Diabetes Treatments

Diabetes is a serious and costly disease in Arizona. diabetes on individuals, families, and communities. diabetes. …

Arizona Diabetes Strategic Plan
2008-2013 Arizona Diabetes Coalition

Office of the Director
150 North 18th Avenue, Suite 500 Phoenix, Arizona 85007-2670 602 542-1025 602 542-1062 FAX
August 4, 2008 Dear Arizona Residents, Diabetes is a serious and costly disease in Arizona The number of people with diabetes in Arizona grows each year In fact, since 1990 the prevalence of diabetes in Arizona has doubled from 4 percent to 85 percent in 2006 We know that type 2 diabetes, which is the most common type of diabetes, can be prevented and that people with diabetes can live healthy and long lives with the proper care Through education, increasing access to care, and other public health strategies, we have a great opportunity to work with our partners in Arizona to reduce the burden of diabetes on individuals, families, and communities The Arizona Diabetes Strategic Plan is the first plan in Arizona to address diabetes from a public health perspective for the entire State It uses public health strategies to address opportunities for improvements in healthcare systems, the diabetes workforce, community partnerships, and local and organizational policies We have great hope that by working
together with partners throughout Arizona that we will be able to reduce the prevalence rate of diabetes and improve the lives of people living with diabetes in Arizona We are proud to be a part of the Arizona Diabetes Coalition Sincerely, JANET NAPOLITANO, GOVERNOR JANUARY CONTRERAS, DIRECTOR, ACTING

January Contreras Acting Director Arizona Department of Health Services

Arizona Diabetes Strategic Plan, 2008 - 2013

A Message from the Chair of the Arizona Diabetes Coalition
The Arizona Diabetes Coalition members worked over the past year to develop this strategic plan It was a true collaborative effort with many leaders and experts in diabetes coming together to address how we can combat diabetes in Arizona We are grateful for the input provided by individuals and families that live day in and day out with this devastating disease These men, women, and children are the reason why we are all committed to the fight against diabetes We realize it is going to take many people and many partners to make changes to improve the lives of people at risk for and living with diabetes in Arizona This strategic plan focuses on four areas for change: 1 2 3 4 Primary prevention of type 2
diabetes; Quality care and treatment with strategies focused on patients; Quality care and treatment with strategies focused on providers; and Public policy

This strategic plan provides an opportunity to improve the burden of diabetes in Arizona Many of our strategies deal with partnerships, because we realize that we cannot do this alone By leveraging our efforts with the efforts of other people and organizations from different areas we can work together to make positive changes We can make a difference Together with partners throughout the State we can make a significantly greater difference in the quality of the lives of people with diabetes and their families than any of us could by working alone Using a coordinated and collaborative approach and maximizing our resources will create a healthier Arizona

Donna Zazworsky, MS, RN, CCM FAAN Chair, Arizona Diabetes Leadership Council and Coalition Director of Network Diabetes and Outreach Carondelet Health Network

Arizona Diabetes Strategic Plan, 2008 - 2013

Table of Contents
Acknowledgements v Background 2 Types of Diabetes2 Treating Diabetes 3 Prevention or Delay of Diabetes 3 Prevention of Diabetes Complications 3 Description
of the Problem 4 Diabetes Prevalence 5 Health Care Access 6 Cost of Diabetes 6 Deaths among persons with Diabetes 7 Diabetes in Persons Less than 18 years of Age 7 Complications of Diabetes 7 Development of the Strategic Plan 9 Background 9 Methods 10 Arizona Diabetes Strategic Plan 13 Priority Area 1: Primary prevention of type 2 diabetes 15 Priority Area 2: Quality care and treatment with strategies focused on people with diabetes 19 Priority Area 3: Quality of care and treatment with strategies focused on health care providers 22 Priority Area 4: Public policy 26 References 28 Abbreviations29

Arizona Diabetes Strategic Plan, 2008 - 2013

ACKNOWLEDGEMENTS
This plan would not have been possible without the support, dedication, and guidance of the Arizona Diabetes Leadership Council Council members developed the strategies outlined in this plan and provided valuable feedback on the draft report Donna Zazworsky, Chair of the Arizona Diabetes Leadership Council, was instrumental in leading this effort and working with the larger Arizona Diabetes Coalition to gather input on strategies and implementation of the plan at the 2007-2008 coalition meetings Staff from the University of
Arizona Mel and Enid Zuckerman College of Public Health facilitated the development of this plan We are thankful for their guidance for keeping us focused and ensuring that our strategies will meet desired outcomes A special thanks to the Arizona Diabetes Coalition members and Committee Advocacy, Education, and Surveillance Chairs for their input We appreciate the valuable work of members who spent time providing feedback and guidance on the strategies We also thank the Bureau of Chronic Disease Prevention and Control staff, especially the Arizona Diabetes Program, for writing, reviewing, editing, and providing valuable comments on the plan

Arizona Diabetes Leadership Council Members
Chair Donna Zazworsky, MS, RN, CCM, FAAN Carondelet Health Network 2007-2008 Chair-Elect E Scott Endsley, MD, MSc Health Services Advisory Group 2007-2008 Advocacy Committee Chair Sue Hendershott, MSN, RN, CDE Caremark 2007-2008 Surveillance Committee Chair Zeenat Mahal, MBBS, MS InterTribal Council of Arizona, Inc 2007-2008 Education Committee Chair Linda Parker, RN Carondelet Health Network 2008 Betty Page Brackenridge, MS, RD, CDE Diabetes Management Training Centers, Inc 2007 Kim Elliot, PhD
Arizona Health Care Cost Containment System 2008 Melissa Spezia Faulkner, DSN, RN, FAAN The University of Arizona College of Nursing 2008 Pam Ferguson American Heart Association 2007-2008 Robert Guerrero, MBA Arizona Department of Health Services 2007-2008 Kimberly D Harris-Salamone, PhD Health Services Advisory Group 2008 Trish Herrmann, MS, RD Arizona Department of Health Services 2007-2008 Darlene Horst, BSN, RN, CDE Mt Graham Regional Medical Center 2008

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Arizona Diabetes Leadership Council Members
Valerie Jones Juvenile Diabetes Research Foundation 2007 Beth R Malasky, MD Native American Cardiology University Medical Center 2007-2008 Suzanne Miller American Diabetes Association 2007-2008 Anita Murcko, MD, FACP Arizona Health Care Cost Containment System 2007-2008 Bobbi Presser, MPH Scottsdale Healthcare 2007-2008 Sara Sparman Juvenile Diabetes Research Foundation 2008 Lisa Staten, PhD University of Arizona Mel Enid Zuckerman College of Public Health 2007-2008 Christine Winters, MS, RD, CDE Yuma Regional Medical Center 2007

Education Subcommittee Chairs
Public Health Chair Leticia Martinez, RD, MPH, MS, BC-ADM El Rio Health
Center 2008 Hospital Chair Debby Beechey Sanofi-Aventis 2008 Provider Chair Scott Endsley, MD, MSc Health Services Advisory Group 2008 Patient Chair Linda Parker, RN Carondelet Health Network 2008

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University of Arizona Mel and Enid Zuckerman College of Public Health
Erin Peacock, MPH Adriana Cimetta, MPH Kim Fielding Anneke Jansen, MPH Ralph Renger, PhD

Arizona Diabetes Program Staff
Trish Herrmann, MS, RD Carmen Ramirez Alexandra Ikeda Kai-Ning Khor

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Our Vision
A state without diabetes

Our Mission
To reduce the health, social, and economic burden of diabetes in Arizona

BACKGROUND
Types of Diabetes1
Diabetes mellitus is a group of diseases characterized by high levels of blood glucose resulting from defects in insulin secretion, insulin action, or both Diabetes can be associated with serious complications and premature death, but people with diabetes can take steps to control the disease and lower the risk of complication Type 1 Diabetes Type 1 diabetes was previously called insulin-dependent diabetes mellitus IDDM or juvenile-onset diabetes Type 1 diabetes may account for 5
percent to 10 percent of all diagnosed cases of diabetes, and usually appears in childhood or adolescence, hence the more familiar term juvenile diabetes The risk factors are less defined for type 1 diabetes than for type 2 diabetes, but autoimmune, genetic, and environmental factors are involved in the development of this type of diabetes Type 2 Diabetes Type 2 Diabetes was previously called non-insulin dependent diabetes mellitus NIDDM or adult-onset diabetes Type 2 diabetes may account for about 90 percent to 95 percent of all diagnosed cases of diabetes, and usually doesnt develop until after age 40 Risk factors for type 2 diabetes include older age, obesity, family history of diabetes, prior history of gestational diabetes, impaired glucose metabolism, physical inactivity, and race/ethnicity African Americans, Hispanic/Latino Americans, American Indians, and some Asian Americans and Pacific Islanders are at particularly high risk for type 2 diabetes
4 Gestational Diabetes1-4

Gestational diabetes mellitus GDM develops in approximately 7 percent of all pregnancies Immediately after pregnancy, 5 to 10 percent of women with gestational diabetes are found to have diabetes, usually
type 2 GDM occurs more frequently in African Americans, Hispanic/Latino Americans, American Indians, persons with a family history of diabetes, and among women who are obese Women who have had GDM are at increased risk for developing type 2 diabetes later in life Between 40 and 60 percent of women with a history of GDM developed diabetes in the future The children of women with a history of GDM are at an increased risk for obesity and diabetes compared to other children Pre-Diabetes D Pre-diabetes is a term used for people who are at increased risk of developing type 2 diabetes, heart disease, and stroke People with pre-diabetes have impaired fasting glucose IFG or impaired glucose tolerance IGT IFG is diagnosed when fasting blood glucose level is elevated 100 to 125 mg/dl after an overnight fast, but is not high enough to be classified as diabetes IGT is a condition in which the blood sugar level is elevated 140 to 199 mg/dl after a 2-hour oral glucose tolerance test, but is not high enough to be classified as diabetes5 Most recent estimates from 2003-2006 indicate that 26 percent of all US adults age 20 years and older had IFG1 Applying this percentage to the entire US and
Arizona population estimates, 57 million Americans and over 11 million Arizonans had impaired fasting glucose in 20066 Other Types Other types of diabetes result from specific genetic syndromes, surgery, drugs, malnutrition, infections, and other illnesses These types of diabetes may account for one percent to five percent of all diagnosed cases of diabetes1

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Treating Diabetes
To survive, people with type 1 diabetes must have insulin delivered by injections or a pump Many people with type 2 diabetes can control their blood glucose by following a careful diet and exercise program, losing excess weight, and taking oral medication Many people with diabetes also need to take medications to control their cholesterol and blood pressure Diabetes self-management education is an integral component of medical care Among adults with diagnosed diabetes, 13 percent take both insulin and oral medications, 14 percent take insulin only, 57 percent take oral medications only, and 16 percent do not take either insulin or oral medications1 Blood pressure control Blood pressure control can reduce cardiovascular disease heart disease and stroke by
approximately 33 percent to 50 percent and can reduce microvascular disease eye, kidney, and nerve disease by approximately 33 percent In general, for every 10 millimeters of mercury mm Hg reduction in systolic blood pressure, the risk for any complication related to diabetes is reduced by 12 percent Control of blood lipids Improved control of cholesterol or blood lipids for example, HDL, LDL, and triglycerides can reduce cardiovascular complications by 20 percent to 50 percent Preventive care practices for eyes, kidneys, and feet Detecting and treating diabetic eye disease with laser therapy can reduce the development of severe vision loss by an estimated 50 percent to 60 percent Comprehensive foot care programs can reduce amputation rates by 45 percent to 85 percent Detecting and treating early diabetic kidney disease by lowering blood pressure can reduce the decline in kidney function by 30 percent to 70 percent Treatment with ACE inhibitors and angiotensin receptor blockers ARBs are more effective in reducing the decline in kidney function than other blood pressure lowering drugs

Prevention of Diabetes Complications
Diabetes can affect many parts of the body and can lead to
serious complications such as blindness, kidney damage, and lower-limb amputations Working together, people with diabetes and their health care providers can reduce the occurrence of these and other diabetes complications by controlling the levels of blood glucose, blood pressure, and blood lipids and by receiving other preventive care practices in a timely manner Glucose control Research studies in the United States and abroad have found that improved glycemic control benefits people with either type 1 or type 2 diabetes In general, for every 1 percent reduction in results of A1C blood tests eg, from 80 percent to 70 percent, the risk of developing microvascular diabetic complications eye, kidney, and nerve disease is reduced by 40 percent

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DESCRIPTION OF THE PROBLEM
Diabetes Prevalence
In 2007, 78 percent, or 236 million, people of all ages in the US have diabetes diagnosed and undiagnosed1 This is a 37 percent increase in diabetes prevalence since 2000 Arizona has seen a 44 percent increase in adults with diabetes from 2000 through 2006, with prevalence rising from 59 percent to 857 The prevalence of persons with diabetes in
Arizona has more than doubled since 1990 see Figure 1 An estimated 385,741 persons aged 18 years and older in Arizona reported to have diabetes in 20066,7 These numbers do not account for undiagnosed diabetes, which is estimated to be one-third of all people with diabetes, bringing the total number of people with diabetes to about 513,000 113 percent8

Prevalence of Diabetes by Race/Ethnicity1
The total prevalence of diabetes among Native Americans, African-Americans, or Asians is not available in Arizona because of small sample sizes of these groups in the Behavioral Risk Factor Surveillance System BRFSS Hispanic or Latino Americans make up almost one-third of the Arizona population In Arizona, 92 percent of Hispanics have diabetes whereas 78 percent of nonHispanic Whites have diabetes7 Nationally, the prevalence of diabetes is also higher among Hispanics 104 than non-Hispanic Whites 66 More than five percent of the population in Arizona is Native American, a group also more likely to develop diabetes than non-Hispanic Whites The national estimate for diabetes prevalence among Native Americans and Alaska Natives is 165 percent, a prevalence almost three times as high as those of
nonHispanic Whites African Americans make up 39 percent of the Arizona population Nationally, the prevalence of diabetes among Blacks 118 is almost twice that of nonHispanic Whites Asian Americans and Pacific Islanders make up about 26 percent of the population in Arizona Nationally, the prevalence of diabetes among Asians is also higher 75 than that of non-Hispanic Whites

Figure 1 Prevalence of Diagnosed Diabetes in Persons Aged 18 years and older in Arizona, BRFSS, 1990-2006

In some cases, we do not have enough data to report Arizona statistics Unless otherwise specified, the data in this report uses National data

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Prevalence of Diabetes by Sex7 National BRFSS 2006 data indicates that prevalence of diabetes is higher in males 80 percent than females 72 percent Arizona also reflects this national trend with 94 percent of males compared to 77 percent of females reporting to have diabetes Prevalence of Diabetes by Age The prevalence of diabetes increases with age Table 1 Twenty-three percent of Americans aged 60 years and older have diabetes, compared to 10 percent of Americans aged 20 years and older1 The Arizona BRFSS data
indicates aging adults, especially above the age of 55, are at higher risk than adults between the ages of 18 and 54

Prevalence of Diabetes by Level of Education and Income7 According to BRFSS data, the prevalence of diagnosed diabetes is higher in populations with lower levels of education Table 2 In Arizona, 113 percent of adults without a high school diploma have diabetes compared to 62 percent of adults with a college diploma In addition, individuals reporting lower income levels have increased prevalence of diabetes In Arizona, 152 percent of adults with annual incomes less than 15,000 have diabetes whereas 61 percent of adults with annual incomes over 50,000 have diabetes

Table 1: Prevalence of Diagnosed Diabetes by Age Group in Persons 18 and Older in Arizona, BRFSS, 2000-2006
18 - 34 Years 35 - 44 Years 45 - 54 Years 55 - 64 Years 65 Years 14 39 85 114 147

Table 2: Prevalence of Diagnosed Diabetes by Education Level in Persons 18 years and older, BRFSS, 2006
Level of Education No High School Diploma High School Graduate Some College College Graduate US including DC and territories 129 89 77 54 Arizona 113 95 88 62

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Health
Care Access
Health care access is critical for persons with diabetes Persons with diabetes are disproportionately affected by several complications, including heart disease, stroke, amputations, kidney disease, eye disease, neuropathy, and depression1 According to National BRFSS data, 145 percent of persons 18 years and older reported not having health care coverage in 2006 In Arizona, Hispanics have a much higher percentage of reporting no health insurance, 199 percent, versus 115 percent of nonHispanic, whites 7 Unlike national statistics, lack of health care coverage in Arizona generally increases as age increases with 20 percent of adults over the age of 55 without health care coverage7

Cost of Diabetes
Diabetes alone accounts for 10 percent of the United States health care expenditure A national study conducted by the American Diabetes Association and endorsed by the National Institutes of Health and the Centers for Disease Control and Prevention CDC estimated the direct and indirect costs attributable to diabetes in 2007 were 174 billion Table 3, which is a 32 percent increase from 2002 Per capita medical expenditures in 2007 were estimated to be 11,744 for people with
diabetes Adjusted for age, sex, and race/ethnicity, medical expenditures for people with diabetes are approximately 24 times more than those for people without diabetes9

Table 3: Cost of Diabetes in the United States9

Type of Cost
Direct Indirect TOTAL

Amount in billions
116 58 174

Diabetes also poses a large burden on the economy in Arizona In 2005, there was nearly 3 billion in charges for inpatient hospital stays for diabetes-related conditions, approximately 6 times higher than the amount in 1994 This estimate does not include charges in federal facilities, such as Indian Health Service facilities

Figure 2 Charges in Arizona for inpatient hospitalizations for diabetes-related diagnoses non-federal facilities, 19942005

Source: Hospital Discharge Database, Bureau of Public Health Statistics, ADHS, 1994-2005

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Deaths among persons with Diabetes10
According to the CDC, diabetes was the seventh leading cause of death in the nation, contributing three percent of all deaths or 72,507 deaths in 200611 In 2005, diabetes was the eighth leading cause of death among Arizona residents directly attributing to 1,196 deaths Nationwide,
diabetes is believed to be underreported on death certificates because persons with diabetes most often die from cardiovascular disease or renal disease and not from causes unique to diabetes, such as ketoacidosis or hypoglycemia1 Studies have found that only about 35 percent to 40 percent of decedents with diabetes had it listed anywhere on the death certificate in only 10 to 15 percent had it listed as the underlying cause of death Overall, the risk for death among people with diabetes is about twice that of people without diabetes of similar age1 In Arizona 1,740 deaths had diabetes assigned as a contributing factor making the diabetes-related mortality rate 49/100,000 or 24 times greater than the rate for diabetes as underlying cause 20/100,000 The 2005 diabetes mortality rate for Arizona was 20 per 100,000 Mortality rates for each race/ethnicity were applied to the 2005 population Diabetes mortality rates for racial/ethnic groups compared to White, non-Hispanics: American Indians were 45 times higher, African Americans were 36 times higher, Hispanics were 3 times higher

Complications of Diabetes
Heart disease and stroke1 Heart disease is the leading cause of death among
persons with diabetes, accounting for about 68 percent of deaths in people with diabetes Heart disease death rates are two to four times higher among adults with diabetes as compared to those without diabetes The risk for stroke is two to four times higher among people with diabetes In Arizona about 25 percent of the adult population that had heart disease, angina and/or stroke also had diabetes 2006 High blood pressure1 About 75 percent of adults with diabetes have blood pressure greater than or equal to 130/80 mm Hg or use prescription medications for hypertension In Arizona 223 percent of the 2005 adult population self-reported they had high blood pressure Blindness1 Diabetes is the leading cause of new cases of blindness among adults aged 20 to 74 years Nationally, diabetic retinopathy causes 12,000 to 24,000 new cases of blindness each year According to the National Eye Institute 2004 approximately 403 percent of the people aged 40 years and older with diabetes had diabetic retinopathy 15 Kidney disease Diabetes is the leading cause of kidney failure, accounting for 44 percent of new cases in 20051 In 2006, 2,071 Arizonans were newly diagnosed with chronic end stage renal
disease ESRD Of those new cases, 51 percent, or 1,055 Arizonans, had a primary diagnosis of diabetes An additional 3,508 Arizonans with diabetes were receiving dialysis and 709 dialysis deaths occurred as a result of diabetes in 200616 Nervous system disease 1 About 60 to 70 percent of people with diabetes have mild to severe forms of nervous system damage The results of such damage include impaired sensation or pain in the feet or hands, slowed digestion of food in the stomach, carpal tunnel syndrome, and other nerve problems Almost 30 percent of people with diabetes aged 40 years or older have impaired sensation in the feet ie, at least one area that lacks feeling Severe forms of diabetic nerve disease are a major contributing cause of lower-extremity amputations

Diabetes in Persons Less than 18 years of age
Type 1 diabetes, an autoimmune disorder that destroys insulin-producing pancreatic cells, is the primary form of diabetes in childhood It is the second most prevalent chronic disease of childhood after asthma Nationally, an estimated one in every 400 to 500 children and adolescents has type 1 diabetes12 Preliminary reports from the Search for Diabetes in Youth Study suggests
that nonHispanic whites have the highest rate for Type 1 Diabetes13 This study reported that type 2 diabetes, although relatively rare, seems to be diagnosed more frequently in adolescent minority populations More than five percent of Arizona high school students reported being informed by a doctor or a nurse that they had diabetes 516 percent14

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Amputations1 More than 60 percent of nontraumatic lower-limb amputations in the United States occur in people with diabetes The rate of amputation for people with diabetes is 10 times higher than for people without diabetes According to the Arizona hospital discharge data, 4,015 lower extremity amputations occurred in persons with diabetes from 2004-2006, averaging 1,338 cases per year This is an increase of 137 cases compared to 2000, where 1,201 lower extremity amputations occurred in persons with diabetes Dental Disease1 Periodontal gum disease is more common in people with diabetes Among young adults, those with diabetes have about twice the risk of those without diabetes Almost one-third of people with diabetes have severe periodontal diseases with loss of attachment of the gums to the
teeth measuring 5 millimeters or more

Complications of pregnancy1 Poorly controlled diabetes before conception and during the first trimester of pregnancy can cause major birth defects in 5 to 10 percent of pregnancies and spontaneous abortions in 15 to 20 percent of pregnancies Poorly controlled diabetes during the second and third trimesters of pregnancy can result in excessively large babies, posing a risk to both mother and child Other Complications1 Uncontrolled diabetes often leads to biochemical imbalances that can cause acute lifethreatening events, such as diabetic ketoacidosis and hyperosmolar nonketotic coma People with diabetes are more susceptible to many other illnesses and, once they acquire these illnesses, often have worse prognoses For example, they are more likely to die with pneumonia or influenza than people who do not have diabetes According to the Arizona BRFSS data, one-third of Arizonans over the age of 65 years did not receive flu or pneumonia shots in 2006

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DEVELOPMENT OF THE STRATEGIC PLAN
Background
The Bureau of Chronic Disease Prevention and Control BCDPC is located within the Arizona Department of
Health Services ADHS Division of Public Health Services The Arizona Diabetes Program is one of many programs housed in the BCDPC Established in 1994 by a cooperative agreement with the Centers for Disease Control and Prevention CDC, the diabetes program aims to reduce the incidence and prevalence of diabetes and the disabling conditions associated with diabetes such as: blindness, amputations and kidney disease, as well as the personal, social and economic consequences of diabetes, ultimately improving the quality of life for individuals and families living with diabetes in Arizona The Arizona Diabetes Program work focuses on health systems infrastructure, community interventions, disease management, wellness, health disparities, and health communications The Arizona Diabetes Program achieves many of its projects with support from partnerships and through the Arizona Diabetes Coalition ADC, a 300 member organization with by-laws and managed by the Arizona Diabetes Program The purpose of the ADC is to reduce the burden of diabetes on individuals, families, communities, the health care system, and the State This is done by increasing awareness of diabetes, advocating for and
promoting policies and programs that improve access to care, treatment, and outcomes for people with diabetes and those at risk for developing diabetes The ADC has three committees: advocacy, education, and surveillance The education committee has four subcommittees: 1 provider, 2 patient, 3 hospital, and 4 public health education The Arizona Diabetes Leadership Council provides direction for the activities of the ADC Both the Arizona Diabetes Leadership Council and ADC meet quarterly each year In January 2007, Arizona Diabetes Program staff contracted for strategic planning services with a planning and evaluation team under the direction of Ralph Renger, PhD at the University of Arizona Mel and Enid Zuckerman College of Public Health The scope of the contract was to engage Arizona Diabetes Program staff, Arizona Diabetes Leadership Council, and ADC members, and other stakeholders in a strategic planning process that would result in the development of a 5-year strategic plan, the Arizona Diabetes Strategic Plan, 2008-2013 This plan is to drive the activities of the ADC and of Arizona Diabetes Program as an important partner in the ADC
Arizona Diabetes Strategic Plan, 2008 -
2013

The strategic planning process consisted of three steps which are further outlined in methods below In step 1, two logic maps, each depicting the relationships between a problem of interest and its roots causes, were created Persons with diabetes in Arizona do not receive recommended care and treatment and There is a high incidence of diabetes/probable high incidence of prediabetes in Arizona were the problems that were explored Experts in diabetes were interviewed to identify root causes of these problems The root causes were prioritized in step 2 In step 3, members of the Arizona Diabetes Leadership Council developed strategies to address the prioritized root causes Strategy development was divided among three sub-groups that focused on 1 primary prevention, 2 improved care and treatment with strategies focused on the patient, and 3 improved care and treatment with strategies focused on the provider A fourth priority area, public policy, was added to strengthen activities the ADC began in 2007

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Methods
Below is a description of steps used to develop the strategic plan The end results of this process are the strategies listed in the next chapter, Arizona Diabetes
Strategic Plan The Leadership Council actively participated in all steps of the process The Chair of the Council updated ADC members at the 2007-2008 Coalition meetings The ADC members were requested to provide input and feedback during all steps of the process

Table 1: Steps in the development of the Arizona Diabetes Strategic Plan

Step
Step 1

Description of Step
Construct a map of underlying conditions identified in expert interviews Systematically prioritize underlying conditions based on prioritization criteria Identify strategies that address the prioritized conditions

Responsible Party
Planning and evaluation team and experts Planning and evaluation team, Arizona Diabetes Leadership Council, and Arizona Diabetes Program staff Arizona Diabetes Leadership Council and Coalition and Arizona Diabetes Program staff with guidance from planning and evaluation team

Step 2

Step 3

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Step 1 is critical to gaining a contextual understanding of the problem and its underlying conditions so that ultimately, strategies can be targeted to root causes of the problem To arrive at this understanding, interviews are conducted with experts in
the problem area For our purposes, experts are defined as persons representing the

various stakeholder groups in the intended program During each interview, a facilitator guides the expert through the process of developing a map that depicts the relationships between the problem and its underlying conditions

Long Term Objectives The CDCs Division of Diabetes Translation DDT administers the state-based Diabetes Prevention and Control Programs DPCP, of which the Arizona Diabetes Program is one Therefore, the program is mandated to develop objectives that mirror the DDT National Objectives The following are the DDT National Objectives: 1 Demonstrate success in achieving an increase in the percentage of persons with diabetes who receive the recommended foot exams 2 Demonstrate success in achieving an increase in the percentage of persons with diabetes who receive the recommended eye exams 3 Demonstrate success in achieving an increase in the percentage of persons with diabetes who receive the recommended influenza and pneumococcal vaccines 4 Demonstrate success in achieving an increase in the percentage of persons with diabetes who receive the recommended A1C tests 5 Demonstrate
success in reducing health disparities for high risk populations with respect to diabetes prevention and control 6 Demonstrate success in establishing linkages for the promotion of wellness, physical activity, weight and blood pressure control, and smoking cessation for persons with diabetes We have included an additional objective Objective 7 related to primary prevention 7 Demonstrate success in reducing the number of people who are diagnosed with pre-diabetes and diabetes

Experts were nominated by Leadership Council and ADC members The Program Manager provided guidance on which 16 persons, from a larger pool of nominees, should be interviewed Two of the recommended experts were unavailable despite several attempts to contact them An

additional expert was added based on a recommendation from the Leadership Chair In the end, those interviewed n15 included health educators n5, community advocates n4, health care providers n3, health system experts n2, and a diabetes patient n1

Figure 1 Problem statement for Step 1

High incidence of diabetes/probable high incidence of prediabetes in Arizona

Persons with diabetes in Arizona do not receive recommended care and treatment

High
incidence of diabetesrelated conditions in Arizona

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Each interview began with a statement of the problem The facilitator asked the expert why the problem exists and noted the experts first response on the map in relation to the problem statement The facilitator then turned to this response and asked why it exists or occurs Again, the experts response was noted on the map The facilitator continued to ask Why? for each response until she reached a clear conclusion to the stream of logic eg, she reached an issue that is unchangeable given available time and resources At that point, the facilitator returned to the problem statement and again asked, Why? The process continued until the expert felt that she had nothing more to add to the map The interview concluded with the facilitator asking the expert, In your opinion, which of the issues you mentioned contributes most significantly to the problem? and What strategies might address this issue? Step 2 involves the systematic prioritization of the underlying conditions identified in Step 1 A facilitator leads a group of decision-makers in this case, Leadership Council members and diabetes
program staff to apply prioritization criteria to each underlying condition in a stepwise manner Conditions that do not meet a given criterion are eliminated and not considered for the next criterion The resulting list is made up of underlying conditions that meet all of the prioritization criteria The group can then engage in Step 3 of the process The Program Manager was consulted for assistance in developing appropriate prioritization criteria based on program conditions and constraints The following are the three criteria that were developed: Within the mission of the Arizona Diabetes Program Changeable within five years Changeable with a budget of 1 million per year

Step 3 involves identification and development of strategies that address the conditions prioritized in Step 2 For each proposed strategy, the group of decision-makers in this case, Leadership Council members and diabetes program staff must explain how it links to one or more prioritized conditions In this way, the group stays focused on addressing the conditions that were identified 1 in Step 1 to be root causes of the problem, and 2 in Step 2 to be priorities for the group For each strategy proposed, the group
was required to provide the following information: The prioritized conditions that the strategy addresses A descripti on of the strategy The rationale linking the strategy to the condition The key audience The potential partners, if any An explanation of how the strategy addresses health disparities, if it does The data that would be needed to effectively plan the strategy, if any An explanation of how the strategy links to the DDT National Objectives, if it does When they were sufficiently familiar with the strategy development process, the group divided into three subgroups, focusing on 1 primary prevention, and improving care and treatment through 2 strategies focused on patients and 3 strategies focused on providers These groups met independently to brainstorm strategies and compile the information listed above for submission to the planning and evaluation team Upon receipt of the information, the team was able to write appropriate short term, intermediate, and long term outcomes for each of the strategies

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ARIZONA DIABETES STRATEGIC PLAN 2008-2013 2
The Arizona Diabetes Strategic plan addresses strategies to improve the lives of
people at risk for or living with diabetes in Arizona over the next five years The plan will be reviewed by the Arizona Diabetes Leadership Council and Arizona Diabetes Coalition ADC each year and is flexible to change or add strategies as opportunities for new programs or partnerships arise The Arizona Legislature has appropriated funds to the Arizona Diabetes Program for diabetes and this plan will help guide the use of these funds Strategies outlined in this plan focus on three goals: Reduce the prevalence of diabetes; Reduce the disabling conditions associated with diabetes; and Reduce the personal social and economic consequences of diabetes Strategies are listed in one of four priority areas: Priority area 1-Primary prevention of type 2 diabetes; Priority area 2-Quality care and treatment with strategies focused on people with diabetes; Priority area 3-Quality care and treatment with strategies focused on health care providers; and Priority area 4-Public policy Once a project is adopted by a committee or partner, an implementation plan with timelines, people/organizations responsible, tasks, and deadlines will be developed to monitor progress Work began on this process at the
October 26, 2007 ADC meeting and continued at the January 18, 2008 ADC meeting In some cases, strategies have action steps outlined in the tables This strategic plan is broad in nature and is intended to guide program and partnership activities In order to evaluate its impact, implementation plans will also address evaluation indicators Each objective will be reviewed to ensure that it is a SMART Specific, Measurable, Attainable, Realistic and Time-sensitive objective and is targeted towards disparate groups most impacted by diabetes The Arizona Diabetes Program will continue to lead the effort to produce and disseminate Arizona surveillance reports Some of the long term objectives can be measured by indicators in these reports The following reports are prepared by State epidemiologists with input and guidance from the ADC Surveillance Committee and partners of the Arizona Diabetes Coalition: Indicators Report The indicators report is prepared annually based on a list of selected measurable indicators of diabetes and its complications to measure progress of diabetes control efforts by various agencies and healthcare systems throughout Arizona These measurable indicators have been
selected by partners that serve on the ADC Surveillance Committee based on quality and availability of the data of those indicators Indicators focus on precursor conditions, primary, secondary, and tertiary prevention, and mortality Diabetes in Arizona Status Report This comprehensive report is prepared every 3 years and examines the burden of diabetes and its complications in Arizona Its purpose is to estimate the impact of prevalence, costs, and complications of people with diabetes The report notes high risk populations and characteristics of people with diabetes

Implementation and Evaluation
For each priority area, key strategies with corresponding short term, intermediate, and long term objectives are outlined in tables To facilitate implementation, each strategy also has the following information provided: target audience, stakeholders critical to the success of the strategy, ADC committee, subcommittee, or ADC partner assigned as the lead group to implement the strategy, and ADHS program partners The committees of the ADC are Advocacy, Education, and Surveillance The Education Committee has four subcommittees: 1 public health; 2 hospital; 3 patient; and 4 provider

Arizona
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Health Disparities
A health disparity is defined as A population is a health disparity population if there is a significant disparity in the overall rate of disease incidence, prevalence, morbidity, mortality or survival rates in the population as compared to the health status of the general population Minority Health and Health Disparities Research and Education Act United States Public Law 106-525 2000, p 2498 Diabetes affects some populations in Arizona more that others Specifically, type 2 diabetes affects African Americans, Hispanics/Latinos, Native Americans, people over the age of 45, overweight and physically inactive people, women with a history of gestational diabetes, and poor, less educated people These populations will be a high priority for this strategic plan We considered health disparities throughout the planning process and drafting of the strategies We specifically asked, Does this strategy address health disparities? And If yes, how? Implementation plans will further address target audiences for each activity

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Priority Area 1: Primary prevention of type 2 diabetes
Primary
prevention is the prevention of type 2 diabetes type 1 diabetes is not preventable and not addressed in this section Strategies focus on modifiable risk factorsoverweight, obesity, and a sedentary lifestyle-for developing type 2 diabetes Results from the Diabetes Prevention Program, a large clinical trial funded by the National Institutes of Health, showed the risk of developing type 2 diabetes for people with pre-diabetes or impaired glucose tolerance can be reduced by 57 percent through intensive counseling on diet, exercise, and behavior modification17 PRIORITY AREA 1: PRIMARY PREVENTION Goal 1: Reduce the Prevalence of Diabetes Strategy Focus: Primary Prevention Partnerships

Long-term Objectives t Increase healthy eating of Arizonans Increase physical activity of Arizonans Strategies These strategies are further outlined in the tables below 1 Primary Prevention Partnerships-Partner with other organizations to support current and new programs that educate and raise awareness about healthy lifestyles and diabetes 2 Healthy School Environments-Advocate for policies and programs that support a healthful school eating and physical activity environment 3 Worksite Wellness-Promote
and support the implementation of worksite wellness programs

Short-term Objectives 1 Year t

By June 30, 2009, 5 collaborations between the Arizona Diabetes Coalition and worksite, school or community organizations will be established By June 30, 2009, identify 2 collaborative projects and begin work to implement in worksites, schools, or communities Implement sustained lifestyle interventions to increase healthy eating and physical activity through the established partnerships Increase healthy eating of students, employees, or community members in participating intervention Increase physical activity of students, employees, or community members in participating intervention Partner with other organizations to support current and new programs that educate and raise awareness about healthy lifestyles and diabetes in school, worksite, and community environments

Intermediate Objectives 3 Years

Long-term Objectives 5 Years t

Strategy

For example: - American Diabetes Association has educational materials for schools - American Heart Association advocates for physical education in schools - Nutrition and Physical Activity Self Assessment for Child Care NAP SACC: NAP SACC is aimed at
improving the nutrition and physical activity environment, policies and practices through self-assessment, action planning, training and targeted technical assistance - Arizona Nutrition Network conducts three campaigns per year for food stamp eligible people
15

Arizona Diabetes Strategic Plan, 2008 - 2013

Potential Target audience

Preschool children and childcare providers, school-age children, Food stamp eligible people, Employees High risk populations African Americans, Native, Americans, Hispanics/Latinos, older people, women with history of gestational diabetes, people with a family history of diabetes, people who do not engage in physical activity, overweight or obese people American Diabetes Association, American Heart Association, Juvenile Diabetes Research Foundation, Health Services Advisory Group, Arizona Nutrition and Physical Activity Alliance, State universities and community colleges in Arizona, Midwestern University, Arizona Nutrition Network Advocacy and Education Arizona Diabetes Program, Nutrition, Physical Activity and Obesity Program, Heart Disease and Stroke Program, and Steps to a Healthier Arizona Initiative

Stakeholders critical to success

ADC
Committees Responsible ADHS Program Partners

PRIORITY AREA 1: PRIMARY PREVENTION Goal 1: Reduce the Prevalence of Diabetes Strategy Focus: Healthy School Environments By June 30, 2009, establish a baseline measure for number of schools that have physical education classes By June 30, 2009, 5 diabetes stakeholders will participate in activities to develop, advocate for, or implement school health policies Increase the number of students who report an increased access to physical activity Increase healthy eating of students Increase physical activity of student Use advocacy committee for awareness and support of policies that support a healthful school eating and physical activity environment Partner with the Arizona Department of Education to support their policies/program relating to healthy schools Target audience Legislatures, School districts, State school superintendent, local school boards American Diabetes Association, American Heart Association, Arizona Action for Healthy Kids, Arizona Public Health Association, Arizona Nutrition and Physical Activity Alliance, Arizona Department of Education, physical activity and nutrition advocacy groups, State universities and community
colleges in Arizona Advocacy Arizona Diabetes Program, and Nutrition, Physical Activity and Obesity Program 16

Short-term Objectives 1 Year t

Intermediate Objectives 3 Years Long-term Objectives 5 Years t

Strategy

Stakeholders critical to success

ADC Committees Responsible ADHS Program Partners

Arizona Diabetes Strategic Plan, 2008 - 2013

PRIORITY AREA 1: PRIMARY PREVENTION Goal 1: Reduce the Prevalence of Diabetes Strategy Focus: Worksite Wellness By June 30, 2009, recruit 60 additional organizations to utilize the Healthy Arizona Worksites Online Assessment and Resource Guide for developing employee wellness programs and policies By June 30, 2009, establish 2 new worksite wellness programs with Arizona employers and 4 worksites that expand or implement new worksite policies Increase number of employers who have physical activity opportunities or access to physical activity for employees Increase the number of workplaces that offer healthy foods Increase healthy eating of employees Increase physical activity of employees Promote and support worksite wellness programs Action Steps: - Assist in development of a promotion plan for the launch of the Healthy Arizona Worksite
Online Assessment and Resource Guide to Arizona employers - Provide feedback to refine and update the Healthy Arizona Worksite Website; add a page that states the business case for educating and providing support for employees, including increased retention and productivity - Develop a speakers bureau for people who can present on worksite wellness - Identify best practices of Arizona worksites and promote access to these best practices - Prepare a list of diabetes prevention resources and programs for worksites to integrate into worksite wellness programs Support the implementation of worksite wellness programs Action Steps: - Advocate at the State Health Department Services level to hire a worksite wellness coordinator to provide technical assistance for implementation of worksite wellness programs - Utilize interns who can assist with worksite wellness technical assistance - Provide grants to employers for worksite wellness programs that provide increased physical activity opportunities and changes in worksites to encourage healthy eating - Assist in the adoption and implementation of a diabetes worksite education program at one Arizona worksite

Short-term Objectives 1 Year
t

Intermediate Objectives 3 Years

Long-term Objectives 5 Years t

Strategy

Arizona Diabetes Strategic Plan, 2008 - 2013

17

Target audience

Arizona employers with special emphasis on small and midsize businesses Community involvement from: Midwestern University, State universities and community colleges in Arizona, Arizona Human Resources Association, Inter Tribal Council of Arizona, Inc, American Diabetes Association, Wellness Council of Arizona, Health Plans, American Heart Association, Arizona Small Business Association, Arizona Chambers of Commerce, Health Services Advisory Group, Governors Council on Health, Physical Fitness, and Sports Education, Public Health Nutrition, Physical Activity and Obesity Program, Arizona Diabetes Program, Steps to a Healthier Arizona Initiative, and Heart Disease and Stroke Program

Stakeholders critical to success

ADC Committees Responsible ADHS Program Partners

Arizona Diabetes Strategic Plan, 2008 - 2013

18

Priority Area 2: Quality care and treatment with strategies focused on people with diabetes
People with diabetes live with this disease 24 hours a day, 7 days a week They can be one of the most important people on their healthcare
team by learning about diabetes, monitoring their blood glucose, and learning good self-management skills The strategies below empower people with diabetes by: 1 learning about selfcare standards; 2 having an increased awareness about the seriousness of diabetes and steps to take to manage this disease; and 3 providing a directory with local resources on where they can access diabetes selfmanagement training, regardless of insurance level

Long-term Objectives t Increase the number of persons with diabetes who receive the recommended care and treatment Strategies These strategies are further outlined in the tables below 1 Standards of Care-Develop, adopt, and promote minimum standards for diabetes care in Arizona 2 Health Communications Campaign-Implement a health communications campaign about proper care and treatment 3 Resource Directory-Review, revise, and disseminate the Arizona Diabetes Resource Directory

PRIORITY AREA 2: QUALITY CARE AND TREATMENT WITH STRATEGIES FOCUSED ON PEOPLE WITH DIABETES Goal 2: Reduce the disabling conditions associated with diabetes Strategy Focus: Standards of Care Short-term Objectives 1 Year t By June 30, 2009, the ADC will develop and adopt
minimum standards for diabetes care in Arizona Deliver DSMT to 400 underserved diabetes patient Increase the number of patients who demonstrate proper self-management Increase the number of patients who seek out proper care and treatment Increase the number of persons with diabetes who receive the recommended care and treatment Develop, adopt, and promote self-care standards for DSMT and clinical standards of care People in Arizona with diabetes Arizonan Providers, health educators at health facilities, community health workers/promotores American Diabetes Association, Community health centers, Arizona Association of Community Health Centers, pharmaceutical companies, Cooperative Extension, County Health Departments, Health Services Advisory Group, Arizona Health Care Cost Containment System AHCCCS Education, Provider with support from Patient subcommittee Arizona Diabetes Program

Intermediate Objectives 3 Years

Long-term Objectives 5 Years t Strategy

Potential Target audience

Stakeholders critical to success

ADC Committees Responsible ADHS Program Partners

Arizona Diabetes Strategic Plan, 2008 - 2013

19

PRIORITY AREA 2: QUALITY CARE AND TREATMENT WITH STRATEGIES FOCUSED ON
PEOPLE WITH DIABETES Goal 2: Reduce the disabling conditions associated with diabetes Strategy Focus: Health Communications Campaign By June 30, 2009, implement a diabetes health awareness campaign about diabetes and its complications By June 30, 2009, increase the number of people who demonstrate increased awareness of the complications of diabetes and how to avoid them By June 30, 2009, increase number of people who demonstrate increased knowledge about diabetes selfmanagement Increase the number patients who seek out proper care and treatment Increase the number of persons with diabetes who receive the recommended care and treatment Partner and provide input on the implementation of a health communications awareness campaign about controlling your diabetes People with diabetes in Arizona National Diabetes Education Program, American Diabetes Association, American Heart Association, Community Health Centers, County Health Departments, Pharmaceutical companies, Health Services Advisory Group Education, Public Health Arizona Diabetes Program Chronic Disease Social Marketing Team

Short-term Objectives 1 Year t

Intermediate Objectives 3 Years Long-term Objectives 5 Years
t

Strategy

Potential Target audience

Stakeholders critical to success

ADC Committees Responsible ADHS Program Partners

Arizona Diabetes Strategic Plan, 2008 - 2013

20

PRIORITY AREA 2: QUALITY CARE AND TREATMENT WITH STRATEGIES FOCUSED ON PEOPLE WITH DIABETES Goal 2: Reduce the disabling conditions associated with diabetes Strategy Focus: Resource Directory Short-term Objectives 1 Year t By June 30, 2009, revise the Arizona Resource Directory By June 30, 2009, distribute the Arizona Resource Directory to diabetes primary care providers in Arizona Increase the number of people who receive diabetes selfmanagement training Increase the number of people who report that they are less overwhelmed by the scope of self-management after being exposed to diabetes self-management training Increase the number of patients who demonstrate proper disease self-management Increase the number of patients who receive the proper care and treatment Increase the number of persons with diabetes who receive the recommended care and treatment Review, revise, and disseminate Arizona Diabetes Resource Directory for distribution at screening facilities and send to providers with the following
information: - Where to go to get care and treatment including lowcost options - Support groups in Arizona - Diabetes education resources eg DSMT programs Link Arizona Diabetes Resource Directory to appropriate Websites health disparities, AZ211, etc People newly diagnosed with diabetes; low-income; Spanish language speakers, people with diabetes who have not received Diabetes Self-Management Training American Diabetes Association, American Heart Association, Arizona Beneficiary Committee, Arizona Insurance Board, AZ211, community health centers, pharmaceutical companies, County Health Departments Education, Patient with support from the Provider subcommittee Arizona Diabetes Program

Intermediate Objectives 3 Years

Long-term Objectives 5 Years t

Strategy

Potential Target audience

Stakeholders critical to success

ADC Committees Responsible

ADHS Program Partners

Arizona Diabetes Strategic Plan, 2008 - 2013

21

Priority Area 3: Quality of care and treatment with strategies focused on health care providers
The Arizona Diabetes Leadership Council wants to share its expertise and knowledge about delivering quality diabetes services in Arizona To do this requires coordination and
partnerships with other organizations, mainly health plans and providers in the State and the use of the Chronic Care Model, an evidence-based approach that addresses community resources and policies and the health system In this model, four areas within the health system need to be addressed: self-management support, delivery system design, decision support, and clinical information systems Use of the model leads to informed engaged patients working and interacting with a prepared and proactive practice team For more information about this model go to wwwimprovingchroniccareorg This goal also addresses the need for both professional and paraprofessional education

Long-term Objectives t Increase the number of persons with diabetes who receive the recommended care and treatment Strategies These strategies are further outlined in the tables below 1 Care and Treatment Partnerships-Align the work of the Arizona Diabetes Coalition with what other agencies, organizations, and companies in Arizona are doing to improve care of people with diabetes 2 Chronic Care Model-Promote the Chronic Care Model 3 Professional/paraprofessional Education-Advance professional/paraprofessional awareness
and education

PRIORITY AREA 3: QUALITY CARE AND TREATMENT WITH STRATEGIES FOCUSED ON HEALTH CARE PROVIDERS Goal 2: Reduce the disabling conditions associated with diabetes Strategy Focus: Care and Treatment Partnerships By June 30, 2009, 10 coalition and Leadership Council members will participate in partners committees and workgroups By June 30, 2009, Leadership Council members will develop partnerships with primary care providers to implement a referral process into the practice for DSMT services for patients with diabetes Increase the number of persons with diabetes who receive the recommended care and treatment Increase the number of persons with diabetes who receive the recommended care and treatment Align the work of the Coalition with what other agencies, organizations, and companies in Arizona are doing to improve care of people with diabetes Action steps: - Become subject matter experts on key committees that work towards improving care For example, have a member of the Arizona Diabetes Leadership Council serve on The Phoenix Healthcare Value Measurement Initiative - Advocate for the reimbursement of DSMT services with the various health plans For example, obtain the
billing codes acceptable for each Arizona health plan, including AHCCCS plans and Medicare, for the providers

Short-term Objectives 1 Year t

Intermediate Objectives 3 Years Long-term Objectives 5 Years t

Strategy

Arizona Diabetes Strategic Plan, 2008 - 2013

22

Potential Target audience

Health care plans Arizona Health Care Cost Containment System AHCCCS, Phoenix Healthcare Value Measurement Initiative, American Diabetes Association, American Heart Association, Health Services Advisory Group Arizona Diabetes Leadership Council Arizona Diabetes Program

Stakeholders critical to success ADC Committees Responsible ADHS Program Partners

PRIORITY AREA 3: QUALITY CARE AND TREATMENT WITH STRATEGIES FOCUSED ON HEALTH CARE PROVIDERS Goal 2: Reduce the disabling conditions associated with diabetes Strategy Focus: Chronic Care Model By June 30, 2009, one Chronic Care Model training will be offered by Coalition partner By June 30, 2009, 10 providers will demonstrate the use of Chronic Care Model tools by making changes in their practice that support the Chronic Care Model Increase the number of providers engaging in Chronic Care Model Methods Increase the number of providers
demonstrating collaboration with other providers Increase the number of persons with diabetes who receive the recommended care and treatment Promote Chronic Care Model Action Steps: - Partner with other agencies, organizations, and companies who are educating providers on the Chronic Care Model - For example, work with MICA medical malpractice insurer to disseminate their CME approved program educating providers on the Chronic Care Model - Prepare best practices report that highlights health care practices that are implementing a part of the Chronic Care Model and show improved patient health outcomes and wellbeing eg, decrease in A1c and costs, patient satisfaction, etc - Develop methods for health providers/administrators to employ patient registries - Train providers on the Chronic Care Model

Short-term Objectives 1 Year t

Intermediate Objectives 3 Years

Long-term Objectives 5 Years t

Strategy

Arizona Diabetes Strategic Plan, 2008 - 2013

23

Potential Target audience

Primary Care Physicians PCPs, internists, Community Health Center providers, and residency programs MICA, American Diabetes Association, American Heart Association, Arizona Health Query, Health Services
Advisory Group, Juvenile Diabetes Research Foundation, National Kidney Foundation, Arizona Kidney Foundation, Maricopa Medical Society, Pima Medical Society, other county medical societies, State universities and community colleges in Arizona, University of Arizona School of Medicine Phoenix and Tucson Residency Programs, Midwestern University, Central Arizona Association of Diabetes Educators, Southern Arizona Chapter of Diabetes Educators, Osteopathic Medical Association, Arizona Medical Association, Arizona Association of Family Practice, Arizona chapters of American College of Physicians and American Academy of Pediatrics Leadership Council Support: Education, Provider Arizona Diabetes Program

Stakeholders critical to success

ADC Committees Responsible ADHS Program Partners

PRIORITY AREA 3: QUALITY CARE AND TREATMENT WITH STRATEGIES FOCUSED ON HEALTH CARE PROVIDERS Goal 2: Reduce the disabling conditions associated with diabetes Strategy Focus: Professional/Paraprofessional Awareness and Education Short-term Objectives 1 Year t Intermediate Objectives 3 Years Long-term Objectives 5 Years t By June 30, 2009, train 60 professionals and 100 paraprofessionals on proper care and
treatment of people with diabetes and pre-diabetes Increase the number of providers/paraprofessionals engaged in professional education for diabetes Increase the number of persons with diabetes who receive the recommended care and treatment Advance professional awareness and education Advance paraprofessional promotores, community health representatives, community health outreach workers awareness and education Develop recruitment plan for training paraprofessionals to be lay leaders for diabetes self-management programs

Strategy

Arizona Diabetes Strategic Plan, 2008 - 2013

24

Potential Target audience

Certified diabetes educators, registered dietitians, Registered Nurses, pharmacists, primary Care physicians, internists, nurse practioners, physician Assistants, community health center providers, residency programs, Promotores, community health representatives, community health outreach workers Arizona Health Education Center, University of Arizona/Arizona State University Medical School, State universities and community colleges in Arizona, Midwestern University, Central Arizona Association of Diabetes Educators, Southern Arizona Association of Diabetes Educators, Health
Services Advisory Group Leadership Council Support: Education, Provider Arizona Diabetes Program

Stakeholders critical to success

ADC Committees Responsible ADHS Program Partners

Arizona Diabetes Strategic Plan, 2008 - 2013

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Priority Area 4: Public policy
Changes in legislation may be necessary in certain cases to effectively reduce the burden of diabetes on the State, improve insurance coverage for people with diabetes, and reduce the costs of complications associated with diabetes Working with and keeping legislators and policy makers informed about the burden of diabetes in Arizona and changes that can make a difference in the lives of people with diabetes and ultimately reduce costs for the State will be key PRIORITY AREA 4: PUBLIC POLICY

Long-term Objectives t Increase the number of persons with diabetes who receive the recommended care and treatment Strategies These strategies are further outlined in the tables below 1 Diabetes Day-Enhance legislative and regulatory advocacy at state and at local levels 2 DSMT-Promote the impact of diabetes services, including self-management training, to legislators and policy makers

Goal 3: Reduce the personal social and economic
consequences of diabetes Strategy Focus: Diabetes Day By June 30, 2009, one diabetes day with legislators will be held By June 30, 2009, membership of Diabetes Caucus at Arizona Legislature will be updated Appropriate legislation introduced as bills Coalition members engaged in support of legislation Increase the number of persons with diabetes who receive the recommended care and treatment Enhance legislative and regulatory advocacy at state and at local levels Action Steps: - Develop and distribute State of the State Diabetes Fact Sheet for legislators - Elicit testimonials, patient stories, and case studies from organizations, and share with policy-making bodies/committees - Support advocacy training Legislators, policy makers American Diabetes Association, American Heart Association, Central Arizona Association of Diabetes Educators, Southern Arizona Chapter of Diabetes Educators, Health facilities in Arizona Advocacy Arizona Diabetes Program

Short-term Objectives 1 Year t

Intermediate Objectives 3 Years Long-term Objectives 5 Years t

Strategy

Potential Target audience Stakeholders critical to success

ADC Committees Responsible ADHS Program Partners

Arizona Diabetes
Strategic Plan, 2008 - 2013

26

PRIORITY AREA 4: PUBLIC POLICY Goal 3: Reduce the personal social and economic consequences of diabetes Strategy Focus: DSMT By June 30, 2009, develop fact sheet outlining evidence of effective diabetes self-management training and distribute to Coalition members and State legislators Increase reimbursement for diabetes self-management training Increase the number of persons with diabetes who receive the recommended care and treatment Promote the impact of diabetes services, including selfmanagement training, to legislators and policy makers Action Steps: - Identify existing evidence for effective diabetes selfmanagement training - Conduct and publish missing gaps in outcomes research to prove effectiveness of DSMT - Request town hall meetings with elected officials to develop strategies for improving federal and state reimbursement for diabetes self-management training and prevention Legislators, other policy makers American Diabetes Association, American Heart Association, Central Arizona Assn of Diabetes Educators, Southern Arizona Chapter of Diabetes Educators, Health facilities in Arizona Advocacy Arizona Diabetes Program

Short-term Objectives
1 Year t

Intermediate Objectives 3 Years Long-term Objectives 5 Years t

Strategy

Potential Target audience Stakeholders critical to success

ADC Committees Responsible ADHS Program Partners

Arizona Diabetes Strategic Plan, 2008 - 2013

27

REFERENCES
1 Centers for Disease Control and Prevention National diabetes fact sheet: general information and national estimates on diabetes in the United States, 2007 Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, 2008 2 Dabelea D, Pettitt DJ: Intrauterine diabetic environment confers risks for type 2 diabetes mellitus and obesity in the offspring, in addition to genetic susceptibility J Pediatr Endocrinol Metab 2001; 148: 1085-91 3 American Diabetes Association: Gestational diabetes mellitus Position statement Diabetes Care 2004;27Suppl 1: S88-S90 4 Pettitt DJ, Knowler WC Pettitt DJ, Knowler WC: Long-term effects of the intrauterine environment, birth weight, and breast-feeding in Pima Indians Diabetes Care 1998; 21 Suppl 2: B138-41 5 National Institute of Diabetes and Digestive and Kidney Diseases National Diabetes Statistics fact sheet: general information and national estimates on
diabetes in the United States, 2005 Bethesda, MD: US Department of Health and Human Services, National Institute of Health, 2005 6 Population data from US Census estimates by age and sex Accessed at http://wwwcensusgov/popest/estimatesphp April 15, 2008 7 Centers of Disease Control and Prevention CDC Behavioral Risk Factor Surveillance Survey Data Atlanta, Georgia: US Department of Health and Human Services, Centers for Disease Control and Prevention, 2000-2006 National estimates include all states, DC and territories 8 Harris MI, Flegal KM, Cowie CC, Eberhartd MS, Goldstein DR, Little RR, Wiedmeyer H, Byrd-Holt DD Prevalence of diabetes, impaired fasting glucose, and impaired glucose tolerance in US adults Diabetes Care 1998;214:518524 9 American Diabetes Association Economic Costs of Diabetes in the US in 2007 Diabetes Care, Volume 31, Number 3, March 2008 10 Arizona Health and Vital Statistics, 2005 Arizona Department of Health Services, Section 2B 11 Centers for Disease Control and Prevention National Center for Health Statistics Death-Leading Causes, 2004 Available at http://wwwcdcgov/nchs/fastats/lcodhtm April 15, 2008 12 Centers for Disease and Control and Prevention CDC
National diabetes fact sheet: general information and national estimates on diabetes in the Unites States, 2002 Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, 2003 13 Dabelea D, Bell R, DAgostino RB, Imperatore G, Johansen JM, Linder B et al Incidence of Diabetes in Youth in the United States JAMA 2007; 297:2716-2724 14 Arizona Department of Health Services Yuma County Report for the 2007 Youth Risk Behavior Survey Steps to a Healthier Arizona Initiative, Arizona Department of Health Services, Public Health Services Prevention, December 2007 15 National Eye Institute, Statistics and Data, Citations and Abstracts from April 2004 Archives of Ophthalmology, The Prevalence of Diabetic Retinopathy Among Adults in the United States Accessed at http://wwwneinihgov/eyedata/pbd3as April 15, 2008 16 The End Stage Renal Disease Network 15 2006 Annual Report Contract Numbers: 500-03-NW15 and HHSM500-2006-NW015C with Centers for Medicaid Medicare Services, Baltimore, MD Accessed at http://wwwesrdnet15org and http://wwwesrdnetworksorg April 15, 2008 17 Diabetes Prevention Program Research Group N Engl J Med Reduction in the Incidence of Type
2 Diabetes with Lifestyle Intervention or Metformin 346:393, February 7, 2002
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ABBREVIATIONS
A1C ACE inhibitors ADC ADHS AHCCCS ARB BCDPC BRFSS CDC CME DDT DPCP DPP DSMT ESRD GDM HDL IFG IGT IDDM LDL NAP SACC NIDDM PCP SMART STOP-NIDDM Hemoglobin A1C Angiotensin converting enzyme inhibitors Arizona Diabetes Coalition Arizona Department of Health Services Arizona Health Care Cost Containment System Angiotensin receptor blockers Bureau Chronic Disease Prevention and Control Behavioral Risk Factor Surveillance Survey Centers for Disease Control and Prevention Continuing Medical Education Division of Diabetes Translation Diabetes Prevention and Control Programs Diabetes Prevention Program Diabetes Self-Management Training synonymous with Diabetes Self-Management Education or DSME End stage renal disease Gestational diabetes mellitus High-density lipoproteins Impaired fasting glucose Impaired glucose tolerance Insulin-dependent diabetes mellitus Low-density lipoprotein Nutrition and Physical Activity Self Assessment for Child Care Non-insulin dependent diabetes mellitus Primary Care Physicians Specific, Measurable, Attainable, Realistic
and Time-sensitive Study to Prevent Non-Insulin-Dependent Diabetes Mellitus

Arizona Diabetes Strategic Plan, 2008 - 2013

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Source:networkofnewengland.org