Diabetes Prevention and Control A Comprehensive Process Commissioner John Auerbach Massachusetts Department of Public Health
Like everywhere else, Massachusetts has a growing diabetes problem
Diabetes in Massachusetts ~360,000 diagnosed people with diabetes 100,000-140,000 are undiagnosed Even more with pre-diabetes #9 leading cause of death New cases of severe complications for 2006 249 cases of blindness 701 cases of renal failure 1,862 lower extremity amputations 3,800 deaths with diabetes as major contributor Sources: Massachusetts Behavioral Risk Factor Surveillance System, Bureau for Health Information, Statistics, Research and Evaluation. Massachusetts Department of Public Health, 2006; Central Register, Report of the Register, Massachusetts Commission for the Blind, 2006. End-stage Renal Disease Network of New England, End-stage renal disease incidence and prevalence for Massachusetts, 2006; Uniform Hospital Discharge Data Set (UHDDS), Massachusetts Division of Health Care Finance & Policy, 2005; MDPH Registry of Vital Records and Statistics, 2006
Prevalence in Massachusetts has increased Percent (%) 7 6 5 4 3 2 1 0 Prevalence of Diabetes in Massachusetts, 1994-2006 5.8 5.6 5.8 6.2 6.4 6.4 5.6 4.7 4.9 4.1 4.3 3.8 3.8 Overall 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Year Source: Massachusetts Behavioral Risk Factor Surveillance System, Bureau for Health Information, Statistics, Research and Evaluation. Massachusetts Department of Public Health, 1994-2006. Note: Estimates have been age-adjusted to the 2000 US Standard Population
An Initial Step: Expand efforts to gather and analyze data Attention to social determinants of health Access to utilization patterns and opportunities for improvement New focus on costs and potential savings
Obesity and Overweight by Race/Ethnicity, 2006 80 70 60 55.5 54.8 70.9 61.4 Obesity Overweight Percent (%) 50 40 30 20 20.3 19.5 38.2 26.0 31.4 10 0 MA White, non- Hispanic Black, non- Hispanic Hispanic Asian Statistically different from state (p.05) Red (*) Statistically worse than state- Green (**) statistically better than state Source: Massachusetts Behavioral Risk Factor Surveillance System, Bureau for Health Information, Statistics, Research and Evaluation. Massachusetts Department of Public Health, 2006.
Substantial Variation in Diabetes Rates by Household Income <$25,000 3+ fold variation $75,000 + Source: NEHI/Boston Foundation: Boston Paradox
Diabetes by Education, 2006 3.5 time more likely in least educated 25 20 Percent (%) 15 10 5 15.6 7.9 5.4 4.4 6.4 0 < HS HS grad 1-3 years college 4+ years college Statistically different from state (p.05) Red (*) Statistically worse than state- Green (**) statistically better than state Source: Massachusetts Behavioral Risk Factor Surveillance System, Bureau for Health Information, Statistics, Research and Evaluation. Massachusetts Department of Public Health, 2006. Note: Estimates have been age-adjusted to the 2000 US Standard Population MA
Prevalence of Diabetes in Massachusetts Varies Significantly by Race/Ethnicity, 2006 14 12 11.9 12.8 10 Percent (%) 8 6 4 4.9 5.4 6.4 2 0 2006 Asian/PI Hispanic Black (NH) White Total Source: Massachusetts Behavioral Risk Factor Surveillance System, Bureau for Health Information, Statistics, Research and Evaluation. Massachusetts Department of Public Health, 2006. Note: Estimates have been age-adjusted to the 2000 US Standard Population
Mortality Rates are Much Higher for Blacks and Hispanics Rate per 100,000 60 50 40 30 20 10 0 1994 Mortality rates for diabetes as the primary cause of death, by race, 1994-2006 47.8 43.94 43.02 54.47 46.08 23.77 26.77 25.94 21.13 20.25 20.84 20.26 20.21 16.71 15.08 19.24 12.65 1995 1996 1997 1998 1999 42.88 36.1 18.5 42.36 34.34 18.72 11.69 11.26 2000 Years 2001 Source: MDPH Registry of Vital Records and Statistics, 1994-2006 44.63 25.78 22.19 19.18 2002 42.61 45.65 40.95 18.88 16.67 2003 30.66 19.68 18.64 2004 34.66 35.5 36.1 26.75 29.48 17.41 16.29 2005 24 14.4 6.98 8.5 2006 White, NH Black, NH Hispanic Asian/Pacific Islander, NH
Diabetes in Massachusetts Health Care Utilization & Morbidity
Utilization Patterns Highlight Disparities Diabetes Hosp. Discharges:2003-2005 MA White Black Hispanic Asian 400 368 350 300 Rate per 100,000 250 200 150 133 114 242 100 50 45 0 Race/Ethnicity Source: Uniform Hospital Discharge Data Set (UHDDS), Massachusetts Division of Health Care Finance & Policy, 2003-2005
Room for Improvement in Preventive Care: % Receiving Recommended Care, 2002-2006 87.2 90 90 83.0 Percent 80 60 76.8 75 75 70.2 66.6 61.9 69.9 60.4 60 60.5 75.8 69.2 50 40 20 0 Foot Exam Eye Exam SMBG Flu Vaccine (50+) Pneumococcal vaccine (65+) HbA1c MA (2002-2006) US (2005) HP 2010 Source: Massachusetts Behavioral Risk Factor Surveillance System, Bureau for Health Information, Statistics, Research and Evaluation. Massachusetts Department of Public Health, 2002-2006
Room for Improvement by Payor 100% 80% 92% 88% 70% 70% 85% 82% 86% 79% Percent (%) 60% 40% 23% 39% 45% 36% 20% 0% HbA1c Test Poor HbA1c Control (>9%) Eye exam Monitoring kidney LDL-C Test LDL-C<100 Mass Commercial MassHealth Source: MassHealth Managed Care 2007 HEDIS report
Lots of Opportunities to Improve Modifiable Risk Factors Prevalence of Modifiable Risk Factors That Cause Complications of Diabetes, 2002-2006 50 43.1 43.8 Percent (%) 40 30 20 10 21.9 30.0 28.3 20.6 0 High BP* High Chol* Current Smoker Diabetes No Diabetes Source: Massachusetts Behavioral Risk Factor Surveillance System, Bureau for Health Information, Statistics, Research and Evaluation. Massachusetts Department of Public Health, 2002-2006
Diabetes in Massachusetts Economic Costs
Preventable Hospitalizations for Diabetes Have Risen Significantly +35% 7000 6000 5000 4000 3000 2000 1000 0 4551 6143 1998 1999 2000 2001 2002 2003 2005 Source: Division of Health Care Finance and Policy
The Department s Diabetes Prevention and Control Program
Diabetes Guidelines Developed DPH worked with all insurers to agree on optimal care for diabetes treatment Focus was on clinical consensus not on guaranteeing coverage was provided
Disease Management and Wellness: Diabetes
Health Care Reform first critical action steps Health Care Reform overcomes a major obstacle to access to care for people with prediabetes and diabetes 100,000s more receive insurance for the first time
Release a Report on the Problem of Overweight and Obesity Document the extent of the obesity epidemic in Massachusetts, including the disproportionate effect on certain populations Highlight innovative and successful programs across the Bay State and present new action steps
Passage of a Menu Labeling Regulation provide the tools Public Health Council has passed a regulation that requires fast food chain restaurants to post the calorie content of their food at the point of purchase
Passage of a regulation requiring student Body Mass Index collection Work in partnership with school nurses and local clinical providers Insure consistent and beneficial communication with parents
Utilize an Interactive Wellness Website Comprehensive information on wellness Links to local resources and events Interactive tools to help individuals set and achieve goals
Implement an Executive order requiring the purchase of healthful foods with state contracts Procurement of foods and snack products which meet criteria based on healthful dietary guidelines for state facilities
Expand Workplace Wellness Initiative MDPH will enroll additional employers in its Wellness Initiative A toolkit and curriculum is available to all employers Mission & Vision Vision: All worksites in Massachusetts will provide social, cultural and physical environments that support optimum employee health and well-being Mission: the mission of the Massachusetts Worksite Wellness Initiative is to promote worksite wellness through information, training, regulation and technical assistance
Initiative a unique public-private partnership to support health cities and towns 5 foundations, an insurer* and DPH have united to fund municipalities Program model was based on proven, evaluated efforts * Blue Cross/Blue Shield Corp./ Foundation, Boston Foundation, Harvard-Pilgrim Foundation, MetroWest Foundation, Tufts Foundation
Payment Reform Offers New Opportunities Reimbursement for a range of new activities - form chronic disease selfmanagement to patient educators Creation of pay for performance incentives that are pegged to proper care and outcomes