Screen, Test, Act-Today

84 million American adults have prediabetes.

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

Electronic health records are an effective way to create registries for referring patients with prediabetes to prevention programs, according to recently published findings from a Medicare demonstration project.

Use of an EHR-based registry is among the methods covered 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 team of AMA researchers field-tested the effectiveness of EHR patient registries as part of a pilot study to evaluate routine screening, testing and referral of patients to a YMCA diabetes prevention program (DPP). The study helped lead to Medicare coverage of Centers for Disease Control and Prevention-recognized lifestyle-change programs. Primary care practices and health systems were provided with an AMA-developed “retrospective prediabetes identification and intervention algorithm,” which entailed querying an EHR to identify patients with prediabetes.

“This approach ensured that as many Medicare-eligible patients with prediabetes were identified, an opportunity that is often missed during an acute or routine visit when competing priorities exist,” said Christopher S. Holliday, PhD, MPH, the AMA’s director of Population Health and Clinical-Community Linkages.

He is a community psychologist and the principal investigator for “Clinical Identification and Referral of Adults with Prediabetes to a Diabetes Prevention Program,” which appeared in Preventing Chronic Disease, published online by the CDC. The study 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.

“Most electronic health records systems are already configured to create a patient registry,” Holliday said. Once established, registries are “relatively easy to maintain”—a smaller practice without a registry-enabled EHR could even use a standard spreadsheet—and are a “very effective clinical principle and practice to help physicians and care teams” identify and reach out to patients requiring referrals.

Thousands of referrals

Of 5,640 patients referred to a DPP in the study, 4,601 patients at 12 clinical care settings were referred through a registry system, one of two approaches tested. Enrollments after referral were 11%. The AMA partnered with the YMCA of the USA in the demonstration project, and patients were referred to DPPs at local YMCAs.

Starting in April 2018, Centers for Medicare & Medicaid Services-approved organizations started billing the Medicare Diabetes Prevention Program (MDPP) expanded model. The eligibility requirements are that patients:

  • 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 percent and 6.4 percent, a fasting plasma glucose between 110–125 mg/dL, or a two-hour plasma glucose between 140–199 mg/dL.

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Medical records flagged

In the study, clinical practice or health system staff used the registries to contact patients by telephone, email or letter regarding their prediabetes condition. Prediabetes was explained to patients and they were encouraged to take part in the YMCA program. The list of patients referred was shared with the YMCA—a business-associate agreement between the practice and the local YMCA made that legal under patient privacy laws. A YMCA DPP coordinator also contacted patients to facilitate the enrollment.

Medical records were flagged so physicians could discuss participation in a DPP at the next patient encounter. For patients who chose not to participate in the DPP, the system made physicians aware that a discussion about diabetes prevention though lifestyle changes was warranted, and encouraged physicians to promote patient enrollment in a DPP.

The demonstration study also compared the patient registry (listing based on a retrospective or “look back” in the medical record) method with a point-of-care model. The point-of-care model was used by 10 practices and produced a substantially smaller number of referrals than EHR registries—437—but also had a markedly higher percentage of enrollments—56% versus 11% for the registry method. Four practices combined a registry with a point-of -care model, resulting in 602 referrals, with 51% of patient enrollments.

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