Translation of the Diabetes Prevention Program: the U.S. National Diabetes Prevention Program

Transcription

1 Translation of the Diabetes Prevention Program: the U.S. National Diabetes Prevention Program Kris Ernst, RN, CDE 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.

2 Disclaimer The findings and conclusions in this presentation are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

3 Learning Objectives Describe the 4 levers of the National Diabetes Prevention Program Discuss the role of the state Diabetes Prevention and Control Programs in ensuring the success of the National Diabetes Prevention Program List the benefits and return on investment related to a structured diabetes prevention program that reduces the incidence of type 2 diabetes

4 26 million with Diabetes 79 million with Prediabetes

5 Incidence of diagnosed diabetes ( ) and projected incidence ( ) Source: http: //

6 1 in 3 U.S. Adults Will Have Diabetes in 2050 If current trends continue Americans are living longer People with diabetes also are living longer Increases in minority groups at high risk for type 2 diabetes New cases of diabetes 1 in 10 U.S. adults have diabetes now Boyle, Thompson, Gregg, Barker, Williamson. Population Health Metrics 2010: 8:29 (22 October 2010)

7 WE WILL SOON BE OVERWHELMED!

8 Brief History of Diabetes Prevention The physician should take pride in the prevention of diabetes in his practice The physician should consider it as important to prevent his patients acquiring diabetes as he feels it incumbent on himself to vaccinate them against small pox or typhoid fever, or to protect them from exposure to tuberculosis. Joslin EP. The prevention of diabetes mellitus. JAMA. 1921;76: Insulin was discovered in 1921.

9 Cumulative incidence (%) DPP Incidence of Diabetes Percent developing diabetes Placebo (n=1082) Metformin (n=1073, p<0.001 vs. Placebo) vs. Met, p<0.001 vs. Plac ) Lifestyle (n=1079, p<0.001 vs. Metformin, Metformin (n=1073, Plac) p<0.001 vs. Placebo) (n=1082) Placebo Risk reduction 31% by metformin 58% by lifestyle All participants from randomization Years The DPP Research Group, NEJM 346: , 2002

10 DPP Intervention Impact by Ethnicity Lifestyle Metformin Placebo Cases/100 person-yr Caucasian (n=1768) African American (n=645) Hispanic (n=508) American Indian (n=171) Asian (n=142) The DPP Research Group, NEJM 346: , 2002

11 Most important determinant of diabetes prevention? For every kilogram of weight loss, there was a 16% reduction in risk, adjusted for changes in diet and activity. (Hamman et al. Diabetes Care 29: , 2006)

12 Further Benefits of Lifestyle Intervention: Other CVD risk factors are also improved BP was present in 30% of subjects at entry - then in placebo and metformin groups, significantly with lifestyle TG levels in all treatment groups, but significantly more with lifestyle intervention Lifestyle intervention significantly HDL level and LDL At 3 yr F/U the use of meds in the lifestyle group was 27 28% for hypertension and 25% for hyperlipidemia compared with placebo and metformin groups DPP. Diabetes Care 28: , 2005

13 Longer-term impact? Diabetes Prevention Program Outcomes Study After 3 years a group version of the core lifestyle intervention was offered to placebo and metformin groups, as well as the original lifestyle group, including 4 group BOOST sessions each year During the total 10-year follow-up, the incidences of type 2 diabetes was still reduced by 34% in the lifestyle group and by 18% in the metformin group Lancet 2009; Published Online October 29,2009

14 Summary of Benefits of DPP Lifestyle Program Treating 100 high risk adults (age 50) for 3 years Prevents 15 new cases of type 2 diabetes 1 Prevents 162 missed work days 2 Avoids the need for BP/Chol pills in 11 people 3 Adds the equivalent of 20 perfect years of health 4 Avoids $91,400 in healthcare costs 5 1 DPP Research Group. N Engl J Med Feb 7;346(6): DPP Research Group. Diabetes Care Sep;26(9): Ratner, et al Diabetes Care 28 (4), pp Herman, et al Ann Intern Med 142 (5), pp Ackermann, et al Am J Prev Med 35 (4), pp ; estimates scaled to 2008 $US

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

16 Selected US Research Studies That Have Translated the DPP Trial Lifestyle Intervention First author DPP N* (% prediabetes) Age 1079 (100) Mean BMI # Core Sessions (wks) Mean Sessions Attended (%) During Core Intervention Wt loss (kg) Wt loss (%) 7% loss (%) (24) 15 (95%) nr 5% loss (%) Ackermann 46 (100) (20) 9 (57) Amundson 295 (52) (16) 14 (91) Aldana 35 (89) nr (24) 11 (67) nr nr Boltri 8 (100) nr (24) 10 (65) nr nr Seidel 88 (42) 54 nr 12 (14) 9 (75) nr nr Kramer 93 (46) (14) 8 (67) McBride 40 (70) (12) nr nr nr Davis-Smith 10 (100) nr (6) 5 (78) nr nr *In lifestyle arm of study nr = not reported Personal communication with Dr. Ronald Ackermann

17 Cost of Group-Based Format $275 -$325 per participant when using trained Y staff (Ackermann, et al) $550 per participant when using CDEs (Amundsen, et al)

18 Per capita costs of the lifestyle intervention program (US$) Interventions Cost per year Intensive Lifestyle (DPP) $1,500 / $700* Group Lifestyle (DPP) $ * Group Lifestyle at YMCA $240** Note: For DPP, $1500 for the first year and $700 for years after the first year Sources: * Herman, Brandle, Zhang, et al. Diabetes Care Jan;26(1): **Ackermann, et al. Am J Prev Med Oct;35(4):357-63

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

20 National Diabetes Prevention Program Goal: Systematically scale the translated model of the Diabetes Prevention Program (DPP) for high risk persons in collaboration with community-based organizations that have necessary infrastructure, health payers, health care professionals, public health, academia, and others to reduce the incidence of type 2 diabetes in the United States.

21 Health Reform In March 2010, Congress passed legislation that specifically addresses diabetes prevention through H.R the Patient Protection and Affordable Care Act, SEC. 399V-3 National Diabetes Prevention Program The legislation authorizes CDC to manage the National Diabetes Prevention Program Establish a network of evidence-based lifestyle intervention programs for those at high risk of developing type 2 diabetes

22 Health Reform Specifically, the legislation states that the program shall include: A grant program for community-based diabetes prevention program model sites A program within the CDC to determine eligibility of entities to deliver community-based diabetes prevention services A training and outreach program for lifestyle intervention instructors Evaluation, monitoring and technical assistance, and applied research carried out by the CDC

23 NATIONAL DIABETES PREVENTION PROGRAM Components Training: Increase Workforce Train the workforce that can implement the program cost effectively Recognition Program: Quality Implement a recognition program that will: Assure quality Lead to reimbursement Intervention Sites: Deliver Program Develop intervention sites that will build infrastructure and provide the program Health Marketing: Support Program Uptake Increase referrals to and use of the prevention program Allow CDC to develop a program registry

24 Employers Providing the Lifestyle Program as a Covered Benefit Best Buy General Electric Delta Airlines Southwest Airlines

25 Role of CDC versus DTTAC CDC Authorized by congress Oversees the Diabetes Prevention Recognition Program (DPRP) Maintains a partnership between DDT, Y USA and UHG to develop intervention sites that will build the infrastructure and provides the program Developed messaging and marketing tools DTTAC Contract with CDC DDT Developed Master Trainer curriculum and unified Lifestyle Coach curriculum Trains the workforce that can implement the program cost effectively Facilitates linking individuals with expertise to consult with CDC

26 Role of DPCPs in the National Diabetes Prevention Program Increase access to sustainable, evidencebased lifestyle interventions to prevent or delay onset of type 2 diabetes among people at high risk (bucket 3 core diabetes intervention)

27 Role of DPCPs Communication/Media-related Strategies: Promote marketing campaigns to raise awareness about prediabetes and the availability of the 16 session core and 6 session post-core structured lifestyle program to prevent type 2 diabetes among health care providers. Create a communication campaign targeting people at risk for diabetes to raise awareness about risk factors and the availability of the 16 session core and 6 session post-core structured lifestyle program to prevent type 2 diabetes. Educate health providers about the positive participant health outcomes achieved (normalized glucose, weight loss, lowered blood pressure and lipids, reduced use of B/P and lipid lowering medication) as a result of the research trial Diabetes Prevention Program structured lifestyle program upon which the CDC s National Diabetes Prevention Program is based.

28 Role of DPCPs Clinical/Health Systems-related Strategies: Implement systems to increase provider referrals of people with pre-diabetes or multiple diabetes risk factors to sites providing the 16 session core and 6 session post-core structured lifestyle program. Implement a health provider protocol for diagnosis of prediabetes in individuals with diabetes risk factors. Implement a health provider protocol for referral of individuals with diagnosed prediabetes or diabetes risk factors to the 16 session core and 6 session post-core structured lifestyle program. Implement a health provider protocol for referral of women with previously diagnosed gestational diabetes to sites offering the 16-session core and 6-session post-core lifestyle program.

29 Role of DPCPs Community Related Strategies: Identify community organizations with the capacity and infrastructure to deliver the 16 session core and 6 session postcore structured lifestyle program to people with diagnosed prediabetes or diabetes risk factors and provide them with information about the National Diabetes Prevention Program Facilitate access to safe, attractive, and affordable places for people with prediabetes or multiple diabetes risk factors to engage in physical activity, including but not limited to promotion of workplace policies and programs that increase physical activity.

30 Role of DPCPs Policy Related Strategies: Influence organizational policy with employers and Insurance plans to offer the 16 session core and 6 session post-core lifestyle program as a covered benefit for their beneficiaries with prediabetes or multiple diabetes risk factors. Influence organizational policy with employers to include the CDC s National Diabetes Prevention Program s 16 session core and 6 session post-core structured lifestyle program to prevent type 2 diabetesas part of their employee wellness benefit. Influence organizational policy with employers to provide incentives for people with diagnosed prediabetes or diabetes risk factors who participate in the CDC s National Diabetes Prevention Program 16 session core and 6 session post-core structured lifestyle program.

31 Role of DPCPs Additional Key Strategies: Educate health providers about the positive participant health outcomes achieved (normalized glucose, weight loss, lowered blood pressure and lipids, reduced use of B/P and lipid lowering medication) as a result of the research trial Diabetes Prevention Program structured lifestyle program upon which the CDC s National Diabetes Prevention Program is based. Provide technical assistance to the staff of health care institutions, providers, provider organizations and community organizational about diabetes risk factors, prevention of type 2 diabetes and the CDC s National Diabetes Prevention Program

32 Role of DPCPs Additional Key Strategies: Convene a group of key partners who share an interest in reducing the burden of diabetes and solicit support and advocacy for reimbursement of the structured lifestyle program for people with diagnosed prediabetes or diabetes risk factors who participate in the 16 session core and 6 session post core structured lifestyle program. Administer the pre-diabetes BRFSS module.

33 Conclusions Strategies to prevent type 2 diabetes need to use a tiered approach that provides proven structured programs for high-risk adults in concert with more general, population-wide initiatives/policies to support healthy eating and physical activity There is sufficient evidence to implement proven, cost-effective type 2 diabetes prevention program

34 Questions?

35 Resources Diabetes Training and Technical Assistance Center: The National Diabetes Prevention Program: