Diabetes Prevention and Control Program. Proposal. Amend Article 13: Death Rates Due to Diabetes. by Race/Ethnicity, NYC, 1990-2001. NYC Adults with Diagnosed …
Improving Diabetes Care for All New Yorkers
Lynn D Silver, MD, MPH Assistant Commissioner Bureau of Chronic Disease Prevention and Control Diana K Berger, MD, MSc Medical Director Diabetes Prevention and Control Program
Proposal
Amend Article 13:
Mandate electronic laboratory reporting of hemoglobin A1C A1C test results Not physician-based reporting
If You Have Diabetes, Know and Control Your A1C
Blood Sugar Level mg/dL
345
A1C Level
12
310
11
275
10
240
9
205
8
170
7
135
6
100
5
65
4
Epidemic of Obesity in US
1985 2003
Epidemic of Diabetes in US
1994 2003
Epidemic of Diabetes in NYC
Adults with Self-Reported Diabetes, NYC, 1994-2003
10 9
Reporting Diabetes
90 79 67 47 37 63
8 7 6 5 4 3 2 1 0 1994-95 1996-97 1998-99 2000-01 2002 2003
NYC Adults with Diagnosed Diabetes
by Borough, 2003
Healthy People 2010 Goal: 25
12 w/Diagnosed Diabetes 10
85 91 97
115 90
8 6 4 2 0
Manhattan Staten Isl Queens Brooklyn Bronx NYC
56
Diabetes Prevalence in NYC
Adults 18, By Ethnicity, 2003
Healthy People 2010 Goal: 25
14
130 120 120 90
With Diagnosed Diabetes
12 10 8 6 4 2 0
55
White
Black
Hispanic
Asian
NYC
Death Rates Due to Diabetes
by Race/Ethnicity,
NYC, 1990-2001
NYC Adults with Diagnosed Diabetes
by Neighborhood, 2003
Deaths from Diabetes
Rate per 100,000 population, by NYC Community District, 2002
Diabetes in Children
1/3 to 1/2 of todays 5 year olds will develop diabetes in their lifetime 1 Up to 50 of new cases of diabetes in children are type 2 2
1 2 Narayan et al Lifetime risk of diabetes in the United States JAMA 2003; 290:1884-1890 CDC
Overweight/Obesity in NYC Kids
Underweight 4 Obese 24
More than 4 in 10 are overweight or obese in Grades K-5
Overweight 19
Normal Weight 53
Diabetes in NYC
Diagnosed Cases: 530,000 Undiagnosed: 265,000 estimated Annual Deaths: 1,891 2003 Amputations: 1,731 2003 Hospitalizations: 19,557 2003 Heart disease, stroke, blindness, kidney failure Psychological distress: relative risk doubled
Diabetes is costly
132 Billion per year in the US
92 billion in direct medical costs People with diabetes incur medical expenses about 2x higher those without diabetes 40 billion in indirect costs Cost of diabetes in NYC estimated at 83 billion per year
7 billion in direct costs, 12 billion in indirect costs
Source: American Diabetes Association
Better A1C control improves outcomes
A1C7 reduces small blood vessel complications by 25 Every 1 drop in A1C eg, 9 to 8 35 reduction in small blood vessel disease UKPDS Control of ABCs A1C, blood pressure, cholesterol, and smoking may lower cardiovascular events by 50 Steno 2
But in US, A1C control is poor
Full risk factor ABC-S control is worse A1C 70 A1C 90 BP 130/80 Total Chol 200 ABC controlled to goal Smoking 37 20 36 48 7 16
Data from NHANES
Saydah et al JAMA 2004; 291:335-42
In NYC: Only 10 of people with diabetes know their A1C 2002 NYC CHS
Epidemiologic transition
Public health lags behind
Chronic disease accounts for 2/3 of disease burden BUT Public health tools are underutilized for chronic disease prevention and control
Public Health Interventions
Surveillance and evaluation Environmental modification Policy development and regulation Direct provision and monitoring of clinical care Health education
Precedents for Disease Registries
Population- 
based:
NYS DOH Cancer Registry NYS DOH Alzheimers and other Dementias Registry NYS DOH Congenital Malformations Registry NYC DOHMH Communicable Disease Registries NYC DOHMH Lead Registry NYC DOHMH Immunization Registry National VA Diabetes
Registry
Disease Registries:
Link Surveillance, Monitoring and Care
Should be: Effective Affordable Sustainable Scalable
Why a Public Health Approach?
Diabetes is epidemic Laboratory reporting is feasible, efficient and reliable Surveillance is essential Registries with feedback are inexpensive, effective, sustainable, and scalable tools to improve clinical outcomes
Effectiveness of Registries: The VA TRIAD Study
Translating Research into Action for Diabetes Study
VA
A1C85 BP130/85 mm Hg LDL100 mg/Dl Current Smoker 83 1173 pts tested 29 1222 pts tested 52 995 pts tested
Commercial Managed Care
65 5769 pts tested 29 6161 pts tested 36 4398 pts tested
not reported
Kerr E, et al Diabetes Care Quality in Veterans Affairs Health Care System and Commercial Managed Care: The TRIAD Study Ann Intern Med 2004;141:272-281
What will happen?
Laboratories performing A1C with electronic reporting capacity via fileupload method will add this test to their reporting DOHMH will create A1C registry
A1C date, result Clinician information Patient information
Registry functions
Surveillance
Map patterns of glycemic control Describe emerging epidemic of type 2 diabetes in
children
Provision of aggregate and individual feedback and support
To patients with poor control of A1C patients may opt out of registry To clinicians in pilot intervention
Pilot Intervention
South Bronx 48,000 with diabetes Approximately 270 clinicians Letter to patients with information and optout opportunity Feedback to clinicians Feedback to patients under poor control
Components of Intervention
To clinicians:
Quarterly roster of their patients stratified by glycemic control, daily alert for A1Cs 80, and best practice recommendations
To patients:
Letter when A1C 80 Educational and resource materials
Note: patient names are fictitious for demonstration purposes
Strict Confidentiality
Registry information available solely to:
the patient treating medical providers
Not provided to other agencies
eg, driver license, life insurance, health insurance
Not provided to others even with patient consent
External Advisory Board
Composition
Diabetes experts, clinicians, patient representatives, diabetes advocates
Advise on intervention design
Clinician, institution, and patient outreach and feedback Data management issues Overlap/ integration/ enhancement
of current practices initiatives
Evaluation
What Proposal is Not
No mandatory case reports from clinicians electronic laboratory reporting only Not pejorative Not a cure for diabetes
Evaluation
Population levels of glycemic control
Is level of control improved eg, number and proportion 95 in 2006 and in 2008
Frequency of A1C monitoring Clinical outcomes eg, hospitalizations, cardiac events, amputations Useful and meaningful for clinicians? Useful and meaningful for patients?
Support
Advisory Board
Local ADA Primary care clinicians Endocrinologists Quality improvement specialists Epidemiologist Nurse Certified Diabetes EducatorCDE Nutritionist CDE Patient advocate
