The diagnosis gap

September 18, 2:18 PMDiabetes ExaminerRobert Scheinman

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American Heart Journal

For most people with type 2 diabetes, diagnosis comes late. How late? Estimates based on epidemiological studies in the United States indicate that on average diagnosis comes about 7 years after onset of detectable hyperglycemia. This has a huge consequence both for the patient and for our health care system.

Even if the patient makes the decision to actively manage their disease those seven years have taken their toll. What is that toll? Heart disease for one thing. About 50% of people who are diagnosed with type 2 diabetes have some manifestation of cardiac disease. Even if we normalize populations for things like smoking, blood pressure, or high cholesterol, the risk of a heart attack is still increased four fold for a person with diabetes. Seventy five percent of hospital admissions for diabetic patients involve cardiac disease. The statistics for these patients is not good. The risk of dying before even making it to the hospital is twice that for an otherwise identical non-diabetic person. Revascularization procedures along with restenosis have a higher failure rate in diabetic patients and ultimately it is estimated that 1/3 of these patients die within a month of admission.

As just one example of the problem: a recent study performed by Dr. van Kuijk and colleagues and published in the American Heart Journal examined 404 non-diabetic patients who had come to them for elective vascular surgery. All had some form of heart disease. When these patients were given an oral glucose tolerance test it turned out that 11% were actually diabetic and an additional 25% showed impaired glucose tolerance (IGT). Further cardiovascular events were followed in these patients for the next 4 years. As one might expect the patients who were normal faired better than the patients who had diabetes or had impaired glucose tolerance. Using a multivariate analysis model (i.e. taking into account all sorts of different factors) it was determined that the increased risk for another cardiac event 2.7 fold in the IGT population as compared to the normal population while the risk of dying was double that of the normal population.

This study is interesting on a number of levels. First of all, it illustrates one more time that the damage caused by increased blood glucose has major health consequences. Second, it shows that a simple oral glucose tolerance test can pick up this population. The test is inexpensive and easily done. If the test was done early enough, blood glucose levels could have been brought under control long before the damage was done. Finally, this population resided in the Netherlands. Now Europe, by and large, has a health care system that is available to everyone. This suggests that the problem that must be solved here is deeper than the argument currently underway in the US. Clearly, without affordable healthcare, this problem will only get worse. I think both Republicans and Democrats agree on this issue. However, whether we go with a “public option” or a “market driven” option we still need to solve the diagnosis gap or we will continue to pay an astounding $100 billion plus dollars in societal costs for this diabetes pandemic.