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Evidence-based Diabetes Prevention – National Policy Considerations Ronald T Ackermann, MD, MPH, FACP Diabetes Translational Research Center Indiana University.

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Presentation on theme: "Evidence-based Diabetes Prevention – National Policy Considerations Ronald T Ackermann, MD, MPH, FACP Diabetes Translational Research Center Indiana University."— Presentation transcript:

1 Evidence-based Diabetes Prevention – National Policy Considerations Ronald T Ackermann, MD, MPH, FACP Diabetes Translational Research Center Indiana University School of Medicine

2 Continuum of Risk & Intervention 200 Million with Obesity Risk Factors? 140 Million Overweight or Obese* 85 Million High Risk for Diabetes Diabetes, Heart Disease, Stroke * Estimated from Flegal KM, et al. JAMA. 2010;303(3): Using ADA prediabetes definition OR A1c %; Source: NHANES Population-based Policies (Social/Cultural Change) Long-term Payoff Resource Intensive Programs (Prevent Obesity-Related Risks) Shorter-term Payoff

3 U.S. Diabetes Prevention Program National comparative effectiveness trial 3,200 overweight / obese adults with prediabetes Compared 3 preventive interventions Brief Education (usual care) Diabetes Pill Metformin Intensive Diet & Physical Activity Program Lifestyle Program most effective Prevented 58% of new diabetes cases Worked for all age, gender, and race subgroups Replicated worldwide – 6 studies; >5,400 total participants * DPP Research Group. N Eng J Med 2002;346(6):

4 DPP Lifestyle Program 16-session course over 24 weeks; then monthly One-on-one personal coach format Goal to lose/maintain 7% of body weight Cut down dietary calories & fat 150 min/week moderate physical activity Education & training in behavior modification (Self- monitoring; problem solving) Strong support structure (building self esteem, empowerment, social support; accountability)

5 DPP: Modest Weight Loss is the Goal In DPP… …every 1 kilogram of weight loss = 16% decrease in chances of getting diabetes …just 5 kg (11 pounds) of weight loss = 58% decrease in chances of diabetes + *Hamman, et al. Diabetes Care 2006; 29:2102–2107.

6 DPP Lifestyle Program Summary 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 Avoids $91,400 in healthcare costs 4 Adds the equivalent of 20 perfect years of health 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 Ackermann, et al Am J Prev Med 35 (4), pp ; estimates scaled to 2008 $US 5 Herman, et al Ann Intern Med 142 (5), pp

7 DPP Dissemination Challenges Too costly ($1,800+) in year 1 alone Intense & long-term – skepticism over replication in the real world

8 IUSMs Approach for DPP Translation Stick to the DPP approach Goal-oriented; weight loss through diet & exercise Target adults at highest risk for diabetes now (prediabetes) Adopt practical solutions for key barriers Minimize intervention costs Group-based delivery Strong, not-for-profit community partner Preserve effectiveness (weight maintenance)

9 DEPLOY 1, DPP-LINC 2, & RAPID 3 Studies 1 R34-DK (NIH); 2 R34-DK (NIH); 3 R18-DK (NIH) 4 Ackermann, et al. Am J Prev Med Oct;35(4):357-63; RAPID study ongoing (unpublished) 5 Ackermann, et al. DPP-LINC Study Results, under review 07/ Long-term DEPLOY Extension Study results under review 07/2010 Community comparative effectiveness trials Group DPP at the YMCA vs. standard advice ~70% of high risk adults with pre-diabetes attend the YMCA at least once if referred 4 Average weight loss among those attending YMCA at least once 5.0% to 6.8% 5 Weight losses still 4.8% after 28 months 6 Cost of YMCA DPP delivery ~$240 in year 1

10 Recipe for Successful Scaling Right People Right Interventions Scalable Delivery Model Cost- Effective Population Based Prevention High risk for short-term obesity-related problems (Pre-Diabetes) Intensive & ongoing (DPP) Lifelong diet & activity changes Achieves modest weight loss Nationwide Accessible Coordinated with Medical Home Valued Health Outcomes Sustainable to Finance

11 Supportive Policy Actions Still Needed Step in the ProcessTarget(s)Supportive Policy Whole population focus on better health HHS; States; Others New policies to make healthy eating & activity desired, normative, convenient, & feasible ($) People seek testing/resourcesCDC; ADARaise awareness of risk factors; how to be tested Clinicians test & offer resources CMS; NCHSRevise ICD/HCPCS to easily document tests/counseling USPSTFRevisit recommendation for targeted screening NCQADevelop performance indicators for testing/referral CMS; payersNew coverage policies to expand testing (A1c); payment policies to reward providers Programs availableHHS; CDCDevelop workforce; recognize community programs that are evidence-based Programs accessibleCPSTFReview / recommend community-based DPP CMS; payersReview coverage policies for community-based prevention services by recognized CBOs Coordination with medical home NCQAReview/recommend as part of PCMH Recognition CMS; payersNew payment policies for CBO referral/feedback


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