Geisinger Obesity Institute Communicating Personalized Diabetes Risk with Options for Weight Management: Recruitment, Enrollment, and Outcomes

Treatment for pre-diabetes Diabetes prevention program*: Intensive lifestyle intervention reduced incidence of diabetes by 58%. 16 lesson curriculum covering diet, exercise, and behavior modification Goal of 7% weight loss Metformin treatment reduced incidence of diabetes by 31%. *Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. The New England Journal of Medicine. 2002;346(6):393–403.

If you build it, they will come? Or maybe not… ~Field of Dreams 1989 Suboptimal provider engagement <33% receive weight management advice from PCP <5% are referred for treatment Low patient engagement 15% pursue weight management based on PCP recommendation

How do we get more patients to treatment? Engagement strategies to get patients to treatment and to finish treatment. (if you build it right, they will come and stay) Personalization of their disease risk Evidence that treatment improves future health Let patient choose their treatment

Create personalized diabetes risk calculator Methods: Identified n=6620 patients with pre-diabetes (A1c 5.7-6.4%) Retrospectively followed patients for 3 years Identify time until progression to diabetes Use multiple logistic regression to derive prediction equation Examine effect modification of weight loss Results: BMI, sex, A1c, and weight loss were associated with diabetes progression (p<0.0001 for each) Age was not significant (p=0.8) but was retained in the model

Diabetes Risk Calculator (we built it) Does weight loss influence risk of progression to diabetes? Weight change in next year Chance of diabetes in 3-years Personalized risk Female Age = 45 Weight = 300 BMI = 42 kg/m2 HbA1c = 6.3% Weight stable 51% Evidence that treatment will decrease risk Lose 15 pounds 41% Lose 30 pounds 33% Lose 45 pounds 25%

Preventing Type 2 Diabetes Study Funding Support: GHP Quality Fund Pilot Project Personalized Diabetes Risk Calculator Home Letter Weight Management Program RD/RDN DPP (Diabetes Prevention Program) Pharm + RD Pharm + DPP Weight Watchers Weight A1c Diabetes Risk Reduction 6 months 12 months Choose treatment that meets their needs

Preventing Type 2 Diabetes Study Current study questions (data source) Will communication of personalized diabetes risk engage patients to pursue weight management? (Recruitment response rate) Will patients be activated to participate in weight management program of choice? (Enrollment in program and completion rates) What is the change in weight, A1c, and diabetes risk among cases? (change from baseline to 6-months)

Study questions Question Outcome Will communication of personalized diabetes risk engage patients to pursue weight management? Recruitment response rate Will patients be activated to participate in weight management program of choice? Enrollment in program and completion rates Did intervention improve diabetes risk indicators? Change in weight, A1c, and diabetes risk score from baseline to 6-months

Preventing Type 2 Diabetes Study Methods: Identify N=338 adults with BMI>27 kg/m2 and pre-diabetes (A1c 5.7-6.4) Patients received letter with current risk of developing type 2 diabetes, estimated reduction with weight loss, and invited to enroll in free weight management program of choice, program information

Preventing Diabetes Study (they came) Will communication of personalized diabetes risk engage patients to pursue weight management? 25% recruitment response rate (n=84 of 338) A higher rate than expected! DPP 27-site trial observed 6.6% recruitment response rate RR Rubin et al. Control Clin Trials 2002;23:157–171. DEPLOY trial observed 7.1% recruitment response rate. RT Ackermann et al. AJPM. 2008;35(4):357-63. Characteristic Sample Age 58.9 y (30-75) Sex 48% Male BMI 34.8 A1c 5.99 Diabetes Risk 23.5%

Preventing Diabetes Study (and stayed) Program Participant Choice Participants Completed initial Session Participants Completing ≥ ¾ Sessions* RD: Telephone counseling with a Dietitian, FitBit, and BMIQ website portal 31% 96% 76% DPP: Diabetes Prevention Program (DPP) 15% 100% 77% MEDS+RD: Pharmacologic Treatment plus RD 33% 92% 83% MEDS+DPP: Pharmacologic Treatment plus DPP 11% 63% WW: Weight Watchers 38% 0% * Denominator: Participants completed initial session

Preventing Diabetes Study (and left with lower risk) Preliminary results (N=55 with 6-month outcomes): Weight loss Mean WL% = 10.3% 78% lost >5% of initial body weight Change in HbA1c Mean decreased from 6.04% to 5.81% 71% decreased their HbA1c Diabetes Risk Reduction None progressed to diabetes Risk decreased from 26.8% to 15.2%

Summary – A field of Dreams! We built a diabetes risk calculator Patients came to participate (2.5x higher rate than expected) Most stayed for the duration of treatment 90% started and 74% of those completed treatment And left with lower risk of progression to diabetes

Preventing Type 2 Diabetes Study Dr. Rolston, WNEP Healthwatch: “Rather than say, go lose weight, we can now put a number to that weight, give them actual data to work with.” Alli Naylor, RDN: "Most worthwhile is the difference our efforts are making in the lives of patients” Patient quote: “I am so thankful for this program and the opportunity to improve my health”

Next Steps Collect 12 month weights, A1c, study questionnaires (satisfaction, involvement in care, quality of life), Compare 3-year outcomes to controls (year 2021) Integrate Diabetes Risk Calculator into EPIC (in process), study implementation strategies EPIC provider view

Preventing Type 2 Diabetes Study Team Dr. Lisa Bailey-Davis Dr. Christopher Still Dr. David Rolston Scott Jamison Jacob Mowery Alli Naylor Krystal Cunningham Adam Cook Chris Seiler Craig Wood