everything you are doing and devote your time to becoming a diabetes care advocate full time. From a strictly practical viewpoint, there will always be potential diabetics with little or no access to healthcare and/or no motivation to participate in managing their condition. So, we can’t save the world.
But, you can do a few things that I believe make sense. Think about diabetes diagnosis and management as more than a lab problem. Vital signs and lab both play a role and you have outstanding suppliers of both product categories to help. From my perspective, it’s worth assessing your customer and prospect base to look for practices with the right patient mix, mind set and personnel to consider initiating or improving their glycemic management program. I would then link up with my best vital signs and lab suppliers and put together a simple story and easy-to-implement program locally. Most distributor home office category teams may have already put together a template to use. It’s worth your time to make sure your best prospects also know about the MACRA implications and best practices regarding glycemic management and control. A list of CMS Core Quality Measures can be found by following the link in this article.
Every big job is really just a collection of smaller activities that are thoughtfully implemented to create a strong solution. Can we solve the challenge of diabetes incidence and health care impact over night? No, but we can take a series of small but meaningful steps to make an impact. Working hand in hand with the supplier community and your key physician practices, you can make a difference.