HOME

CDC RESOURCES AND GUIDANCE


DIABETES PREVENTION


SELF- MANAGEMENT


HEALTH CARE EXTENDERS


BI-DIRECTIONAL REFERRAL SYSTEM


SCHOOL
HEALTH

GLOSSARY OF TERMS AND ACRONYMS


SUCCESS
STORIES

DIABETES PREVENTION THE NATIONAL DIABETES PREVENTION PROGRAM

STRATEGY LIST

1305 Basic

Strategy 6: Promote awareness of prediabetes among people at high risk for type 2 diabetes

Performance Measure B.6.01

Prevalence (%) of people with self-reported prediabetes


The purpose of this performance measure is to assess grantee efforts to increase prediabetes awareness statewide among people at high risk for type 2 diabetes. It is important that those with prediabetes or type 2 diabetes are aware that they have the condition, because early treatment can prevent serious problems that diabetes can cause, such as loss of eyesight or kidney damage. Studies also show that people with prediabetes can prevent or delay type 2 diabetes by losing 5% to 7% of their weight (DPP Research Group 2002). The vast majority of people living with prediabetes do not know they have it. In the United States during 2005-2010, awareness of prediabetes estimated from NHANES was < 14% across all population subgroups, different levels of health-care access or use, and other factors (CDC 2013).

1305 Enhanced

Strategy 2: Increase use of lifestyle intervention programs in community settings for the primary prevention of type 2 diabetes

Intervention: Increase referrals to, use of, and reimbursment for CDC-recognized lifestyle change programs for the prevention of type 2 diabetes. (See also Bi-directional Referral System)

Short-term:

Performance Measure 4.2.01

Proportion of health care systems with policies or practices to refer persons with prediabetes or at high risk for type 2 diabetes to a CDC-recognized lifestyle change program


The purpose of this performance measure is to look at health care systems that have policies or practices to refer persons with prediabetes or at high risk for type 2 diabetes to a CDC-recognized lifestyle change program. The recognition program requires that a minimum of 50% of program's participants must have had a recent (within the past year), documented, blood-based diagnostic test indicating they have prediabetes, or a history of gestational diabetes mellitus (GDM), according to one of the following specifications:

  1. Fasting plasma glucose of 100 to 125 mg/dl
  2. Plasma glucose measured 2 hours after a 75 gm glucose load of 140 to 199 mg/dl
  3. A1c of 5.7 to 6.4
  4. Clinically diagnosed GDM during a previous pregnancy (may be self-reported)

Performance Measure 4.2.02

Proportion of participants in CDC-recognized lifestyle change programs who were referred by a health care provider


The purpose of this performance measure is to assess grantee efforts to: 1) increase the number of health care providers referring people with prediabetes or at high risk for type 2 diabetes to a CDC recognized lifestyle change program, and 2) increase the number of participants who were referred by a health care provider. One of the standards for CDC recognition is that a minimum of 50% of a program’s participants must have had a recent (within the past year), documented, blood-based diagnostic test indicating they have prediabetes or a history of gestational diabetes mellitus (GDM), according to one of the following specifications:

  1. Fasting plasma glucose of 100 to 125 mg/dl
  2. Plasma glucose measured 2 hours after a 75 gm glucose load of 140 to 199 mg/dl
  3. A1c of 5.7 to 6.4
  4. Clinically diagnosed GDM during a previous pregnancy (may be self-reported)

Performance Measure 4.2.03

Number of Medicaid recipients or state/local public employees with prediabetes or at high risk for type 2 diabetes who have access to evidence-based lifestyle change programs as a covered health benefit


The purpose of this performance measure is to assess grantee efforts to increase Medicaid or state/local public employee coverage for an evidence-based lifestyle change program for people with prediabetes or at high risk for type 2 diabetes. A sustainable payment model is a core element for the National Diabetes Prevention Program, which has the long term goal to prevent or delay the onset of type 2 diabetes in the United States (National DPP 2012).

Intermediate:

Performance Measure 4.2.04

Number of persons with prediabetes or at high risk for type 2 diabetes who enroll in a CDC-recognized lifestyle change program


The purpose of this performance measure is to assess grantee efforts to increase the number of people enrolled in a CDC recognized lifestyle change program. Clinical studies have demonstrated that participating in an evidence-based lifestyle change program often prevents or delays the onset of type 2 diabetes among people with prediabetes or at high risk for type 2 diabetes (The CDC's National Diabetes Prevention Program).

Long-term:

Performance Measure 4.2.05

Percent of participants in CDC-recognized lifestyle change programs achieving 5-7% weight loss (as reported by the CDC Diabetes Prevention Recognition Program)


The purpose of this performance measure is to assess grantee efforts to directly or indirectly support participants in evidence-based lifestyle change programs to achieve the desired outcome of 5-7% weight loss. The Diabetes Prevention Program (DPP) research study showed that making modest behavior changes helped participants lose 5% to 7% of their body weight - that is 10 to 14 pounds for a 200-pound person - and that these lifestyle changes reduced the risk of developing type 2 diabetes by 58% in people with prediabetes (DPP Research Group 2002).

1422 Component 1

Strategies to build support for healthy lifestyles, particularly for those at high risk, to support diabetes and heart disease and stroke prevention efforts


Strategy 1.5: Plan and execute strategic data-driven actions through a network of partners and local organizations to build support for lifestyle change

Short-term:

Performance Measure 9

Number of unique sectors represented in the network (e.g. employers, insurers, health systems, representatives of community organizations, food banks, and others)


The purpose of this performance measure is to assess grantee efforts to develop and implement collaborative action approaches to scaling and sustaining the National DPP through establishing effective partnerships with key stakeholders. A recent review identified involvement of key sectorial stakeholders as a core operating principle of successful partnerships (Jolin 2012). The Community Toolbox notes the importance of collaborative work between funders and health and human service organizations in various sectors to make progress on large and complex social problems and provides information on models such as collective impact that can facilitate this process (KU Work Group for Community Health and Development 2014).

Performance Measure 10

Annual participation/response rate of network partners in network self-assessments based on shared measurement


The purpose of this performance measure is to assess grantee success in ensuring that network partners are working collaboratively to achieve impact on common goals related to scaling and sustaining the National DPP. While there are many ways to measure the success of collaborative action approaches, the focus of this measure is on the commitment of partners to continuous self-assessment and shared measurement. The Community Toolbox notes that while which partners a grantee brings together is important, how the grantee brings them together is even more important. Grantees should help the network to create structures that bring partners together regularly to look at data in new ways that are appropriate to achieving population-level change and to help the group move from technical solutions to adaptive solutions. To accomplish this, the network should work toward the establishment of shared measurement practices. Regular self-assessment is a feature of "adaptive capacity," which is an evidence-based indicator of coalition success (Raynor et al. 2011).

Intermediate:

Performance Measure 23

Number of persons with prediabetes or at high risk for type 2 diabetes who enroll in a CDC recognized lifestyle change program


The purpose of this performance measure is to assess grantee efforts to increase the number of people enrolled in a CDC-recognized lifestyle change program. Clinical studies have demonstrated that participating in an evidence-based lifestyle change program often prevents or delays the onset of type 2 diabetes among people with prediabetes or at high risk for type 2 diabetes. (The National Diabetes Prevention Program)

Strategy 1.6: Implement evidence-based engagement strategies (e.g. tailored communications, incentives) to build support for lifestyle change (scaling and sustaining the CDC-recognized lifestyle change program for priority populations)

Short-term:

Performance Measure 11

Number of people reached through evidence-based engagement strategies


The purpose of this performance measure is to assess changes in the number of people reached by multi-channel, community-wide communication activities promoting the National DPP among priority populations in the states, large cities, and funded communities. This performance measure is focused on the total size of the audience(s) to whom messages about the National DPP were disseminated via multiple channels, including traditional and social media.

For purposes of this profile, evidence-based engagement strategies are limited to marketing and communication. Based on strong evidence of effectiveness for producing intended behavior changes, the Community Preventive Services Task Force recommends: (1) community-wide campaigns that involve many community sectors and include highly visible, broad-based, multicomponent strategies (e.g., social support, risk factor screening, or health education) (Community Preventive Services Task Force 2001); and (2) health communication campaigns that use multiple channels, one of which must be mass media, combined with the distribution of free or reduced-price health related products (Community Preventive Services Task Force 2014). Mass media efforts should be coordinated with a diverse mix of other communication channels, some interpersonal and some community-based, in order to extend the reach and frequency of the campaign's messages (Coffman 2002). Reach to relevant audiences is essential, and the communication channels selected should be able to reach a large part of the audience (Snyder & Hamilton 2002, Hornik & Kelly, 2007).

Intermediate:

Performance Measure 23

Number of persons with prediabetes or at high risk for type 2 diabetes who enroll in a CDC recognized lifestyle change program


The purpose of this performance measure is to assess grantee efforts to increase the number of people enrolled in a CDC-recognized lifestyle change program. Clinical studies have demonstrated that participating in an evidence-based lifestyle change program often prevents or delays the onset of type 2 diabetes among people with prediabetes or at high risk for type 2 diabetes. (The National Diabetes Prevention Program)

Strategy 1.7: Increase coverage for evidence-based supports for lifestyle change by working with network partners (e.g. educate employers about the benefits and cost-savings of evidence-based lifestyle change programs as a covered health benefit)

Short-term:

Performance Measure 12

Number of employees with prediabetes or at high risk for type 2 diabetes who have access to evidence-based lifestyle change programs as a covered benefit


The purpose of this performance measure is to assess grantee success at increasing private sector/non-governmental employee coverage for an evidence-based lifestyle change program for people with prediabetes or at high risk for diabetes. The Diabetes Prevention Program (DPP) research study showed that making modest behavior changes helped participants lose 5% to 7% of their body weight - that is 10 to 14 pounds for a 200-pound person - and that these lifestyle changes reduced the risk of developing type 2 diabetes by 58% in people with prediabetes (DPP Research Group 2002). A sustainable payment model is a core element of the National Diabetes Prevention Program, which has the goal of systematically scaling the translated model of the DPP for high risk persons to reduce the incidence of type 2 diabetes in the United States (National DPP 2012).

Intermediate:

Performance Measure 23

Number of persons with prediabetes or at high risk for type 2 diabetes who enroll in a CDC recognized lifestyle change program


The purpose of this performance measure is to assess grantee efforts to increase the number of people enrolled in a CDC-recognized lifestyle change program. Clinical studies have demonstrated that participating in an evidence-based lifestyle change program often prevents or delays the onset of type 2 diabetes among people with prediabetes or at high risk for type 2 diabetes. (The National Diabetes Prevention Program)

1422 Component 2

Health System Interventions to Improve the Quality of Health Care Delivery to Populations with the Highest Hypertension and Prediabetes

Community programs linked to clinical services strategies to Support Heart Disease and Stroke and Diabetes Prevention Efforts

Strategy 2.5: Implement systems to facilitate identification of patients with undiagnosed hypertension and identification of people with prediabetes (See also the Health Systems Resource Guide)

Short-term:

Performance Measure 17a

Percentage of patients within health care systems with policies or systems to facilitate identification of patients with undiagnosed hypertension


The purpose of this performance measure is to assess the change in the percent of patients within health care systems who have policies or systems in place to identify patients whose hypertension is undiagnosed. One in three adults are hypertensive and 48 percent of those with hypertension do not have their blood pressure under control. Of those with uncontrolled hypertension, 36 percent are unaware that they are hypertensive, and as a result are not taking any anti-hypertensive medication (Wall HK, Hannan JA, Wright JS., 2014). Data such as these suggest that despite the fact that a significant percent of the population receives routine care from a health care professional, there are still potentially millions of patients with uncontrolled hypertension that go undiagnosed within clinical settings each year. These frequent health encounters provide an optimal opportunity to identify patients that have not been diagnosed as being hypertensive (Farley TA, Dalal MA, Mostashari F,Frieden TR, 2010). In instances where direct encounters for diagnosis have been missed another opportunity exists whereby clinical indicators from patient medical records can be used to identify these same patients (Rakotz, et a, 2014). Implementation of such strategies has been shown to be effective, and useful in helping to reduce poor cardiovascular outcomes such as heart attack and stroke (Association of State Territorial Health Officials, 2014)

Performance Measure 17b

Percentage of patients within health care systems with policies or systems to facilitate identification of people with prediabetes


The purpose of this performance measure is to assess the increase in the percent of people who have access to screening for prediabetes as a result of being treated in a health care system that has implemented a systems level screening protocol for prediabetes. Prediabetes is a health condition characterized by blood glucose levels that are higher than normal, but not high enough to be diagnosed as diabetes. In 2009 - 2012, based on fasting glucose or A1C levels, 37% of U.S. adults aged 20 years or older had prediabetes (51% of those aged 65 years or older). Applying this percentage to the entire U.S. population in 2012 yields an estimated 86 million Americans aged 20 years or older with prediabetes (more than 1 out of every 3 adults.) Prediabetes is treatable, but only about 10 percent of people who have it are aware that they do. Without weight loss and moderate physical activity, 15-30% of those people will develop type 2 diabetes within 5 years. Diabetes and its related complications account for $245 billion in total medical costs and lost work and wages. People with diabetes are at increased risk of serious health complications including blindness, heart disease, stroke, kidney failure, amputation of toes, feet, or legs, and premature death. Prevention efforts nationwide are crucial to combat these serious health risks. (Information from the CDC National Diabetes Statistics Report, 2014.)


The CDC-led National Diabetes Prevention Program (National DPP) is an evidence-based lifestyle change program for preventing type 2 diabetes. Work with health care systems to implement policies and system-level changes to facilitate identification of people with prediabetes is critical. CDC's Diabetes Prevention Recognition Program (DPRP) requires that a minimum of 50% of a CDC recognized lifestyle change program's participants must have had a recent (within the past year), documented, blood-based diagnostic test indicating they have prediabetes, or a history of gestational diabetes mellitus (GDM), according to one of the following specifications:

  1. Fasting plasma glucose of 100 to 125 mg/dl
  2. Plasma glucose measured 2 hours after a 75 gm glucose load of 140 to 199 mg/dl
  3. A1c of 5.7 to 6.4
  4. Clinically diagnosed GDM during a previous pregnancy (may be self-reported)

As part of the National DPP, the American Medical Association (AMA) and CDC are collaborating to create tools and resources that care teams can use to identify patients with prediabetes, and refer eligible patients to in-person or online diabetes prevention programs. The AMA and CDC recently released "A Guide to Refer Your Patients with Prediabetes to an Evidence-Based Diabetes Prevention Program." (AMA and CDC, 2014) The Guide addresses items such as implementing either point of care or retrospective methods for identifying people with prediabetes and ICD-9 coding for prediabetes.

Intermediate:

Performance Measure 23

Number of persons with prediabetes or at high risk for type 2 diabetes who enroll in a CDC recognized lifestyle change program


The purpose of this performance measure is to assess grantee efforts to increase the number of people enrolled in a CDC-recognized lifestyle change program. Clinical studies have demonstrated that participating in an evidence-based lifestyle change program often prevents or delays the onset of type 2 diabetes among people with prediabetes or at high risk for type 2 diabetes. (The National Diabetes Prevention Program)

Performance Measure 24

Proportion of adults with high blood pressure in adherence to medication regimens


The purpose of this performance measure is to assess the change in the proportion of adults adherent [i.e., proportion of days covered (PDC) value of 80% or higher as a measure of secondary adherence] with taking their antihypertensive medications (AHMs). The specifications outlined below for this measure involves use of the PDC methodology applied to administrative pharmacy claims data to assess adherence to renin angiotensin system antagonist (RASA) medications. Adherence to RASA medications can be used as a proxy for adherence to all AHMs. This method is supported by the Pharmacy Quality Alliance (PQA) and a similar method is used by the Centers for Medicare and Medicaid Services in their Star Rating methodology. Other methods to assess population-level AHM adherence can be used by the grantee, including use of clinical data, but they must first receive approval to do so by their CDC Evaluator.

Strategy 2.6: Increase engagement of community health workers to promote linkages between health systems and community resources for adults with high blood pressure and adults with prediabetes or at high risk for type 2 diabetes (See also the Health Systems Resource Guide)

Short-term:

Performance Measure 18A

Number of health systems that engage Community Health Workers (CHWs) to link patients to community resources that promote self-management of high blood pressure


The purpose of this performance measure is to assess health care system engagement in the promotion of self-management of high blood pressure through the use of Community Health Workers (CHWs). Research and practice evidence indicates that CHWs help reduce barriers to care and increase treatment adherence. Their inclusion in disease prevention and management efforts for chronic conditions, including cardiovascular disease, has been associated with improved health outcomes. Additionally, integration of CHWs into care delivery has been shown to lower health care costs by reducing the number of emergency room visits and hospitalizations (Brownstein et al., 2007; Brownstein et al., 2005; Martinez et al., 2011; IOM 2010).

Performance Measure 18B

Number of health systems that engage Community Health Workers (CHWs) to link patients to community resources that promote prevention of type 2 diabetes


The purpose of this performance measure is to assess health care system engagement in the prevention of type 2 diabetes via utilization of Community Health Workers (CHWs). Research and practice evidence indicates that CHWs help reduce barriers to care and increase treatment adherence. Their inclusion in disease prevention and management efforts for chronic conditions, including type 2 diabetes, has been associated with improved health outcomes.

Intermediate:

Performance Measure 23

Number of persons with prediabetes or at high risk for type 2 diabetes who enroll in a CDC recognized lifestyle change program


The purpose of this performance measure is to assess grantee efforts to increase the number of people enrolled in a CDC-recognized lifestyle change program. Clinical studies have demonstrated that participating in an evidence-based lifestyle change program often prevents or delays the onset of type 2 diabetes among people with prediabetes or at high risk for type 2 diabetes. (The National Diabetes Prevention Program)

Performance Measure 24

Proportion of adults with high blood pressure in adherence to medication regimens


The purpose of this performance measure is to assess the change in the proportion of adults adherent [i.e., proportion of days covered (PDC) value of 80% or higher as a measure of secondary adherence] with taking their antihypertensive medications (AHMs). The specifications outlined below for this measure involves use of the PDC methodology applied to administrative pharmacy claims data to assess adherence to renin angiotensin system antagonist (RASA) medications. Adherence to RASA medications can be used as a proxy for adherence to all AHMs. This method is supported by the Pharmacy Quality Alliance (PQA) and a similar method is used by the Centers for Medicare and Medicaid Services in their Star Rating methodology. Other methods to assess population-level AHM adherence can be used by the grantee, including use of clinical data, but they must first receive approval to do so by their CDC Evaluator.

Performance Measure 25

Proportion of patients with high blood pressure that have a self-management plan (may include medication adherence, self-monitoring of blood pressure levels, increased consumption of nutritious food and beverages, increased physical activity, maintaining medical appointments)


The purpose of this performance measure is to increase the proportion of patients with high blood pressure who have developed and implemented self-management plans to monitor their blood pressure. Self-measured blood pressure monitoring (SMBP) plus additional clinical support is one strategy that is being promoted by healthcare and public health professionals to improve blood pressure control. SMBP broadly refers to the regular use of a personal blood pressure measurement device that is used by the patient outside a clinical setting (Uhlig K, Balk EM, Patel K, Ip S, Kitsios GD, Obadan NO, et al, 2012). Patient self-management of chronic hypertension has been shown to encourage lifestyle changes that mediate risks related to high blood pressure including weight loss and weight control, increased physical activity, decreased alcohol intake, and increased medication compliance (Fleischmann, 2004; Zarnke, 1997).

Strategy 2.8: Implement systems and increase partnerships to facilitate bi-directional referral between community resources and health systems, including lifestyle change programs (e.g. EHRs, 800 numbers, 211 referral systems, etc.)(See also Bi-directional referral)

Short-term:

Performance Measure 20A

Number of health care systems with an implemented community referral system for evidence-based lifestyle change programs for people with hypertension


The purpose of this performance measure is to assess the increase in the number of health care systems that have implemented a referral system to evidence-based lifestyle change programs for people identified with high blood pressure. Ideally, the referral system will be integrated with an EHR system and will facilitate electronic bi-directional feedback between the evidence-based lifestyle program and the health care system (e-referral system). A bi-directional process considers both the information going from the health care system to the evidence-based lifestyle change program and the information returning from that program to the health care system.

Performance Measure 20B

Number of health care systems with an implemented community referral system to CDC recognized lifestyle change programs for people with prediabetes


The purpose of this performance measure is to assess the increase in the number of health care systems that have implemented a referral system to CDC recognized lifestyle change programs for people identified with prediabetes. (See performance measure 17B.) Ideally, the referral system will be integrated with an EHR system and will facilitate electronic bi-directional feedback between the CDC recognized lifestyle program and the health care system (e-referral system.) A bi-directional process considers both the information going from the health care system to the CDC recognized lifestyle change program and the information returning from that program to the health care system.

Intermediate:

Performance Measure 23

Number of persons with prediabetes or at high risk for type 2 diabetes who enroll in a CDC recognized lifestyle change program


The purpose of this performance measure is to assess grantee efforts to increase the number of people enrolled in a CDC-recognized lifestyle change program. Clinical studies have demonstrated that participating in an evidence-based lifestyle change program often prevents or delays the onset of type 2 diabetes among people with prediabetes or at high risk for type 2 diabetes. (The National Diabetes Prevention Program)

Performance Measure 26

Number of persons with high blood pressure who enroll in an evidence-based lifestyle change program


The purpose of this performance measure is to assess grantee efforts to increase the number of people with high blood pressure enrolled in an evidence-based lifestyle change program. High blood pressure is one of the leading causes of heart disease and stroke. One in 3 U.S. adults has high blood pressure, and half of these individuals do not have their condition under control (Million Hearts, 2015). Persons with high blood pressure are often encouraged to take steps (i.e., lifestyle changes) to lower and control their blood pressure, including eating a healthier diet, managing their weight and increasing physical activity. In addition, clinical studies have demonstrated that participating in an evidence-based lifestyle change program can help control blood pressure in persons with hypertension, thus decreasing their risks for heart disease and stroke.