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Diabetes Prevention and Control –A Comprehensive Process
Commissioner John AuerbachMassachusetts Department of Public Health
Like everywhere else, Massachusetts has a growing
diabetes problem
~360,000 diagnosed people with diabetes100,000-140,000 are undiagnosedEven more with pre-diabetes#9 leading cause of deathNew cases of severe complications for 2006
249 cases of blindness701 cases of renal failure1,862 lower extremity amputations
3,800 deaths with diabetes as major contributor
Diabetes in Massachusetts
Sources: Massachusetts Behavioral Risk Factor Surveillance System, Bureau for Health Information, Statistics, Research and Evaluation. Massachusetts Department of Public Health, 2006; Central Register, Report of the Register, Massachusetts Commission for the Blind, 2006.End-stage Renal Disease Network of New England, End-stage renal disease incidence and prevalence for Massachusetts, 2006; Uniform Hospital Discharge Data Set (UHDDS), Massachusetts Division of Health Care Finance & Policy, 2005; MDPH Registry of Vital Records and Statistics, 2006
Prevalence in Massachusetts has increased
4.13.8
4.74.3
3.8
4.9
5.8 5.6 5.86.2
5.6
6.4 6.4
0
1
2
3
4
5
6
7
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
Year
Pe
rcen
t (%
)
Overall
Source: Massachusetts Behavioral Risk Factor Surveillance System, Bureau for Health Information, Statistics, Research and Evaluation. Massachusetts Department of Public Health, 1994- 2006. Note: Estimates have been age-adjusted to the 2000 US Standard Population
Prevalence of Diabetes in Massachusetts, 1994-2006
An Initial Step: Expand efforts to gather and analyze
data
Attention to social determinants of healthAccess to utilization patterns and opportunities for improvementNew focus on costs and potential savings
Obesity and Overweight by Race/Ethnicity, 2006
55.5 54.8
70.9
61.4
31.4
19.520.3
38.2
26.0
0
10
20
30
40
50
60
70
80
MA White, non-Hispanic
Black, non-Hispanic
Hispanic Asian
Pe
rce
nt
(%)
ObesityOverweight
Statistically different from state (p ≤.05)– Red (*) Statistically worse than state- Green (**) statistically better than state
Source: Massachusetts Behavioral Risk Factor Surveillance System, Bureau for Health Information, Statistics, Research and Evaluation. Massachusetts Department of Public Health, 2006.
Source: NEHI/Boston Foundation: Boston Paradox
3+ fold variation
$75,000 +
<$25,000
Substantial Variation in Diabetes Rates by Household Income
Diabetes by Education, 20063.5 time more likely in least educated
6.47.9
15.6
5.44.4
0
5
10
15
20
25
< HS HS grad 1-3 yearscollege
4+ yearscollege
MA
Perc
en
t (%
)
Statistically different from state (p ≤.05)– Red (*) Statistically worse than state- Green (**) statistically better than state
Source: Massachusetts Behavioral Risk Factor Surveillance System, Bureau for Health Information, Statistics, Research and Evaluation. Massachusetts Department of Public Health, 2006. Note: Estimates have been age-adjusted to the 2000 US Standard Population
4.9
11.912.8
5.46.4
0
2
4
6
8
10
12
14
2006
Pe
rce
nt
(%)
Asian/PI Hispanic Black (NH) White Total
Prevalence of Diabetes in Massachusetts Varies Significantly by Race/Ethnicity, 2006
Source: Massachusetts Behavioral Risk Factor Surveillance System, Bureau for Health Information, Statistics, Research and Evaluation. Massachusetts Department of Public Health, 2006. Note: Estimates have been age-adjusted to the 2000 US Standard Population
Mortality Rates are Much Higher for Blacks and Hispanics
Source: MDPH Registry of Vital Records and Statistics, 1994-2006
Mortality rates for diabetes as the primary cause of death, by race, 1994-2006
21.13 20.25 20.84 20.26 20.2114.4
47.843.94 43.02
54.47
46.0842.88
34.34
44.63 42.6145.65
34.66 35.5 36.1
16.71
26.77 25.94
36.142.36
25.7830.66
26.7529.48
24
12.65 15.0811.69 11.26
6.98 8.5
17.41 16.2918.64
18.88
19.18
18.7218.523.77
40.95
19.68
16.67
22.1919.24
0
10
20
30
40
50
60
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
Years
Ra
te p
er
10
0,0
00
White, NH Black, NH Hispanic Asian/Pacific Islander, NH
Health Care Utilization & Morbidity
Diabetes in Massachusetts
Utilization Patterns Highlight DisparitiesDiabetes Hosp. Discharges:2003-2005
133114
368
242
45
0
50
100
150
200
250
300
350
400
Race/Ethnicity
Rate
pe
r 1
00,0
00
MA White Black Hispanic Asian
Source: Uniform Hospital Discharge Data Set (UHDDS), Massachusetts Division of Health Care Finance & Policy, 2003-2005
Room for Improvement in Preventive Care:% Receiving Recommended Care, 2002-2006
66.661.9 60.4 60.5
69.2
75 75
60
90 90
50
69.9
87.2
76.8
70.2
83.0
75.8
0
20
40
60
80
Foot Exam Eye Exam SMBG Flu Vaccine(50+)
Pneumococcalvaccine (65+)
HbA1c
Pe
rce
nt
MA (2002-2006) US (2005) HP 2010
Source: Massachusetts Behavioral Risk Factor Surveillance System, Bureau for Health Information, Statistics, Research and Evaluation. Massachusetts Department of Public Health, 2002-2006
23%
85%
45%
92%86%
70%
36%
79%82%
70%
88%
39%
0%
20%
40%
60%
80%
100%
HbA1c Test Poor HbA1cControl(>9%)
Eye exam Monitoringkidney
LDL-C Test LDL-C<100
Pe
rce
nt
(%)
Mass Commercial MassHealth
Source: MassHealth Managed Care 2007 HEDIS report
Room for Improvement by Payor
Lots of Opportunities to Improve Modifiable Risk Factors
Prevalence of Modifiable Risk Factors That Cause Complications of Diabetes, 2002-2006
43.1 43.8
28.321.9
30.0
20.6
0
10
20
30
40
50
High BP* High Chol* Current Smoker
Pe
rce
nt
(%)
Diabetes No Diabetes
Source: Massachusetts Behavioral Risk Factor Surveillance System, Bureau for Health Information, Statistics, Research and Evaluation. Massachusetts Department of Public Health, 2002-2006
Economic Costs
Diabetes in Massachusetts
6143
4551
01000200030004000500060007000
1998 1999 2000 2001 2002 2003 2005
Source: Division of Health Care Finance and Policy
+35%
Preventable Hospitalizations for Diabetes Have Risen Significantly
The Department’s Diabetes Prevention and Control
Program
Diabetes Guidelines Developed
DPH worked with all insurers to agree on optimal care for diabetes treatmentFocus was on clinical consensus not on guaranteeing coverage was provided
Disease Management and Wellness: Diabetes
Health Care Reform first critical action steps
Health Care Reformovercomes a majorobstacle to accessto care for people with prediabetes and diabetes – 100,000s more receive insurancefor the first time
Document the extent of the obesity epidemic in Massachusetts, including the disproportionate effect on certain populationsHighlight innovative and successful programs across the Bay State and present new action steps
Release a Report on the Problem of Overweight and Obesity
Passage of a Menu Labeling Regulation – provide the tools
Public Health Council has passed a regulation that requires fast food chain restaurants to post the calorie content of their food…at the point of purchase
Passage of a regulation requiring student Body Mass Index collection
Work in partnership with school nurses and local clinical providersInsure consistent and beneficial communication with parents
Comprehensive information on wellnessLinks to local resources and eventsInteractive tools to help individuals set and achieve goals
Utilize an Interactive Wellness Website
Implement an Executive order requiring the purchase of healthful foods with state contracts
Procurement of foods and snack products which meet criteria based on healthful dietary guidelines for state facilities
Expand Workplace Wellness Initiative
MDPH will enroll additional employers in its Wellness Initiative
A toolkit and curriculum is available to all employers
Mission & Vision
Vision: All worksites in Massachusetts will provide social, cultural and physical environments that support optimum employee health and well-being
Mission: the mission of the Massachusetts Worksite Wellness Initiative is to promote worksite wellness through information, training, regulation and technical assistance
Initiative a unique public-private partnership to support health cities and towns
5 foundations, an insurer* and DPH have united to fund municipalitiesProgram model was based on proven, evaluated efforts
* Blue Cross/Blue Shield Corp./ Foundation, Boston Foundation, Harvard-Pilgrim Foundation, MetroWest Foundation, Tufts Foundation
Payment Reform Offers New Opportunities
Reimbursement for a range of new activities - form chronic disease self-management to patient educatorsCreation of pay for performance incentives that are pegged to proper care and outcomes