Engaging Payors and Primary Care Physicians Together in Improving Diabetes Prevention

START Diabetes Prevention: A Multi-Level Strategy for Primary Care Clinics

Background

Prediabetes, a high-risk state for developing diabetes, affects more than 1 in 3 adults nationally. However, <5% of people with prediabetes are receiving any treatment for prediabetes. Prior intervention studies for increasing prediabetes treatment uptake have largely focused on individual barriers with few multi-level interventions that address clinician- and system-level barriers.

Objective

To measure the effectiveness of a multi-level intervention on uptake of prediabetes treatment in a primary care clinic.

Design

Pragmatic study of the START (Screen, Test, Act, Refer and Treat) Diabetes Prevention intervention.

Participants

The START Diabetes Prevention intervention was implemented in a suburban primary care clinic outside of Baltimore compared to a control clinic in the same area over a 12-month period.

Intervention

START Diabetes Prevention intervention included a structured workflow, shared decision-making resources and electronic health record clinical decision support tools.

Main Measures

Uptake of prediabetes treatment, defined as Diabetes Prevention Program referral, metformin prescription and/or medical nutrition referral within 30 days of any PCC visit.

Key Results

We demonstrated greater uptake of preventive treatment among patients with prediabetes in the intervention clinic vs. control clinic receiving usual care (11.6% vs. 6.7%, p<0.001). More patients in the intervention vs. control clinic reported their PCC discussed prediabetes with them (60% vs. 48%, p=0.002) and more felt overall that they understood what their doctor was telling them about prediabetes and that their opinion was valued. The START Diabetes Prevention Strategy had greater acceptability and usefulness to PCCs at the study end compared to baseline.

Conclusions

A low-touch multi-level intervention is effective in increasing prediabetes treatment uptake. The intervention was also acceptable and feasible for clinicians, and enhanced patient understanding and discussions of prediabetes with their clinicians.

Using the Translating Research into Practice framework to develop a diabetes prevention intervention in primary care: a mixed-methods study

BACKGROUND

Pre-diabetes affects one-third of US adults and increases the risk of type 2 diabetes. Effective evidence-based interventions, such as the Diabetes Prevention Program, are available, but a gap remains in effectively translating and increasing uptake of these interventions into routine care.

METHODS

We applied the Translating Research into Practice (TRiP) framework to guide three phases of intervention design and development for diabetes prevention: (1) summarise the evidence, (2) identify local barriers to implementation and (3) measure performance. In phase 1, we conducted a retrospective cohort analysis of linked electronic health record claims data to evaluate current practices in the management of pre-diabetes. In phase 2, we conducted in-depth interviews of 16 primary care physicians, 7 payor leaders and 31 patients to elicit common barriers and facilitators for diabetes prevention. In phase 3, using findings from phases 1 and 2, we developed the core elements of the intervention and performance measures to evaluate intervention uptake.

RESULTS

In phase 1 (retrospective cohort analysis), we found few patients with pre-diabetes received diabetes prevention interventions. In phase 2 (stakeholder engagement), we identified common barriers to include a lack of knowledge about pre-diabetes among patients and about the Diabetes Prevention Program among clinicians. In phase 3 (intervention development), we developed the START Diabetes Prevention Clinical Pathway as a systematic change package to address barriers and facilitators identified in phases 1 and 2, performance measures and a toolkit of resources to support the intervention components.

CONCLUSIONS

The TRiP framework supported the identification of evidence-based care practices for pre-diabetes and the development of a well-fitted, actionable intervention and implementation plan designed to increase treatment uptake for pre-diabetes in primary care settings. Our change package can be adapted and used by other health systems or clinics to target prevention of diabetes or other related chronic conditions.

Enhancing access and impact of the Medicare Diabetes Prevention Program using telehealth: a narrative review

Background and Objective

Over 26 million older adults in the United States (US) have prediabetes, which is often a precursor to type 2 diabetes. The Medicare Diabetes Prevention Program (MDPP) is an evidence-based, lifestyle program for older-adult Medicare beneficiaries to prevent progression to diabetes. However, the MDPP has been drastically underutilized. Telehealth delivery may be a promising strategy to increase the reach and impact of the MDPP, including for underserved populations. The objective of this narrative review is to explore the role of telehealth on the accessibility and effectiveness of diabetes prevention programs (DPPs) for older adults.

Methods

We searched the online databases of MEDLINE, APA PsycInfo, CINAHL, and Academic Search Elite for studies that used telehealth to deliver DPPs to older adults through distance learning, i.e., live program delivery where participants join via phone- or video-conferencing. Relevant information from policy documents and related publications was also included.

Key Content and Findings

Three themes emerged from the literature on telehealth delivery of DPPs for older adults (I) clinical effectiveness for weight loss, (II) feasibility and acceptability of this format; and (III) policy considerations to support greater public health impact. There is a growing body of recent evidence to suggest that older adults achieve a clinically meaningful amount of weight loss from participation in telehealth DPPs. The literature suggests that telehealth program delivery is feasible, and older adults find it acceptable, with some specific accommodations. Effectiveness and acceptability of telehealth interventions were also noted for older adults from rural, ethnically-diverse, and low-income groups. Policy considerations include adjustments in rulemaking by the Centers for Medicare and Medicaid Services (CMS) to allow MDPP delivery via telehealth using distance learning, along with sufficient reimbursement rates.

Conclusions

The evidence indicates that delivery of the MDPP via telehealth is beneficial for increasing program reach and impact, including among underserved groups, as well as providing social support for older participants. Scalable delivery of the MDPP via telehealth is essential to make a national, population-level impact for older adults with prediabetes who receive Medicare benefits.