Scalability Challenges: Digital Diabetes Prevention

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.

Since launching 10 years ago, 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?

The DPP can clearly improve health outcomes and address the $327 billion annual burden of diabetes in the U.S. Plus, over 86 million - 1 in 3, American adults have prediabetes, and most of those could likely benefit from the program. Why, then, is the DPP not ubiquitous? A shortage of in-person locations and lifestyle coaches can be a barrier to increased participation rates nationwide.

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!

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.

It’s equally as important to make the DPP “sexy” to consumerize access. If it remains a ‘prescription service’ that we hope doctors refer patients to at scale, without reimbursement, then we will see a tide of Type 2 Diabetes sweep our nation and our facilities. This is where it’s important to think outside the box, such as with Lark’s recent partnership with 23andMe. Lark has screened nearly 450,000 people for prediabetes using similar tactics.

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, additional expert lifestyle coaches are leveraged and their skills are used at the most impactful times. This is in contrast to the linear additional person-hours and salaries required when a traditional, in-person 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 DPP that will assist in the logistics from enrollment through implementation.

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 scale and enrollment.

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

·      Lack of program costs such as facility rentals or linear 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.

Crunching the Numbers: Shortages of Coaches & Sites

The numbers are not definitive, but the conclusion seems clear: there are simply not enough lifestyle coaches reach the 86 million Americans who are prediabetic under the existing model touted by many digital health firms. In our analysis, there is variation in aspects such as the number of participants per DPP class and the number of classes offered per site or organization, but here are some of our calculations.

“Thousands” of Coaches

The CDC says that “there are thousands of trained lifestyle coaches nationwide.” Let’s assume that the CDC means 10,000 coaches. With 86 million Americans with prediabetes, each lifestyle coach would need to reach an average of 8600 participants in their DPP programs – which, as a reminder, include a minimum of 22 sessions over the course of the year. 

In-Person or Telephonic Coaching: A Mathematical Impossibility!

Doing the calculations, assuming an average class capacity of 20 participants, each lifestyle coach’s 8,600 participants would be split into 430 classes. To hit those 22 annual sessions, each coach would need to conduct 9,460 classes. At an hour per class, that adds up to each coach working nonstop (no sleeping or eating) for 394 days per year to reach their allotted participants.

That is right: with these numbers, it would be physically impossible to bring a DPP to all prediabetics without adding about 80,000 additional health coaches. 

Inadequate Reach of Diabetes Prevention Program Coaching

Going back to an estimate of 10,000 coaches, let us assume, generously and unrealistically, that they teach DPP sessions full-time (and have no other professional duties), spend two hours per session preparing and teaching, and have 20 participants per class. Using the standard full-time year of 2,080 hours, that would allow for 47 separate 22-session courses, serving a total of 940 participants. That number is not even 11% of the number they would need to reach to serve the entire population of prediabetes patients. 

Even Greater Shortcomings with Different Calculations

Approaching the estimates from a different direction, let’s take a look at a large study examining the nationwide effects of the DPP. The study included data from 435 DPP organizations that served 35,844 participants, or an average of 82.4 participants per site [2]. (The estimate of 82.4 participants per site seems reasonable when checked against a different review article looking at sites with an average of 70.9 participants per site [3]).

Extrapolating that ratio to 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. That means fewer than 2 out of every 1,000 individuals with prediabetes are benefiting from the DPP!

Massive Shortages of Lifestyle Coaches

A reason for the inadequate number of DPP lifestyle coaches may be trouble obtaining certification. An individual must go through a recognized training program to become a DPP lifestyle coach. The CDC has signed a memorandum of understanding (MOU) with 9 organizations that offer online or on-site training [4]. This number of organizations may seem like a small number to serve the entire country, and it seems even more inadequate when considering limitation such as:

• Offering only 4 to 12 sessions per year.
• Capping enrollment at numbers such as 24 participants per session.
• Meeting synchronously at times that may be impossible for potential enrollees to attend and therefore preclude them from being coaches.

The Case for A.I-Augmenting Expert Coaches

A digital DPP augmented by A.I, popularized by Lark and fully recognized by the CDC and multiple peer-reviewed journals, can swiftly address the shortfalls in numbers of DPP lifestyle coaches by dramatically increasing scalability. A.I-Augmentation can serve vastly greater numbers of prediabetes patients and reduce the ratio of participants to coaches that are required for effective education and lifestyle change.

A mobile-based DPP that is delivered entirely digitally requires far fewer lifestyle coaches, and Lark’s 2017 study in the JMIR proved that this model has equivalent clinical outcomes to in-person programs.

Other reasons why a well-chosen digital DPP can improve DPP adoption nationwide include:

• Ease of implementation, with seamless integration into your organization and assistance with cost or insurance if applicable.
• Support when setting up the program, associated digital scales or other devices, and throughout the program.
• Lower cost when compared to in-person interventions that require payment for facilities and personnel.
• Potential for higher engagement, due to participant convenience, and better results.

Regardless of which estimates you use, it seems clear that there is a shortfall of trained lifestyle coaches, and in this economy, a shortage of workers overall. Also clear is that a digital DPP can be a simple, quick, and effective solution. A digital DPP has immense scalability because it can get more mileage from each trained lifestyle coach to serve more participants, and it is easy for organizations to implement regardless of their expertise in this area. Shouldn’t you be looking into digital solutions?

Lark's Digital DPP

With nearing 100,000 participants, Lark's DPP is the most scalable and the fastest growing. It is based on a combination of clinically-validated Artificial Intelligence (AI), expert health coaches and nutritionists who execute targeted and timely interventions, plus connected devices to track participant data in real time. Lark is one of many wonderful organizations dedicated to this effort. It’s important that, unlike the last 10 years, the next 10 years of DPP sees more than 1.1% enrollment.