diabetes

Leadership Perspective: Prediabetes Tsunami — We Can’t Just Wait For It to Hit

Editor’s Note: This post is part of the “Leadership Perspectives” series on the Center for Total Health blog —  a collection of guest blog posts from Kaiser Permanente leaders all about why we need to take a Total Health approach.

Today’s guest author is Trina Histon, PhD, senior principal consultant with the Kaiser Permanente Care Management Institute, who shares her thoughts on prediabetes.

 

Few would deny the burden diabetes places on those who suffer from it and their loved ones who support them as they manage this disease. Estimates suggest that Americans with diabetes spend about $6,000 out of pocket per year managing their disease, monies that could be put to other use if we had more comprehensive ways implemented nationwide to prevent diabetes.

Trina Histon, PhD
Trina Histon, PhD

Many liken the next wave of diabetes as a tsunami that will hit the United States and its citizens, so let’s play that analogy through. Recent weather patterns have shown how devastating tsunamis are in the world, so much so, that efforts have been put in place to create sophisticated warning systems. So should another tsunami strike, countries will have advance warning so they are able to evacuate low-lying coastal areas and get people to safety.

In the U.S., the screening equivalent of that warning system for diabetes is an a1C test and the ADA has established a range of 5.7-6.4 as placing the individual in the “prediabetes” range. There are other tests, such as fasting blood sugar, but more and more health care is moving away from fasting blood work as it’s hard for people to fast for long periods of time. So this a1C range is our early warning system, and like most systems, it’s not perfect. In the literature this year, a few articles that discuss diabetes care and BMI have called into question the value of addressing prediabetes. These critiques are valid and perform an important function in both advancing the science and dialogue of where we want to spend our precious health care dollars.

Preparing for a Disaster We Know is on the Horizon

Kaiser Permanente today has 600,000 members with diabetes. We have also developed a cohort of just under one million members with lab values in the prediabetes range. Rather than wait for perfect science on exactly who needs an intervention, we feel ethically that if someone has a risk we should inform them and partner with them to address that risk, should they choose. One of the complexities of determining prediabetes risk is the prediabetes range has varying origins. For example, an a1C of 5.8 does not necessarily mean you will convert to diabetes, but you are at higher risk, and clearly are showing early signs of beta cell damage. What we do see is those with an a1C of 6.0 and higher and with BMIs in the obese range are most likely to convert. We are looking at our own data to see how we can further subtype the prediabetes risk spectrum and then subtype the interventions.

The Powerful Effect of Lifestyle Changes

The good news is lifestyle is the first line of treatment. The original diabetes prevention program (DPP) and subsequent translation trials show that those who lost 5 to 7 percent of their weight and increased their activity to 150 minutes/week prevented or delayed diabetes in 58 percent of participants over a three-year period – and 52 percent over 10 years. For most people, that translates to a 12- to 15-pound reduction, more attainable than the 30-40 percent of weight people might like to lose as reported on consumer surveys.

Spreading Health: Reducing heart attacks and strokes with those at highest risk.

What if there were a simple treatment that was proven to prevent heart attacks and strokes in people with diabetes?

In truth, this isn’t a “what if” scenario.  This exists right now.

In fact, Kaiser Permanente is furthering its reach to low-income populations with this simple treatment that has been preventing thousands of heart attacks and strokes in diabetic patients.

The organization released a video (posted above) to 55 community clinics across the country to help patients understand the significance of a treatment that could save their lives. The video (also available in Spanish) explains about a program – called “ALL/PHASE” – that includes the use of three low-cost medications to reduce heart attacks and strokes.

Since 2007, more than 60 of Kaiser Permanente’s community partners in California, the Northwest, Mid-Atlantic States and Colorado have implemented ALL/PHASE, improving the health of nearly 100,000 low-income diabetic patients.

To learn more about the benefits of the program and community outreach, we reached out to Kaiser Permanente’s Jim Dudl, MD, diabetes clinical lead, Care Management Institute, and Winston Wong, MD, medical director and community benefit director, Disparities Improvement and Quality Initiatives.

How did Kaiser Permanente’s ALL/PHASE program come about?

Dr. Dudl: “The ALL (Aspirin, Lisinopril, and a lipid-lowering medication) initiative was developed by Kaiser Permanente in 2003 to reduce cardiovascular disease among our diabetic patients over age 50 by prescribing the ALL triad of medications. It was critical to us because heart disease and stroke was – and still is – the leading cause of death and disability in the United States and the world. People with diabetes are two to four times more likely to have a heart attack or stroke and 65 percent of those will die from one of those events. But it can be prevented with this very simple and cost effective treatment.

There have a few regional variations to the program over the years to include the promotion of healthy lifestyle changes. Northern California added PHASE (which stands for Preventing Heart Attacks and Strokes Everyday). In Southern California, we have ALL HEART (Heart Smart Diet, Exercise, Alcohol Limits, Rx Medicine Compliance, and Tobacco Cessation Aspirin Lisinopril and Lipid lowering). Whether it’s ALL/PHASE or ALL HEART, the central component is the same, which is the use of the three medications.

What benefits did this program have on Kaiser Permanente members?

Dr. Dudl:  We found that over a three year period, 70,000  Kaiser Permanente members who took both the Lisinopril and the lipid lowering pills lowered their incidence of heart attacks and strokes by more than 60%. The evaluation also proved that if administered to the entire Kaiser Permanente diabetic population, ALL/PHASE would prevent more than 8,000 hospitalizations for heart attacks and strokes each year.

Based on this great success, we knew we wanted to share ALL/PHASE more broadly.

Why did you reach out to community clinics specifically?

Dr. Wong:  Kaiser Permanente is committed to its partnerships with the institutions that serve on the front lines of health care for the uninsured and underserved. These relationships are critical to fulfilling our mission, which is to provide affordable, high quality healthcare services to improve the health of our members and the communities we serve. We do this by investing in quality improvement and population health and support efforts which will transform care and improve health care access for our most vulnerable populations. Sharing our ALL/PHASE initiative is a perfect example of how we can do that.

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