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Strengthening Patient Access for Type 2 Diabetes Preventive Services

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Summary

Type 2 diabetes (T2D) rates have grown substantially over the years and have placed a significant burden on the US healthcare system. While prevention efforts continue to advance, including the availability of screening tools and early prevention therapies, systemic disparities still preclude equitable access to preventive services. These will need to be addressed as a key component of strengthening patient access to preventive care and lowering the incidence of disease.

Roughly 1 in 10 American adults lives with diabetes, of which ~90–95% have T2D. Another 1 in 3 adults is estimated to have prediabetes. Diabetes (all types) is the seventh highest cause of death in the US, and management of the condition costs approximately $327 billion annually in direct medical costs and reduced productivity. T2D prevalence has grown substantially over the years. While healthcare stakeholders have led significant efforts to combat the disease, including the provision of improved screening and preventive efforts, health, social, and economic access barriers continue to prove challenging in ensuring equitable access to important preventive care.

T2D Prevention Efforts

Methods of preventing T2D include conducting screenings for T2D and prediabetes, using early preventive therapies, adopting lifestyle modifications, and promoting community-based interventions. Academic and professional societies have developed and refined clinical practice guidelines for use by clinicians, which include recommendations for T2D screening, lifestyle interventions (e.g., nutrition, smoking cessation, digital health), and treatment options (e.g., metformin for select age and body mass index classes). Other organizations, such as the Centers for Disease Control and Prevention (CDC), have compiled resources and guidance to help clinicians prevent T2D among their patient population.

Some therapies indicated to treat T2D have supportive evidence for use as a preventive measure. While these drugs are not approved by the Food & Drug Administration for T2D prevention, existing evidence has allowed clinical organizations to support physician prescribing and payer coverage. For example, the American Academy of Family Physicians released content this year stating that use of metformin may reduce the risk of developing T2D in patients with high risk compared with counseling on diet and exercise.

Access Barriers to T2D Prevention

Various stakeholders are actively working to promote preventive efforts and improve T2D management. However, patient barriers to access screenings and preventive care, as well as the ability to modify their lifestyle, are significant limiting factors. Evidence suggests disparities related to housing access, income, education, and other social determinants of health (SDOH) are major challenges to the prevention of T2D. Individuals with less income and education are 2-to-4 times more likely to develop T2D than those with higher incomes or education levels.

Figure 1. T2D Access Barriers
Figure 1. T2D Access Barriers

Given that T2D can be prevented, there are opportunities to reduce the incidence and the associated burden on the health care system through efforts focusing on combatting T2D-related SDOH. Understanding community needs and opportunities to facilitate equal access and use of screenings and treatments in communities facing SDOH-related challenges can be a critical step in addressing these barriers.

Continued Government Action

Several lifestyle modification tools have been developed to help clinicians address SDOH risk factors associated with T2D development, including stress levels, education, income, and other domains. Still, opportunities remain for healthcare stakeholders to play a stronger role in developing targeted recommendations and resources for use by clinicians and patients to assess risk and inform direct lifestyle and community-based interventions (e.g., transportation support) to prevent T2D.

For example, government stakeholders have played a considerable role in boosting prevention activities and could further advance efforts to establish equity in access to screening and preventive tools:

  • Mandating national guidelines: In 2015, the US Preventive Services Task Force (USPSTF) recommended abnormal blood glucose screenings and behavioral counseling support services for adults 40+ who are overweight or obese with a B rating. Such a recommendation expands access to these screenings for patients, as insurers are required to follow all USPSTF recommendations that receive a rating of A or B. Additionally, USPSTF recently released a research plan for evaluating T2D screenings for children and adolescents.
  • National prevention initiative: The CDC’s National Diabetes Prevention Program is a public-private partnership. Developed in 2010, the program provides a curriculum and other tools for providers, pharmacists, insurers, and employers to prevent, delay onset, and manage T2D.
  • Value-based payment design: The Center for Medicare & Medicaid Innovation’s Medicare Diabetes Prevention Program Expanded Model is a behavior-change intervention that aims to prevent T2D among Medicare beneficiaries with prediabetes. Under the model, beneficiaries are provided structured lifestyle modification sessions using CDC-approved curriculum and suppliers are paid under a performance-based model.

In addition, other healthcare stakeholders, such as patient advocacy organizations, professional societies, payers, pharmacies, and health systems, are similarly undertaking programs to support expanded screening and prevention, as well as tackle SDOHs that may impact patients’ risk of developing T2D.

Outlook to Strengthen Patient Access

As healthcare stakeholders consider novel avenues to increase access to T2D preventive services, stakeholder initiatives can facilitate earlier monitoring, lifestyle management, and diagnosis. For example, opportunities may exist for stakeholders to engage in the following:

  • Value-based payment models to incentivize care tied to preventing or delaying T2D onset among patients with prediabetes
  • Guideline development or modification with professional societies and the USPSTF to share evidence-based recommendations that facilitate broader patient access to T2D preventive therapies and lifestyle modification programs for prevention
  • Development of patient resources or tools to support patient education, self-monitoring, and adherence to lifestyle modifications and pharmacologic therapies
  • Identification and considerations of equity-driven initiatives to reduce SDOH-related drivers of T2D risk within affected communities

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Notes

  1. Zgibor, J. C., & Songer, T. J. (2001). External barriers to diabetes care: Addressing personal and health systems issues. Diabetes Spectrum, 14(1), 23–28.
  2. Keene, D. E., Guo, M., and Murillo, S. (2018). “That wasn’t really a place to worry about diabetes”: Housing access and diabetes self-management among low-income adults. Social Science & Medicine, 197, 71–77.
  3. Pouwer, F., Kupper, N., and Adriaanse, M. C. (2010). Does emotional stress cause type 2 diabetes mellitus? A review from the European Depression in Diabetes (EDID) Research Consortium. Discovery Medicine, 9(45), 112–118.
  4. Schillinger, D., Grumbach, K., Piette, J., Wang, F., Osmond, D., Daher, C., and Bindman, A. B. (2002). Association of health literacy with diabetes outcomes. JAMA, 288(4), 475–482.
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