Oregon Progress Report on Diabetes

Transcription

1 Diabetes Awareness and Education Oregon Progress Report on Diabetes September 2008 Oregon Diabetes Coalition 1

2 Contributors

3 Diabetes Awareness and Education Oregon Progress Report on Diabetes Compiled by the Oregon Diabetes Coalition Data Workgroup: Grieg Anderson, American Diabetes Association Bev Bromfield, American Diabetes Association Bryan Goodin, DHS Immunization Program Rich Clark, MD, MPH, Mid Valley IPA Richard Leman, MD, DHS Health Promotion and Chronic Disease Prevention Program Kerri Lopez, Northwest Portland Area Indian Health Board Siobhan Maty, PhD, PSU School of Community Health Ruth Medak, MD, Acumentra Health Amy Zlot, MPH, DHS Genetics Program Prepared by: Chondra M. Lockwood, PhD This publication was supported by Grant/Cooperative Agreement #U32/CCu from the Centers for Disease Control and Prevention (CDC), Diabetes Prevention and Control Program. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of CDC. All material in this report is in the public domain and may be reproduced or copied without permission. The Diabetes Coalition appreciates citation and notification of use. Suggested Citation: Oregon Diabetes Coalition. Oregon Progress Report on Diabetes. Department of Human Services, Health Services, Oregon Diabetes Program, Portland, Oregon, If you have questions or need this material in an alternative format, please contact: Oregon Diabetes Program Department of Human Services 800 NE Oregon Street, Suite 730 Portland, OR Phone: TTY: Fax: Oregon Diabetes Coalition 3

4 Contributors Diabetes Prevention & Control Program Center for Health Statistics Office of Medical Assistance Programs Oregon Health Care Quality Corporation Acumentra Health American Diabetes Association serving Oregon & Southwest Washington 2 Oregon Diabetes Coalition

5 Table of Contents Page Contributors...2 List of Action Plan Objectives...4 Executive Summary...6 Burden of Diabetes...6 Progress Report Highlights...8 Progress on Oregon Diabetes Coalition Action Plan...9 Diabetes Awareness and Education...10 Diabetes Knowledge...10 Diabetes Risk Factors...11 Diabetes in Rural Areas...13 Gestational Diabetes...14 Youth at Risk for Diabetes...15 Reaching At-Risk Populations...16 Worksite Health Promotion...17 Diabetes Resources...19 Diabetes Education...21 Worksite Health Promotion Resources...22 Risk for Complications...22 Self-management Practices...23 Self-management Support...25 Diabetes Quality Health Systems...27 Electronic Health and Medical Records...27 Receipt of Preventive Services...29 Receipt of Preventive Services by Specific Populations...31 Clinical Outcomes Data...32 Oregon s Population-Based Guidelines...34 Chronic Care Model Implementation...35 Aligning Forces for Quality (AF4Q)...36 Oregon Diabetes Coalition 3

6 Table of Contents Page Diabetes Advocacy and Policy...37 Oregon Legislative Activity...37 Diabetes Rights...39 Access to Diabetes Data...41 Description of Data Sources...45 List of State Action Plan Objectives Page Diabetes Awareness and Education Increase knowledge of Oregonians about prevention, risk factors, symptoms, complications, treatments and financial impact...10 Identify at-risk populations and reduce disparities among Oregonians by increasing access to and improving diabetes education...11 Identify and expand community partnerships that result in outreach to Oregonians at risk for diabetes or with prediabetes...16 Provide and support resources for Oregonians to make lifestyle changes to delay or prevent the onset of diabetes...17 Increase availability and accessibility of culturally and age appropriate health care, education, and community resources to help Oregonians manage diabetes...19 Increase the percentage of Oregonians affected by diabetes who understand, value and carry out self-management behaviors to reduce complications and improve quality of life...22 Diabetes Quality Health Systems Clinical practices and health plans use electronic tracking systems to identify their patients with diabetes and ensure appropriate care Oregon Diabetes Coalition

7 Table of Contents List of State Action Plan Objectives (continued) Page Increase continuity of care across systems for Oregonians with diabetes...28 Provide easy access to proactive planned support to assist Oregonians with diabetes...34 Purchasers plans, and systems recognize and reward providers who report key diabetes indicators and who demonstrate quality diabetes outcomes...36 Diabetes Advocacy and Policy Promote and implement a diabetes policy agenda...37 Strengthen and increase awareness about diabetes related rights...39 Access to Diabetes Data Implement and maintain processes that ensure the confidentiality, completeness, and quality of diabetes data collected and disseminated in Oregon...41 Improve data collection, analysis, and dissemination strategies among priority populations disproportionately affected by diabetes...42 Develop and integrate new data collection and analysis strategies to make diabetes health data more comprehensive and informative on both an individual and a population basis...42 Promote the dissemination and use of data that informs health policies and identifies best practices for diabetes prevention and control at the community, health system, and individual level...43 Oregon Diabetes Coalition 5

8 Executive Summary The Oregon Diabetes Coalition is pleased to provide this 2008 Progress Report as a means of tracking our progress in achieving the goals outlined in our Action Plan for Diabetes. Monitoring our progress and success is a collective effort among Coalition partners. Together we strive to make this assessment complete and meaningful by providing information on a variety of diabetes-related outcomes among different populations in Oregon. From year to year this progress report will highlight valuable information from several sources including statewide health surveillance systems, health care systems, and special data projects. Burden of Diabetes This report focuses on the progress made in implementing the state plan. Presented here in brief, the full repot on the burden of diabetes in Oregon has been presented in a separate surveillance document prepared by the Oregon Diabetes Program, available online at Diabetes is an increasing problem in Oregon, with a prevalence 35% higher than 10 years ago. Diabetes disproportionately affects the elderly, certain racial and ethnic communities, and the poor. In 2006: One in fifteen adult Oregonians have been diagnosed with diabetes, a prevalence higher than the national average Over 15% of Oregonians age 65 years or older have diabetes 6 Oregon Diabetes Coalition

9 Executive Summary Diabetes is more prevalent among Asian/Pacific Islanders, American Indians and Alaska Natives, African Americans, and Hispanics Economically disadvantaged Oregonians are 1.5 times as likely to have diabetes Diabetes leads to significant health problems and premature death. In 2005, diabetes was the sixth leading cause of death in Oregon; over 30% of those deaths occurred in people younger than 75 years old During 2006, diabetes hospitalization costs in Oregon were over $1.1 billion, and total estimated medical costs for diabetes were over $2 billion Oregonians with diabetes have increased rates of coronary heart disease, heart attacks, and strokes Oregonians with diabetes are twice as likely to report depression as those without diabetes, and more than four times as likely to report that their general health status is fair or poor instead of good or excellent Oregonians without diabetes have significant risk of developing the disease. Over 76,000 Oregonians are estimated to have undiagnosed diabetes Obesity is the primary modifiable risk factor for diabetes 58% of adult Oregonians without diabetes are overweight or obese Among adult Oregonians without known diabetes, 33% have multiple risk factors for developing it Adequate screening and risk counseling may be lacking; 16% of Oregonians have no health insurance Oregon Diabetes Coalition 7

10 Executive Summary Progress Report Highlights Statewide efforts are making a difference: Knowledge about diabetes and its complications is increasing. There are favorable upward trends in self-management activities such as blood glucose monitoring and daily foot checks among Oregonians with diabetes. Receipt of Hemoglobin A1c tests has shown significant increase among Oregonians with diabetes. A large percentage of Oregonians with diabetes report that they are receiving self-care education from their doctor or other health care providers. Oregon doctors are increasingly using Electronic Medical Records, which can be useful in management of patients with diabetes. Availability of resources for health care providers and for those with diabetes continues to increase. The Oregon legislature has highlighted the growing diabetes problem in the state. However, we still face some challenges: Certain groups of Oregonians are disproportionately affected by diabetes prevalence, morbidity, and mortality; Rates of dilated eye exams, influenza vaccinations, and dental exams have not been increasing among Oregonians with diabetes Among adult Oregonians at high risk for diabetes (3-4 risk factors), 45% were not at all worried about getting diabetes in the future Overweight and obesity continue to be a problem in Oregon, for those with and without diabetes. Getting regular physical activity and eating fruits and vegetables continue to be difficult self-care tasks for those with diabetes. 8 Oregon Diabetes Coalition

11 Progress on Oregon s Action Plan for Diabetes In 1999, the Oregon Diabetes Coalition, made up of members from health care and social service agencies, individuals living with diabetes, and concerned citizens and professionals, developed the first Action Plan to improve diabetes care and the health of people living with diabetes in Oregon. Revised in to reflect the changing environment, the Action Plan focuses on four main topics: 1) diabetes awareness and education; 2) diabetes quality health systems; 3) diabetes policy and advocacy; and 4) access to diabetes data. This report details our efforts thus far in meeting the goals set out in the Action Plan. Selected objectives from each topic area are highlighted as a means of tracking our progress. Oregon Diabetes Coalition 9

12 Diabetes Awareness and Education Objective: Increase knowledge of Oregonians about prevention, risk factors, symptoms, complications, treatments and financial impact. Diabetes Knowledge Oregonians knowledge of diabetes has been improving. Significantly more adults without diabetes know about complications related to the disease and that it has no cure. GOAL: Oregonians know the impact of diabetes and take action to decrease their risk of developing diabetes There is still room for improvement in making the general population aware that diabetes is most common in those 45 years and older, that diabetes has no cure, and that weight loss and physical activity reduce the risk of diabetes. Diabetes knowledge among adult Oregonians without diabetes % Agree Knowledge statement A person can have diabetes and not know it 94% 94% 99% Diabetes can harm a person s body before diagnosis 93% 93% 98%* Diabetes can cause blindness 85% 86% 96%* Diabetes can cause leg amputations 79% 86% 92%* Diabetes can cause kidney disease 64% 65% 91%* Diabetes can cause heart disease 45% 61% 88%* Diabetes is most common in those age 45+ years 43% 48% 61%* Diabetes has no cure 49% 73% 79%* Good diabetes knowledge (Agree with 7 or more of the statements above) 32% 49% 78%* Weight loss can reduce diabetes risk 78% Physical activity can reduce diabetes risk 88% Good diabetes knowledge (Agree with 8 or more of all 10 statements) 88% *Significant increase in knowledge from 2003 to 2007 Sources: Oregon Public Health Division & 2007 General Knowledge Survey, 2003 BRFSS 10 Oregon Diabetes Coalition

13 Diabetes Awareness and Education Still, overall knowledge in the general population increased significantly between 2003 and 2007, and knowledge in the general population that a person can have diabetes without knowing it in its early stages remains high. Objective: Identify at-risk populations and reduce disparities among Oregonians by increasing access to and improving diabetes education. Diabetes Risk Factors Certain conditions or characteristics can increase a person s risk of developing diabetes, some of which can be changed and some of which cannot. Non-modifiable risk factors include being over 45 years old, having a close relative (parent or sibling) with diabetes, having certain racial/ethnic backgrounds (African American, American Indian/Native Alaskan, Asian/Pacific Islander, or Hispanic), and having had gestational diabetes or a baby weighing more than nine pounds at birth. Modifiable risk factors include overweight or obesity, high blood pressure, low HDL (or good) cholesterol, high triglyceride levels and lack of physical activity. In 2006, almost three-quarters (73%) of adult Oregonians without diabetes report having at least one of the following risk factors for developing diabetes family history of diabetes, age 45 years or older, obesity, or physical inactivity. Approximately 33% have at least two risk factors, 9% have at least three, and 2% have all four. Among adult Oregonians with multiple risk factors for diabetes, only half report worrying about getting diabetes. Source: Oregon Public Health Division BRFSS Oregon Diabetes Coalition 11

14 Diabetes Awareness and Education Diabetes Risk Factors Among Oregonians Without Diabetes BMI* overw eight 36% obese 22% Physical inactivity 15% Family history 31% High cholesterol 33% High blood pressure 21% Tobacco user 19% History of angina, CHD, heart attack 4% 0% 10% 20% 30% 40% 50% 60% 70% Percent * Overweight=body mass index (BMI) kg/m 2, obese=bmi kg/m 2. Inactivity=no physical activity during leisure time. Family history=have parent or sibling related by blood with diabetes, excluding diabetes only during pregnancy. Diagnosed by doctor, nurse, or other health professional. 100% Worry about getting diabetes by number of risk factors 80% 60% % % 0% or 4 Risk Factors very or somew hat w orried not very w orried not at all w orried *Risk factors include: family history of diabetes, obesity, age 45+ years, and no physical activity. Source: Oregon Public Health Division BRFSS 12 Oregon Diabetes Coalition

15 Diabetes Awareness and Education In conducting the statewide Behavioral Risk Factor Surveillance System survey in 2004 and 2005, additional African-American, American Indian, Asian/Pacific Islander, and Latino Oregonians were interviewed to learn more about risk factors for diabetes and its complications in these populations. It should be noted that although additional people were surveyed, total numbers of respondents from each of these groups remained small, and the following results should be interpreted with caution. Diabetes Prevalence by Race/Ethnicity, Percent African American American Indian/Alaska Native Asian/Pacific Islander Hispanic White African American, American Indian, and Hispanic Oregonians have significantly higher diabetes rates than non-hispanic Whites. Diabetes in Rural Areas Another consideration regarding diabetes disparities is rurality. Rural counties in Oregon tend to have lower average incomes than urban counties, and income is clearly related to diabetes prevalence. 1 Oregonians Source: Oregon Public Health Division BRFSS Race Oversample Oregon Diabetes Coalition 13

16 Diabetes Awareness and Education in rural areas may have less access to diabetes related resources, be they physicians, education programs, or other types of support. The following table shows the rates of diabetes by county in Oregon, and there is generally a trend for urban counties to have lower diabetes rates. Diabetes rate by county Urban County Age-Adjusted Diabetes Rate Rural County Age-Adjusted Diabetes Rate Benton 4.7% Baker 8.3% Clackamas 4.5%** Clatsop 6.5% Columbia 8.5% Coos 6.8% Deschutes 4.7%** Crook 7.3% Jackson 6.3% Curry 7.8% Lane 6.4% Douglas 7.0% Marion 7.4% Gilliam/Wheeler 8.5% Multnomah 6.6% Grant 4.5% Polk 6.0% Harney 6.3% Washington 5.2% Hood River 4.1% Yamhill 6.0% Jefferson 11.5%** Josephine 6.7% Klamath 5.6% Lake 7.7% Lincoln 6.7% Linn 7.8% Malheur 7.1% Morrow 7.8% Sherman/Wasco 7.7% Tillamook 4.9% Umatilla 8.0% Union 4.0% Wallowa 4.3% An urban county has an urbanized area of 50,000 or more with a high degree of integration with the urbanized core 2 ** indicates county rate is significantly different from overall state rate of 6.6% Gestational Diabetes Gestational diabetes is another major risk factor for developing diabetes. Women who have had gestational diabetes have a 20 to 50 percent chance of developing Type 2 diabetes in the next 5 to 10 years. According to statewide vital statistics in 2006, 5% of all births in Oregon were to mothers Sources: County Prevalence Oregon Public Health Division Combined BRFSS; Gestational Diabetes 2006 Birth Certificate Statistical File 14 Oregon Diabetes Coalition

17 Diabetes Awareness and Education with gestational diabetes (consistent with the national estimate, which ranges from 3% to 5%). The percentage of births to mothers with gestational diabetes varies by racial/ethnic group and tends to run higher among groups with higher prevalence of diabetes overall (4.3% Non- Hispanic White, 7.9% African American, 4.5% American Indian, 7.6% Asian, and 9.3% Hispanic). Youth at Risk for Diabetes Type 2 diabetes, a disease usually diagnosed in adults, is becoming increasingly common among young persons. Obesity and lack of physical activity are two major contributors to the development of this disease and are particularly important because both can be modified through lifestyle changes. Nearly half (46%) of Oregonian 8th and 11th graders report getting less than the recommended activity level of at least 60 minutes most days of the week. Only 20% report getting 5 or more servings of fruits and vegetables per day, and 10% report getting less than 1 serving per day. In the past several years, the Body Mass Index (BMI) of middle and high school youth has been steadily increasing. The following chart depicts the percentage of 8th and 11th graders in Oregon who are overweight. Source: Oregon Public Health Division Oregon Healthy Teens Oregon Diabetes Coalition 15

18 Diabetes Awareness and Education Percentage of Overweight Oregon Teens 12% 10% 8% 6% 8th Grade 11th Grade 4% 2% 0% Year *Adolescents at or above the 95th percentile of Body Mass Index (BMI) by sex and age are considered overweight. Objective: Identify and expand community partnerships that result in outreach to Oregonians at risk for diabetes or with pre-diabetes. Reaching At-Risk Populations The Multnomah County Diabetes Coalition (MCDC), through a grant from the American Diabetes Association, completed a survey to evaluate health knowledge about diabetes among Spanish and Chinese speaking populations in the Portland area. The MCDC also conducted a provider survey to assess availability of resources for Portland, Oregon area residents with diabetes or at risk for diabetes. This resulted in an education Source: Oregon Public Health Division. Oregon Healthy Teens 16 Oregon Diabetes Coalition

19 Diabetes Awareness and Education and resource guide for individuals seeking diabetes support available in Spanish/English and Chinese/English. Paper copies have been distributed to community partners around Multnomah County. Downloadable PDF versions will soon be on the MCDC website that is currently under construction ( The MCDC website will also feature a searchable database containing the information in the guide. The Oregon Diabetes Program instituted a media campaign directed at Spanish speakers. In collaboration with Univision (KUNP), the Spanish language television station, airings of diabetes public service announcements were secured, featuring both prevention and management information. The media campaign also included advertisements in El Centinela, a local Spanish language newspaper with a distribution of over 10,000. Following this media campaign, the 2008 ADA Expo saw an increased attendance of 35% from the previous year. Objective: Provide and support resources for Oregonians to make lifestyle changes to delay or prevent the onset of diabetes. Worksite Health Promotion Oregon Healthy Worksites is a partnership between DHS public health chronic disease prevention programs and other public and private employers that promote and support healthy worksites throughout Oregon. They aim to support healthy behaviors by making the healthy choice the easy choice. The Healthy Worksites Initiative provides an assessment tool and a toolkit for building a healthy worksite at Oregon Diabetes Coalition 17

20 Diabetes Awareness and Education In 2006, the Healthy Worksite Initiative released an employer survey, which was an inventory of worksite support for healthy behaviors across Oregon. Almost 2,500 worksites responded to the survey, and among those employers who responded: 17% allow flextime for physical activity 11% have written guidelines encouraging availability of healthy foods 17% have classes, workshops, lectures or special events about exercise or physical activity 12% have classes, workshops, lectures or special events about healthy food choices 9% have classes, workshops, lectures or special events about weight control 7% have classes, workshops, lectures or special events about managing chronic disease This is an encouraging beginning to support Oregonians in delaying or preventing the onset of diabetes, but there is clearly room for improvement. Source: Oregon Public Health Division. Healthy Worksite Initiative Employer Survey Report, Oregon Diabetes Coalition

21 Diabetes Awareness and Education Objective: Increase availability and accessibility of culturally and age appropriate health care, education, and community resources to help Oregonians manage diabetes. Diabetes Resources The Oregon Diabetes Coalition Awareness and Education Workgroup has been focusing on reducing disparities related to diabetes through the creation of the Oregon Diabetes Resource Bank. This collection of lowliteracy educational handouts are to be used by health care providers, community organizations, persons with diabetes, GOAL: Oregonians affected by diabetes are able to manage their disease to prevent complications. and their support persons. The completed material titles are: Staying healthy with diabetes Blood glucose, insulin, and Type 1 diabetes Blood glucose, insulin, and Type 2 diabetes The A-1-C blood glucose test: what it is and how it can help you Keeping your eyes healthy when you have diabetes These materials are available for free download from the Oregon Diabetes Program at Additional materials for the Oregon Diabetes Resource Bank are in development; potential topics include getting quality care for diabetes, getting healthier with diabetes, and a document to help patients gather specific questions they may have about diabetes. Oregon Diabetes Coalition 19

22 Diabetes Awareness and Education Diabetes Education In 2006, 69% of adult Oregonians with diabetes report receiving formal diabetes education at some point in the past, which included either a class or one-on-one training with a diabetes educator. Oregonians with diabetes who received diabetes education in the past are more likely to report receiving recommended diabetes-related preventive services. Oregonians with Diabetes Receiving Formal Diabetes Education Percent Year Receipt of Preventive Services by Receipt of Diabetes Education in Oregonians 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Yes No All 5 Services 3-4 services <3 services Received Formal Diabetes Education *Five services include: biannual A1c test, annual foot exam, annual dilated eye exam, annual flu shot, and previous pneumococcal vaccination. Source: Oregon Public Health Division BRFSS 20 Oregon Diabetes Coalition

23 Diabetes Awareness and Education Worksite Health Promotion Resources In partnership with the Oregon Healthy Worksites project, the Oregon Diabetes Program sponsored an educational promotion for Diabetes Awareness Month (November 2006) called Fight Diabetes: Healthy from Head to Toe. This promotion focused on self-management of diabetes and support for people living with diabetes. The campaign included activities such as an information booth located in the Portland State Office Building (PSOB) where the Oregon Department of Human Services is housed. The booth included information on the management of diabetes with healthy eating, Care Cards, self-management classes, and the link between diabetes and heart disease; informational brochures and display pieces were provided by the local American Diabetes Association chapter. In addition, many resources were available to the PSOB, as well as many other state agency sites. These resources included informational web sites, targeted s, brochures/flyers, incentives, and suggestions for agency Wellness Committees about implementing policy changes. In addition, agency sites were encouraged to schedule brown-bag lunch sessions for employees to watch "The Debilitator," a health education docudrama that examines the impact of diabetes and its complications, and to hold a follow-up discussion utilizing questions from the diabetes discussion guide "New Beginnings". Three agency sites contacted the Oregon Diabetes Program for these resources. (For more information about The Debilitator and New Beginnings, visit and Oregon Diabetes Coalition 21

24 Diabetes Awareness and Education Objective: Increase the percentage of Oregonians affected by diabetes who understand, value, and carry out self-management behaviors to reduce complications and improve quality of life. Risk for Complications Many people with diabetes are at risk for diabetes complications, because of other existing health conditions and because of lifestyle choices. The following chart shows the prevalence of risk factors for complications among adult Oregonians with diabetes. Effective self-management can reduce the risk for diabetes complications Diabetes Risk Factors for Complications Among Oregonians With Diabetes BMI* >25 overw eight 25% obese 48% Physical inactivity 32% Family history 59% High cholesterol 50% High blood pressure 57% Tobacco user 17% History of angina, CHD, heart attack 17% 0% 10% 20% 30% 40% 50% 60% 70% 80% * Overweight=body mass index (BMI) kg/m 2, obese=bmi kg/m 2. Inactivity=no physical activity during leisure time. Family history=have parent or sibling related by blood with diabetes, excluding diabetes only during pregnancy. Diagnosed by doctor, nurse, or other health professional. Source: Oregon Public Health Division & 2006 BRFSS 22 Oregon Diabetes Coalition

25 Diabetes Awareness and Education Self-management Practices The charts below show trends in the percentage of adults with diabetes engaging in important self-management activities: daily blood glucose check, daily foot check, aspirin therapy, healthy diet, and physical activity. 100 Percentage of Oregonians with Diabetes Who Check Blood Glucose Daily Ye a r P ercentage of Oregonians with Diabetes Who Check Feet Daily Ye a r Source: Oregon Public Health Division BRFSS Oregon Diabetes Coalition 23

26 Diabetes Awareness and Education P ercentage of Oregonians with Diabetes Who Take Aspirin Daily or Every Other Day Ye a r P ercentage of Oregonians with Diabetes Who Eat 5 FV Daily Y ear P ercentage of Oregonians with Diabetes Who Get Any P hysical Activity Ye a r All rates are age-adjusted to the U.S Standard Population 24 Oregon Diabetes Coalition

27 Diabetes Awareness and Education Although many are doing a good job, there is still room for improvement, particularly in the areas of nutrition and physical activity. Only 1 in 5 adult Oregonians with diabetes get five or more servings of fruit and vegetables per day. The physical activity results depicted below are the most lenient definition of physical activity any activity at all outside of work. Even with that definition, 30% of adults with diabetes report getting no physical activity at all. Self-management Support Meals Made Easy. To promote understanding of the value of diabetes selfmanagement skills and to increase effectiveness of diabetes selfmanagement among Oregonians, the Oregon Diabetes Coalition has developed community self-management resources for people with diabetes and other chronic conditions. Meals Made Easy for Diabetes, a program that teaches meal planning and food preparation skills to people with diabetes and their support persons is currently being taught in five counties. The Meals Made Easy for Diabetes curriculum has been recently revised to reflect the 2005 USDA Dietary Guidelines and was translated into Spanish. Both versions are available at The Oregon Diabetes Coalition Awareness and Education Workgroup is investigating how to best market the curriculum. During the revision, evaluation of the curriculum was revised to reflect the changing data needs and to collect demographics of class participants. Lincoln County has reported 111 participants in the program, 65% of whom have diabetes. The Oregon Diabetes Program will conduct evaluations as the curriculum is used. Oregon Diabetes Coalition 25

28 Diabetes Awareness and Education Living Well with Chronic Conditions. Living Well is a six-week chronic disease self-management workshop that provides tools for living a healthy life with chronic health conditions, including diabetes, arthritis, asthma and heart disease. Through weekly sessions, the workshop provides support for continuing normal daily activities and overcoming barriers that may stand in the way of effective self-care. Tomando Control de su Salud is the Spanish version of Living Well. From May 2006 through April 2008, 150 Living Well workshops and 14 Tomando Control programs were conducted in communities across Oregon. Participants were invited to complete an anonymous demographic questionnaire during the first session, and 29% of participants reported that they are living with diabetes. Ten Living Well leader trainings have been held during that same time frame, in Albany, Bend, Coos Bay, Newport, Portland (4), Eugene and Medford, with an estimated 111 leaders trained. Three new leaders from the Warm Springs Reservation were trained in Bend; this represents the Oregon Diabetes Program s first partnership with a Federally recognized tribe to deliver self-management programs. Three Tomando Control leader trainings (Eugene and Gresham) trained 25 new leaders, including representatives from Tuality HealthCare (Hillsboro), La Clinica del Valle (Medford), Multnomah County Health Department (Portland), Portland State University (Portland) and United Way of Lane County (Eugene). This will greatly enhance capacity for delivery of the Tomando Control program in Portland and Eugene, and enable delivery of the program in two new sites serving rural/low-income Latinos (Hillsboro and Medford). References 1 Oregon Public Health Division. (2008). The Burden of Diabetes in Oregon: Surveillance Report. 2 Crandall, M. & Weber, B. (2005, November). Defining Rural Oregon: An Exploration. Rural Studies Working Paper Series, No Oregon Diabetes Coalition

29 Diabetes Quality Health Systems Objective: Clinical practices and health plans use electronic tracking systems to identify their patients with diabetes and ensure appropriate care. Electronic Health and Medical Records In 2006, the Oregon Health Care Quality Corporation conducted a survey of electronic health record (EHR) adoption. 1 Their survey included 2,403 Oregon ambulatory clinics and physician practices, representing 2,054 organizational entities. Responses were received from 1,118 practices, representing 8,144 clinicians. Fifty-three percent GOAL: Health systems consistently improve health outcomes for Oregonians affected by diabetes.. of non-federal clinicians report that they work in a practice that uses EHRs, compared to 29% nationally. Acumentra Health, Oregon s Medicare Quality Improvement Organization (formerly OMPRO), is working with 42 Oregon primary care practices engaged in implementing EHR systems. This assistance is provided under the national Doctor s Office Quality Information Technology (DOQ IT, pronounced docket ) initiative, funded by the Medicare program. Acumentra Health has provided assistance to five Oregon independent physician associations (IPAs) and individual practices in selecting systems and planning their implementation projects as well as optimization. As part of DOQ IT, Acumentra Health is also helping practices learn how to use their EHRs clinical information management capabilities for more effective management of chronic conditions, at the population level as well as in individual patient care. Oregon Diabetes Coalition 27

30 Diabetes Quality Health Systems Objective: Increase continuity of care across systems for Oregonians with diabetes. Receipt of Preventive Services Below is a review of reported receipt of preventive services among adults with diabetes statewide over time. There has been significant improvement in receipt of annual foot exams, pneumococcal vaccinations, annual cholesterol checks, and semi-annual HbA1c tests. In 2006, the proportion of adult Oregonians with diabetes who received an annual foot exam was 79%, exceeding the Healthy People 2010 goal of 75%. The proportion of Oregonians with diabetes who have received a pneumococcal vaccine in their lifetime is slowly but steadily increasing. This is good news, but there is still work to do. Annual cholesterol checks are now received at about the same rate as annual foot exams. Finally, the proportion of adult Oregonians with diabetes who received at least two HbA1c tests in the prior year was 81%, far exceeding the Healthy People 2010 goal of 50% of persons with diabetes receiving one HbA1c test annually. Annual Foot Exam Annual Dilated Eye Exam Ye a r Ye a r 28 Oregon Diabetes Coalition

31 Diabetes Quality Health Systems Annual Influenza Vaccination Pneum ococcal Vaccination Ye a r Ye a r Semi-annual Visits to Health Care Provider Annual Cholesterol Check Ye a r Ye a r Semi-Annual A1c Test Annual Dental Exam Ye a r Ye a r Despite these favorable upward trends, there is still considerable room for improvement. There has essentially been no movement in the proportion of Oregonians with diabetes that receive an annual dilated eye exam, approximately 62% over the past ten years, compared to the Healthy People 2010 goal of 75%. There has been quite a bit of variability in receipt Oregon Diabetes Coalition 29

32 Diabetes Quality Health Systems of influenza vaccines, but not much of an overall upward trend. Older Oregonians with diabetes are more likely to receive an influenza vaccination, possibly because of general (not diabetes-specific) guidelines for vaccinations. The importance of influenza vaccinations does not seem to be recognized among younger adults with diabetes. The proportion of Oregonians with diabetes who are making at least two visits to a health care provider annually has remained fairly stable over the last 10 years, around 70%. This is also true with annual dental visits, though the proportion is lower, around 65%. Number of 7 preventive services received by adult Oregonians with diabetes all 7 services 14% 5-6 services 43% 0-2 services 18% 3-4 services 25% Services included are: annual foot exam annual dilated eye exam annual flu vaccine pneumococcal vaccine semi-annual visit to HCP semi-annual A1c test annual dental exam *Note: annual cholesterol check not asked in 2006 Although many of the trends above are positive, when we look at all the pieces together, only 14% of Oregonians received all of the recommended services (only seven are included as cholesterol screening was not asked in 2006). Nearly one-fifth of adult Oregonians with diabetes report receiving two or fewer of the recommended services at appropriate intervals. Source: Oregon Public Health Division BRFSS Source: Oregon Public Health Division BRFSS 30 Oregon Diabetes Coalition

33 Diabetes Quality Health Systems Receipt of Preventive Services by Specific Populations Data have been gathered from a variety of sources to assess the receipt of preventive care services for individuals with diabetes among specific populations in Oregon. This information provides us with an overall picture of diabetes care among Medicaid recipients, Medicare Advantage enrollees, Northwest Indian tribes, and state employees in Oregon. Medicaid. The Oregon Division of Medical Assistance Programs (DMAP) collected data on individuals receiving Medicaid through claims and encounter data in calendar years 2005 and 2006 by health plans participating in the Oregon Health Plan. Measures assessed include LDL screening, HbA1c testing, microalbumin testing, and dilated eye exam. Data are from clients enrolled continuously for 6 months with no more than a 45 day break, resulting in 7,239 clients with diabetes in 2005 and 7,014 in Medicare Advantage (MA). Acumentra Health compiled data from health plans administering Medicare Advantage programs. Measures assessed include LDL screening, HbA1c testing, microalbumin testing, and dilated eye exam. Note that the rates reported for the Medicare Advantage groups are synthetic estimates because counts of clients with diabetes were unavailable. * Northwest Indian Tribes. Information on Northwest Indian Tribes comes from the Northwest Portland Area Indian Health Board (NPAIHB). It is based on claims data from 37 Northwest Special Diabetes Programs for Indians in Measures assessed from these patients include LDL * Synthetic estimates for the Medicare Advantage (MA) population were calculated by using enrollment counts for each health care plan and assuming the same rate of diabetes (14.4%) across plans. The rate of diabetes was calculated using age specific rates in Oregon and Oregon Medicare enrollment rates for the aged and disabled. Oregon Diabetes Coalition 31

34 Diabetes Quality Health Systems screening, urinalysis, foot exams, dilated eye exams, dental exams, influenza vaccinations, and pneumococcal vaccinations. NPAIHB received information about 5,587 active patients with diabetes. It is important to note that these numbers are not Oregon specific, as they are compiled for the Northwest area, including Washington, Oregon, and Idaho. Nonetheless, the NPAIHB data provide some insight into the extent of preventive services received among Oregon Indians with diabetes. Public Employees Benefit Board. Information on state employees comes from the Public Employees Benefit Board, which administers benefits to over 130,000 state employees, dependents, and retirees. In 2005, 5,256 members with diabetes were identified, 4% of the population. Portland Veterans Affairs Medical Center (VA). Information on veterans comes from the Portland Veterans Affairs (VA) Medical Center. Measures assessed from these patients include HbA1c screening, LDL screening, urinalysis, and dilated eye exams. Measure DMAP DMAP MA NPAIHB PEBB VA HbA1c test 80.4% 80.8% 90.1% % 96% LDL-C screening 63.7% 63.9% 86.0% % 95% Microalbumin test* 38.8% 40.5% 84.0% 75% - - Dilated eye exam 95.4% 95.7% 76.2% 47% 53.5% 79% Foot exam % - - Dental exam % - - Influenza vaccination % - - Pneumococcal vaccination % - - *NPAIHB data are for urinalysis, which may include a microalbumin test Clinical Outcomes Data Clinical outcomes data is available from Acumentra Health, NPAIHB, PEBB, and the Portland VA. Although these outcomes relate to specific populations, they do shed some light on diabetes management in Oregon. 32 Oregon Diabetes Coalition

35 Diabetes Quality Health Systems Acumentra Health gathered outcomes information for Medicare Advantage plans. As seen in the graph below, the percentage of patients with diabetes who have good cholesterol control (LDL-C < 100) ranges between 37% and 64%. The percentage with good blood pressure control (BP < 140/90) ranges between 53% and 67%. Although this is good news, there is still room for improvement. 80% 70% Blood Pressure and Cholesterol Control Among Oregonians with Medicare Percent of Patients 60% 50% 40% 30% 20% Systolic BP < 140 and Diastolic < 90 LCL-C < % 0% A B C D E F G H I J K Health Plan The NPAIHB reports both the percentage of patients with diabetes that have good HbA1c control (equal to or below 6.5%) and patients with diabetes that have poor HbA1c control (above 10%). In 2005, 29% of the monitored patients had controlled blood sugar and 12% had poorly controlled blood sugar. The percentage of patients with poor glycemic control has fallen since This decline and the small percentage of patients with high HbA1c levels are impressive and suggest effective Oregon Diabetes Coalition 33

36 Diabetes Quality Health Systems collaboration between persons with diabetes and their health care providers in achieving blood sugar control. The Public Employees Benefit Board (PEBB) has collected clinical outcomes data. Of the members with diabetes whose lab data was available in 2005, 27% had poor HbA1c control (above 9%) and 56% had poor cholesterol control (LDL-C 100 mg/dl). Of patients with diabetes being treated by the Portland VA in 2005, 17% had poor HbA1c control (above 9%) and 40% had poor cholesterol control (LDL- C 100 mg/dl). These rates are favorable compared to available national HEDIS data, a testament to the effective implementation of systems that promote chronic disease management by the VA. Objective: Provide easy access to proactive planned support to assist Oregonians with diabetes. Oregon s Population-Based Guidelines The Oregon Diabetes Coalition updated Measuring Quality in Health Systems: Oregon s Population-Based Guidelines for Diabetes Care in Clinicians were surveyed about the guidelines at the American Diabetes Association s Annual Diabetes Update in October The feedback was incorporated into the design and content of a tri-fold brochure to inform providers about the guidelines, which was mailed to 5,600 clinicians in March The brochure provided a quick reference tear-off sheet with recommended preventive services, interventions, and clinical management goals for adults with diabetes, and informed clinicians about available selfmanagement resources. 34 Oregon Diabetes Coalition

37 Diabetes Quality Health Systems The guidelines have been well received. In the 12 months from September 2006 through August 2007, the PDF version of Measuring Quality in Health Systems: Oregon s Population-Based Guidelines for Diabetes Care was downloaded over 2,300 times (available at The guidelines offer a clear plan for diabetes care, as well as markers for providers to assess their overall care of a population with diabetes. Chronic Care Model Implementation After engaging key partners (Acumentra Health, Conference of Local Health Officials, Oregon Rural Practice Research Network, Oregon Health Care Quality Corporation), the Oregon Diabetes Program collaborated with the Oregon Heart Disease & Stroke Prevention, Asthma, and Tobacco programs to provide four Chronic Care Model Implementation Grants to Jackson County Health Department, Lincoln County Health Department, Deschutes County Health Department, and Samaritan Health System in coordination with Linn and Benton Counties. Key objectives of the grants are to use clinical data to improve quality of care for chronic disease patients, build referral systems to self-management programs in the community, and establish linkages between providers of care and other community partners to strengthen the overall delivery of quality care in the community. So far, the grantees have enhanced overall awareness of diabetes (and other chronic diseases) in their communities through providers and other partners. Each grantee is building infrastructure to deliver Living Well with Chronic Conditions (Chronic Disease Self-management Program) classes and has increased the awareness of these classes and hence, attendance in their communities. Many of the grantee s clinical partners have begun to use the clinical measures data to improve the receipt of preventive care including foot and eye exams. Oregon Diabetes Coalition 35

38 Diabetes Quality Health Systems Objective: Purchasers, plans, and systems recognize and reward providers who report key diabetes indicators and who demonstrate quality diabetes outcomes. Aligning Forces for Quality (AF4Q) In 2007, the Oregon Health Care Quality Corporation received one of fourteen grants from Aligning Forces for Quality, The Regional Market Project, a national program of the Robert Wood Johnson Foundation to improve the quality of health care provided to people with chronic illnesses, including diabetes. Aligning Forces for Quality is designed to help communities do three things to advance the quality of chronic care provided in doctors offices, clinics, and other outpatient settings: (1) help health care providers improve their own ability to deliver quality care; (2) help providers measure and publicly report their performance; and (3) help patients and consumers understand their role in demanding high quality care. A project spearheaded by the Oregon Health Care Quality Corporation, Common Measures for Evaluating Performance, has convened stakeholders to select a common set of measures that can quantify and guide Oregon s healthcare quality improvement efforts for outpatient practice. A background report, Measuring Health Care Value in Oregon: Ambulatory Care has been prepared, and an expert committee has selected an initial set of draft measures, including HbA1c monitoring, HbA1c control, blood pressure control, lipid profile/monitoring, lipid control, eye exam, and nephropathy assessment. References 1 Office for Oregon Health Policy Research and Oregon Health Care Quality Corporation. Oregon Electronic Health Record Survey: Ambulatory Practices and Clinics, Oregon Diabetes Coalition

39 Diabetes Advocacy and Policy Objective: Promote and implement a diabetes policy agenda. Legislative Activity The 2007 Oregon Legislative Session was very active with regard to diabetes related issues. House Resolution 4 recognized the severity of diabetes and encouraged all Oregonians to seek early screening for diabetes and health care providers to engage in aggressive programs with their diabetic patients, including dietary counseling, instructions on proper exercise and measurements of body weight. Further, House Bill 3486 was passed, directing the Department of Human Services to develop a plan to slow the escalation in diabetes rates by GOAL: Policies in Oregon improve prevention, care and protection for people with diabetes. The legislature also posted bills that promote healthy nutrition and combat obesity, both of which strengthen efforts to prevent and control diabetes. HB2650 specifies minimum nutrition standards for food and beverages sold in public schools and SB931 establishes a task force to study obesity treatment and prevention. HB3141 included establishing minimum minutes for grades K-8, provision of assessment tools and evaluation of physical education as well as implementation of a grant program to assist in hiring PE specialists where needed. In addition, there were successes in improving access to health care. SB329 establishes the Oregon Health Fund Board to develop a program to reduce the number of uninsured and SB188 makes dentists eligible for loan repayment in rural areas. With 14% reporting they were unable to see a doctor in the past year because of costs, and 20% reporting they could not see a dentist, health care access is a critical issue for Oregonians with diabetes. Oregon Diabetes Coalition 37

40 Diabetes Advocacy and Policy Diabetes related bills from the 2007 Oregon Legislative Session Bill # Summary Status HB3486 Directs Department of Human Services to develop a plan to slow rate of diabetes caused by obesity and other environmental factors by Passed, signed HB2650B Specifies minimum nutrition standards for food and beverages sold in public schools starting in July 2008 for vending machines and student Passed, signed stores and July 2009 for items sold individually in the cafeteria. Special events such as concerts and band programs are exempt from these rules. HB2801B Establishes Human Stem Cell Research Committee in Department of Human Services. The committee would develop guidelines for research involving the derivation or use of human embryonic stems cells and to create, solicit funds for and administer a grant program for this kind of research. The bill also requires DHS to ensure that providers of fertility treatments obtain informed consent from persons who donate embryos for research and sanctions providers who fail to do so. Died HB3141 SB931A SB1031 HB2634 SB329B SB188 SB3/SJR4 Establishes minimum requirements for time spent in physical education classes by kindergarten through grade 8 public school students. Specifies requirements for physical education instruction. Passed, signed Establishes task force in DHS to study obesity treatment and prevention. Passed, signed Requires Department of Human Services to create voluntary guidelines Died for restaurants regarding display of calorie content and other nutritional information. Appropriates $230,000 from General Fund to Department of Human Died Services for the purpose of providing fresh fruits, vegetables and cut herbs from farmer s markets and roadside stands to eligible low-income seniors under the Oregon Farm Direct Nutrition Program. Establishes the Healthy Oregon Act and the Oregon Health Fund Board. Passed, The Board, a seven-member group, is charted with developing a signed program to decrease the number of uninsured Oregonians, ensure universal access, contain costs and address the quality of healthcare services. The Oregon Health Policy Commission, the Office of Health Policy and Research and the Medicaid Advisory Council are charged with compiling data and conducting research to inform the committee s work. The Oregon Health Fund Board shall report to the Legislative Assembly no later than February 29, Adds dentists to the list of health care providers eligible for loan repayment in rural areas of Oregon. The bill also ties the benefit to a qualifying dental shortage site. Statutory referral to the ballot to create the Oregon Healthy Kids Program, which includes private health option to provide health care coverage to children. The bill also covers more uninsured adults in the OHP Standard Program, expands Tobacco Prevention and Education Programs and provides grants to safety-net clinics and rural health clinics. Passed, signed Passed, but necessary ballot measure failed 38 Oregon Diabetes Coalition

41 Diabetes Advocacy and Policy Members of the ODC supported several other diabetes related bills. Because regular physical activity decreases the risk of developing Type 2 diabetes, ODC supported a bill that would have increased physical education in schools. Though this bill did not pass, the campaign for it raised awareness of an important strategy for diabetes and obesity prevention. Members of ODC also worked for a bill to improve nutrition among low-income seniors. The American Diabetes Association, a core ODC partner, also supported legislation to establish a Human Stem Cell Research Committee. This body would have coordinated efforts to use stem cells to treat or cure diabetes and other conditions. This bill did not pass. Although the legislature approved the Oregon Healthy Kids program, funding was contingent on a ballot measure which failed after a record-setting investment of opposition funds from the tobacco industry. The Oregon Legislative Assembly will reconvene in Objective: Strengthen and increase awareness about diabetes related rights. Diabetes Rights Core ODC partner the American Diabetes Association continues to be at the forefront of securing diabetes rights. The Association s call center provides information about discrimination and referrals to legal advocates. Access to medication, food, and knowledgeable adults at school continues to be an important issue for children and adolescents with diabetes. The ADA s Safe at School Committee focuses on these issues. The past year saw the committee team with the Oregon Diabetes Program to complete a revision of the Emergency Glucagon Providers Training Manual. This manual provides up-to-date information, helping schools and employers recognize and treat episodes of low blood sugar. Oregon Diabetes Coalition 39

42 Diabetes Advocacy and Policy The newly formed Oregon Diabetes Caucus may be one of the most useful venues to strengthen and increase awareness about diabetes rights. This group of Oregon legislators will develop an agenda to improve the lives of those with diabetes. 40 Oregon Diabetes Coalition

43 Access to Diabetes Data Objective: Implement and maintain processes that ensure the confidentiality, completeness, and quality of diabetes data collected and disseminated in Oregon. Access to Data workgroup members collaborated with primary collectors of data obtained through surveys and medical record review to ensure data quality (through consultation on survey methodology, question selection, and medical record abstraction documents) and GOAL: Accurate diabetes data are integrated, accessible and used. confidentiality (through confirmation of procedures to minimize access to identifying information or its inadvertent release). Workgroup members also regularly meet with representatives of the Oregon Center for Health Statistics and other data collecting agencies to discuss strategies to ensure quality of diagnosis information from death certificate data and potential strategies to minimize racial misclassification. For example, beginning with data year 2006, tribal affiliation is being collected in the death certificate database. Also, in data year 2008, the state Hospital Discharge Index will collect information about race among Oregonians who are hospitalized. The efforts of the Coalition to encourage use of Electronic Health Records have been successful, as noted previously. Adoption of EHRs in Oregon has outpaced the rate nationally. Oregon Diabetes Coalition 41