Reducing the Burden of Diabetes Mellitus in the State of Missouri: A Call to Action

Background

Diabetes mellitus is a major national health concern due to the burden of disease in terms of prevalence, complications, increased mortality, and cost. The state of Missouri is no exception, with diabetes mellitus being identified as a high priority for prevention and treatment by Missouri legislature and the Missouri Department of Health and Senior Services (DHSS).¹ In the 2014 legislative session, a “Diabetes Care and Control” amendment to the public health bill (SB 716) introduced by Representative Diane Franklin requires MO HealthNet and the DHSS to “collaborate to coordinate goals and benchmarks associated with diabetes.”

Furthermore, the bill mandates a report on the status of diabetes care in Missouri every two years. The first of these biannual reports was published in January 2015 and provides a comprehensive review of diabetes care and strategic goals from the DHSS. Prevalence of diabetes varies across individual communities and counties, but Missouri has an overall prevalence of diagnosed diabetes mellitus in adults of 11.1% in 2014.²

Over 25% of people with diabetes are not diagnosed³, and thus the actual prevalence of diabetes in adults in Missouri is about 15%. Furthermore, over a third of adults have prediabetes (blood glucose higher than normal, but not high enough to diagnose diabetes). For the state’s six million residents⁴, that equates to about 700,000 individuals with diabetes (of whom 170,000 are undiagnosed) and another 1.4 million with prediabetes (of whom 90% or more are unaware of their condition).

This burden of diabetes mellitus and prediabetes in our state is staggering in terms of impact on health and health care costs. This burden is even heavier in some racial and ethnic groups and older age groups. Both diabetes mellitus and prediabetes increase with age, such that a quarter of the population over age 65 has diabetes mellitus, and half have prediabetes. Geographically, the largest relative burden of diabetes and prediabetes is in the southeast area of the state. (See Figure 1.) Prevalence of diagnosed diabetes is over 18% in three counties in this region (Carter, Pemiscot, and Washington), based on the 2011 County-level Study funded by the Missouri Foundation for Health.⁵

Figure 1.

Prevalence of Diabetes in Missouri Counties, 2011 (5)

County-Level Study funded by the Missouri Foundation for Health

Reproduced by permission from the Missouri Department of Health and Senior Services

Although progression of prediabetes to diabetes mellitus rates varies by age, race/ethnicity, and degree of impaired glucose metabolism, it is estimated that between 15% and 30% will develop diabetes within five years if left untreated. Using a more conservative estimate of 20% progression of prediabetes to diabetes mellitus over 10 years⁶, approximately 280,000 adults in Missouri are at high risk for this progression to diabetes mellitus.

Economic Costs

Nationally, the economic burden of diagnosed diabetes mellitus⁷ is $245 billion, with $176 billion in direct costs, and an additional $69 billion in indirect costs due to reduced productivity (missed days of work, lower productivity while at work, inability to work, etc.). Health care spending on people with diagnosed diabetes accounts for over one in five of health care dollars. Most of the health care expenditures are on inpatient hospital stays and diabetes medications and supplies. Spending on physician office visits accounts for less than 10% of health care spending on diabetics. The average cost of care for an individual with diabetes is over twice that of one without diabetes.

The cost of care for people with diagnosed diabetes is only part of the cost of elevated blood glucose.⁸ Individuals with undiagnosed diabetes, prediabetes, and gestational diabetes also have increased direct and indirect costs. Nationally, in 2012, the annual burden of excess cost averaged $10,970 per person for those diagnosed with diabetes, $5,800 for those with gestational diabetes, $4,030 for those with undiagnosed diabetes, and $510 for those with prediabetes. This makes the total annual cost of care for elevated blood sugar $322 billion ($244 billion direct costs and $78 billion indirect costs), which is $77 billion over the excess cost of care for just those with diagnosed diabetes. Part of this additional cost is due to the fact that complications of elevated glucose, especially cardiovascular complications, start at glucose levels below the threshold for diagnosis of diabetes.⁹ The estimated total excess costs of care for people with elevated glucose levels in Missouri is just over $5.9 billion. (See Table 1.)⁸

Table 1.

Excess health care costs in Missouri in 2012 due to elevated glucose.

Condition	Direct Costs in Millions	Indirect Costs in Millions
Diagnosed Diabetes Mellitus	$3244	$1,243
Undiagnosed Diabetes Mellitus	$439	$164
Prediabetes	$817
Gestational Diabetes Mellitus	$20

Adapted from Dall et al., Diabetes Care, 20148

In regard to the health complications of diabetes mellitus, the microvascular (retinopathy, neuropathy, and nephropathy) and macrovascular (stroke and myocardial infarction) complications are well known. Lower extremity amputations result from a combination of microvascular and macrovascular processes. Diabetes mellitus is present in over half of the adults who have non-traumatic lower extremity amputations, and is the primary cause of nearly half of new cases of renal failure.³ Rates of myocardial infarctions, strokes, and death from cardiovascular disease are one-and-a-half to two times more common in people with diabetes mellitus than those without. Diabetes mellitus is the seventh leading cause of death, both nationally and locally¹⁰, but is likely underreported on death certificates as an underlying cause to mortality. Cause of death¹¹ is more likely to be hyperglycemia crisis (i.e. ketoacidosis) or hypoglycemia in type 1 diabetes (T1D), and more likely to be due to cardiovascular disease¹² in type 2 diabetes (T2D). Individuals with T2D have a high prevalence of co-morbidities that contribute to cardiovascular morbidity and mortality, specifically hypertension, hyperlipidemia, and tobacco use. Seventy-one percent of adult diabetics have elevated blood pressure and 65% have hyperlipidemia.³ Hypertension management deserves special mention, since it is a contributing cause to both microvascular and macrovascular complications. Hypoglycemia also deserves special mention as it is increasingly recognized and tracked as a complication. Hypoglycemia accounted for over a quarter of a million emergency visits³ in 2011 and is the major limitation to tight control of glucose levels, especially in individuals on insulin therapy, the very young, the very old, and those with a longer duration of diabetes.¹³ Hypoglycemia is suspected in contributing to cardiovascular deaths in older individuals with more severe atherosclerosis.

In Missouri in 2013, diabetes accounted for 42% (857 out of 2,058) of individuals newly diagnosed with end stage renal disease (14), 73% (1,988 out of 4,135) of lower extremity amputations, and 4,135 emergency room visits with hypoglycemia as the principal diagnosis.¹

Improving Outcomes

Despite the dramatic increase in obesity and T2D over the past 25–30 years¹⁵, there is reason for hope that the burden of diabetes can be effectively addressed in our community. Based on research over the past two to three decades, we have good evidence-based approaches to both prevention of T2D, as well as treatment of T1D and T2D to reduce complications. Much of this research was publicly funded, especially by the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH). The evidence-based practice guidelines that have resulted provide an excellent example of how federally funded research can impact important health issues that affect a large segment of the population. Furthermore, this research spans both population health approaches as well as clinical care.

Medical Care Improvement

In regard to improving clinical care of diabetes, the Diabetes Control and Complications Research Group¹⁶ and the UK Prospective Diabetes Study Group¹⁷ provided definitive evidence that good glucose control reduces the rate of microvascular complications in both T1D and T2D. Despite the strong correlation between elevated glucose levels and cardiovascular disease¹² there is limited evidence that glucose control impacts cardiovascular outcomes, especially in relation to the impact of other risk factor interventions. Lifestyle modification, hypertension management, lipid-lowering therapy, and tobacco cessation are the most critical interventions in reducing cardiovascular morbidity and mortality, and there is good evidence of success in these approaches. Although certainly multifactorial causes are at work, diabetes complications dropped dramatically from 1990 to 2010, especially in acute myocardial infarction, which decreased about 68% among adults in the US.¹⁸ The good news is that implementing standards of care¹⁹ makes a difference in outcomes. Unfortunately, nearly half of adult diabetics²⁰ are not at treatment goals. Thus, there is significant opportunity to improve care and outcomes even more.

Prevention and Lifestyle Modification

There is also good news in regard to prevention of T2D. Adults at increased risk of T2D and prediabetes can be predicted based on good screening tools, including simple questionnaires from the CDC (http://www.cdc.gov/diabetes/prevention/pdf/prediabetestest.pdf) and the American Diabetes Association (http://www.diabetes.org/are-you-at-risk/diabetes-risk-test/?loc=atrisk-slabnav).

Prediabetes is defined as a glycated hemoglobin of 5.7%–6.4%, a fasting glucose of 100–125 mg/dl, or 2-hour oral glucose tolerance test of 140–199 mg/dl. The National Diabetes Prevention Program (DPP) demonstrated that lifestyle modification can reduce the risk of progression to T2D by 58% through 150 minutes of physical activity weekly and modest weight loss.²¹ The effect is even more pronounced in older adults, with a 71% reduction in risk in those over age 60. Recent reviews of combined physical activity and diet programs by the Community Preventive Services Task Force for individuals at risk for T2D provide evidence that these programs are both clinically effective²² and cost effective.²³ The US Preventive Services Task Force (USPSTF)²⁴ now recommends (Grade B) behavioral counseling on diet and exercise to reduce cardiovascular disease in those at higher risk (including obesity, hypertension, and diabetes). In October 2015, the USPSTF finalized new screening guidelines for prediabetes and T2D; it supports screening for prediabetes and T2D for individuals at high risk²⁵ http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/screening-for-abnormal-blood-glucose-and-type-2-diabetes). The USPSTF recommendations are of great importance to the clinical practice community, payers, and the public, as they form the basis for the required full coverage of preventive services by private plans under the 2010 Patient Protection and Affordable Care Act.²⁶ The current list of required coverage for preventive services includes screening for T2D in individuals with hypertension and diet counseling for those at “higher risk for chronic disease.” (The full list of required preventive services is available at https://www.healthcare.gov/preventive-care-benefits/.) The median costs of behavioral intervention programs are approximately $500 per person, and vary by location and setting.²³

The CDC certifies DPP programs that are year-long, intensive behavior modification programs. In the Kansas City area, the YMCA is currently the only CDC-certified DPP provider, with programs available throughout the metropolitan region. The Social Welfare Board provides services at their free clinic in the St. Joseph area. In the St. Louis area, there are three CDC-certified DPP providers, including Community Health-In-Partnership Services, Gateway Region YMCA, and the Community Wellness Project. The contact information of these providers can be found at the CDC website: https://nccd.cdc.gov/DDT_DPRP/Registry.aspx?STATE=MO There are also online or combination in-person/online DPP programs, which can also be found at the CDC website: https://nccd.cdc.gov/DDT_DPRP/City.aspx?STATE=OTH&CITY=OTH

With the increasing evidence of effectiveness of behavioral interventions, an increasing number of payers are covering behavior modification programs for prevention (including the YMCA DPP and other programs), and employers are increasingly providing programs in the workplace and incentives for lifestyle modifications. In March 2016, Health and Human Services Secretary Sylvia M. Burwell announced that Medicare will cover the DPP based on the report of the Office of the Actuary in the Centers for Medicare & Medicaid Services (CMS) that certified the cost effectiveness of the DPP (https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/ActuarialStudies/Downloads/Diabetes-Prevention-Certification-2016-03-14.pdf). Currently, the State of Montana Medicaid Program covers the National DPP, and many other states are in varying stages of work on getting their Medicaid participants covered. The Missouri Department of Health and Senior Services is working with MO HealthNet Division, Missouri Consolidated Health Care Plan and county and city governments to explore the possibilities to have Medicaid participants, and state, county and city government employees covered.

The CDC and the American Medical Association (AMA) are working together to encourage health care professionals to refer patients with prediabetes to CDC-recognized lifestyle change programs by creating a toolkit to make it easier for health practices to incorporate screening, testing, and referrals. The tool kits can be found at http://www.cdc.gov/diabetes/prevention/pdf/STAT_Toolkit.pdf. In January 2016, the CDC, the AMA, the American Diabetes Association, and the Ad Council jointly launched a national campaign with public service announcements to raise the awareness of prediabetes (http://www.cdc.gov/media/releases/2016/p0121-prediabetes.html). Missouri DHSS also launched a large media campaign to raise awareness of prediabetes and the national DPPs among healthcare providers, people at higher risk for diabetes, and the general public in 2016.

Public Health Impact

Public health departments are increasingly addressing chronic disease prevention and management, including diabetes mellitus. A recent survey of local health departments in Missouri²⁷ reveals that our local health departments are very engaged in diabetes prevention through implementation of evidence-based practices in nutrition education, access to healthy foods, promotion of physical activity, and workplace initiatives for their own employees. Nutrition counseling deserves special mention with the increasing evidence that drinking sugar-sweetened beverages over time increases risk of T2D independent of obesity.²⁸ Health departments are also engaged in addressing the up-stream social and environmental factors that influence development of prediabetes, diabetes mellitus, and the related obesity epidemic. There is increasing evidence that the surge in these conditions goes well beyond the individual and is driven by socioecological conditions in communities, workplaces, and schools.²⁷ Poverty is a predictor of lower health status, and there may be multiple factors in low-income neighborhoods that contribute to obesity and diabetes, but environments that support physical activity may be especially important²⁴, and simply moving from a neighborhood with a high level of poverty to a lower level of poverty may reduce obesity and diabetes.²⁹

The Role of Physicians in a Combined Medical/Public Health Model

Reducing the burden of diabetes in our community will require continuing both public health and clinical approaches.³⁰ Physicians have a critical role in reducing this burden, both on the clinical side with the care of individual patients to screen, diagnosis and treat both prediabetes and diabetes, but to also engage with health departments, the public, and elected officials on health policy and promotion of neighborhoods and communities with socioecological environments that support health in general. Physicians do embrace their public roles, with one survey indicating that 90% of physicians regard public service as important; the majority participate in public activities; and that they consider their role in socioeconomic issues that affect health as very important.³¹ The efforts to reduce tobacco use over the past 50 years are an example of a successful partnership between physicians and public health to address an important health issue.³² These efforts are continuing, and are especially important in reducing cardiovascular complications, since tobacco use and abnormal glucose are additive in cardiovascular risk.

In Missouri, there are an estimated 2.1 million individuals with diabetes mellitus and prediabetes, combined, including both diagnosed and undiagnosed. Effective diabetes prevention and treatment programs could potentially reduce morbidity and mortality through decreasing risk of complications, as well as prevent progression to diabetes mellitus in the 1.4 million of Missouri adults with prediabetes. The health and economic impact of improving prevention and treatment is profound. The specific actions physicians can take are in screening, treatment, assessment of quality, public health, and policy:

Screening

Patients at high risk for diabetes and prediabetes should be screened. There are effective behavior intervention programs in the community for prevention of progression of prediabetes to diabetes, and there is a good toolkit (Prevent Diabetes STAT) for physicians for screening and referral developed by the CDC and AMA (preventdiabetesstat.org). The behavioral approaches are increasingly available in the community and in the workplace, and are increasingly covered by payers. It is especially important to screen patients with other cardiovascular risk factors, including hypertension, hyperlipidemia, and tobacco use.

Treatment

Each patient with diagnosed diabetes mellitus should have an individualized treatment plan to prevent risk of complications based on evidence-based guidelines. Use of these guidelines and implementation of chronic disease care strategies to prevent complications have proven to be effective over the past two decades, but there is still ample room to improve quality of care.

Assessment

Quality of care for both individuals and populations of patients should be continually assessed, so that care can be continually improved. Electronic health records and clinical registries can be helpful in assessing quality of care outcomes. Physicians must participate in the development and implementation of appropriate quality measures, and we must evaluate approaches to quality in the context of pragmatic, scalable, and sustainable clinical care.

Public Health

Physicians, health departments, and other community agencies need to partner on access to community services for health, nutrition, and physical activity. The diabetes epidemic and related obesity epidemic cannot be resolved by clinical treatment of individuals alone, and must include meaningful, sustained partnerships with public health and utilization of community resources for broad community lifestyle changes around nutrition and physical activity. Physicians should support and advocate for health departments in their mission to address the socioecological environment for health at the local, state, and national levels.

Policy

Physician participation in policy development is essential and is a key responsibility of physician professionalism. This participation can occur through the legislative process, through work with associations, and through serving as experts. It includes not only direct health policy, but also policy related to economic development, education, transportation, housing, safety, etc. Hospitals, payers, health departments, and the public are our partners in advocating for policies that support healthy communities broadly defined.

Summary

Diabetes mellitus places a staggering health and economic burden on communities across the United States, including Missouri. Based on good evidence from publically and privately funded research, there is much that has been done in the past two decades to understand treatment and prevention of diabetes mellitus. There is also much left to be done to apply that understanding. Physicians are critical to devising and implementing solutions that will work in our own region, and public health departments, employers, hospitals, payers, and the public are eager to work with us toward those solutions.

Biography

Betty M. Drees, MD, FACP, FACE, (left), MSMA member since 2000 and Missouri Medicine Contributing Editor, is Professor of Medicine and Dean Emerita at the University of Missouri-Kansas City School of Medicine in Kansas City, Missouri. Shumei Yun, MD, PhD, (right), is a State Chronic Disease Epidemiologist, Office of Epidemiology, Missouri Department of Health and Senior Services Jefferson City, Missouri.

Contact: DreesB@umkc.edu