Primary Care Providers' Prediabetes Screening, Testing, and Referral Behaviors

EHR Smart Phrases Used as Enrollment Mechanism in Diabetes Self-Management Support Programs: Preliminary Outcomes

ABSTRACT

Diabetes in the United States is increasing rapidly. Innovative strategies are needed for diabetes prevention and self-management. This study assessed the usability, acceptability, and awareness of an electronic health record (EHR) tool for referring patients to a community-based diabetes self-management support program. Mixed-methods approaches were used, using EHR data and key informant interviews to assess the implementation of this quality improvement (QI) process intervention. The implementation of a smart phrase tool within the EHR led to a substantial increase in referrals (773) to the Health Extension for Diabetes (HED) program. Clinical health care professionals have actively used the referral mechanism; they reported using smart phrases to increase efficiency in patient care. Lack of training and program awareness was identified as a barrier to adoption. Awareness of the HED program and .HEDREF smart phrase was limited, but improved with targeted QI and training interventions. The .HEDREF smart phrase demonstrated effectiveness in increasing patient referrals to the HED program, highlighting the potential of EHR tools to streamline documentation and promote patient engagement in diabetes self-management. Future research should focus on broader health care contexts, patient perspectives, and integration of technology for optimal patient outcomes.

Increasing provider awareness of PrEP on HBCU campuses and beyond: A case study of the HBCU HIV prevention project (H2P)

BACKGROUND

The HBCU-HIV Prevention Project (H2P) is a culturally-tailored, targeted intervention at Historically Black Colleges and Universities (HBCUs) aimed at training health care providers as key players in reducing HIV infections and improving healthcare outcomes among HBCU students.

METHODS

A cross-sectional purposive sample of health care providers at health centers on HBCU campuses and invited health care professionals from partnering organizations in their surrounding communities participated in an 11-module series on the CDC's evidence-based HIV prevention strategy for high-risk individuals, pre-exposure prophylaxis (PrEP). The intervention was aimed at increasing provider awareness and knowledge about PrEP and the importance of HIV testing and counseling as well as promoting provider intentions to use PrEP (initiating discussions with students and prescribing). Pre- and post-module quizzes served as awareness and knowledge assessments and providers also received online surveys about their intentions and uses of PrEP at 30 and 60 days post-training.

RESULTS

Both on-campus and off-campus providers showed trending gains in awareness and knowledge for information in all modules. The off-campus providers appear to be more willing to use the information for initiating discussions and prescribing PrEP; however, HBCU providers also expressed similar intentions, although at lower rates.

CONCLUSIONS

The project successfully increased provider awareness of pre-exposure prophylaxis (PrEP), effective HIV testing, and strategies for reducing HIV infection among HBCU college students. Findings highlight the project's impact on enhancing provider training and the potential of this impact on addressing HIV disparities among African Americans on HBCU campuses and their surrounding communities. The success of the H2P Project provides valuable insights for future interventions, reinforcing the importance of targeted, systems-level approaches in mitigating health disparities among marginalized populations. Implications are also drawn as to the potential for expanding such provider-level interventions to address other health conditions and informing policy development in African American communities.

Test and Treat for Prediabetes: A Review of the Health Effects of Prediabetes and the Role of Screening and Prevention

The term prediabetes describes blood glucose levels above the normal range but below the threshold to diagnose type 2 diabetes. Several population health initiatives encourage a test and treat approach for prediabetes. In this approach, screening and identification of individuals with prediabetes should be followed by prompt referral to structured lifestyle modification programs or pharmacologic interventions that have been shown to prevent or delay the progression to type 2 diabetes in clinical trials. Here we provide a critical review of evidence for this test and treat approach by examining health outcomes associated with prediabetes and the availability and effectiveness of lifestyle modification approaches that target prediabetes. We also describe current limitations to the reach and uptake of evidence-based treatment options for prediabetes. Finally, we highlight lessons learned from identifying and labeling other preconditions to consider challenges and opportunities that may arise with increasing awareness of prediabetes as part of routine preventive care.

Prevalence of Testing for Diabetes Among US Adults With Overweight or Obesity, 2016-2019

Introduction

Screening for prediabetes and type 2 diabetes may allow earlier detection, diagnosis, and treatment. The US Preventive Services Task Force recommends screening every 3 years for abnormal blood glucose among adults aged 40 to 70 years with overweight or obesity. Using IQVIA Ambulatory Electronic Medical Records, we estimated the proportion of adults aged 40 to 70 years with overweight or obesity who received blood glucose testing within 3 years from baseline in 2016.

Methods

We identified 1,338,509 adults aged 40 to 70 years with overweight or obesity in 2016 and without pre-existing diabetes. We included adults whose records were present in the data set for at least 2 years before their index body mass index (BMI) in 2016 and 3 years after the index BMI (2017-2019), during which we examined the occurrence of blood glucose testing. We calculated the unadjusted and adjusted prevalence of receiving blood glucose testing.

Results

The unadjusted prevalence of receiving blood glucose testing was 33.4% when it was defined as having a hemoglobin A1c or fasting plasma glucose measure. The unadjusted prevalence was 74.3% when we expanded the definition of testing to include random plasma glucose and unspecified glucose measures. Adults with obesity were more likely to receive the test than those with overweight. Men (vs women) and adults aged 50 to 59 years (vs other age groups) had higher testing rates.

Conclusion

Our findings could inform clinical and public health promotion efforts to improve screening for blood glucose levels among adults with overweight or obesity.

Factors Influencing the Referral of Patients with Prediabetes to a Diabetes Prevention Program in the Bronx, New York

INTRODUCTION

Disparate engagement in the Diabetes Prevention Program (DPP) may occur as early as the point of referral for certain subgroups, including Black and Hispanic men. We aimed to determine patient demographic and provider characteristics associated with referrals to a health system DPP in the Bronx, New York.

METHODS

Patient and health system characteristics for DPP-eligible patients seen in primary care between July 1, 2015, and December 31, 2017, were obtained through the electronic health record. Generalized mixed-effects modeling was used to test the association between referral rate and clinical and sociodemographic variables.

RESULTS

Of 26,727 eligible patients, 66% were female, 46% were Hispanic, and 39% were non-Hispanic Black. Only 10% (n = 2,785) of eligible patients were referred to DPP. In the adjusted analyses, lower odds of referral were observed for men versus women (OR = 0.60; 95% CI, 0.52-0.66), for non-Hispanic White versus Hispanic patients (OR = 0.53; 95% CI, 0.40-0.71), and for uninsured patients versus Medicaid patients (OR = 0.66; 95% CI, 0.54-0.80). The odds were higher for patients in the highest versus lowest hemoglobin A1c (OR = 2.49; 95% CI, 2.27-2.72) category; for those in the highest versus lowest body mass index categories (OR = 1.61; 95% CI, 1.45-1.79); for middle-aged patients (aged 45-64 y) versus those aged 18-26 y (OR =1.63; 95% CI, 1.33-2.00); and for patients being seen by a family versus an internal medicine physician (OR = 1.65; 95% CI, 1.22-2.22).

CONCLUSION

We identified under-referral for men and highlighted other patient and health system factors associated with referral rates. Interventions to address bias in referrals and increase referrals for men at high risk for diabetes, not typically represented in DPP, are recommended.

Stakeholder analysis: Medicare Diabetes Prevention Program awareness and implementation

OBJECTIVES

The Medicare Diabetes Prevention Program (MDPP) provides unprecedented coverage of a behavior change program for older adult Medicare beneficiaries, but uptake has been extremely limited; only 1.5 sites deliver the program per 100,000 beneficiaries nationwide. Inadequate reach and utilization of the MDPP threaten its long-term success; thus, the purpose of this project was to determine facilitators and barriers to MDPP implementation and use in western Pennsylvania.

STUDY DESIGN

We conducted a qualitative stakeholder analysis project with suppliers of the MDPP and health care providers.

METHODS

Using an implementation science framework, we conducted individual interviews with 5 program suppliers and 3 health care providers (N = 8) to determine their perspectives on positive aspects of the program and reasons for MDPP unavailability and lack of use. Data were analyzed using Thorne and colleagues' approach of interpretive description.

RESULTS

Three main themes emerged: (1) facilitators and attributes of the MDPP, (2) barriers to MDPP implementation, and (3) suggestions for improvement. Facilitators of the program included technical support and webinars from Medicare to assist with the application process. Barriers such as financial reimbursement constraints and a lack of a systematic referral process were noted. Stakeholders suggested refinements to participant eligibility and performance-based payments, a seamless method of flagging and referring patients through the electronic health record, and ongoing virtual program delivery options.

CONCLUSIONS

Findings from this project can be used to improve implementation of the MDPP in western Pennsylvania, support Medicare policy refinement, and inform implementation research to promote broader adoption of the MDPP across the United States.

Fatty Liver Disease in Patients with Prediabetes and Overweight or Obesity

Non-alcoholic fatty liver disease (NAFLD) is a global health problem associated with liver morbimortality, obesity, and type 2 diabetes mellitus. This study aimed to analyze the prevalence of NAFLD (defined as a fatty liver index [FLI] ≥ 60) and its association with other cardiovascular risk (CVR) factors in patients with prediabetes and overweight/obesity. The present cross-sectional analysis uses baseline data from an ongoing randomized clinical trial. Sociodemographic and anthropometric characteristics, CVR (assessed by the REGICOR-Framingham risk equation), metabolic syndrome (MetS), and FLI-defined NAFLD (cut-off value of ≥60) were assessed. The prevalence of FLI-defined NAFLD was 78% overall. Men exhibited a worse cardiometabolic profile as compared to women, specifically, with higher values of systolic blood pressure (137.02 ± 13.48 vs. 131.22 ± 14.77 mmHg), diastolic blood pressure (85.33 ± 9.27 vs. 82.3 ± 9.12 mmHg), aspartate aminotransferase (AST) (27.23 ± 12.15 vs. 21.23 ± 10.05 IU/L), alanine aminotransferase (ALT) (34.03 ± 23.31 vs. 21.73 ± 10.80 IU/L), and higher CVR (5.58 ± 3.16 vs. 3.60 ± 1.68). FLI-defined NAFLD was associated with elevated AST, ALT, and the presence of MetS (73.7%) and CVR for the whole sample. People with prediabetes present a high burden of comorbidities related to CVR, despite clinical follow-up, and it is recommended to actively begin working with them to reduce their risks.

The National Clinical Care Commission Report to Congress: Leveraging Federal Policies and Programs to Prevent Diabetes in People With Prediabetes

Individuals with an elevated fasting glucose level, elevated glucose level after glucose challenge, or elevated hemoglobin A1c level below the diagnostic threshold for diabetes (collectively termed prediabetes) are at increased risk for type 2 diabetes. More than one-third of U.S. adults have prediabetes but fewer than one in five are aware of the diagnosis. Rigorous scientific research has demonstrated the efficacy of both intensive lifestyle interventions and metformin in delaying or preventing progression from prediabetes to type 2 diabetes. The National Clinical Care Commission (NCCC) was a federal advisory committee charged with evaluating and making recommendations to improve federal programs related to the prevention of diabetes and its complications. In this article, we describe the recommendations of an NCCC subcommittee that focused primarily on prevention of type 2 diabetes in people with prediabetes. These recommendations aim to improve current federal diabetes prevention activities by 1) increasing awareness of and diagnosis of prediabetes on a population basis; 2) increasing the availability of, referral to, and insurance coverage for the National Diabetes Prevention Program and the Medicare Diabetes Prevention Program; 3) facilitating Food and Drug Administration review and approval of metformin for diabetes prevention; and 4) supporting research to enhance the effectiveness of diabetes prevention. Cognizant of the burden of type 1 diabetes, the recommendations also highlight the importance of research to advance our understanding of the etiology of and opportunities for prevention of type 1 diabetes.

Clinical Care Among Individuals with Prediabetes in Primary Care: a Retrospective Cohort Study

BACKGROUND

The incidence of diabetes in the general US population (6.7 per 1000 adults in 2018) has not changed significantly since 2000, suggesting that individuals with prediabetes are not connecting to evidence-based interventions.

OBJECTIVE

We sought to describe the clinical care of individuals with prediabetes, determine patient factors associated with this care, and evaluate risk for diabetes development.

DESIGN

Retrospective cohort study using linked claims and electronic health record data.

PARTICIPANTS

We created a cohort of adults with prediabetes based on laboratory measures. We excluded patients with a prior history of diabetes, pregnancy in prior 6 months, or recent steroid use.

MAIN MEASURES

We measured ordering and completion of clinical services targeting prediabetes management and diabetes incidence within 12 months following cohort entry. We tested the strength of the association between individuals' characteristics and outcomes of interest using bivariate and multiple logistic regression.

RESULTS

Our cohort included 3888 patients with a laboratory diagnosis of prediabetes (incident or prevalent prediabetes). Within 12 months, 63.4% had repeat glycemic testing, yet only 10.4% had coded diagnoses of prediabetes, 1.0% were referred for nutrition services, and 5.4% were prescribed metformin. Most patients completed labs and nutrition visits when referred and filled metformin when prescribed. Individuals with a higher glycemic level or BMI were more likely to receive prediabetes clinical care. Six percent of individuals developed diabetes within 12 months of cohort entry and had higher glycemic levels and BMI ≥ 30 kg/m². In the adjusted model, Black individuals had 1.4 times higher odds of developing diabetes than White individuals.

CONCLUSIONS

Rates of prediabetes clinical care activities are low and have not improved. Strategies are urgently needed to improve prediabetes care delivery thereby preventing or delaying incident diabetes.

Patient and Provider Prediabetes Knowledge, Attitudes, and Behaviors in a Large Urban Family Medicine Practice

One-third of U.S. adults have prediabetes, but only 11% are aware of their condition. Many do not receive education or treatment. The purpose of this study is to understand family medicine providers’ and patients’ attitudes, knowledge, and behaviors regarding prediabetes and its management, to guide future management interventions. Cross-sectional surveys of providers ( n = 54, 57% response rate) and patients with prediabetes ( n = 148, 16.5% response rate) were administered at a large urban academic family medicine practice. Nearly all providers agree prediabetes screening is important, but over half were unaware of the national Diabetes Prevention Program (DPP) and most do not prescribe metformin to eligible patients. Over half of patients reported being told they have prediabetes but <5% had been referred to DPP and over half were unaware of medication options. In open-ended responses, providers suggested nutrition counseling resources and an improved DPP referral process to improve prediabetes care. Patients requested clear diagnosis, education on treatment options, and nutritional counseling. This study indicates that notable gaps continue to exist in provider and patient understanding and management of prediabetes, suggesting that interventions to improve prediabetes care should include more effective counseling on diagnosis and treatment and expanding access to nutrition and educational resources.

Public-Private Partnerships to Lower the Risk of Diabetes Among Black Women Using Cooperative Agreements: The National Diabetes Prevention Program and the Black Women's Health Imperative

The National Diabetes Prevention Program (National DPP) is a partnership of public and private organizations working to build a nationwide delivery system for a lifestyle change program (LCP), which is proved to prevent or delay onset of type 2 diabetes in adults with prediabetes. Through this program, the Centers for Disease Control and Prevention (CDC) establishes partnerships with organizations to prevent or delay the onset of type 2 diabetes by using the evidence-based and audience-tailored LCP. The DP17-1705 cooperative agreement aims to expand the reach of the program in underserved areas and to populations currently underrepresented in the program relative to their risk. This article highlights a successful adaptation of the National DPP PreventT2 curriculum to address the needs of women who are Black funded by this cooperative agreement. The Change your Lifestyle, Change your Life (CYL²) program resulted from a partnership between CDC and the Black Women's Health Imperative. Successes and challenges associated with this program are highlighted. Lessons learned from these efforts can be used by practitioners to inform future type 2 diabetes prevention initiatives.

Domains from the health belief model predict enrollment in the National Diabetes Prevention Program among insured adults with prediabetes

AIMS

To examine enrollment in the National Diabetes Prevention Program (DPP) by insured adults with prediabetes according to domains of the Health Belief Model (HBM).

METHODS

Between 2015 and 2019, University of Michigan employees, retirees, and dependents with prediabetes were offered the National DPP at no out-of-pocket cost. Individuals with prediabetes were identified and mailed letters encouraging them to enroll. We surveyed those who enrolled and a random sample of those who did not using the HBM as a framework to examine factors associated with enrollment. Analyses were performed using multivariable logistic regression models.

RESULTS

Of 64,131 employees, retirees, and dependents, 8131 were identified with prediabetes and 776 (9.5%) enrolled in the National DPP. Of those surveyed, 532 of 776 National DPP enrollees and 945 of 2673 non-enrollees responded to the survey (adjusted response rates 74% and 43%, respectively). Among survey respondents, factors associated with National DPP enrollment included older age, female sex, higher BMI, prediabetes awareness, greater perceived benefits of health-protective action, and one or more cues to action.

CONCLUSIONS

Optimizing National DPP enrollment among adults with prediabetes will require identifying individuals with prediabetes, increasing personal awareness of the diagnosis, increasing perceived benefits of enrollment, and providing strong cues to action.

Qualitative inquiry with primary care providers and specialists about adult weight management care and referrals

Obesity is a highly prevalent disease and providers are expected to offer or refer patients for weight management yet increasingly fewer clinical visits address obesity. Challenges to offering care are known but less is known about referrals and how specialists who treat obesity-related comorbidities address care and referrals. This study explored perceptions of primary care providers (PCPs) and specialty providers regarding care and referrals for weight management, specifically referrals to programs in the community setting. A qualitative design was used to interview 33 PCPs (mean age 54 years) and 31 specialists (cardiology, gynecology, endocrinology, and orthopedics [mean age 62 years]) in the USA during 2019. Each interview was conducted by telephone, audio-recorded, and transcribed verbatim. Inductive analysis was used and followed the constant comparative method. Four themes emerged from the data including (a) Clinical guidelines and provider discretion influence obesity care; (b) Facilitators and barriers to discussing weight and small step strategies; (c) Informal referrals are made for weight management in community settings; and (d) Opportunities and challenges for integrating clinical and community services for weight management. Facilitating referrals to effective programs, ideally with a feedback loop could coordinate care and enhance accountability, but education, compliance, and cost issues need addressed. Care may be offered but not be well-aligned with clinical guidelines. Knowledge gaps regarding community programs' offerings and efficacy were evident. Referrals could be systematically promoted, facilitated, and tracked to advance weight management objectives.

Developing weight navigation program to support personalized and effective obesity management in primary care settings: protocol for a quality improvement program with an embedded single-arm pilot study

BACKGROUND

Primary care providers (PCPs) are expected to help patients with obesity to lose weight through behavior change counseling and patient-centered use of available weight management resources. Yet, many PCPs face knowledge gaps and clinical time constraints that hinder their ability to successfully support patients' weight loss. Fortunately, a small and growing number of physicians are now certified in obesity medicine through the American Board of Obesity Medicine (ABOM) and can provide personalized and effective obesity treatment to individual patients. Little is known, however, about how to extend the expertise of ABOM-certified physicians to support PCPs and their many patients with obesity.

AIM

To develop and pilot test an innovative care model - the Weight Navigation Program (WNP) - to integrate ABOM-certified physicians into primary care settings and to enhance the delivery of personalized, effective obesity care.

METHODS

Quality improvement program with an embedded, 12-month, single-arm pilot study. Patients with obesity and ≥1 weight-related co-morbidity may be referred to the WNP by PCPs. All patients seen within the WNP during the first 12 months of clinical operations will be compared to a matched cohort of patients from another primary care site. We will recruit a subset of WNP patients (n = 30) to participate in a remote weight monitoring pilot program, which will include surveys at 0, 6, and 12 months, qualitative interviews at 0 and 6 months, and use of an electronic health record (EHR)-based text messaging program for remote weight monitoring.

DISCUSSION

Obesity is a complex chronic condition that requires evidence-based, personalized, and longitudinal care. To deliver such care in general practice, the WNP leverages the expertise of ABOM-certified physicians, health system and community weight management resources, and EHR-based population health management tools. The WNP is an innovative model with the potential to be implemented, scaled, and sustained in diverse primary care settings.

Did the 2015 USPSTF Abnormal Blood Glucose Recommendations Change Clinician Attitudes or Behaviors? A Mixed-Method Assessment

BACKGROUND

In 2015, the US Preventive Services Task Force (USPSTF) revised clinical recommendations to more broadly recommend abnormal blood glucose screening and more clearly recommend referral to behavioral interventions for adults with prediabetes.

OBJECTIVE

To assess the effects of the 2015 USPSTF recommendation changes on abnormal blood glucose screening and referral to behavioral interventions, and to examine physicians' perceptions of the revised recommendation.

DESIGN

We utilized a sequential, dependent mixed-methods triangulation design.

PARTICIPANTS

A total of 33,444 patients meeting USPSTF abnormal blood glucose screening criteria within 15 health system-affiliated primary care practices and 20 primary care physicians in North Carolina.

MAIN MEASURES

We assessed monthly abnormal blood glucose screening rate and monthly referral rate to behavioral interventions. To estimate trend changes in outcomes, we used segmented linear regression analysis of interrupted time-series data. We gathered physicians' perspectives on the 2015 USPSTF abnormal blood glucose recommendation including awareness of, agreement with, adoption of, and adherence to the recommendation. To analyze qualitative data, we used directed content analysis.

KEY RESULTS

There was a slight significant change in trend in abnormal blood glucose screening rates post-recommendation. There was a slight, statistically significant decrease in referral rates to behavioral interventions post-recommendation. Physicians were generally unaware of the revisions to the 2015 USPSTF abnormal blood glucose recommendation; however, once the recommendations were described, physicians agreed with the screening recommendation but felt that the behavioral intervention referral recommendation was hard to implement.

CONCLUSION

The 2015 USPSTF abnormal blood glucose guideline had little to no effect on abnormal blood glucose screening or referral to behavioral interventions in North Carolina practices. Potential interventions to improve these rates could include clinical decision tools embedded in the electronic health record and better referral systems for community-based diabetes prevention programs.

Health Care Providers' Knowledge, Attitudes, and Practices and the Association With Referrals to the National Diabetes Prevention Program Lifestyle Change Program

Purpose

To examine how health care providers’ knowledge, attitudes, and practices affect their referrals to the National Diabetes Prevention Program.

Design

Cross-sectional, self-report data from DocStyles—a web-based survey

Setting

USA

Sample

Practicing family practitioners, nurse practitioners, pharmacists, and internists, n = 1,503.

Measures

Questions regarding health care providers’ knowledge, attitudes, and practices and their referrals to the National Diabetes Prevention Program.

Analysis

Bivariate and multivariate analyses were used to calculate predictive margins and the average marginal effect.

Results

Overall, 15.2% of health care providers (n = 1,503) reported making a referral to the National Diabetes Prevention Program. Health care providers were more likely to make referrals if they were familiar with the program (average marginal effect = 36.0%, 95% CI: 29.1%, 42.8%), reported knowledge of its availability (average marginal effect=49.1%, 95% CI: 40.2%, 57.9%), believed it was important to make referrals to the program (average marginal effect = 20.7%, 95% CI: 14.4%, 27.0%), and used electronic health records to manage patients with prediabetes (average marginal effect = 9.1%, 95% CI: 5.4%, 12.7%). Health care providers’ demographic characteristics had little to no association with making referrals.

Conclusion

Making referrals to the National Diabetes Prevention Program was associated with health care providers’ knowledge of the program and its reported availability, their attitudes, and their use of the electronic health record system to manage patients with prediabetes.

Using a certified electronic health record technology platform to screen, test and refer patients with prediabetes

The objective of this study was to determine if certified electronic health record technology (CEHRT) can be used to identify and refer patients with prediabetes to lifestyle change programs (LCPs) recognized by the National Diabetes Prevention Program (DPP). This pilot utilized a prediabetes registry, patient portal, and clinical decision support to increase referrals. Data from 36 primary care providers showed 4930 patients were eligible for DPP LCP, 293 referrals were generated, compared to 20 referrals in the baseline period, and 116 patients enrolled. Referral to enrollment conversion rates were 41% in the study period and 69% in the post-study 1-year period. CEHRT functionalities can support systematic identification and management of prediabetes. The referral rate increased 7-fold compared to the baseline period, with high referral to enrollment conversion rates. CEHRT coupled with active provider engagement can serve as a tool to identify prediabetes patients and facilitate LCP referrals and enrollment.

Current practices, facilitators, and barriers experienced by program providers implementing the National Diabetes Prevention Program in Los Angeles County

Individuals with prediabetes can lower their diabetes risk by participating in the National Diabetes Prevention Program (National DPP), an evidence-based, group lifestyle change program that is taught by a certified lifestyle coach. To date, studies have not explicitly compared National DPP implementation across multiple settings (i.e., types of organizations) to understand comparative setting advantages or challenges to engaging priority groups. The purpose of this study was to gain an in-depth understanding of: (a) the variation in National DPP implementation across clinic, community-based, and digital settings and (b) associated facilitators and barriers. The study focused on three core implementation domains: recruitment, retention, and data reporting. This study used a descriptive, qualitative approach to identify current practices, facilitators, and barriers to National DPP implementation by conducting semistructured key informant interviews in spring 2018 with 12 organizations delivering the National DPP in Los Angeles County. There was a general commonality between in-person settings (clinics and community-based), while the experiences of digital providers were relatively distinct. Recruitment and retention were widely described by all settings as labor- and time-intensive, while data reporting was seen as relatively less burdensome. All respondents reported using multiple recruitment strategies. Lifestyle coaches were seen as key to retention, and they spent substantial time engaging with participants outside of class, which often was not accounted for in program costs. Data reporting was easier for organizations that invested in sophisticated data management systems and had staff with sufficient data experience. This study advances knowledge around the translation of the National DPP in diverse settings in the nation's largest county and highlights opportunities for targeted, setting-specific support.

Facilitators to referrals to CDC's National Diabetes Prevention Program in primary care practices and pharmacies: DocStyles 2016-2017

Despite evidence of the effectiveness of behavioral change interventions for type 2 diabetes prevention, health care provider referrals to organizations offering the National Diabetes Prevention Program (National DPP) lifestyle change program (LCP) remain suboptimal. This study examined facilitators of LCP referrals among primary care providers and pharmacists (providers). We analyzed data on 1956 providers from 2016 to 2017 DocStyles web-based surveys. Pearson chi-square or Fisher's exact tests were used for bivariate associations between facilitators, provider characteristics, and their self-reported referral and bi-directional referral (where they received patient status updates back from the LCPs) to an LCP. Multiple logistic regressions were used to estimate the effects of facilitators to referral practices, controlling for providers' characteristics. Geocoding was done at the street level for in-person, public LCP class locations and at the zip code level for survey respondents to create a density measure for LCP availability within 10 miles. Overall, 21% of providers referred their patients with prediabetes to LCPs, and 6.4% engaged in bi-directional referral. Provider practices that established clinical-community linkages (CCLs) with LCPs (AOR = 4.88), used electronic health records (EHRs) to manage patients (AOR = 2.94), or practiced within 10 miles of an in-person, public LCP class location (AOR = 1.49) were more likely to refer. Establishing CCLs with LCPs (AOR = 8.59) and using EHRs (AOR = 1.86) were also facilitators of bi-directional referral. This study highlights the importance of establishing CCLs between provider settings and organizations offering the National DPP LCP, increasing use of EHRs to manage patients, and increasing availability of in-person LCP class locations near provider practices.

The Effectiveness of a Proactive, Three-Level Strategy to Identify People With Prediabetes in a Large Workforce With Employer-Sponsored Health Insurance

OBJECTIVE

Rates of diagnosis of prediabetes and uptake of the National Diabetes Prevention Program (NDPP) are low. We evaluated a proactive three-level strategy to identify individuals with prediabetes in a population with employer-sponsored health insurance.

RESEARCH DESIGN AND METHODS

We studied 64,131 insured employees, dependents, and retirees ≥18 years of age without diagnosed diabetes, 19,397 (30%) of whom were estimated to have prediabetes. Individuals with prediabetes were identified by 1) searching claims diagnoses and previously performed HbA1c test results, 2) risk stratifying people 40-64 years of age without diabetes, prediabetes, or documented normal HbA1c to identify individuals at higher risk and encourage them to be tested, and 3) using a media campaign to encourage employees not otherwise targeted to self-screen and, if at higher risk, to be tested.

RESULTS

Using claims and laboratory data, 11% of the population was identified as having prediabetes. Of those 40-64 years of age, 25% were identified as being at higher risk, and 27% of them were tested or diagnosed within 1 year. Of employees exposed to the media campaign, 14% were tested or diagnosed within 1 year. Individuals with prediabetes were older, heavier, and more likely to have hypertension and dyslipidemia. Testing and diagnosis were associated with receiving medical care and provider outreach. A total of 8,129 individuals, or 42% of those with prediabetes, were identified.

CONCLUSIONS

Analysis of existing health insurance data facilitated the identification of individuals with prediabetes. Better identification of people with prediabetes is a first step in increasing uptake of the NDPP.

Development and Evaluation of a Prediabetes Decision Aid in Primary Care: Examining Patient-Reported Outcomes by Language Preference and Educational Attainment

PURPOSE

The purpose of this study was to examine the development and preliminary effectiveness of a novel Prediabetes Decision Aid on adoption of intensive lifestyle interventions (ILIs) and metformin. Little research has focused on increasing uptake of these evidence-based treatments, especially among non-English speakers and those with low educational attainment.

METHODS

Investigators developed an English and Spanish decision aid displaying information about type 2 diabetes (T2DM) risk and treatments to prevent T2DM and prompting patients to identify next steps for management. This pilot study was a single-arm, pretest-posttest trial of 40 adult patients with prediabetes, obesity, and ≥1 office visit within the prior 12 months. Participants reviewed this tool briefly with a study team member, and data were collected on 3 coprimary outcomes: knowledge about T2DM risk, decisional conflict, and intention to adopt treatment. Exploratory outcomes included subsequent documentation of prediabetes in chart notes and adoption of ILIs or metformin.

RESULTS

Almost all participants were women, with nearly half expressing Spanish language preference and low educational attainment. A nonsignificant increase in knowledge was observed across all subgroups. Decisional conflict was significantly reduced from pretest to posttest and was similar between subgroups defined by language preference and educational attainment. While intention to adopt ILIs increased across all subgroups, this change was only significant among Spanish speakers and participants with low educational attainment. At 6 months, 17 participants had subsequent provider documentation of prediabetes, and 12 adopted ILIs or metformin.

CONCLUSIONS

The decision aid improved patient-reported outcomes and promoted treatment adoption in a diverse patient sample.

Monitoring Prediabetes Screening in Two Primary Care Offices in Rural Appalachia: A Quality Improvement Process

BACKGROUND

One-third of the U.S. population has prediabetes, but 90% remain undiagnosed because healthcare providers are not screening for this condition.

OBJECTIVE

The purpose of this quality improvement project was to monitor prediabetes screening and identification, and implement evidence-based recommendations including registered dietician referral.

METHODS

This project involved using an evidence-based screening tool to measure individual risk of prediabetes. Aggregate data was collected to evaluate screening implementation, evidence-based recommendations offered by providers, and assess patient risk factors.

RESULTS

The percentage of patients at risk for prediabetes was 41.3% (n = 111). The most frequent risks were identified as overweight, history of hypertension, family history of type 2 diabetes mellitus (T2DM), and older age. Providers offered education on weight loss 68.5% (n = 76) and exercise 76.6% (n = 85) but referred 33.3% (n = 37) patients for nutrition education. The screening rates were 52.3% (n = 176) and 72.5% (n = 244) in clinics A and B respectively.

CONCLUSIONS

A gap remains in using evidence-based recommendations to decrease risk of prediabetes. Prediabetes screening identified a greater percentage of persons in this population.

IMPLICATIONS FOR NURSING

There is a need for consistent practice of evidence-based recommendations. This project set the benchmark for future efforts to educate, encourage, and measure providers successes.

Primary Care Cluster RCT to Increase Diabetes Prevention Program Referrals

INTRODUCTION

The Diabetes Prevention Program, an intensive lifestyle change program, effectively reduces the risk of progression from prediabetes to type 2 diabetes but is underutilized. An implementation study using formative research was undertaken to increase Diabetes Prevention Program referrals at a primary care clinic.

STUDY DESIGN

A pragmatic, cluster randomized, mixed-methods study.

SETTING/PARTICPANTS

Clusters were teams of primary care clinicians from 2 primary care clinics. The 3 intervention clusters had 8-11 clinicians, and the 3 control clusters had 7-20 clinicians.

INTERVENTION

Implementation activities occurred from December 2017 to February 2019. The activities included targeted clinician education, a prediabetes clinician champion, and a custom electronic health record report identifying patients with prediabetes.

MAIN OUTCOME MEASURES

The primary outcome was referral of patients with prediabetes to the institutional Diabetes Prevention Program. Study data, including patient demographic and clinical variables, came from electronic health record. Interviews with clinicians evaluated the implementation strategies. Generalized estimating equation analyses that accounted for multiple levels of correlation and interview content analysis occurred in 2019.

RESULTS

Study clinicians cared for 2,992 patients with a prediabetes diagnosis or HbA1c indicative of prediabetes (5.7%-6.4%). Clinicians in the intervention clusters referred 6.9% (87 of 1,262) of patients with prediabetes to the Diabetes Prevention Program and those in the control clusters referred 1.5% (26 of 1,730). When adjusted for patient age, sex, race, HbA1c value, HbA1c test location, and insurance type, intervention clinicians had 3.85 (95% CI=0.40, 36.78) greater odds of referring a patient with prediabetes to the Diabetes Prevention Program. The 11 interviewed intervention clinicians had mixed opinions about the utility of the interventions, reporting the prediabetes clinic champion (n=7, 64%) and educational presentations (n=6, 55%) as most helpful.

CONCLUSIONS

Intervention clinicians were more likely to make Diabetes Prevention Program referrals; however, the study lacked power to achieve statistical significance. Clinician interviews suggested that intervention components that triggered Diabetes Prevention Program referrals varied among clinicians.

Evidence and Challenges for Translation and Population Impact of the Diabetes Prevention Program

PURPOSE OF REVIEW

Type 2 diabetes is common, burdensome, and preventable. Landmark trials such as the Diabetes Prevention Program (DPP) demonstrated that resource-intensive lifestyle support interventions resulting in modest weight loss via healthy diet changes and physical activity can lower the rate of diabetes development by 58%. We performed a review of efforts to translate and implement DPP-like programs throughout the USA to identify challenges and opportunities for improvement.

RECENT FINDINGS

For more than a decade, multiple stakeholders have worked to translate evidence-based principles of diabetes prevention to reach 84 million Americans with prediabetes. DPP-like programs have been delivered by over 1500 organizations, reaching almost 300,000 people, but this number represents less than 1% of the target population. Research has uncovered large gaps in efforts to diagnose, raise awareness, and provide access to DPP-like programs for adults with prediabetes, requiring further stakeholder engagement and coordination to resolve. Efforts to address prevailing gaps in diabetes prevention must address distinct and sometimes conflicting priorities and concerns of stakeholders. Our review recommends several areas of further research and action to improve type 2 diabetes prevention on a population scale.

Current Perspectives on the Impact of the National Diabetes Prevention Program: Building on Successes and Overcoming Challenges

To address the public health and economic burden of type 2 diabetes, the Centers for Disease Control and Prevention (CDC) began dissemination of the National Diabetes Prevention Program (NDPP) in the United States in 2010. Based on the intensive lifestyle intervention from a large efficacy trial, the NDPP aims to reduce incidence through lifestyle change and weight loss. This narrative review summarizes evidence on reach, effectiveness, and sustainability of the NDPP, while highlighting opportunities to overcome challenges in these areas. Major successes include reaching hundreds of thousands of at-risk individuals across the nation, with notable effectiveness upon full participation and widespread insurance coverage. Yet, more work is needed to ensure greater public health impact, particularly among priority populations at heightened risk who also experience disparities in program outcomes. Preliminary evidence suggests a number of strategies may improve reach and effectiveness of the NDPP, often with more rigorous study needed prior to widespread uptake. Updating the NDPP to better match the current evidence-base may also be important, such as directly targeting glycemia with a patient-centered approach and promoting metformin as an adjunct or second-line treatment. Finally, revisiting pay-for-performance reimbursement models may be critical to sustainability by ensuring adequate availability of suppliers and ultimately reducing diabetes prevalence.

The Reach of an Urban Hospital System-Based Diabetes Prevention Program: Patient Engagement and Weight Loss Characteristics

PURPOSE

The purpose of this study was to identify patient and program delivery characteristics associated with engagement and weight loss in a Diabetes Prevention Program (DPP) implemented in an urban hospital system.

METHODS

Patient and program delivery data were collected between July 2015 and December 2017. DPP eligibility was determined based on age, body mass index (BMI), and hemoglobin A1C data via the electronic health record. Engagement was measured at 3 levels: ≤3 sessions, 4 to 8 sessions, and ≥9 sessions. Weight was measured at each DPP session.

RESULTS

Among the eligible patients (N = 31 524), referrals and engagement were lower in men than women, in Spanish speakers than English speakers, in younger (18-34 years) and middle-aged (35-54 years) than older adults, and in patients receiving Medicaid than other patients. Referral and engagement were higher in patients with higher BMIs and those prescribed ≥5 medications. Current smokers were less frequently engaged. Prior health care provider contact was associated with higher engagement. Overall, 28% of DPP participants achieved ≥5% weight loss; younger and middle-aged patients and those who gained weight in the prior 2 years were less likely to lose weight.

CONCLUSION

This assessment identified characteristics of patients with lower levels of referral and engagement. The DPP staff may need to increase outreach to address barriers to referral and during all points of engagement among men, younger patients, and Spanish speakers. Future research is needed to increase understanding with regard to why referrals and engagement are lower among these groups.

Impact of rurality on diabetes screening in the US

Background

Due to the high prevalence of diabetes risk factors in rural areas, it is important to identify whether differences in diabetes screening rates between rural and urban areas exist. Thus, the purpose of this study is to examine if living in a rural area, rurality, has any influence on diabetes screening across the US.

Methods

Participants from the 2011, 2013, 2015, and 2017 nationally representative Behavioral Risk Factor Surveillance System (BRFSS) surveys who responded to a question on diabetes screening were included in the study (n = 1,889,712). Two types of marginal probabilities, average adjusted predictions (AAPs) and average marginal effects (AMEs), were estimated at the national level using this data. AAPs and AMEs allow for the assessment of the independent role of rurality on diabetes screening while controlling for important covariates.

Results

People who lived in urban, suburban, and rural areas all had comparable odds (Urban compared to Rural Odds Ratio (OR): 1.01, Suburbans compared to Rural OR: 0.95, 0.94) and probabilities of diabetes screening (Urban AAP: 70.47%, Suburban AAPs: 69.31 and 69.05%, Rural AAP: 70.27%). Statistically significant differences in probability of diabetes screening were observed between residents in suburban areas and rural residents (AMEs: − 0.96% and − 1.22%) but not between urban and rural residents (AME: 0.20%).

Conclusions

While similar levels of diabetes screening were found in urban, suburban, and rural areas, there is arguably a need for increased diabetes screening in rural areas where the prevalence of diabetes risk factors is higher than in urban areas.

Public Health Approaches to Type 2 Diabetes Prevention: the US National Diabetes Prevention Program and Beyond

PURPOSE OF REVIEW

This article highlights foundational evidence, translation studies, and current research behind type 2 diabetes prevention efforts worldwide, with focus on high-risk populations, and whole-population approaches as catalysts to global prevention.

RECENT FINDINGS

Continued focus on the goals of foundational lifestyle change program trials and their global translations, and the targeting of those at highest risk through both in-person and virtual modes of program delivery, is critical. Whole-population approaches (e.g., socioeconomic policies, healthy food promotion, environmental/systems changes) and awareness raising are essential complements to efforts aimed at high-risk populations. Successful type 2 diabetes prevention strategies are being realized in the USA through the National Diabetes Prevention Program and elsewhere in the world. A multi-tiered approach involving appropriate risk targeting and whole-population efforts is essential to curb the global diabetes epidemic.

An assessment of medical students' knowledge of prediabetes and diabetes prevention

BACKGROUND

The United States has 84 million adults with prediabetes, putting them at a higher risk than the general population for developing type 2 diabetes. Missed opportunities among primary care providers in diagnosing and managing patients with prediabetes represent a gap in care, suggesting there is a need to educate practicing physicians and medical students about diabetes prevention. The purpose of this study is to assess medical students' basic knowledge of prediabetes and diabetes prevention, identify potential educational needs, and target areas for improvement in undergraduate medical education curricula.

METHODS

A cross-sectional study to assess medical students' preclinical and clinical management knowledge of prediabetes and diabetes prevention. Medical students attending the 2016 American Medical Association's annual meeting took a 6-item knowledge questionnaire using a mobile application or a paper version. Scores were reported for the full sample of respondents, by year in medical school, by topic area, and by mode of survey response.

RESULTS

The average student answered fewer than half of the questionnaire questions correctly. Scores on some items addressing preclinical content were higher among third- and fourth-year students compared to first- and second-year students (p = 0.039 and effect size = 0.363). Average scores on the items addressing clinical management were not significantly different by year in medical school, but the item measuring effectiveness of metformin to a lifestyle change program had 41.9% correct answers among the mobile application respondents compared to 21.5% among paper test respondents (p = 0.003 and effect size = 0.463).

CONCLUSIONS

Medical student performance on the prediabetes knowledge questionnaire was low. Students' year in medical school had a slight impact on overall performance, but only for certain questions. The results suggest the need for improvements in current medical school curricula for increasing the awareness of screening for prediabetes as well as the benefits of the lifestyle change programs in the National Diabetes Prevention Program.

Reach and Use of Diabetes Prevention Services in the United States, 2016-2017

IMPORTANCE

Coordinated efforts by national organizations in the United States to implement evidence-based lifestyle modification programs are under way to reduce type 2 diabetes (hereinafter referred to as diabetes) and cardiovascular risks.

OBJECTIVE

To provide a status report on the reach and use of diabetes prevention services nationally.

DESIGN, SETTING, AND PARTICIPANTS

This nationally representative, population-based cross-sectional analysis of 2016 and 2017 National Health Interview Survey data was conducted from August 3, 2017, through November 15, 2018. Nonpregnant, noninstitutionalized, civilian respondents 18 years or older at high risk for diabetes, defined as those with no self-reported diabetes diagnosis but with diagnosed prediabetes or an elevated American Diabetes Association (ADA) risk score (>5), were included in the analysis. Analyses were conducted for adults with (and in sensitivity analyses, for those without) elevated body mass index.

MAIN OUTCOMES AND MEASURES

Absolute numbers and proportions of adults at high risk with elevated body mass index receiving advice about diet, physical activity guidance, referral to weight loss programs, referral to diabetes prevention programs, or any of these, and those affirming engagement in each (or any) activity in the past year were estimated. To identify where gaps exist, a prevention continuum diagram plotted existing vs desired goal achievement. Variation in risk-reducing activities by age, sex, race/ethnicity, educational attainment, insurance status, history of gestational diabetes mellitus, hypertension, or body mass index was also examined.

RESULTS

This analysis included 50 912 respondents (representing 223.0 million adults nationally) 18 years or older (mean [SE] age, 46.1 [0.2] years; 48.1% [0.3%] male) with complete data and no self-reported diabetes diagnosis by their health care professional. Of the represented population, 36.0% (80.0 million) had either a physician diagnosis of prediabetes (17.9 million), an elevated ADA risk score (73.3 million), or both (11.3 million). Among those with diagnosed prediabetes, 73.5% (95% CI, 71.6%-75.3%) reported receiving advice and/or referrals for diabetes risk reduction from their health care professional, and, of those, 35.0% (95% CI, 30.5%-39.8%) to 75.8% (95% CI, 73.2%-78.3%) reported engaging in the respective activity or program in the past year. Half of adults with elevated ADA risk scores but no diagnosed prediabetes (50.6%; 95% CI, 49.5%-51.8%) reported receiving risk-reduction advice and/or referral, of whom 33.5% (95% CI, 30.1%-37.0%) to 75.2% (95% CI, 73.4%-76.9%) reported engaging in activities and/or programs. Participation in diabetes prevention programs was exceedingly low. Advice from a health care professional, age range from 45 to 64 years, higher educational attainment, health insurance status, gestational diabetes mellitus, hypertension, and obesity were associated with higher engagement in risk-reducing activities and/or programs.

CONCLUSIONS AND RELEVANCE

Among adults at high risk for diabetes, major gaps in receiving advice and/or referrals and engaging in diabetes risk-reduction activities and/or programs were noted. These results suggest that risk perception, health care professional referral and communication, and insurance coverage may be key levers to increase risk-reducing behaviors in US adults. These findings provide a benchmark from which to monitor future program availability and coverage, identification of prediabetes, and referral to and retention in programs.

The Behavioral Medicine Research Council: Its origins, mission, and methods

The Behavioral Medicine Research Council (BMRC) is a new, autonomous joint committee of 4 of the leading behavioral medicine research organizations, including the Academy of Behavioral Medicine Research, the American Psychosomatic Society, the Society for Health Psychology, and the Society of Behavioral Medicine. The BMRC's work has important implications for the science and practice of behavioral medicine. The distinguished senior scientists who comprise this new committee will identify a series of strategic research goals for behavioral medicine and promote systematic, interdisciplinary efforts to achieve them. This special report discusses the developments that led to the formation of the BMRC, describes the BMRC's mission, and explains the methods that its members will use. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Patient and Clinician Perceptions of Prediabetes: A Mixed-Methods Primary Care Study

Purpose

The purpose of the study was to assess patient and clinician perceptions of prediabetes in an academic family medicine practice. Data were collected in preparation for an implementation study to increase utilization of the National Diabetes Prevention Program (N-DPP).

Methods

In this mixed-methods study, discussions from 3 focus groups composed of patients with prediabetes were evaluated using thematic analysis for their understanding of and beliefs about prediabetes, care experiences, and attitudes toward N-DPP. Clinicians completed a Likert-scaled survey assessing attitudes and perceived barriers to providing prediabetes care.

Results

Among the 15 focus group participants, more than half were not aware of their diagnosis. Attitudes toward prediabetes were mixed: while many believed it was serious and elicited more fear than being “at risk,” others thought there were varying degrees of risk within the same diagnosis, making the diagnosis less impactful. Patients repeatedly expressed the perception that clinicians were not forthcoming about necessary behavior changes. Patients agreed on barriers to N-DPP, including scheduling and transportation. Clinicians (N = 31) concurred that patients lack awareness of their prediabetes diagnosis. They reported that time is available to screen all patients and that a prediabetes diagnosis is effective for advising patients of the need for lifestyle modification. There was consensus from both patients and clinicians that prediabetes is curable.

Conclusions

Increased patient awareness and patient-centered education is needed to overcome barriers to prediabetes care. To facilitate implementation of N-DPP referral processes, clinicians should clearly communicate risk, treatment information, and linkage to N-DPP as the suggested treatment plan.

Building Toward a Population-Based Approach to Diabetes Screening and Prevention for US Adults

PURPOSE OF REVIEW

Evidence-based treatments for prediabetes can prevent and delay the development of type 2 diabetes in adults. In this review, we propose a framework for population-based diabetes prevention that links screening and prevention activities across key stakeholders. We also discuss gaps in current practice, while highlighting opportunities to improve diabetes screening and prevention efforts population-wide.

RECENT FINDINGS

Awareness of diabetes risk is low, and many adults with prediabetes are not identified through existing screening efforts. Accumulating evidence and policies support expansion of the Diabetes Prevention Program (DPP) into clinical and community settings. However, the infrastructure to facilitate referrals and promote data exchange among patients, clinical settings, and community-based DPP programs is lacking. Development of evidence-driven, scalable processes for assessing diabetes risk, screening eligible adults, and delivering preventive treatments are needed to effectively improve the glycemic health of the US adult population.