A patient-flow model used to identify patients with prediabetes and refer them to diabetes prevention programs in a Medicare pilot project demonstrates the effectiveness of a systematic approach combined with the power of a physician’s personal recommendation.

AMA researchers provided the point-of-care model and training to 10 primary care practices and health systems. It was part of a pilot study to evaluate routine screening, testing and referral of patients with prediabetes to diabetes prevention programs (DPPs), which helped lead to Medicare coverage for CDC-recognized lifestyle change programs.

Screen, Test, Act-Today

84 million American adults have prediabetes.

Nine out of 10 people with prediabetes don’t know they have it.

The point-of-care model, focused on when patients not diagnosed with diabetes, but at high risk for it, came in for other treatment, resulted in 437 referrals, with 56% of those patients enrolled. The AMA partnered with the YMCA of the USA, and patients were referred to DPPs at local YMCAs.

The point-of-care model is one clinical practice process included in the AMA’s Diabetes Prevention Guide, which 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 the risk of developing type 2 diabetes, including referring patients at risk to a diabetes prevention lifestyle-change program based on their individual needs.

A “physician's recommendation and discussion one-on-one with the patient tends to increase motivation and activation to actually enroll in a program,” said community psychologist Christopher S. Holliday, PhD, MPH.

He is director of Population Health and Clinical-Community Linkages at the AMA and principal investigator for “Clinical Identification and Referral of Adults With Prediabetes to a Diabetes Prevention Program.” The study appeared in Preventing Chronic Disease, which is published by the Centers for Disease Control and Prevention, and was co-written by AMA colleagues Janet Williams, MA, and Vanessa Salcedo, MPH, as well as Namratha R. Kandula, MD, MPH, of the Northwestern University Feinberg School of Medicine.

Beginning in April 2018, the Centers for Medicare & Medicaid Services (CMS) allowed approved organizations to bill for Medicare Diabetes Prevention Program (MDPP) services. The MDPP eligibility requirements are that patients must:

  • Be a Medicare Part B beneficiary.
  • Have a body mass index of at least 25 or 23 if self-identified as Asian.
  • Have no previous diagnosis of type 1 or type 2 diabetes (other than gestational diabetes).
  • Not have end-stage renal disease.
  • Have either a hemoglobin A1c test with a value between 5.7% and 6.4%, a fasting plasma glucose between 110–125 mg/dL, or a two-hour plasma glucose between 140–199 mg/dL.

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How to identify patients with undetected prediabetes

The point-of-care model starts before the patient engages with a physician and is designed to efficiently establish at the clinical visit which patients are indicated and eligible for diabetes prevention assistance. Then these steps follow.

Measure. At check-in, patients may be asked to complete the prediabetes risk test. This could also have been completed via the patient portal as part of previsit planning. Once in the exam room, the patient’s body mass index is calculated, risk score reviewed, and laboratory values for elevated blood sugar or history of gestational diabetes determined.

Act. Once prediabetes is confirmed, the patient is educated about the condition. If the patient agrees, a referral to a DPP is offered. If the patient declines, other treatment options may be explored such as metformin or medical nutrition therapy.

Partner. The clinical team supports the patient’s participation in the lifestyle-change program.

The three steps were designed around the AMA’s M.A.P. framework for hypertension control: Measure Accurately, Act Rapidly, and Partner with Patients.

An alternative method, focused on patient registries created in an electronic health record, was also tested in the DPP study. Of 5,640 patients referred overall, 4,601 patients at 12 clinical practices were referred by staff using registries. Although registries produced more referrals, the actual enrollment rate was much lower—11% versus 56% for the patient-flow model—suggesting the power of physician engagement.

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