A cascade of care for diabetes in the United States: visualizing the gaps

Ann Intern Med. 2014 Nov 18;161(10):681-9. doi: 10.7326/M14-0019.


Background: A "cascade-of-care" concept helped to address implementation gaps in HIV care.

Objective: To develop a similar cascade for U.S. diabetes care to visualize gaps in awareness of diagnosis, engagement, and treatment.

Design: Nationally representative cross-sectional surveys.

Setting: 2007 to 2012 NHANES (National Health and Nutrition Examination Surveys).

Participants: Nonpregnant civilians aged 18 years or older.

Measurements: Standardized data collection and laboratory procedures. Diabetes care was benchmarked against recent diabetes and cardiovascular risk reduction guidelines.

Results: In 2012, an estimated 28.4 million (11.8%) U.S. adults had diabetes, of whom 20.5 million (72.2%) were aware of their diagnosis. Among diagnosed adults, 95.3% had a usual care provider and 91.7% made 2 or more visits in the past year. In contrast, among undiagnosed adults, 84.5% had a usual care provider and 66.5% reported 2 or more visits in the past year. Among diagnosed adults, 63.7%, 65.5%, 56.6%, and 80.6% met individualized hemoglobin A1c, blood pressure (BP <140/80 mmHg), lipid (low-density lipoprotein [LDL] cholesterol <2.6 mmol/L [<100 mg/dL]), and nonsmoking goals, respectively; 26.7% met combined ABC (hemoglobin A1c, BP, and LDL cholesterol) targets, and 21.3% met combined ABC targets and did not smoke. Among undiagnosed adults, 77.0%, 57.9%, 36.0%, and 77.9% met hemoglobin A1c, BP, lipid, and nonsmoking goals, respectively; 22.1% met combined ABC targets; and 18.8% met combined ABC targets and were nonsmokers.

Limitation: Institutionalized and noncivilian persons are not surveyed in NHANES.

Conclusion: Three of 10 adults with diabetes remain undiagnosed, which may be related to less access to care. Compared with diagnosed adults, undiagnosed adults have less elevated hemoglobin A1c levels, less lipid treatment and worse control, and similarly poor BP and combined ABC control regardless of smoking status. Addressing these care gaps in both groups would prevent long-term complications.

Primary funding source: None.

MeSH terms

  • Adult
  • Blood Glucose / analysis
  • Cross-Sectional Studies
  • Diabetes Mellitus / blood
  • Diabetes Mellitus / diagnosis
  • Diabetes Mellitus / therapy*
  • Humans
  • Nutrition Surveys
  • Patient Care Management*
  • United States


  • Blood Glucose