2018 Health Care & Education Presidential Address: The American Diabetes Association in the Era of Health Care Transformation

The Centers for Disease Control and Prevention (CDC) 2017 national diabetes statistics estimate 30.3 million people with diabetes in the United States and another 84.1 million with prediabetes (1). Diabetes has overwhelmed our health systems, ranking first in spending on health care (ambulatory care, inpatient care, pharmaceuticals, emergency care, and nursing facility care) and public health (2). The ADA study on the economic costs of diabetes, released in May 2018, revealed a total economic cost of diagnosed diabetes of $327 million USD per year (3). Yet, despite spending and significant advances in diabetes discovery and treatments, diabetes outcomes have remained relatively unchanged at the population level. In fact, Lipska et al. (4), in an analysis of claims data on more than 1.6 million insured patients with type 2 diabetes, found that in the 8-year period between 2006 and 2013, despite increases in the use of the diabetes medications metformin, dipeptidyl peptidase 4 inhibitors, and insulin, the proportion of patients with an A1C <7.0% declined, and the proportion of patients with A1C ≥9% increased. In addition, diabetes risk, prevalence, morbidity, and mortality continue to differ by socioeconomic status and by race/ethnicity (1,5), with patterns of health disparity largely attributable to social determinants (5). Measurable disparities in care also persist, with lower socioeconomic status groups and racial/ethnic minorities receiving lower quality of diabetes care (6). Poor quality of care, combined with social determinants, contributes to avoidable diabetes health costs in these populations.

Hence, diabetes underscores the challenges health care transformation seeks to address. To contribute to transformation of the nation’s outcomes in diabetes, the ADA must advance bold initiatives in the current era and beyond.

Population health provides a road map for the ADA to achieve a population-level impact in the current era. Population health is defined as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group” (7). Population health also includes the patterns of health determinants and the interventions and policies that link the determinants and health outcomes (7). Figure 1 shows a model designed by colleagues and myself to depict the diabetes population health continuum (8). The model also presents the population health process from population risk stratification to interventions and outcomes.

The goal of diabetes population health is to achieve equity by addressing the population distribution with the right interventions, at the right time, in the right place, and using the right workforces. Population health spans medical care (population health management) and public health (population health improvement). Key to population health is the use of data and population-level analytics to identify and define the populations and population subgroups, characterize the population with regard to health metrics and measures, and monitor and evaluate the outcomes of population health initiatives. In addition, key to population health is moving beyond health care through clinic-community partnerships, multisector partnerships, and policy.

For the ADA, diabetes population health can be viewed as a means of operationalizing the ADA’s mission “to prevent and cure diabetes and to improve the lives of all people affected by diabetes.” However, the population health path forward necessitates broadened research scopes and competencies for investigators and diabetes research funders (9,10). It also calls for new educational programs for health care professionals (11–13) and new translation, dissemination, and implementation skills applied to populations and population subgroups. Finally, population health involves the leveraging of new opportunities and resources such as community health needs assessments and Community Benefit Dollars for initiatives that reinvest in the health of community populations (14,15).

The ADA is making progress toward a diabetes population health road map. I will highlight several of our population health management and population health improvement initiatives (Table 1).

Diabetes population health management focuses on cohorts of patients or other populations defined within the context of a health care setting or system (16). Population health management often uses multilevel interventions that are carried out within health care settings to improve the clinical outcomes and quality metrics of patient populations. The following sections describe two of the ADA’s current population health management initiatives designed for national impact.

Diabetes INSIDE (Inspiring System Improvement with Data-Driven Excellence) is the ADA’s long-term strategy to translate more than 78 years of our science and advocacy into action by supporting our nation’s health care systems to improve population outcomes for people with diabetes. In 2009, the ADA began working with the company Intelligent Medical Decisions (iMD). iMD successfully designed and implemented Diabetes INSIDE as an integration of the ADA’s Standards of Medical Care in Diabetes and professional education activities directly into health care quality improvement (QI) initiatives. In 2015, the ADA board of directors made a strategic decision to commit to goals of national diabetes population health management using the Diabetes INSIDE program. The ADA acquired iMD in 2016—its first private company acquisition—bringing the iMD expert team of Gregory Liptak; Elise Furman, RN, MBA, MEd; and Roy Furman, MD, PhD to the ADA.

The goal of Diabetes INSIDE is to catalyze, accelerate, and sustain health care improvement across health care systems, public health departments, payers, and the range of stakeholders and organizations committed to improving diabetes outcomes. To do so, Diabetes INSIDE applies population health and health services research methodologies, tools, and activities to improve diabetes quality of care and population outcomes within health care settings. Using population health data science and analytics, interventions are tailored to the needs, goals, resources, and demographics of health care partners and the populations they serve. Interventions include QI training for health care personnel, multidisciplinary health care team coaching and provider professional development, patient self-management education and support program resources, community-integrated health strategies, and recognition and dissemination strategies.

Figure 2 shows the ADA’s phased strategy for growth of Diabetes INSIDE for national population health impact. Between 2012 and the present, Diabetes INSIDE has been used within eight single health systems (phase 1). It has expanded to multisector partnerships in urban settings and is advancing into regional collaboratives that more effectively bring together health systems, payers, industry, and community organizations (phase 2). The first pilot collaborative is underway in Philadelphia, PA. Thomas Jefferson University Department of Internal Medicine and Department of Family and Community Medicine, University of Pennsylvania, and Hackensack University Medical Center are partnering with the ADA in this initiative. Rural clinics are key to the national strategy, and these are necessitating broader partnerships with federal and state government agencies (phase 3).

Diabetes INSIDE is leading to population health results. QI data from one of the original eight single health systems, Parkland Health & Hospital System in Texas, provide an example. Diabetes INSIDE was carried out within an urban safety-net hospital in this health system. The focus of the QI project was low initiation of insulin in patients with uncontrolled diabetes (A1C >9.0%). QI interventions included electronic medical record updates for identifying and tracking patients with unmanaged diabetes, previsit planning for insulin initiation goals, shared medical appointments, and provider education and training. After the targeted intervention, insulin initiation increased by 24% at the population level, and subsequent reductions were observed in the proportion of patients with an A1C >9.0% and in the mean population-level A1C (from 8.3 to 7.8%) (Fig. 3).

Observed improvements in diabetes control at the level of an entire diabetes population within a health care system are not easy to achieve. However, they are possible using a systematic approach to expert consultation and QI, such as that of Diabetes INSIDE. Importantly, the economic and quality-of-life impacts of such improvements are significant. The Health Resources and Services Administration of the U.S. Department of Health and Human Services (HRSA) reports that, with every 1% reduction in A1C, the risk of developing eye, kidney, or nerve disease is reduced by 40%, and the risk of heart attack is reduced by 14% (17). Within a health care population in poor diabetes control, a 1.25% reduction in A1C can potentially result in savings of more than $3 billion USD over 3 years (18). For Diabetes INSIDE, ADA received the 2015 Award for Outstanding Continuing Education Outcomes Assessment and the 2016 Award for Outstanding Innovation in Continuing Professional Development from the Alliance of Continuing Education in the Health Professions. Further details and outcomes of Diabetes INSIDE will be disseminated through publications.

There are additional long-term health care and education labors of love that are achieving goals. In 2016, the ADA published its first position statement on the psychosocial needs and care of people with diabetes (19). The position statement recommends that all diabetes health care professionals have awareness of and proficiency in addressing the nonclinical (normative) psychosocial symptoms and behaviors common in diabetes, such as diabetes distress. However, there is also a tremendous need for a workforce of licensed and credentialed mental health providers who are trained in diabetes. This workforce is essential for assessing, diagnosing, and treating mental health disorders in people with diabetes.

Due to the efforts of the ADA’s expert behavioral health professionals and of past President of Health Care & Education, David Marrero, PhD, the ADA and the American Psychological Association (APA) entered into a partnership to meet this need. The partnership created the first diabetes-focused continuing education (CE) program for licensed mental health providers. This training continues to expand in reach and impact. Licensed mental health providers who complete the CE program become eligible for inclusion in the ADA’s Mental Health Provider Referral Directory. In addition, they receive 12 CE credits from APA and membership in the ADA at the Associate level. Moreover, these providers gain access to ongoing learning and mentoring through a new ADA listserv for behavioral health and psychosocial topics and monthly peer-mentoring calls with expert professionals in the field. All professional members are encouraged to help direct mental health practitioners toward this program to increase the behavioral health workforce available to all people with diabetes.

For providers seeking to refer patients for diabetes-appropriate mental health services, the Mental Health Provider Referral Directory is now available to assist in locating diabetes-proficient providers by geographic region (professional.diabetes.org/ada-mental-health-provider-directory). Thanks to this ADA-APA educational program, the network of providers promises to grow into a valuable behavioral health resource for diabetes team care.

Interventions for population health improvement are designed to be proactive, targeting activities addressing prevention, risk reduction, health equity, and health promotion (16). Often, goals are for long-term and sustained improvement in community health status. By addressing social and behavioral determinants of health, population health improvement can reduce avoidable causes of health care utilization. In doing so, we can reduce the proportion of the population that enters into and must depend on medical care. Following are three examples of current ADA initiatives toward population health improvement.

In 2016, a first-of-its-kind national campaign was launched as a joint effort of the ADA, CDC, American Medical Association, and Ad Council. This public service campaign aimed to promote public awareness of prediabetes and the National Diabetes Prevention Program (National DPP) to reduce the incidence of type 2 diabetes. I had the pleasure of representing the ADA and spreading the word in the popular media, alongside Dr. Ann Albright, Director of the CDC Division of Diabetes Translation and a former ADA President of Health Care & Education. We are all indebted to Dr. Albright and her teams for the standardization, implementation, and oversight of the National DPP.

Today, the ADA is driving the Risk Test Campaign. The Risk Test (diabetes.org/risktest) allows people to determine their risk of prediabetes using an online tool that takes about 1 min to complete. The Risk Test is also available in a paper format. The Risk Test online tool gives those at high risk of prediabetes (score ≥5) information on how to discuss prediabetes with a doctor and resources to register for a local or online National DPP. Those at low risk (score <5) are given healthy living information and programs, caregiver toolkits and services, advocate tools, and invitations to rescreen periodically. The ADA’s 2020 goals for the Risk Test Campaign are to reach 20 million people taking the Risk Test, with a resulting 2.5 million people referred to a program meeting the CDC’s National DPP criteria. The ADA aims to reach populations and communities that are at highest risk of prediabetes and type 2 diabetes, including individuals aged 45–65 years and racial/ethnic minority populations such as Black/African Americans, Native Americans, Hispanic/Latino Americans, and Asian Americans. To ignite this movement, the ADA is engaging our members, supporters, partners, and stakeholders via multiple channels, including social media, health care provider outreach, and community-based outreach. The ADA invites all professional members to share the Risk Test with individuals and populations at risk.

When diabetes prevention became U.S. policy with Congress’ passage of The Diabetes Prevention Act of 2009, the National DPP became the most successful research to policy to practice example of our time. Further progress has been made with the Centers for Medicare & Medicaid Services (CMS) reimbursement for Medicare suppliers of the National DPP, both in community-based non–health care organizations and within health care organizations. However, even with the doors opened by these accomplishments, the National DPP still must reach those who are most in need to realize the promise of diabetes prevention policy throughout the nation.

The ADA is one of ten organizations awarded a CDC Cooperative Agreement to scale the National DPP to underserved areas. Objectives are to increase the availability of National DPP–recognized programs; increase screening, diagnosis, and detection of prediabetes; increase enrollment and retention rates in National DPP sites; and provide evidence for expanding benefit coverage for these programs. The ADA is implementing the National DPP in underserved areas in the states of Arizona, California, Kansas, Oklahoma, and Texas, with a dissemination focus on Hispanic/Latino populations, Medicare beneficiaries, and men.

In addition to serving as a dissemination channel for scaling the National DPP, the ADA is building resources to facilitate other National DPP sites across the nation. One example is the ADA’s launch of its National DPP documentation platform, DPP Express. DPP Express is a web-based, secure platform to aid National DPP suppliers in the routine collection and documentation of program measures required for CDC reporting. The platform was designed to meet several needs. First, it is compliant with the Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health (HITECH) Act. Second, it incorporates the CDC 2018 DPP Standards and the CMS Medicare DPP reimbursement requirements. Third, it provides documentation fields for CDC-required DPP session data, and it enables users to document additional biometrics/data points for generation of CDC Recognition reports. Finally, it provides a billing alert when DPP participants meet Medicare reimbursement requirements. Figure 4 is a screen shot of the documentation tool. DPP Express is available for use by ADA’s Diabetes Education Recognition Programs, as well as any community or health care supplier of a National DPP. This is especially important because, as a public health program, the National DPP is being conducted in communities and nontraditional care sites around the country that do not have clinic-based health records or documentation platforms. Thus, DPP Express is a valuable tool for these providers.

We know that, despite our best efforts and interventions, subgroups of the population are left behind. People with diabetes in the community where I was born and raised fare no better today than was the case in the era when I was diagnosed. The past few years have brought increasing focus on the role of social determinants of health in the patterns of socioeconomic and racial/ethnic disparities observed in health outcomes in the United States. These patterns are seen broadly in the health of the nation, and they are observed in diabetes outcomes in particular.

The ADA has commissioned a Social Determinants of Health Scientific Review Committee, and the work of this committee has just gotten underway. The committee will conduct a rigorous review and synthesis of the literature on the role of social determinants in diabetes outcomes and the impact of social determinant intervention approaches on these outcomes. The committee’s report will serve as an authoritative, up-to-date resource to identify research and knowledge gaps and to guide evidence-based recommendations for action in clinical and community settings and multisector partnerships.

Finally, just as diabetes has overwhelmed U.S. health care by way of economic costs and the human costs in length and quality of life, psychosocial burden, and disability, so too has our global community been adversely affected by diabetes. Since 2009, I have had the opportunity to spend a considerable portion of my professional life working toward population health initiatives in countries with some of the greatest diabetes burden, including the Caribbean nations and Saudi Arabia. I have observed the influence of the ADA, through its Standards of Medical Care in Diabetes, in each of the partnering countries. Now more than ever, it is time for the ADA to lend its knowledge and evidence base to the cause of global diabetes population health. To increase its reach and impact on populations, the ADA is partnering with organizations with shared interests and missions, both domestically and internationally. Look for more joint statements and initiatives, for example, with organizations including the American Heart Association and the European Association for the Study of Diabetes, as we work toward common language and recommendations regarding diabetes care.

In conclusion, I hope you are as energized as I am about health care and education science and practice opportunities in the ADA. This is an era of increasing challenges and demands, leading to new opportunities for population impact. Through numerous initiatives and collaborations now underway, including Diabetes INSIDE, the Mental Health Provider Training and Referral Directory, the Risk Test Campaign, National DPP scaling and dissemination support, and the social determinants of health scientific review, the ADA’s national and global relevance in this era is palpable and measurable.

Acknowledgments. I would like to acknowledge and thank my parents, Talmadge L. Hill and Shirley T. Hill; my sister, Talmira Hill DeLena; my husband, Ian R. Briggs; and my son, Julian R. Briggs for living through my type 1 diabetes and through my professional commitments with me and for inspiring me every day on this journey to change the world. I would like to recognize my research and professional mentors Frederick L. Brancati, MD, MHS (in memoriam); Stanley Weiss, PhD; and Ruben J. Echemendia, PhD. A special thank you goes to my fellow officers of the ADA board of directors and to the ADA staff who work tirelessly to achieve our mission.

Funding. Portions of this publication were made possible by the Johns Hopkins Institute for Clinical and Translational Research (ICTR), which is funded in part by grant number UL1 TR001079 from the National Center for Advancing Translational Sciences (NCATS), a component of the National Institutes of Health (NIH), and NIH Roadmap for Medical Research. Its contents are solely the responsibility of the author and do not necessarily represent the official view of the Johns Hopkins ICTR, the NCATS, or the NIH.

Duality of Interest. No potential conflicts of interest relevant to this article were reported.