Diabetes Prevention and Control –A Comprehensive Process

Commissioner John AuerbachMassachusetts Department of Public Health

Like everywhere else, Massachusetts has a growing

diabetes problem

~360,000 diagnosed people with diabetes100,000-140,000 are undiagnosedEven more with pre-diabetes#9 leading cause of deathNew cases of severe complications for 2006

249 cases of blindness701 cases of renal failure1,862 lower extremity amputations

3,800 deaths with diabetes as major contributor

Diabetes in Massachusetts

Sources: Massachusetts Behavioral Risk Factor Surveillance System, Bureau for Health Information, Statistics, Research and Evaluation. Massachusetts Department of Public Health, 2006; Central Register, Report of the Register, Massachusetts Commission for the Blind, 2006.End-stage Renal Disease Network of New England, End-stage renal disease incidence and prevalence for Massachusetts, 2006; Uniform Hospital Discharge Data Set (UHDDS), Massachusetts Division of Health Care Finance & Policy, 2005; MDPH Registry of Vital Records and Statistics, 2006

Prevalence in Massachusetts has increased

4.13.8

4.74.3

3.8

4.9

5.8 5.6 5.86.2

5.6

6.4 6.4

0

1

2

3

4

5

6

7

19

94

19

95

19

96

19

97

19

98

19

99

20

00

20

01

20

02

20

03

20

04

20

05

20

06

Year

Pe

rcen

t (%

)

Overall

Source: Massachusetts Behavioral Risk Factor Surveillance System, Bureau for Health Information, Statistics, Research and Evaluation. Massachusetts Department of Public Health, 1994- 2006. Note: Estimates have been age-adjusted to the 2000 US Standard Population

Prevalence of Diabetes in Massachusetts, 1994-2006

An Initial Step: Expand efforts to gather and analyze

data

Attention to social determinants of healthAccess to utilization patterns and opportunities for improvementNew focus on costs and potential savings

Obesity and Overweight by Race/Ethnicity, 2006

55.5 54.8

70.9

61.4

31.4

19.520.3

38.2

26.0

0

10

20

30

40

50

60

70

80

MA White, non-Hispanic

Black, non-Hispanic

Hispanic Asian

Pe

rce

nt

(%)

ObesityOverweight

Statistically different from state (p ≤.05)– Red (*) Statistically worse than state- Green (**) statistically better than state

Source: Massachusetts Behavioral Risk Factor Surveillance System, Bureau for Health Information, Statistics, Research and Evaluation. Massachusetts Department of Public Health, 2006.

Source: NEHI/Boston Foundation: Boston Paradox

3+ fold variation

$75,000 +

<$25,000

Substantial Variation in Diabetes Rates by Household Income

Diabetes by Education, 20063.5 time more likely in least educated

6.47.9

15.6

5.44.4

0

5

10

15

20

25

< HS HS grad 1-3 yearscollege

4+ yearscollege

MA

Perc

en

t (%

)

Statistically different from state (p ≤.05)– Red (*) Statistically worse than state- Green (**) statistically better than state

Source: Massachusetts Behavioral Risk Factor Surveillance System, Bureau for Health Information, Statistics, Research and Evaluation. Massachusetts Department of Public Health, 2006. Note: Estimates have been age-adjusted to the 2000 US Standard Population

4.9

11.912.8

5.46.4

0

2

4

6

8

10

12

14

2006

Pe

rce

nt

(%)

Asian/PI Hispanic Black (NH) White Total

Prevalence of Diabetes in Massachusetts Varies Significantly by Race/Ethnicity, 2006

Source: Massachusetts Behavioral Risk Factor Surveillance System, Bureau for Health Information, Statistics, Research and Evaluation. Massachusetts Department of Public Health, 2006. Note: Estimates have been age-adjusted to the 2000 US Standard Population

Mortality Rates are Much Higher for Blacks and Hispanics

Source: MDPH Registry of Vital Records and Statistics, 1994-2006

Mortality rates for diabetes as the primary cause of death, by race, 1994-2006

21.13 20.25 20.84 20.26 20.2114.4

47.843.94 43.02

54.47

46.0842.88

34.34

44.63 42.6145.65

34.66 35.5 36.1

16.71

26.77 25.94

36.142.36

25.7830.66

26.7529.48

24

12.65 15.0811.69 11.26

6.98 8.5

17.41 16.2918.64

18.88

19.18

18.7218.523.77

40.95

19.68

16.67

22.1919.24

0

10

20

30

40

50

60

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

Years

Ra

te p

er

10

0,0

00

White, NH Black, NH Hispanic Asian/Pacific Islander, NH

Health Care Utilization & Morbidity

Diabetes in Massachusetts

Utilization Patterns Highlight DisparitiesDiabetes Hosp. Discharges:2003-2005

133114

368

242

45

0

50

100

150

200

250

300

350

400

Race/Ethnicity

Rate

pe

r 1

00,0

00

MA White Black Hispanic Asian

Source: Uniform Hospital Discharge Data Set (UHDDS), Massachusetts Division of Health Care Finance & Policy, 2003-2005

Room for Improvement in Preventive Care:% Receiving Recommended Care, 2002-2006

66.661.9 60.4 60.5

69.2

75 75

60

90 90

50

69.9

87.2

76.8

70.2

83.0

75.8

0

20

40

60

80

Foot Exam Eye Exam SMBG Flu Vaccine(50+)

Pneumococcalvaccine (65+)

HbA1c

Pe

rce

nt

MA (2002-2006) US (2005) HP 2010

Source: Massachusetts Behavioral Risk Factor Surveillance System, Bureau for Health Information, Statistics, Research and Evaluation. Massachusetts Department of Public Health, 2002-2006

23%

85%

45%

92%86%

70%

36%

79%82%

70%

88%

39%

0%

20%

40%

60%

80%

100%

HbA1c Test Poor HbA1cControl(>9%)

Eye exam Monitoringkidney

LDL-C Test LDL-C<100

Pe

rce

nt

(%)

Mass Commercial MassHealth

Source: MassHealth Managed Care 2007 HEDIS report

Room for Improvement by Payor

Lots of Opportunities to Improve Modifiable Risk Factors

Prevalence of Modifiable Risk Factors That Cause Complications of Diabetes, 2002-2006

43.1 43.8

28.321.9

30.0

20.6

0

10

20

30

40

50

High BP* High Chol* Current Smoker

Pe

rce

nt

(%)

Diabetes No Diabetes

Source: Massachusetts Behavioral Risk Factor Surveillance System, Bureau for Health Information, Statistics, Research and Evaluation. Massachusetts Department of Public Health, 2002-2006

Economic Costs

Diabetes in Massachusetts

6143

4551

01000200030004000500060007000

1998 1999 2000 2001 2002 2003 2005

Source: Division of Health Care Finance and Policy

+35%

Preventable Hospitalizations for Diabetes Have Risen Significantly

The Department’s Diabetes Prevention and Control

Program

Diabetes Guidelines Developed

DPH worked with all insurers to agree on optimal care for diabetes treatmentFocus was on clinical consensus not on guaranteeing coverage was provided

Disease Management and Wellness: Diabetes

Health Care Reform first critical action steps

Health Care Reformovercomes a majorobstacle to accessto care for people with prediabetes and diabetes – 100,000s more receive insurancefor the first time

Document the extent of the obesity epidemic in Massachusetts, including the disproportionate effect on certain populationsHighlight innovative and successful programs across the Bay State and present new action steps

Release a Report on the Problem of Overweight and Obesity

Passage of a Menu Labeling Regulation – provide the tools

Public Health Council has passed a regulation that requires fast food chain restaurants to post the calorie content of their food…at the point of purchase

Passage of a regulation requiring student Body Mass Index collection

Work in partnership with school nurses and local clinical providersInsure consistent and beneficial communication with parents

Comprehensive information on wellnessLinks to local resources and eventsInteractive tools to help individuals set and achieve goals

Utilize an Interactive Wellness Website

Implement an Executive order requiring the purchase of healthful foods with state contracts

Procurement of foods and snack products which meet criteria based on healthful dietary guidelines for state facilities

Expand Workplace Wellness Initiative

MDPH will enroll additional employers in its Wellness Initiative

A toolkit and curriculum is available to all employers

Mission & Vision

Vision: All worksites in Massachusetts will provide social, cultural and physical environments that support optimum employee health and well-being

Mission: the mission of the Massachusetts Worksite Wellness Initiative is to promote worksite wellness through information, training, regulation and technical assistance

Initiative a unique public-private partnership to support health cities and towns

5 foundations, an insurer* and DPH have united to fund municipalitiesProgram model was based on proven, evaluated efforts

* Blue Cross/Blue Shield Corp./ Foundation, Boston Foundation, Harvard-Pilgrim Foundation, MetroWest Foundation, Tufts Foundation

Payment Reform Offers New Opportunities

Reimbursement for a range of new activities - form chronic disease self-management to patient educatorsCreation of pay for performance incentives that are pegged to proper care and outcomes