Diabetes Prevention Programs Go Unused Even as Prediabetes Soars

Despite the increasing prevalence of prediabetes in the United States, access to resources and participation in preventive care remain low, according to a study recently published in Health Affairs.

One of the findings of the study showed that the National Diabetes Prevention Program, an effective intervention for diabetes prevention, has only been used by 3% of adults with prediabetes and has only 2098 providers nationally.

Researchers sought to clarify the existing gaps in managing prediabetes, defined as a hemoglobin A1c level ranging from ≥5.7% to <6.5%. About 96 million Americans are considered to be prediabetic and are at future risk of developing type 2 diabetes.

Their study also sought to find ways to bolster disease prevention efforts to address these gaps.

The study estimated prediabetes prevalence rates, testing rates, and access to preventive care by sociodemographic characteristics. Data on prediabetes, glucose testing, access, and cost barriers were gathered from the Behavioral Risk Factor Surveillance System (BRFSS) from 2010-2020. The National Health Interview Survey (NHIS) from 2016-2017 was used to obtain data on National Diabetes Prevention Program referrals and participation, national-level information on diabetes risk, and family history of diabetes.

Results showed:

• The estimated prevalence of diagnosed prediabetes in the overall population was 13.5% in 2020.
• Prediabetes prevalence roseby 4.8% between 2010 and 2020.
• Prevalence was highest among people with high body mass index (BMI) levels ( > 25 kg/m2)
• Nearly 20% of those with prediabetes had BMI of less than 25.
• Diagnosed diabetes prevalence was higher among women (15.9%) compared with men (10.8%).
• Women were also more likely to be tested than men, by 4.3%.
• Testing differences across sexes were more pronounced among non-Hispanic Black and Hispanic Black adults than among White adults.
• Prediabetes testing peaked after age 65, when most patients are covered by Medicare.

The analysis showed that 30% of the population is potentially undiagnosed with prediabetes, with differences even more pronounced by ethnicity: Asian adults were 14% less likely and Hispanic adults 9% less likely than Non-Hispanic White adults to be undiagnosed.

Even when patients were diagnosed with prediabetes, only 5% were referred to a diabetes prevention program by a health care provider, and only 3% of patients diagnosed with prediabetes have ever used the National Diabetes Prevention Program.

The National Diabetes Prevention Program, an intensive, 12-month, first-line lifestyle intervention, teaches healthy eating and physical activity in order to reduce weight by about 5% to 7%. Medicare began covering the benefit in 2018, but as of February 2022, there are only 2098 providers across the country, and some states have none (Nevada, Rhode Island, South Dakota, and Vermont). Just 14 states include the program as a Medicaid benefit. It is covered by some private insurance plans.

The results point to a variety of gaps in preventive services for prediabetes, and the authors called for 3 actions to improve uptake of diabetes prevention efforts:

• Increase payment for preventive interventions to avoid supply distortions
• Improve data integration and patient follow-up to increase testing
• Extend coverage and broaden access to preventive interventions to reach a larger share of the population at risk

Although CMS is making adjustments to the program in 2022, the authors said it is unclear whether any reimbursement changes will boost the supply of providers.

They also raised concerns over the impact of pay-for-performance on outreach.

“Although the NHIS data do not show discrimination in referrals, pay-for-performance might lead providers to offer the Medicare Diabetes Prevention Program in predominantly affluent White neighborhoods, leading to higher White participation and increasing the gap in diabetes prevalence between non-Hispanic White adults and other groups,” they wrote. Currently, Non-Hispanic White adults are mostly likely to achieve the mean 5% weight loss goal linked to Medicare Diabetes Prevention Program pay-for-performance reimbursement.

The authors also recommended policy changes to help reduce the barriers to preventive care such as fragmentation in the health care system and challenges to interoperability of electronic medical record systems, to improve the persistently low rates of prediabetes awareness and physician referrals to prevention programs.

To improve access, the authors suggested reducing the restrictiveness and complexity of eligibility for the National Diabetes Prevention Program, expanding to accept a greater range of BMIs and ages, as well as removing or extending time limits. They also recommend population-level interventions such as taxes on sugar-sweetened beverages, public infrastructure, safety net programs, and mandating restaurants to provide nutrition information.

“These opportunities must be capitalized on, and the chances of halting prediabetes for all Americans must be improved,” the authors concluded.

Reference

Alva ML, Chakkalakal RJ, Moin T, Galaviz KI. The diabetes prevention gap and opportunities to increase participation in effective interventions. Health Aff (Millwood). 2022;41(7):971-979. doi:10.1377/hlthaff.2022.00259