Editor,
Yudkin and Montori make many valid points in their article on the epidemic of prediabetes (1) The topic of whether it is the medical profession's role to prevent disease is quite new, but important as we determine whether the disability and cost for diabetes complications can be prevented. From our perspective, the question is not whether we have a responsibility in prevention, but how we help individuals make good decisions for their own health, what the most evidence-based interventions are, and whether a person experiences better health outcomes as a result.
Health care in the U.S. is going through many changes with a distinct movement toward population health in addition to traditional health care. Looking upstream to prevent chronic disease in a systematic way, we believe, is an important aspect of new models of care. Working with our approximately 9.5 million members to restore them to health when they are ill, in addition to keeping them healthy as long as possible, is our core mission. We believe giving individuals information about their risk of developing diabetes is one area where we can leverage engagement of the individual, the health system, and the community to prevent chronic disease. In this way, we are choosing to lean into the complexity of the spectrum and develop approaches to support our members and our care teams to optimize health and prevent disease.
Since 2011, Kaiser Permanente has been developing a national approach to addressing prevention of Type 2 diabetes mellitus. This has entailed cohort development, testing interventions for prediabetes, and building capacity to offer members who want to address their risk and the options to do so. Today we have over 500,000 members with diabetes, and through our cohort development work we have identified just under 1 million with prediabetes out of the approximately 9.5 million members we serve.
While it is not our intent to engage in diagnosis creep given the broad HbA1c range defining prediabetes, we do feel we have an obligation to work with our members and let them know their risk for developing diabetes. Rather than wait for perfect evidence to guide us, we are working to determine rates of conversion to diabetes along the risk spectrum as we know those with higher BMI’s (>30) AND a higher A1c ( >6.2) are more apt to develop diabetes in a more accelerated timeline. There is an order of magnitude difference in diabetes risk across the spectrum of prediabetes.
We anticipate being able to further subdivide these risk strata to offer more intensive intervention bundles to those most likely to convert to diabetes, but offer anyone at risk an opportunity to address it in a variety of ways, whether in-person, online, telephonically, etc. We do feel an obligation to mention to our members that by criteria approved by the ADA that they may be at increased risk for diabetes, and that simple weight loss and exercise may prevent it.
We do recognize the Diabetes Prevention Program findings as being robust and the multiple subsequent translation trials demonstrate effectiveness of this program, even without the intensity of the original DPP. We feel that lifestyle is a reasonable first-line approach and that supporting our members with modest weight loss (goal of 5 percent) and improvement in activity levels (goal of 150 minutes/week) is possible in routine care delivery. We also recognize that not everyone who is at risk for developing diabetes will want or be able to take action. Part of our demonstration is also engaged in leveraging the latest science in behavior change and behavior design to determine the optimal engagement approaches for our members with prediabetes. We recognize the need to strike the right balance of on one side not over-medicalizing an issue and its solutions and on the other side the desire to partner with our members in maintaining optimal health. Given the changing role of health care in the U.S., we are mindful of playing the right role in this space.
1) The epidemic of pre-diabetes: the medicine and the politics John S Yudkin, Victor M Montori,: BMJ 2014;349:g4485
Competing interests:
No competing interests
30 September 2014
Jim R Dudl, MD
Diabetes Clinical Lead, Kaiser Permanente, Care Management Institute
Jim R Dudl, MD, Diabetes Clinical Lead, Kaiser Permanente Care Management Institute, Harry Glauber, MD, Endocrinologist, NW Permanente, Portland, OR, Trina Histon, PhD, Senior Principal Consultant, Kaiser Permanente, Care Management Institute, Lisa Schilling, RN, MPH, VP Healthcare Performance Improvement, Center for Health System Performance, Kaiser Permanente
Kaiser Permanente, Care Management Institute
KP CMI, One Kaiser Plaza 16L, Oakland, CA 94612, USA
Rapid Response:
Editor,
Yudkin and Montori make many valid points in their article on the epidemic of prediabetes (1) The topic of whether it is the medical profession's role to prevent disease is quite new, but important as we determine whether the disability and cost for diabetes complications can be prevented. From our perspective, the question is not whether we have a responsibility in prevention, but how we help individuals make good decisions for their own health, what the most evidence-based interventions are, and whether a person experiences better health outcomes as a result.
Health care in the U.S. is going through many changes with a distinct movement toward population health in addition to traditional health care. Looking upstream to prevent chronic disease in a systematic way, we believe, is an important aspect of new models of care. Working with our approximately 9.5 million members to restore them to health when they are ill, in addition to keeping them healthy as long as possible, is our core mission. We believe giving individuals information about their risk of developing diabetes is one area where we can leverage engagement of the individual, the health system, and the community to prevent chronic disease. In this way, we are choosing to lean into the complexity of the spectrum and develop approaches to support our members and our care teams to optimize health and prevent disease.
Since 2011, Kaiser Permanente has been developing a national approach to addressing prevention of Type 2 diabetes mellitus. This has entailed cohort development, testing interventions for prediabetes, and building capacity to offer members who want to address their risk and the options to do so. Today we have over 500,000 members with diabetes, and through our cohort development work we have identified just under 1 million with prediabetes out of the approximately 9.5 million members we serve.
While it is not our intent to engage in diagnosis creep given the broad HbA1c range defining prediabetes, we do feel we have an obligation to work with our members and let them know their risk for developing diabetes. Rather than wait for perfect evidence to guide us, we are working to determine rates of conversion to diabetes along the risk spectrum as we know those with higher BMI’s (>30) AND a higher A1c ( >6.2) are more apt to develop diabetes in a more accelerated timeline. There is an order of magnitude difference in diabetes risk across the spectrum of prediabetes.
We anticipate being able to further subdivide these risk strata to offer more intensive intervention bundles to those most likely to convert to diabetes, but offer anyone at risk an opportunity to address it in a variety of ways, whether in-person, online, telephonically, etc. We do feel an obligation to mention to our members that by criteria approved by the ADA that they may be at increased risk for diabetes, and that simple weight loss and exercise may prevent it.
We do recognize the Diabetes Prevention Program findings as being robust and the multiple subsequent translation trials demonstrate effectiveness of this program, even without the intensity of the original DPP. We feel that lifestyle is a reasonable first-line approach and that supporting our members with modest weight loss (goal of 5 percent) and improvement in activity levels (goal of 150 minutes/week) is possible in routine care delivery. We also recognize that not everyone who is at risk for developing diabetes will want or be able to take action. Part of our demonstration is also engaged in leveraging the latest science in behavior change and behavior design to determine the optimal engagement approaches for our members with prediabetes. We recognize the need to strike the right balance of on one side not over-medicalizing an issue and its solutions and on the other side the desire to partner with our members in maintaining optimal health. Given the changing role of health care in the U.S., we are mindful of playing the right role in this space.
1) The epidemic of pre-diabetes: the medicine and the politics John S Yudkin, Victor M Montori,: BMJ 2014;349:g4485
Competing interests: No competing interests