Creating Policy to Promote and Support Individual Change. Ann Albright, PhD, RD

Transcription

1 Creating Policy to Promote and Support Individual Change Ann Albright, PhD, RD Director, Division of Diabetes Translation Centers for Disease Control and Prevention The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the CDC.

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3 Vision World free of the devastation of diabetes

4 Where are We?

5 Age-adjusted Percentage of U.S. Adults with Diagnosed Diabetes or Obesity Diabetes No Data <4.5% % % % >9.0% Obesity (BMI 30 kg/m 2 ) No Data <14.0% % % % >26.0%

6 Age-adjusted Percent of Adults 20 Years Old with Diagnosed Diabetes, 2007 MMWR 58: , 2009

7 Age-adjusted Percent of Adults 20 Years Old Who are Obese, 2007 MMWR 58: , 2009

8 Counties in the Top and Bottom 2 Quintiles of Both Diabetes and Obesity, 2007 MMWR 58: , 2009

9 Public Health Implications The prevalence and incidence of diagnosed diabetes has increased rapidly, particularly since the 1990s Number of factors may be driving increase change in diagnostic criteria enhanced case detection decreased mortality or a true increase in incidence

10 SEARCH for Diabetes in Youth Prevalence (p er 1, 000) Years Years NHW AA H API AI T1 T2 T1 T2 SEARCH Study Group, Pediatrics, 2006

11 1 in 3 Americans born in 2000 are expected to develop diabetes sometime during their lifetime Narayan, Boyle, Geiss, Saaddine, Thompson. Diabetes Care 29(9): , 2006

12 Diabetes is a Growing Problem Projected Burden, U.S Numbers with diagnosed diabetes (M illions) Narayan et al. JAMA 2003 Year

13 Preventive Care Practices

14 Opportunities to Control Diabetes Eye exams lead to 50-60% decrease Vision Loss Foot exams lead to 45-85% decrease Foot ulcers and amputations Glucose control lead to 40% decrease Kidney failure, Vision loss Lipid control lead to 20-50% decrease Cardiovascular Disease Flu vaccine Narayan et al., 2006 leads to 32% decrease Hospitalization

15 Progress in Control: Diabetes Preventive Care Between and % Foot exams Flu vaccine Lipid testing Eye exams Aspirin use Saaddine et al. Annals of Internal Medicine, 2006

16 Trends in Processes of Diabetes Care from to , United States Foot Exams Eye Exams Lipid Test NHW Non-white Low Educ No Health Insurance NHW Non-white Low Educ No Health Insurance NHW Non-white Low Educ No Health Insurance Saaddine et al., Ann Intern Med, 2006; additional analyses, 2008

17 Foot Exam in the Last Year 1995 and Age-adjusted rates per 100 adults with diabetes. Centers for Disease Control and Prevention. Diabetes Surveillance System at

18 > 2 A1c Tests in the Last Year 2000 and Age-adjusted rates per 100 adults with diabetes. Centers for Disease Control and Prevention. Diabetes Surveillance System at

19 Eye Exams in the Last Year 1995 and Age-adjusted rates per 100 adults with diabetes. Centers for Disease Control and Prevention. Diabetes Surveillance System at

20 Intermediate Outcomes

21 Secular Changes in Quality Measures of Diabetes Care, and % Foot exams Flu vaccine Lipid testing Eye exams Aspirin use HbA1c >9.0% BP <140/90 LDL <130 mg/dl Processes of care Intermediate measures Saaddine et al. Annals of Internal Medicine, 2006

22 Prevalence of high cholesterol among U.S. adults with diabetes aged from 1971 to 2006, according to poverty income ratio 50 Prevalence (%) Lowest 25% of income Middle 50% of income Highest 25% of income Year Cheng and Gregg, Unpublished Analyses, NHANES, 2008

23 Prevalence of high blood pressure among U.S. adults with diabetes aged from 1971 to 2006, according to poverty income ratio 60 Prevalence (%) Lowest 25% of income Middle 50% of income Highest 25% of income Year Cheng and Gregg, Unpublished Analyses, NHANES, 2008

24 Prevalence of smoking among U.S. adults with diabetes aged 20-74, according to income group, 1971 to 2002 Prevalence (%) Lowest 25% of income Middle 50% of income Highest 25% of income Cheng and Gregg, Unpublished Analyses, NHANES, 2008 Year

25 Distal Outcomes

26 Progress in Control: Diabetes Outcomes 1995 to 2005 Vision Loss 25% Amputation 36% End Stage Renal Disease 23% CVD Hospitalization 16% Total Hospitalization 33%

27 Persons with Diagnosed Diabetes

28 Total Population

29 Successes in the Public Health Response to Diabetes: Impact of Clinical and Public Health Advances Fewer acute complications/hospitalization Lower amputation rates Lower incidence of end stage renal disease Reduced CVD hospitalization Reduced mortality rates..for the average person with diabetes

30 Closing the Gap

31 "We can't solve problems by using the same kind of thinking we used when we created them." Albert Einstein

32 Ecological Model Community and policy System, group, culture Family, friends, small group Individual The health of individuals is inseparable from the health of communities (Healthy People 2010)

33 Must Address Disparities/Social Determinants of Health Stalling of some risk factor improvements Persistent disparities Renal disease in African Americans, Native American, Latinos Stroke in African Americans Blood pressure and glucose Diabetes incidence and prevalence in non-whites Trends in incidence of diabetes Growing burden in youth and young adults represent a newer area of concern

34 POLICY DISTRIBUTION POLICY AVAILABILITY POLICY EFFECTIVENESS EFFICIENCY Supply Diffusion of interventions BASIC SCIENCE EFFICACY Biggest effect on most people Real world settings Ideal settings Molecular/ physiological

35 Transforming Health Care Chronic (Planned) Care Model Creating partnerships between health system and community Community: resources and policies Health System: self-management support, delivery system design, decision support, clinical information systems

36 Critical Elements collaborating cooperating coordinating networking True synergy to cocreate & achieve mutual benefit Altering & sharing resources for a common goal Identifying & aligning complimentary resources Exchanging information for mutual benefit

37 System Dynamics Modeling Population Flow Map Burden of diabetes People with normal blood sugar levels Obesity in general population Prediabetes onset Recovery People with prediabetes Diabetes Onset Pre-diabetes detection and management People with undiagnosed diabetes Deaths Total Prevalence (People with diabetes) Diagnosis Diabetes detection Unhealthy days per person with diabetes People with diagnosed diabetes Costs per person with diabetes Deaths Diabetes management Children Adults

38 Prevention of Type 2 Diabetes The Community Clinic Partnership Model Community Clinic Insurers Employers Informed Population Strong Community Organizations Healthy Public Policy } Screening for High Risk Partnership Zone Reimbursement Lifestyle DPP-like Programs Diagnosis of Pre-diabetes Proactive Practice Team Decision Support Information Systems Supportive Environments Regular Glucose Monitoring Informed, Activated Patients Total Population Pre-diabetes Diabetes Complications

39 Prevention of Type 2 Diabetes Goal: Systematically scale the translated model of the Diabetes Prevention Program (DPP) with the Y, Indiana University and others to reduce the incidence of type 2 diabetes

40 Four Key CDC Levers (1) Training the work force that can implement the program cost effectively (2) Implementing a recognition program that will contribute to assuring quality, lead to reimbursement, and allow CDC to develop a registry of programs

41 Four Key CDC Levers (3) Implementing model sites that will build the infrastructure and provide a laboratory for additional refinement of this prevention system (4) Increasing referrals and utilization of the prevention system

42 Control and Primary Prevention Sustaining and building on gains in control Building and expanding primary prevention

43 Leadership matters most in times of uncertainty Michael Useem, The Leadership Moment

44 24 million with Diabetes 57 million with Prediabetes