Clinical Identification and Referral of Adults With Prediabetes to a Diabetes Prevention Program

Abstract

Purpose and ObjectivesCommunity programs to prevent or delay the onset of type 2 diabetes are effective, but implementing these programs to maximize their reach and impact remains a challenge. The American Medical Association (AMA) partnered with the YMCA of the USA, as part of a Centers for Medicare and Medicaid Innovation demonstration project, to develop, implement, and evaluate innovative quality improvement strategies to increase routine screening, testing, and referral of Medicare patients with prediabetes to diabetes prevention programs (DPPs) at local YMCAs.Intervention ApproachAMA recruited 26 primary care practices and health systems in 17 US communities to implement point-of-care and retrospective methods (or a combination of both) for screening, testing, and referral of Medicare patients with prediabetes. Evaluation MethodsWe assessed changes in rates of referral and enrollment of patients among participating practices. We used a mixed-methods pretest–posttest evaluation design to determine if use of certain tools and resources, coupled with systems changes, led to increased screening and referrals.ResultsPractices referred a total of 5,640 patients, of whom 1,050 enrolled in a YMCA DPP (19%; range, 2%–98%). Practices (n = 12) that used retrospective (ie, electronic medical record [EMR]) systems to identify eligible Medicare patients via a registry referred more people (n = 4,601) to the YMCA DPP than practices (n = 10) that used a point-of-care method alone (n = 437 patients) or practices (n = 4) that used a combination of these approaches (n = 602 patients). All approaches showed increased enrollment with point-of-care methods being most successful.Implications for Public HealthLessons learned from this intervention can be used to increase diabetes prevention in the United States and support the Centers for Medicare and Medicaid Services (CMS) decision to expand Medicare coverage to include the DPP for all Medicare beneficiaries.

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

“…A large study led by the American Medical Association found 56% enrollment upon point-of-care referrals to the NDPP and 11% enrollment using a retrospective, algorithm-based approach to referrals. 16 These results are fully consistent with the first known study of NDPP uptake with provider referrals. 17 Despite the comparably low rate of engagement upon algorithmic referrals, the potential to automate this approach is important for scalability, as well as reducing provider burden to meet US Preventive Services Task Force recommendations to refer at-risk individuals to intensive lifestyle interventions.…”

“…18,19 Relatively few point-of-care referrals to the NDPP are made currently. 16 First, many providers are unaware of the NDPP as a resource for their patients. A 2016 survey of over 1,200 primary care providers found that only 38% were aware of the NDPP, and fewer (23%) had referred patients to the program.…”

Community Pharmacy Engagement in Diabetes Prevention: Key Informant Interviews with Pharmacy Executives

“…Collaboration among pharmacists and others is critical to improve chronic disease outcomes, and pharmacists should be included in value-driven, collaborative models such as patient-centered medical homes and accountable care organizations. Furthermore, fostering strong relationships between physicians and pharmacists on care teams is well documented as critical to patient care (31). Specific to diabetes prevention, Medicare beneficiary enrollment in a PREVENTING CHRONIC DISEASE VOLUME 17,E90 PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY…”

Health Systems Approaches to Preventing Chronic Disease: New Partners, New Tools, and New Strategies

“…Health care providers and systems, especially those in primary care, generated multiple examples of systems of care innovations, such as coordinating care for those with HIV infection (1), expanding screening for colorectal cancer through a Medicaid accountable care organization primary care learning collaborative (2), and linking primary care patients with farmers markets (3). A partnership between the American Medical Association and the YMCA, a Center for Medicare and Medicaid Innovation demonstration project, tested increased screening, testing, and referral of Medicare patients with prediabetes seen in primary care practices in 17 US communities to diabetes prevention programs at local YMCAs, supported by a toolkit of workflows and process maps (4). The team was able to achieve a 19% enrollment rate, noting higher referral rates for practices that used a prediabetes registry — an emerging better practice.…”

“…The evaluation methods reported are striking for the predominance of mixed methods; the use of diverse data sources, including commercial health claims data sets (15,16), electronic health records (4), geotags (16), and new measures such as Facebook click-through rates (13); the use of well-established frameworks such as RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) (4); and for their high level of sophistication (10). Although it is possible to use simple evaluation methods when assessing the value of single components of a larger program (such as the comparative value of different social media methods [13]), evaluation of large, complex programs requires considerable expertise, planning time, and funding.…”