Black women are 2.3 times as likely and Hispanic women 1.4 times more likely to die of diabetes as non-Hispanic white women, according to the U.S. Department of Health and Human Services Office of Minority Health.
One approach to addressing these health inequities in Black and Hispanic women is promoting diabetes prevention within the health care setting. Research shows focusing on efforts to minimize gaps in care can dramatically boost the referral rates to National Diabetes Prevention Program (National DPP) lifestyle-change programs which are effective in preventing or delaying progression to type 2 diabetes for those at risk. Referral rates for these groups more than doubled expectations at three health care organizations—significantly eclipsing the anticipated 25% referral rate.
As part of a 5-year Centers for Disease Control and Prevention cooperative agreement, the AMA in collaboration with the American College of Preventive Medicine and the Black Women's Health worked on a pilot with an aim to build organizational capacity to screen, test, refer and enroll Black and Hispanic women—two population groups that have been disproportionately affected by diabetes—to National DPP sites.
This work formed the foundation of two studies published in AJPM Focus, a journal of the Association for Prevention Teaching and Research and the American College of Preventive Medicine. One study outlined the cascade model developed by the AMA Improving Health Outcomes group and tested at the pilot sites, and the other was an executive summary of lessons learned.
“We were able to create the theoretical model, and test that model at these sites,” said Tamkeen Khan, PhD, the AMA’s lead economist for outcomes analytics and the lead author of the AJPM Focus study.
“The end goal was to get the most eligible patients enrolled in a diabetes prevention program as possible,” Khan added. “Awareness is huge—If patients don't know what's going on with them, they're not going to do anything about it.”
The participating health care organizations provided quarterly and annual data on patients, such as screenings, referrals and enrollments over a 36-month period from July 2019 to July 2022. In addition, they reported on barriers and facilitators to enrollment in the National DPPs.
The structured, National DPP lifestyle-change program has been proven effective at preventing or delaying progression to type 2 diabetes for people at risk.
The AMA’s Diabetes Prevention Guide supports physicians and health care organizations in defining and implementing evidence-based diabetes prevention strategies.
This comprehensive and customized approach helps clinical practices and health care organizations identify patients with prediabetes and manage their risk of developing type 2 diabetes, including referring patients at risk to a National DPP lifestyle-change program based on their individual needs.
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Taking it to the next level
Health care organizations “play a critical role in advancing equity at every stage of the diabetes prevention cascade,” Khan and her colleagues wrote. “Leadership support and systematic changes were key to advance and sustain equitable diabetes prevention processes in reducing the burden on inequities in chronic disease management.”
The cascade model is a stepwise framework that can reveal gaps in the continuum of care and provides areas of opportunity for improvements.
“Screening is level one, ordering the labs is level two,” Khan explained. “If they are not ordering the labs after screening, then that is a gap.”
The next step was patient awareness followed by referral to a lifestyle-change program if patients were at risk for prediabetes. The final level in the cascade model concludes with patient enrollment in a National DPP.
“The data helped us to identify the gaps, or the leakage points,” Khan said. “What can we work on together to help fill in these leakage points and help the most patients using the cascade model?”
Pilot sites added clinical decision-support alerts to identify patients eligible for screening, the study says. They also screened for, and worked to address, social determinants.
Black patients received nutrition examples specific to African American or Southern diets, the executive summary says. Citizen advisory boards were convened to develop a sense of community ownership, and program sessions were held in churches and other community centers that helped build trust.
Programs for Hispanic patients were offered in Spanish, according to the summary. Peer educators helped engage patients as did cooking demonstrations and an emphasis on family support.
A newly revamped AMA STEPS Forward® toolkit, “Team-Based Care of Type 2 Diabetes and Prediabetes,” can improve physicians’ capacity to help patients reach their glycemic goals through such an approach. The toolkit also pinpoints opportunities to improve the health of patients with prediabetes and diabetes while saving time for the care team.
Physician champions enable success
The role of physicians as “program champions” was highlighted in the executive summary.
“Health care organizations reduce disparities and advance health equity for disproportionately affected populations by cultivating program champions, engaging in community outreach, and advocating for systemic changes to increase accessibility,” the summary says.
Last October, Khan and colleagues from the AMA and the North Carolina Medical Society examined the role of physician champions in a study published in the Journal of Public Health Management and Practice.
“The champion’s responsibilities included supporting diabetes prevention awareness efforts and disseminating clinical content,” Khan wrote.
“Successes reported by the physician champions include increased awareness of prediabetes through outreach and clinical education,” she added. “It also enabled collaborations with community-based organizations, adopting shared learnings and best practices, and availability of statewide referral platforms that aided champions in engaging peers.”
Not only do physician program champions get things done, but they are also more likely to ensure that those things “get done well with better outcomes,” Khan said.
