Scaling the DPP: Urgent but Possible

Background:

While nearly 2,000 local groups offer in-person diabetes prevention classes, the market for effective and scalable DPPs that meet the security and ease-of-use requirements of commercial and government payors has quickly consolidated into 4 providers who collectively enroll over 95% of participants in the NDPP.

The numbers on diabetes may be familiar, but they are still jarring. Diabetes is the most expensive chronic condition in the country with an annual cost of over $245 billion for healthcare expenses and lost productivity.[1] Nearly 1 in 8 American adults has diabetes, including 1 in 6 Americans 45 to 64 years old, and 1 in 4 over 64 years. [2] Health consequences include heart disease, stroke, kidney disease, neuropathy, and more.

But here’s the thing: these exorbitant economic costs and devastating health consequences are largely avoidable. Most cases of diabetes can be prevented with simple lifestyle changes, such as losing weight and increasing physical activity. There is even a national program in place – the CDC-recognized Diabetes Prevention Program (DPP) – to encourage patients at high risk for diabetes to make these changes.

Given that we know how to prevent diabetes and there are DPP providers nationwide, why are cases of diabetes increasing, and how can we reverse the trend? The problem is that only a small fraction of high-risk individuals are in a DPP and getting the support they need to lower their diabetes risk.

Only 1.1% of eligible people are participating in a potentially life-saving DPP.[3]

Why is this, and what can you do to reverse the trend?

Prediabetes, Diabetes, and Causes

The vast majority of diabetes cases are type 2, which means that they occur after the patient has prediabetes. Prediabetes and diabetes are a result of increasing insulin resistance. The prevalence of prediabetes is 1 in 3, and most patients with prediabetes progress to diabetes within years without treatment. By one estimate, 37% of untreated prediabetes cases progress to type 2 diabetes within 4 years.[4]

Prediabetes and diabetes have common risk factors. Some are unavoidable, such as being of a certain ethnic background or having a family history of diabetes. Other risk factors are modifiable and related to lifestyle choices, such as the following.

·      Being overweight or obese.

·      Being physically inactive.

·      Eating a poor-quality diet rich in low-nutrient foods or low in high-nutrient foods.

·      Being short on sleep.

·      Having too much stress.

Weight loss and increased physical activity are two of the most effective ways to increase insulin sensitivity and lower diabetes risk. The DPP emphasizes these two lifestyle changes, with goals of weight loss of 5 to 7% of body weight and 150 minutes per week of physical activity.

Diabetes Prevention Program Effectiveness and Cost-Savings Potential

The DPP has been tested in a multicenter clinical trial and shown to be more effective than placebo or metformin in preventing diabetes among overweight or obese individuals with prediabetes. [5] Risk was reduced by 58% overall in the lifestyle group and 31% in the metformin group compared to placebo.

Other results stemming from this trial, follow-up studies, and economic models promise additional health and economic benefits.

·      27% reduction in diabetes incidence in lifestyle intervention group compared to placebo over 15-year follow-up.[6]

·      34% reduction in 10-year risk of diabetes incidence.[7]

·      Estimated 3 to 81% 5-year return on investment (ROI).[8]

·      $2,671 higher average annual per-person medical expenditures for each prediabetes case who progresses to diabetes.[9]

The American Diabetes Association (ADA) recommends that individuals with prediabetes enroll and participate in a DPP.[10]

Data like these seem to leave no doubt that enrolling eligible participants in a DPP can be cost-saving and healthy. That makes the fact that only a tiny fraction of those who could benefit are enrolled in a DPP even more shocking.

DPP Shortages

When looking at the low participation rate of eligible patients in DPP, one glaring problem is the woefully inadequate number of programs and providers.[11] Estimates vary depending on the methods used, but the conclusions are consistent. There is a shortage of opportunities for participants.

The CDC mentions “thousands of trained lifestyle coaches nationwide.” Assuming 10,000 full-time coaches each teaching classes of 20 participants for the 22-lesson program over a year, the coaches would be able to reach only 940 participants each, or a total only 11% of the estimated 86,000 participants.

An estimate in the American Journal of Preventive Medicine found a much smaller number of participants. [12] After contacting a variety of self-reported high-risk individuals, researchers calculated that only 1.1% of eligible patients were participating in a DPP.

As grim as these numbers are, other calculations lead to estimations of even lower DPP participation rates. Consider a study looking at 435 DPP organizations that served 35,844 participants, or an average of 82.4 participants per site. [13] If that ratio were representative of the approximately 1,800 organizations that currently have CDC DPP recognition, there would be an estimated 148,320 prediabetic patients currently participating in the DPP. That value is a measly 0.17% of the 86 million adults with prediabetes – or fewer than 2 out of every 1,000 individuals with prediabetes! [14]

What to do: Increase Awareness

Most people at high risk for diabetes or with prediabetes can benefit from raised awareness. More screenings could potentially help, given that 90% of individuals with prediabetes are unaware that they have it. [15] Regular blood glucose tests as well as education on the risks of excess weight can increase awareness and possibly precipitate action.

Healthcare providers and healthcare plans also have a role to play. When appropriate, healthcare providers should refer their patients to DPP providers. Healthcare plans
and employers should publicize the availability of programs and make them easy to learn about and enroll in. Some DPP providers, such as Lark, assist by determining eligibility and facilitating enrollment.

What to do: Reduce Participant Barriers

An approach to increasing participation is to make the DPP more attractive to potential participants by making it more accessible and comfortable. Barriers to accessibility can include lack of convenient times and locations of DPP sessions. Individuals of lower socioeconomic status may have less time to dedicate to program and driving.

In-person DPP sessions, which comprise the majority of the currently-approved CDC-DPP, present certain risks of discomfort. For example, participants may not want to weigh in in front of their lifestyle coach, or they may feel shy talking in front of others during the DPP lessons. Cultural considerations can include a feeling of disconnect between participants and lifestyle coaches if they are of different ethnic or socioeconomic backgrounds.

What to do: Decrease Costs

The greater the cost-savings potential and ROI, the more irresistible offering a DPP will be for employers and healthcare insurers. The economic benefits increase when costs are lowered, and digital solutions offer a simple approach to lowering costs. Multiple studies have found that online DPP can be as effective as in-person programs, and engagement tends to be higher. [16]

The costs of online DPP can be lower because of the lack of need to pay for brick-and-mortar facilities for the sessions – count on 22 sessions per year per class to meet CDC requirements. In addition, an online program can be used to additionally provide guidance on when to contact healthcare professionals. The result can be fewer unnecessary calls and, consequently, fewer wasted dollars on medical staff fielding calls.

Fewer personnel are necessary if the online programs use artificial intelligence (AI)-powered coaching, as is the case with Lark DPP. As the program expands, no additional lifestyle coaches are needed. This is in contrast to the additional person-hours and salaries required when a traditional, in-person or hybrid program expands.

What to do: Reduce Implementation Barriers

Health insurers and employers can use a hand in offering a DPP. The easiest is to contract with a third-party employer that will assist in the logistics from enrollment through implementation. Lark DPP helps with patient eligibility and enrollment, getting reimbursement, and delivering scales to patients. In addition, Lark takes the burden of complying with CDC requirements for reporting DPP outcomes according to the Operating Procedures. [17] Lark Health is now Fully CDC Recognized.

The Case for Digital DPP

There is a clear need to expand DPP access and enrollment to reduce unnecessary healthcare spending on diabetes and its complications and comorbidities, to improve productivity in the workplace, and, not least, to improve people’s lives. Just as clear is the need to consider digital DPP providers to lead the way in the mission. A digital DPP such as Lark offers the following features that are conducive to infinite and instant scaling.

·      Fully automated conversational AI coach that requires no additional manpower when additional patients join the program.

·      Unlimited, personalized coaching for each user.

·      Lack of participant barriers such as inconvenient or uncomfortable in-person meetings.

·      Lack of program costs such as facility rentals or hiring additional personnel as your program grows.

·      A central entity handling logistics and providing support to relieve the burden of implementation and administration.

Time to Make a Difference

There is no question that the DPP has a world of benefits for participants, insurers, and employers. The evidence is there to show that the DPP can be economically worthwhile and good for health, but the program is woefully inadequate as it stands, leaving 70 to 80 million or more Americans at unnecessarily high risk for type 2 diabetes.

With a sound strategy and good choice of DPP providers, you can close the coverage gap, starting today. Contact Lark to learn how easily you can get started.

References

1. National Center for Chronic Disease Prevention and Health Promotion. Health and Economic Costs of Chronic Diseases. https://www.cdc.gov/chronicdisease/about/costs/index.htm. Reviewed February 2, 2017. Accessed February 4, 2019.
2. National Center for Chronic Disease Prevention and Health Promotion, Division of Diabetes Translation. National Diabetes Statistics Report, 2017: Estimates of Diabetes and Its Burden in the United States. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf
3. Prevalence and Correlates of Diabetes Prevention Program Referral and Participation. Venkataramani, Maya et al. American Journal of Preventive Medicine, Volume 0, Issue 0. https://www.ajpmonline.org/article/S0749-3797(18)32334-1/fulltext
4. Tuso P. Prediabetes and lifestyle modification: time to prevent a preventable disease. Perm J. 2014;18(3):88-93. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4116271/
5. Diabetes Prevention Program Research Group. Reduction in the Incidence of Type 2 Diabetes with Lifestyle Intervention or Metformin. February 7, 2002. N Engl J Med 2002; 346:393-403. DOI: 10.1056/NEJMoa012512 https://www.nejm.org/doi/full/10.1056/NEJMoa012512
6. Diabetes Prevention Program Research Group. Long-term effects of lifestyle intervention or metformin on diabetes development and microvascular complications over 15-year follow-up: the Diabetes Prevention Program Outcomes Study. Lancet Diabetes Endocrinol. 2015;3(11):866-75. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4623946/
7. Diabetes Prevention Program Research Group, Knowler WC, Fowler SE, et al. 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. Lancet. 2009;374(9702):1677-86. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3135022/
8. American Medical Association. DPP cost saving calculator. https://ama-roi-calculator.appspot.com/
9. Khan T, Tsipas S, Wozniak G. Medical Care Expenditures for Individuals with Prediabetes: The Potential Cost Savings in Reducing the Risk of Developing Diabetes. Popul Health Manag. 2017;20(5):389-396. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5649409/
10. American Diabetes Association. Standards of medical care in diabetes – 2019. Diabetes Care 2019 Jan; 42(Supplement 1): S1-S2. https://doi.org/10.2337/dc19-Sint01.
11. Konchak JN, Moran MR, O’Brien MJ, Kandula NR, Ackermann RT. The State of Diabetes Prevention Policy in the USA Following the Affordable Care Act. Curr Diab Rep. 2016;16(6):55.
12. Prevalence and Correlates of Diabetes Prevention Program Referral and Participation. Venkataramani, Maya et al. American Journal of Preventive Medicine, Volume 0, Issue 0. https://www.ajpmonline.org/article/S0749-3797(18)32334-1/fulltext
13. Ely EK, Gruss SM, Luman ET, Gregg EW, Ali MK, Nhim K, Rolka DB, Albright AL. A National Effort to Prevent Type 2 Diabetes: Participant-Level Evaluation of CDC’s National Diabetes Prevention Program. Diabetes Care. 2017 Oct;40(10):1331-1341. doi: 10.2337/dc16-2099. Epub 2017 May 12. PMID: 28500215
14. https://www.lark.com/scalability-digital-dpp/
15. National Center for Chronic Disease Prevention and Health Promotion, Division of Diabetes Translation. National Diabetes Statistics Report, 2017: Estimates of Diabetes and Its Burden in the United States. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf
16. Moin T et al. Results From a Trial of an Online Diabetes Prevention Program Intervention. A J Preventive Medicine. November 2018Volume 55, Issue 5, Pages 5
    
    83–591. DOI: https://doi.org/10.1016/j.amepre.2018.06.028. https://www.ajpmonline.org/article/S0749-3797(18)32104-4/fulltext
17. Centers for Disease Control and Prevention. Diabetes Prevention Recognition Program: Standards and Operating Procedures. March 1, 2018. OMB No. 0920-0909. https://www.cdc.gov/diabetes/prevention/pdf/dprp-standards.pdf　83–591. DOI: https://doi.org/10.1016/j.amepre.2018.06.028. https://www.ajpmonline.org/article/S0749-3797(18)32104-4/fulltext
18. Centers for Disease Control and Prevention. Diabetes Prevention Recognition Program: Standards and Operating Procedures. March 1, 2018. OMB No. 0920-0909. https://www.cdc.gov/diabetes/prevention/pdf/dprp-standards.pdf