FPA-63

PHE 630 Final Project. Program Analysis and Recommendation Paper

Program: CDC Recognized National Diabetes Prevention Program (CDC RNDPP).

The incidence of Diabetes in the US has been steadily increasing year by year. In 2014, the estimated population living with diabetes was 9.3%. (CDC 2014). It is estimated that in the US, a total of 30.3 million are diabetic, however, 7.2 million people are undiagnosed diabetics. That is, they are diabetic but are not officially diagnosed with this disease. As a consequence, they are not receiving any therapy. Under diagnosing is a major problem that has significant health and economic consequences. Diabetes as other chronic degenerative diseases when left untreated have severe consequences affecting all organs. With these numbers, we can see that, approximately one out of every 4 patients with diabetes are undiagnosed. From 1958 to 2015 the prevalence of diabetes has increased from 0.94% to 7.4%. (CDC 2017). However, in those people older than 65 years of age, the prevalence is at 25.2%. (ADA 2017). There are 1.5 million cases of diabetes diagnosed each year. These trends, are among the highest of any disease in the US.

Even though diabetes affects the entire population, there are indeed important differences when race, education level and socioeconomic level are taken into consideration.

Diabetes is more prevalent among American Indians, African American and Hispanics. (CDC 2017). Prevalence varies markedly by education level. This is an indicator of socioeconomic status. Specifically, in people with less than high school education, the prevalence is 12.6%, whereas the incidence is 9.5% and 7.2% of those with high school education and more than a high school education respectively. (CDC 2017, Geiss 2014). Conversely, these ethnic groups and the less educated people have less access to healthcare. (Geiss 2014).

On top of this very prevalent health problem, there is major underdiagnosing. It is estimated that 7.2 million diabetics, are not diagnosed. Diabetes is a condition that takes years to become a full-blown disease. There is a stage called prediabetes, where the person has been identified with glucose related metabolic abnormalities but has not reached the diagnostic criteria to be called diabetic. This stage, nonetheless, is associated to major health complications. The CDC has estimated that, 34% of the population older than 18 years and 48.3% of those older than 65 are prediabetic. (CDC 2017). The presence of 3 of the following 5 conditions: hyperglycemia, hypertriglyceridemia, high blood pressure, overweight, and low HDL encompass a condition called metabolic syndrome or prediabetes. This condition is known to be the most common cause of heart disease and precedes diabetes in most cases. Furthermore, if we take into consideration that 97% of the people with metabolic syndrome are not aware of having the condition, it becomes clear that, we are failing to address a major epidemic properly and multiple years go by before adequate therapy is started.

In my own experience, on a daily basis I diagnosed diabetes in patients that regularly follow with a primary care physician and either they were not diagnosed with the condition or they were not aware of the diagnosis.

The American Diabetes Association estimated that in 2012 the total costs of diagnosed diabetes were $245 billion. (ADA 2012). Importantly so, diabetes is the leading cause of kidney failure, limb amputations and blindness in our country. (CDC 2011).

With these devastating statistics and the pace with which this disease is affecting the population, is imperative that something is done to decrease its incidence as well as its complications.

The CDC-Recognized Diabetes Prevention Lifestyle Change Program

The CDC-Recognized Diabetes Prevention Lifestyle Change Program has been developed to prevent diabetes. It is a year-long program that focuses on long-term lasting lifestyle changes. Given the impact diabetes and its associated health problems have as well as the familiarity I have with this condition, I felt it was the most appropriate program to be evaluated.

Program Description and Analysis

Programs:

Given the magnitude and the great impact in health diabetes has, the US government has created numerous initiatives and programs to address this problem. There are Federal, State and local programs, the common goal, is the prevention of this disease.

Examples of these are; the National Diabetes Education Program (NDEP). This is a CDC national program that through the diffusion or media by stakeholder’s partners, are distributed among the population in general with the purpose of educating them about the lifestyle changes needed to prevent diabetes. (CDC 2016). The Chronic Kidney Disease Initiative. This is another CDC program that was created in 2006 to try to provide the public health strategies for promoting kidney health. As mentioned before, the leading cause of kidney failure is diabetes, therefore, this program among other procedures, aims at preventing diabetes.

Another program is the Native Diabetes Wellness Program (NDWP). This program addresses the health inequities so starkly revealed by diabetes in Indian Country and communities. Another program is the Prevent Diabetes STAT, which stand for Screen, Test and Act Today. This is an American Medical Association and CDC conjoint program that is directed to the public, health providers, employers and health insurance companies to try to persuade them to screen for diabetes and act upon the results.

Programs and policies are important to make people and providers aware of this important disease. Policies, can make a major difference. For instance, with the Affordable Care Act Medicaid expansion, the detection and diagnosis, of diabetes was made at an earlier stage in those states that adopted the expansion, as opposed to those that did not. (Kauffman 2015). There are multiple other programs attempting to prevent diabetes. In this case, here, the CDC-Recognized Diabetes Prevention Lifestyle Change Program, also called the National Diabetes Prevention program or NDPP is described and analyzed.

The NDPP is a structured program developed specifically to prevent type 2 diabetes. In can be done in person, or online. It is designed for people at risk to develop diabetes type 2 or that have prediabetes. A trained and certified lifestyle coach leads the program helping people change their eating behaviors, diet, physical activity etc. It is a year-long program that focuses on long term changes and goals. The basis of the program comes from an NIH research study, where structured lifestyle changes were implemented and followed, cut the risk of developing diabetes by 58%. Further research showed that even 10 years later people that had completed the program were 33% less likely to develop diabetes. (DPPRG 2002). The program invites organizations and clinics that have lifestyle coaches to participate in the program. After submitting an application, the CDC makes sure certain standards are met. The participating organization must track results and share the data with the CDC which becomes the feedback and part of the evaluation process of the program. The participants are taught about nutrition, physical activity, medications, and about lifestyle changes and way to live to prevent diabetes.

Looking at the data mentioned above, it is clear that these kinds of programs are beneficial and that they have the expected results. However, looking at the pace of progression in the prevalence of diabetes it seems that no major indentation has been made against this disease. The question is why? Why, if there are great programs like the NDPP we have not seen a significant decrease or at least a slower pace in the incidence of diabetes. The likely answer is, low participation and low enrollment of patients. We can have an idea of this by entering a zip code in the find-a-program link of the website. For instance, the Zip code 79902 which belongs to the city of El Paso, Texas. Being the 17th largest city in the US turned 2 centers as result. This means that in this large city only 2 centers offer enrollment into this program. Furthermore, a phone called was made to one of the 2 centers to inquiry about the program and the answering person was not aware of what kind of program was inquired about.

With these kind of participation, even a proven successful program is not likely to make the difference.

The stakeholders, mainly the health providers and the population at risk, need to have a more active participation. Important changes should be applied to increase the participation of the population and also, the number of clinics offering this program. One important way to increase participation would be for these very beneficial programs to include an incentive to make participation and involvement more attractive hence, robust.

Having a proven program that has already demonstrated the kind of results it can draw, is not enough if participation is low.

As it is the case with other chronic diseases, the less educated and the minorities have less access to health programs. These populations also have the higher prevalence therefore, these populations would be the ones drawing a higher benefit at participating in these programs. Higher participation of minorities, as well as lower socioeconomical and cultural groups would help close the gap in the disparity this disease has in the population.

Alternative Strategic Approach to Selected Existing Program

The CDC RNDPP is a program that aims at preventing diabetes. Identifying and referring high risk patients to those CDC recognized centers is the first step. Patients also can self-refer to those centers. The CDC has specific webpages through which patients can find out information about this program.

Who is considered high risk?

All adults with overweight or obesity or anyone older than 45 with one of the following risk factors, are considered candidates. (HHS 2008).

1. Being physically inactive.

2. Having a parent, brother, or sister with diabetes.

3. Having a family background that is African American, Alaska Native, American Indian, Asian American, Hispanic/Latino, or Pacific Islander.

4. Giving birth to a baby weighing more than 9 pounds or being diagnosed with gestational diabetes—diabetes first found during pregnancy.

5. Having high blood pressure— 140/90 mmHg or above—or being treated for high blood pressure.

6. Having HDL, or “good,” cholesterol below 35 mg/dL, or a triglyceride level above 250 mg/dL.

7. Having polycystic ovary syndrome or PCOS.

8. Having impaired fasting glucose (IFG) or impaired glucose tolerance (IGT) on previous testing.

9. Having other conditions associated with insulin resistance, such as severe obesity or acanthosis nigricans.

10. Having a history of cardiovascular disease.

In those centers, patients are evaluated, if they are found to be candidates they may be enrolled into the program. The program includes visits, education about nutrition, exercise or physical activity, and general lifestyles as well as possible medical therapy. These interventions were found to be successful in preventing diabetes in the mentioned above, diabetes prevention program.

Problems and gaps of the selected program:

1. The enrollment into the program is left to the public own decision. In other words, the public needs to find out information about it and make an effort to get enrolled. While this is certainly a possible way to enroll patients, when it comes down to the public being the ones looking for information and enrolling, it is likely that the enrollment will be quite low.

2. As a matter of testing, a search of clinics offering the selected program was conducted. Using the Zip codes of 79902 which is a central zip code for the city of El Paso, Texas and the Zip code 79821 which is a city limits Zip code for the same city and a radius of 100 miles around both Zip codes, only 2 clinics or healthcare centers were found. Both clinics were called twice and in all attempts voice messages were left. Several days went by and a called back has not been received. This shows that, recognized diabetes prevention programs are very few. In the 17-19th largest city in the US, only 2 centers were found in a radius of approximately 150 miles. Both clinics appear to be too busy to return calls. This represents an obstacle for patient’s enrollment in an already low enrollment. If we take in to consideration that approximately 75% of the population are at least overweight, we would expect a very large potential enrollment in a city this size. This size enrollment would not be able to be handled by only 2 clinics.

3. Lack of incentives. When the public or the stake holders are incentivized, it is more likely that their participation will be larger and stronger. (RAND 2015). It is known that preventing diabetes by itself should be a great incentive, however, in real life it is difficult for the general population to recognize such important goal as a big enough enrollment. Furthermore, it is not known whether there is a charge to the patients to get enrolled into the program. Those clinics contacted have not returned the phone call to the time of submission of this milestone and one of the questions to those programs, was exactly to know if there is a charge to get enrolled.

Proposal:

1. All clinics enrolling into the NDPP would receive a 0.5% increase in reimbursement for those CPT codes that are directly related to diabetes, metabolic syndrome, and overweight across the board. According to Ashkenazy et al (2006), 34% of the Medicare expenditure is on Diabetes. Any successful prevention of this very prevalent disease, would mean a very significant savings as will be seen below.

2. All patients will receive a health savings card. This is a service is already being offered by Medicare users. Patients will get compensation (see compensation schedule table below) in the way of credit added into these cards if during follow up appointments their laboratory values are better, as well as by a decrease in BMI. This compensation will only be payable if at least 4 of the 5 questions of the health questionnaire questions are successfully answered. These health questions about diabetes, prediabetes and related topics such as, nutrition and physical activity will be obtained from the teaching materials is being already utilized by this program. A pool of a total of only 15 key questions will be used. Therefore, these questions will tend to repeat serving the main purpose of having people be knowledgeable about the basics of diabetes, nutrition and physical activity.

Expenditure on diabetes alone in 2012 was $245 billion. (ADA 2012). This figure keeps increasing yearly. The vast majority of the expenses, are covered by Medicare. Preventing diabetes would have substantial savings with which, the proposed incentives to clinics and patients could be funded. As mentioned before, an NIH research study, where structured lifestyle changes where followed cut the risk of developing diabetes by 58%. In this program, 10 years later people that had completed the program were 33% less likely to develop diabetes. (DPPRG 2002). Based on this numbers we can hypothetically calculate how much this kind of results could mean if a program is successful.

Clinical trials have strict follow up and the range of patients lost to follow up tend to be lower than real world experience. Furthermore, clinical trials tend to have higher rates of compliance. For this reason, we should be conservative and estimating that in real life perhaps prevention could be in the range of 30% instead as the 58% seen in studies. We can also arbitrarily could assign a 20% increase in participation if the proposed changes and incentives are adopted or implemented.

Therefore, a 30% prevention in diabetes cases, would mean approximately an $80 billion savings for Medicare. A portion of these funds would constitute some of the economic resources available to fund the proposed changes in the way of incentives to the participating clinics.

Compensation Schedule Table:

Parameter Change Compensation in health savings card

BMI A drop of 1 $25

A drop of 2 $35

A1C Hgb A drop of 0.5% $25

A drop of 1% $35

A drop of 2% or more $50

The above amounts will be deposited into the health savings card. The health savings card is a program that is already in place for Medicare users. The same format will be utilized for the participant patients of this program. This way, no major resources to create another system will be needed. Those patients that are not Medicare beneficiaries will have a health savings account or card like those Medicare beneficiaries.

It is believed that the proposed changes will increase the number of clinics as well as the amount of people enrolled into the program. As a consequence, the benefits seen in this program would have a broader reach which it should be the goal of any public health program.

These results would represent a major advantage of an already in place program. Given the above numbers, it is estimated that, there would not be an increase in the economic resources needed. In fact, if the already enrolled clinics could be places of training for new enrolling clinics in the same area, no major funding will be needed from any governmental agency.

Diabetes is a devastating chronic disease that has multiorgan complications and major disability in the US. The multiple associated diseases, such as obesity, metabolic syndrome and multiple others, together, make it a very important and needed area of work. Preventing diabetes would not only prevent diabetes, it would prevent its complications as well as represent a major step towards a healthier country in all the extent of the word. Any effort implemented would have substantial pay back. The resources needed to execute the proposed changes are already in place and being utilized. The proposed changes would be a seamless addition to the already in place and progress program.

Implementation and Communication Strategy

While studies based on lifestyle modification have shown the efficacy to prevent type 2 diabetes (Knowler 2002, Pan 1997, Tuomilehto 2001) a key obstacle remains their implementation and a wide participation of the public. The National Diabetes Prevention Program, is a national partnership of public and private organization offering a lifestyle modification program to prevent type 2 diabetes. Specific inclusion criteria, makes a person have a high risk of developing type 2 diabetes. Once patients are enrolled into the program, very detailed and complete education about nutrition, physical activity, general lifestyle and therapy is given and the patient is followed closely to monitor their results.

It doesn’t matter how effective a program may be, if it doesn’t reach the needed target population, the benefits would not be seen.

Target Population

Type 2 diabetes mellitus used to be called, adult onset diabetes, however, almost 30 million children in the US are diabetic. Furthermore, 23,500 children are diagnosed with diabetes each year (ADA 2015) and 37% of all people in the USA older than 20 years are prediabetic. For this reason, programs preventing diabetes should reach all age groups, both genders and all ethnic backgrounds.

Reaching the entire population is challenging. Difference in age generally means a difference in activities, level of technology utilized and environment. Technology has revolutionized the way people interact with the world as well as with other people. Whereas the radio and television were the main source of information or communication in the past, now, with the advent of many different vehicles or ways of watching television such as Netflix, YouTube, Apple TV and others, hardly any of the population below 30 uses regular television, cable or satellite TV.

For this reason, the target population for this program has been divided into three groups; the young people, those below 30, the middle age group, those between 30 and 60 and, the older population, who are those above 60 years of age.

For the young people, the use of social media is almost ubiquitous, therefore, the main source of communication will be social media. This group tends to use more Instagram and Snap Chat, for this reason the communication will be through those social media.

The middle age group, tends to use more Facebook, for this reason this group will be reached that way. The older population still spends a significant amount of time watching regular television in the way of cable or a satellite television. Therefore, the main way of communication with this group will be in the way of regular television. Even though, there are marked differences in the way the communication will be conveyed, it is known that there will be some amount of hybrid reaching. In other words, some people belonging to a specific group, may be reached through a communication means that was targeted to other group.

According to Evans (2006) The six basic stages of healthcare social marketing are: 1. developing plans and strategies using behavioral theory; 2. selecting communication channels and materials based on the required behavioral change and knowledge of the target audience; 3. developing and pretesting materials, typically using qualitative methods; 4. implementing the communication program or “campaign”; assessing effectiveness in terms of exposure and awareness of the audience, reactions to messages, and behavioral outcomes; 5. refining the materials for future communications, and 6. The last stage feeds back into the first to create a continuous loop of planning, implementation, and improvement.

Developing plans and strategies using a behavioral theory.

In this implementation we will use the Health Belief Model. This model was developed in the 1950’s to help understand why people did not user preventive services, therefore, it is felt that it fits the needs. People should be given several criteria of what high risk to develop type 2 diabetes means.

Examples:

“Are you overweight? Do you feel tired? Do you have frequent headaches? these could be signs that you may have a condition called prediabetes. Go to any healthcare center and have yourself checked. Don’t wait, act now”.

“A person with diabetes, dies 6 years earlier than a person without diabetes. If you are overweight, you could have prediabetes. Act now”

The same kind of message will be given irrespective of the vehicle or source of communication chosen or age group, TV or social media.

Monitoring reach

In the case of social media, the person receiving the message or communication could click a “learn more” button and get referred to a link where according to their location could be referred to the nearest clinic offering the program.

As the message is given to the public, it is possible to monitor the implemented communication plan. Social media can easily be tracked. In the case of the regular television communication, the monitoring could also be done. Participating clinics should keep track of phone calls and visits from people inquiring about the program and on a monthly basis, report the number of inquiries to the steering committee of the program, in this case, the CDC.

As was mentioned before, a way to increase clinics participation is to increase reimbursement by 0.5% or 1%. The cost of diagnosed diabetes in 2012 was $245 billion (ADA 2015). The NDPP showed that, participants lowered the chance to develop diabetes type 2 by 58-71%. (NIDDKD). This translates into significant savings which could be partially utilized to fund the increase in reimbursement to clinics.

The incentive to the population was planned to be in the way of electronic related products for the young group, as well as health savings cards to the older group. The middle-aged group will be given the choice between the 2 kinds of incentives. Teen agers spend around 9 hours per day in social media (Tsukayama 2015). If the incentive would be a Spotify, iTunes cards or some other credit to be utilized in any application of their choice, then it would call their attention.

Likewise, the health-savings card which is currently utilized by multiple insurances, would be attractive to those middle-aged and older groups.

Limitations

An expected limitation is funding. However, as mentioned above, diabetes and related diseases is very costly to our healthcare system. The NDPP has shown to be effective. Conservatively applying the data of this study, assuming a 50% reduction in cases of diagnosed diabetes and a $245 billion cost annually, the potential savings from a successful program would be substantial and plenty to offset the cost of applying the program that is already in place and the proposed incentives.

Another important limitation could be, the power of reaching the population. The plan includes regular Television, as well as different social media. It is believed that this plan offers the possibility of reaching the desired population, however, the monitoring resources proposed above, will allow for feedback and as a loop of continues assessment, monitoring, implementation and improvement.

Data Collection

The key components of the DPP are lessons on nutrition and physical activity. A lifestyle coach is in charge of these teaching or coaching for a full year. It also includes a support group composed of people with similar goals and objectives.

When it comes to follow and monitor prediabetes, most markers for follow up are quantitative markers and variables. Using qualitative variables albeit, more complete and perhaps desired, would make the results less reliable and the need for resources, higher. Quantitative variables and results are closer to be “hard end-points”, which means that are end-results that are easier to translate into results in any given program.

In the case of prediabetes, those risk factors are variables that can be measured. Values such as blood pressure, body weight, body mass index, body fat percent, A1C Hgb, amount of physical activity, calorie intake etc. In this program, qualitative results are not needed and when the quantitative data is so robust, it would make the qualitative data less reliable and the resources needed to capture these data could be saved.

Currently, all clinics measure those quantitative variables mentioned. The laboratory components are often sent to be done at local laboratories. This kind of practice and measuring of laboratory results as well as follow up vital signs are routine practices to any clinic. A doctor’s progress note in not complete without these data. Participating clinics will be mandated to check these quantitative data and values. It is a routine practice that is done seamlessly on a daily basis and will be required to be done. With the advent of mandated electronic medical records systems, keeping track and monitoring those mentioned values or variables becomes easier and more reliable. The validity and reliability of results is higher and stronger. Electronic medical records will facilitate the review of these data. Clinics are compensated for participating in this program and not by showing better results. This practice and way of incentive ensures reliability as well as validity. Besides, the collection of data is done in an at least quarterly basis, any deviation of results will alert for the lack of validity as well as reliability.

Given the fact that laboratory values are handled by a third party and most of the times they are ran by the same lab, validity and reliability are, expected. Besides, those variables are always measured and monitored. They also become a component of the patient’s record. Therefore, values out of range could be sorted out. The other variables such as weight, BMI, fat percentage and others are measured onsite at the clinic and also become part of the medical record which is a legal document. All clinics routinely measure these quantitative results. Not only that, electronic medical records are accessible to Medicare and private insurances, which assure closer and more reliable monitoring. Given the fact that the variables mentioned above are routinely followed in daily practice, recording, tabulating and monitoring those values mentioned will not change daily practice, hence, resources will not be significantly altered.

Cultural competence is the ability to treat equally and respectfully all people, independently or race, culture and economical status. Given the fact that prediabetes is more prevalent among minorities as well as less educated people, monitoring the ethnicity as well as the socioeconomic group patients belong to is important. In current practice, the front end of any clinic includes a very important step; obtaining all demographic data. This includes race, as well as a zip code.

By tabulating zip codes by average per capita income, the socioeconomic level can be kept. By monitoring ethnicity, this other important demographic component can also be tracked and followed. All clinics are currently recording these data, following these data through EMR can be done in an easily manner. By using EMR capability software that is already part of any EMR, any deviation in demographics can be detected.

This proposal is felt to be able to increase the participation of the public as well as the number of clinics. Drawing a larger participation into a program that has been validated would be quite a milestone towards the prevention of a major public health problem and population threat.

References