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Two Decades Into the Quality Improvement Era, Health Care Quality is Falling

August 18, 2021

Trends in Diabetes Treatment and Control in U.S. Adults, 1999–2018
New England Journal of Medicine
June 10, 2021
By Fang M et al.METHODS

We conducted a cross-sectional analysis of data from adults with diabetes in the United States participating in the National Health and Nutrition Examination Survey (NHANES) to assess national trends in diabetes treatment and risk-factor control from 1999 through 2018.


Diabetes control improved from 1999 to the early 2010s among the participants but subsequently stalled and declined. Between 2007–2010 and 2015–2018, the percentage of adult NHANES participants with diabetes in whom glycemic control (glycated hemoglobin <7%) was achieved declined from 57.4% to 50.5%. … From 2011–2014 to 2015–2018, the percentage of participants in whom blood-pressure control (<140/90 mm Hg) was achieved decreased from 74.2% to 70.4%.

Trends in Blood Pressure Control Among US Adults With Hypertension, 1999-2000 to 2017-2018.
September 9, 2020
Muntner P et al.

Design, Setting, and Participants: Serial cross-sectional analysis of National Health and Nutrition Examination Survey data, weighted to be representative of US adults, between 1999-2000 and 2017-2018 . . .

Results: . . . the age-adjusted estimated proportion with controlled BP increased from 31.8% in 1999-2000 to 48.5% in 2007-2008 (P < .001 for trend), remained stable and was 53.8% in 2013-2014 (P = .14 for trend), and then declined to 43.7% in 2017-2018 (P = .003 for trend).

NOTE: Confidence intervals removed to improve readability.

Comment by David Himmelstein and Steffie Woolhandler

Hypertension and diabetes are the most common causes of excess mortality in the US for which excellent treatments are available. Yet despite two decades of health policies allegedly focused on quality improvement, control of both conditions has deteriorated. The only plausible explanation is worsening access to care. This compelling indictment of the US healthcare system mandates fundamental reexamination of how we pay for, organize and deliver care.

To quote the sign Archie Cochrane (the true founder of evidence based medicine) carried to a demonstration in the 1930s, “All effective treatments must be free.”  

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