You Don’t Have to Get Diabetes!

Over the past decade, the Centers for Medicare & Medicaid Services’ (CMS) Innovation Center has initiated a wide range of alternative payment and care delivery models designed to reduce health care costs while improving care quality.

According to a 2018 analysis by the US General Accounting Office, only four models achieved lower spending and higher quality: the Pioneer Accountable Care Organization (ACO) initiative, the Initiative to Prevent Avoidable Hospitalizations among Nursing Facilities Residents Phase I, the lower-extremity joint replacement bundles under the Bundled Payments for Care Improvement (BPCI) initiative, and the National Diabetes Prevention Program (DPP).¹ 

Of these, the CMS Innovation Center recommended only two of the models for expansion, the Pioneer ACO model and the National DPP.

With the heavy and growing burden of treating diabetes in my practice, lab results representing prediabetes (an “HbA_1c” value between 5.7% and 6.4%) often escaped my attention. My focus had always been to reduce those high HbA_1cs in my patients with diabetes. According to the most recent National Diabetes Statistics Report from the US Centers for Disease Control and Prevention (CDC), 11.3% of the US population had diabetes in 2019, and 8.5 million adults (23.0% of adults with diabetes) were not aware of having diabetes.²

After joining a regional collaborative with the College of Population Health, the American Medical Association, and the CDC to promote the CDC National DPP, my perspective dramatically changed.

What I quickly learned: Diabetes is just the tip of the iceberg!

Nearly 100 million Americans (38% of our population) have prediabetes. Many of them are at high risk to develop diabetes over the ensuing 5 years. There is more prediabetes as we age; almost half of our population over the age of 65 years has prediabetes.

The DPP is a well-studied, evidence-based, successful program. The CDC initiated a randomized, controlled clinical trial in 1996 with 3 arms: a lifestyle change program, a metformin treatment program, and a control group. The DPP Outcomes Study (DPPOS) began in 2002, and it is still ongoing. The DPPOS showed that after 10 years there was a 34% delay in progression to DM2 (which translates into participants developing DM 4 years later than those not participating) with an even greater 49% delay in patients older than 60 years.

The structure, group support, and learning are the “secret sauce” of the DPP program. DPP is a program of 22 hour-length classes over one year with a specific curriculum administered by a trained facilitator. After serving as a “guest expert” at several local DPP meetings, I was amazed at hearing participants’ stories of weight loss and reduction of their prediabetes HbA_1c through lifestyle change. Some members achieved reversal of prediabetes despite a lack of support or knowledge from their health care provider. While patients can self-refer to the program, a referral from their health care provider further encourages participation.

Many DPP groups have converted to virtual format due to the pandemic; our group enrollment has increased with the convenience of being able to participate from home.

Addressing prediabetes is a critical example of the population health strategy to work upstream—addressing conditions to mitigate the downstream work of treating diseases and their complications.

Through my experience, I have become a fervent advocate for the DPP. I can now look my patient with prediabetes in the eye and state with confidence, “You don’t have to get diabetes!”

I have promoted DPP to health care providers through lectures and grand rounds presentations, often including patients who have successfully made lifestyle changes through the DPP. Their testimonials are powerful and have an impact on providers. When I present Grand Rounds on prediabetes, I ask providers:

Would you prescribe a treatment, taken once a week, that could delay or even avoid your patient’s progression to type 2 diabetes? There would be no out-of-pocket cost to your patient; potential side effects include increased patient self-efficacy and self-esteem, and an opportunity for greater community interaction.

Despite the demonstrated success of the DPP, national engagement and retention in the program has lagged.³  

CMS is trying to reduce barriers to participation with, for example, a recent waiver of the application fee for DPP providers.⁴ 

The CDC also published marketing strategy guidance for the DPP earlier this year.⁵ Perhaps what we need is marketing of the program comparable to ads promoting new diabetes drugs during primetime TV. Imagine happy people mowing lawns or leading marching bands—happy because they have avoided getting diabetes through participation in the DPP!

References:

1. US Government Accountability Office. CMS Innovation Center: Model Implementation and Center Performance. April 25, 2018. Accessed July 7, 2022. https://www.gao.gov/products/gao-18-302
2. Centers for Disease Control and Prevention. National Diabetes Statistics Report. January 18, 2022. Accessed July 7, 2022. https://www.cdc.gov/diabetes/data/statistics/statistics-report.html. 
3. Williams Baucom KJ, Pershing ML, Dwenger KM, et al. Barriers and facilitators to enrollment and retention in the National Diabetes Prevention program: perspectives of women and clinicians within a health system. Women’s Health Reports. Published online May 12, 2021. doi:10.1089/whr.2020.0102
4. Centers for Medicare & Medicaid Services. Final policies for the medicare diabetes prevention program (MDPP) expanded model for the calendar year 2022 Medicare physician fee schedule. November 2, 2021. Accessed July 7, 2022. https://www.cms.gov/newsroom/fact-sheets/final-policies-medicare-diabetes-prevention-program-mdpp-expanded-model-calendar-year-2022-medicare
5. Centers for Disease Control and Prevention: Accessed July 7, 2022. https://nationaldppcsc.cdc.gov/s/article/National-DPP-Marketing-Success