Financial incentives for diabetes prevention in a Medicaid population: Study design and baseline characteristics

BackgroundMedicaid beneficiaries at high risk for diabetes can benefit from the Diabetes Prevention Program (DPP) lifestyle intervention. The We Can Prevent Diabetes (WCPD) trial examined whether financial incentives are more effective than no financial incentives in sustaining participation in the DPP and increasing weight loss. Here we describe the study design and baseline characteristics.MethodsThe WCPD was a 3-arm group-randomized controlled trial. Medicaid beneficiaries were aged 18 to 74 years, had prediabetes or gestational diabetes, and were overweight or obese. Subjects enrolled from 13 primary care clinics into groups of 8 to 15 participants. Participants received the 12-month DPP delivered by the YMCA or trained clinic staff, free of costs. Participants from groups randomized into the intervention conditions were eligible to receive incentives up to $520 by attending sessions and meeting weight loss goals.ResultsThe WCPD enrolled 1154 participants into 98 groups. Among the 847 attending at least one DPP session, 71.2% were women; the mean age was 48.3 years; 79.3% were obese; and 87.6% entered the study with an elevated HbA1c or fasting plasma glucose. Participants' primary languages were Somali (21.0%), Hmong (3.1%), Spanish (2.2%), or English (72.4%).ConclusionsThe WCPD trial demonstrated that a collaborative approach with primary care clinics and the YMCA can efficiently identify, enroll, and deliver the 12-month DPP to Medicaid beneficiaries. If the WCPD incentive arms increase attendance and weight loss, the use of financial incentives may be an avenue for engaging low-income, high-risk patients in lifestyle change.     

Regression From Prediabetes to Normal Glucose Regulation Is Associated With Reduction in Cardiovascular Risk: Results From the Diabetes Prevention Program Outcomes Study

OBJECTIVE

Restoration of normal glucose regulation (NGR) in people with prediabetes significantly decreases the risk of future diabetes. We sought to examine whether regression to NGR is also associated with a long-term decrease in cardiovascular disease (CVD) risk.

RESEARCH DESIGN AND METHODS

The Framingham (2008) score (as an estimate of the global 10-year CVD risk) and individual CVD risk factors were calculated annually for the Diabetes Prevention Program Outcomes Study years 1–10 among those patients who returned to NGR at least once during the Diabetes Prevention Program (DPP) compared with those who remained with prediabetes or those in whom diabetes developed during DPP (N = 2,775).

RESULTS

The Framingham scores by glycemic exposure did not differ among the treatment groups; therefore, pooled estimates were stratified by glycemic status and were adjusted for differences in risk factors at DPP baseline and in the treatment arm. During 10 years of follow-up, the mean Framingham 10-year CVD risk scores were highest in the prediabetes group (16.2%), intermediate in the NGR group (15.5%), and 14.4% in people with diabetes (all pairwise comparisons P < 0.05), but scores decreased over time for those people with prediabetes (18.6% in year 1 vs. 15.9% in year 10, P < 0.01). The lower score in the diabetes group versus other groups, a declining score in the prediabetes group, and favorable changes in each individual risk factor in all groups were explained, in part, by higher or increasing medication use for lipids and blood pressure.

CONCLUSIONS

Prediabetes represents a high-risk state for CVD. Restoration of NGR and/or medical treatment of CVD risk factors can significantly reduce the estimated CVD risk in people with prediabetes.     

Improving quality in Medicaid: the use of care management processes for chronic illness and preventive care

BACKGROUND: Care management processes (CMPs), tools to improve the efficiency and quality of primary care delivery, are particularly important for low-income patients facing substantial barriers to care. OBJECTIVE: To measure the adoption of CMPs by medical groups, Independent Practice Associations, community clinics, and hospital-based clinics in California's Medicaid program and the factors associated with CMP adoption. METHODS: Telephone survey of every provider organization with at least 6 primary care physicians and at least 1 Medi-Cal HMO contract, Spring 2003. One hundred twenty-three organizations participated, accounting for 64% of provider organizations serving Medicaid managed care in California. We surveyed 30 measures of CMP use for asthma and diabetes, and for child and adolescent preventive services. RESULTS: The mean number of CMPs used by each organization was 4.5 for asthma and 4.9 for diabetes (of a possible 8). The mean number of CMPs for preventive services was 4.0 for children and 3.5 for adolescents (of a possible 7). Organizations with more extensive involvement in Medi-Cal managed care used more CMPs for chronic illness and preventive service. Community clinics and hospital-based clinics used more CMPs for asthma and diabetes than did Independent Practice Associations (IPAs), and profitable organizations used more CMPs for child and adolescent preventive services than did entities facing severe financial constraints. The use of CMPs by Medicaid HMOs and the presence of external (financial and nonfinancial) incentives for clinical performance were strongly associated with use of care management by provider organizations. CONCLUSIONS: Physician and provider organizations heavily involved in California's Medicaid program are extensively engaged in preventive and chronic care management programs.     

Effective Translation of an Intensive Lifestyle Intervention for Hispanic Women With Prediabetes in a Community Health Center Setting

OBJECTIVE

The Diabetes Prevention Program (DPP) demonstrated that weight loss from intensive lifestyle intervention (ILI) in adults with prediabetes could decrease progression to type 2 diabetes. Inner-city, low-income Hispanic women are at high risk for developing type 2 diabetes; however, this type of intervention is not well established in this group. We hypothesized that a DPP intervention modified for a community health center (CHC) setting would decrease weight and improve metabolic measures in Hispanic women with prediabetes.

RESEARCH DESIGN AND METHODS

Women diagnosed with prediabetes on a screening oral glucose tolerance test were recruited from a CHC. Participants (90% of whom were Hispanic) were randomized to either usual care (age 43 ± 9.7 years, BMI 35.2 ± 7.3 kg/m²) or ILI (age 43.8 ± 10.8 years, BMI 35.4 ± 8.5 kg/m²), structured as 14 weeks of group sessions focused on food choices, behavior change, physical activity, and weight loss. One year after enrollment, 122 women repeated baseline measures.

RESULTS

Groups had similar baseline weight, BMI, and fasting and 2-h glucose. One year later, the ILI group had lost 3.8 kg (4.4%), while the usual care group had gained 1.4 kg (1.6%, P < 0.0001). Two-hour glucose excursion decreased 15 mg/dL (0.85 mmol/L) in the ILI and 1 mg/dL (0.07 mmol/L) in the usual care group (P = 0.03). Significant decreases favoring the ILI group were noted in BMI, percent body fat, waist circumference, and fasting insulin.

CONCLUSIONS

A 14-week ILI program based on the DPP can effectively be translated into a predominantly Hispanic CHC setting, resulting in decreased weight, improved fasting insulin, and smaller glucose excursions 1 year after enrolling in the program.     

Development and evaluation of an enhanced diabetes prevention program with psychosocial support for urban American Indians and Alaska natives: A randomized controlled trial

Diabetes is highly prevalent, affecting over 25 million adults in the US, yet it can be effectively prevented through lifestyle interventions, including the well-tested Diabetes Prevention Program (DPP). American Indian/Alaska Native (AIAN) adults, the majority of whom live in urban settings, are more than twice as likely to develop diabetes as non-Hispanic whites. Additionally, prevalent mental health issues and psychosocial stressors may facilitate progression to diabetes and hinder successful implementation of lifestyle interventions for AIAN adults. This 2-phased study first engaged community stakeholders to develop culturally-tailored strategies to address mental health concerns and psychosocial stressors. Pilot testing (completed) refined those strategies that increase engagement in an enhanced DPP for urban AIAN adults. Second, the enhanced DPP will be compared to a standard DPP in a randomized controlled trial (ongoing) with a primary outcome of body mass index (BMI) and a secondary outcome of quality of life (QoL) over 12 months. Obese self-identified AIAN adults residing in an urban setting with one or more components of the metabolic syndrome (excluding waist circumference) will be randomized to the enhanced or standard DPP (n = 204). We hypothesize that addressing psychosocial barriers within a culturally-tailored DPP will result in clinical (BMI) and superior patient-centered (QoL) outcomes as compared to a standard DPP. Exploratory outcomes will include cardiometabolic risk factors (e.g., waist circumference, blood pressure, fasting glucose) and health behaviors (e.g., diet, physical activity). Results of this trial may be applicable to other urban AIAN or minority communities or even diabetes prevention in general.     

Preventing diabetes with digital health and coaching for translation and scalability (PREDICTS): A type 1 hybrid effectiveness-implementation trial protocol

BackgroundDiabetes prevention remains a top public health priority; digital approaches are potential solutions to existing scalability and accessibility challenges. There remains a gap in our understanding of the relationship between effectiveness, costs, and potential for sustained implementation of digital diabetes prevention strategies within typical healthcare settings.PurposeTo describe the methods and design of a type 1 hybrid effectiveness-implementation trial of a digital diabetes prevention program (DPP) using the iPARIHS and RE-AIM frameworks.MethodsThe trial will contrast the effects of two DPP interventions: (1) small group, in-person class, and (2) a digital DPP consisting of small group support, personalized health coaching, digital tracking tools, and weekly behavior change curriculum. Each intervention includes personal action planning with a focus on key elements of the lifestyle intervention from the CDC National DPP. Adults at risk for diabetes (BMI ≥25 and 5.7% ≤ HbA1c ≤ 6.4) will be randomly assigned to either the intervention group (n = 241) or the small group (n = 241). Assessment of primary (HbA1c) and secondary (weight loss, costs, cardiovascular risk factors) outcomes will occur at baseline, 4, and 12 months. Additionally, the trial will explore the potential for future adoption, implementation, and sustainability of the digitally-based intervention within a regional healthcare system based on key informant interviews and assessments of organizational administrators and primary care physicians.ConclusionThis trial of a digital DPP will allow the research team to determine the relationships between reach, effectiveness, implementation, and costs.     

Strategies for the prevention of elderly-onset type 2 diabetes mellitus

The recent medical statistics have revealed that the incidence of type 2 diabetes increased more rapidly in elderly people than that of manhood. Several randomized clinical trials to evaluate the strategies for preventing type 2 diabetes such as Diabetes Prevention Program (DPP), The Finnish Diabetes Prevention Study, The STOP-NIDDM, have been conducted. These studies suggested that a lifestyle intervention and treatment with antihyperglycemic agent inhibit the onset of diabetes in elderly people as well as manhood. However, the evidence for elderly people is not sufficient. The social and physical features of elderly persons should also been taken into account for the strategies to prevent the elderly-onset type 2 diabetes.     

Impact of a supervised multicomponent physical exercise program on cognitive functions in patients with type 2 diabetes

This study evaluated the impact of a multicomponent exercise program on cognitive functions in participants with Type 2 Diabetes. Participants (n = 70, 65.6 ± 5.9 years) engaged in the program (75 min per session; 3 x week) for 32 weeks. A battery of cognitive tests was performed at baseline and study completion. Two groups were formed according to their attendance rate (low and high attendance), and statistical comparisons were computed on their changes in cognitive performance. Such changes were also associated with the attendance rate for all participants. Results showed no significant differences between groups in their change scores, although there were some within-group differences in both groups. Correlation analysis showed that the attendance rate was not associated with cognitive performance changes, except for one variable. As the exercise program did not improve cognitive function, we discuss the potential of future interventions to incorporate dual-task activities merging physical and cognitive stimulation.     

PS1-35: Impact of an ADA-Accredited Diabetes Education on Healthcare Utilization

Background/Aims Diabetes self-management education delivered by certified diabetes educators (CDE) can improve persons' self-management skills, self-efficacy for managing their diabetes, and clinical outcomes among patients with Type II diabetes. In addition, these education programs have the potential to reduce healthcare utilization, costs, and disabilities associated with the disease. Objective The purpose of this study was to measure the impact of Type 2 Diabetes BASICS education program (obtained from the International Diabetes Center in Minneapolis) on healthcare utilization among Scott & White SeniorCare members. The Diabetes Education site at Scott & White is nationally certified by the American Diabetes Association (ADA). Methods This was a retrospective cohort study of participants who attended the education program at a single program delivery site. Subjects were program participants who attended four BASICS class sessions over a six months period between January 2005 and July 2010 and were also enrolled in a Medicare Cost Contract product. About 349 subjects were included in the analysis. The key outcome variables were number of outpatient visits, number of inpatient hospitalization and length of inpatient stay. Differences in average number of outpatient visits, number of inpatient hospitalization, and length of inpatient stay were compared for the 12-months before participants began the education program and the 12-months after the completion. The unadjusted men differences were calculated using paired t-test. Adjusted mean difference in outpatient utilization was estimated from a linear regression and inpatient utilization by negative binomial regression adjusting for patient's age and gender. Results On average, the number of outpatient visits decreased from 8.38 in the year before participants began the program to 7.70 (p=0.04) in the year after they finished the program. In addition, the unadjusted mean number of inpatient admissions per year was significantly reduced from 0.34 to 0.20(p=0.02). The adjusted mean difference in outpatient visits decreased by 0.72 (p<0.001), however, no significant difference was observed for adjusted inpatient utilization. Discussion Health plan members who participated in the ADA-certified diabetes education class showed significant reductions in both outpatient and inpatient health service utilization in the year following class participation compared to the year before their participation.     

Genetic Risk of Progression to Type 2 Diabetes and Response to Intensive Lifestyle or Metformin in Prediabetic Women With and Without a History of Gestational Diabetes Mellitus

OBJECTIVE

The Diabetes Prevention Program (DPP) trial investigated rates of progression to diabetes among adults with prediabetes randomized to treatment with placebo, metformin, or intensive lifestyle intervention. Among women in the DPP, diabetes risk reduction with metformin was greater in women with prior gestational diabetes mellitus (GDM) compared with women without GDM but with one or more previous live births.

RESEARCH DESIGN AND METHODS

We asked if genetic variability could account for these differences by comparing β-cell function and genetic risk scores (GRS), calculated from 34 diabetes-associated loci, between women with and without histories of GDM.

RESULTS

β-Cell function was reduced in women with GDM. The GRS was positively associated with a history of GDM; however, the GRS did not predict progression to diabetes or modulate response to intervention.

CONCLUSIONS

These data suggest that a diabetes-associated GRS is associated with development of GDM and may characterize women at risk for development of diabetes due to β-cell dysfunction.     

Not Only Diabetes but Also Prediabetes Leads to Functional Decline and Disability in Older Adults

OBJECTIVEDiabetes is linked to functional decline, but the impact of prediabetes on physical function is unknown. We aimed to examine and compare the impact of prediabetes and diabetes on physical function and disability progression and to explore whether cardiovascular diseases (CVDs) mediate these associations.RESEARCH DESIGN AND METHODSA cohort of 2,013 participants aged ≥60 from the Swedish National Study on Aging and Care in Kungsholmen, an ongoing population-based longitudinal study, was monitored for up to 12 years. Physical function was measured with chair stand (s) and walking speed (m/s) tests, and disability was measured by summing the numbers of impaired basic and instrumental activities of daily living. Diabetes was identified through medical examinations or clinical records, medication use, or glycated hemoglobin (HbA_1c) ≥6.5%. Prediabetes was defined as HbA_1c ≥5.7–6.4% in participants free of diabetes. CVDs were ascertained through clinical examinations and the National Patient Register. Data were analyzed using mixed-effect models and mediation models.RESULTSAt baseline, 650 (32.3%) had prediabetes and 151 had diabetes (7.5%). In multiadjusted mixed-effect models, prediabetes was associated with an increased chair stand time (β 0.33, 95% CI 0.05–0.61), a decreased walking speed (β −0.006, 95% CI −0.010 to −0.002), and an accelerated disability progression (β 0.05, 95% CI 0.01–0.08), even after controlling for the future development of diabetes. Diabetes led to faster functional decline than prediabetes. In mediation analyses, CVDs mediated 7.1%, 7.8%, and 20.9% of the associations between prediabetes and chair stand, walking speed, and disability progression, respectively.CONCLUSIONSPrediabetes, in addition to diabetes, is associated with faster functional decline and disability, independent of the future development of diabetes. This association may be in part mediated by CVDs.     

An evaluation of cost sharing to finance a diet and physical activity intervention to prevent diabetes

OBJECTIVE: The Diabetes Prevention Program (DPP) lifestyle intervention is a cost-effective strategy to prevent type 2 diabetes, but it is unclear how this intervention could be financed. We explored whether this intervention could be offered in a way that allows return on investment for private health insurers while remaining attractive for consumers, employers, and Medicare. RESEARCH DESIGN AND METHODS: We used the DPP and other published reports to build a Markov simulation model to estimate the lifetime progression of disease, costs, and quality of life for adults with impaired glucose tolerance. The model assumed a health-payer perspective and compared DPP lifestyle and placebo interventions. Primary outcomes included cumulative incidence of diabetes, direct medical costs, quality-adjusted life-years (QALYs), and cost per QALY gained. RESULTS: Compared with placebo, providing the lifestyle intervention at age 50 years could prevent 37% of new cases of diabetes before age 65, at a cost of $1,288 per QALY gained. A private payer could reimburse $655 (24%) of the $2,715 in total discounted intervention costs during the first 3 intervention years and still recover all of these costs in the form of medical costs avoided. If Medicare paid up to $2,136 in intervention costs over the 15-year period before participants reached age 65, it could recover those costs in the form of future medical costs avoided beginning at age 65. CONCLUSIONS: Cost-sharing strategies to offer the DPP lifestyle intervention for eligible people between ages 50 and 64 could provide financial return on investment for private payers and long-term benefits for Medicare.     

Healthy Living Partnerships to Prevent Diabetes (HELP PD): Design and methods

Although the Diabetes Prevention Program (DPP) developed a lifestyle weight loss intervention that has been demonstrated to prevent type 2 diabetes in high-risk individuals, it has yet to be widely adopted at the community level. The Healthy Living Partnership to Prevent Diabetes study (HELP PD) was designed to translate the DPP approach for use in community settings as a cost-effective intervention led by Community Health Workers (CHW's) and administered through a Diabetes Care Center (DCC). Approximately 300 overweight and obese (BMI 25-40 kg/m²) individuals with prediabetes (fasting blood glucose 95-124 mg/dl) were randomly assigned to either a lifestyle weight loss intervention (LW) or an enhanced usual care comparison condition (UC). The goal of LW is ≥ 7% weight loss achieved through increases in physical activity (180 min/wk) and decreases in caloric intake (approximately 1500 kcal/day). The intervention consists of CHW-led group-mediated cognitive behavioral meetings that occur weekly for 6 months and monthly thereafter for 18 months. UC consists of 2 individual meetings with a registered dietitian and a monthly newsletter. The primary outcome is change in fasting blood glucose. Secondary outcomes include cardiovascular risk factors, health-related quality of life, and social cognitive variables. Outcomes are masked and are collected every 6 months. The cost-effectiveness of the program will also be assessed. A community-based program that is administered through local DCC's and that harnesses the experience of community members (CHW's) may be a promising strategy for the widespread dissemination of interventions effective at preventing type 2 diabetes in high risk individuals.     

The short-term impact of a continuing medical education program on providers' attitudes toward treating diabetes

OBJECTIVE: The objective of this study was to evaluate the short-term impact of a 7-h type 2 diabetes continuing medical education (CME) program. Outcomes included a measure of health care providers' diabetes knowledge and the Diabetes Attitude Scale (DAS), a validated measure of attitudes toward diabetes. RESEARCH DESIGN AND METHODS: A CME program on type 2 diabetes was presented by an expert panel in Chicago during November 1998. A before-after trial with pre- and postintervention measurements of diabetes knowledge and attitudes toward diabetes was administered as part of the program. A convenience sample of the 129 health care providers in attendance resulted in 91 (71%) completed pre- and postintervention surveys. RESULTS: Within-subjects analysis revealed increases in knowledge and more favorable attitudes toward diabetes after the program. Between-subjects analysis revealed that attitude changes differed for physicians as compared with allied health care providers. CONCLUSIONS: A CME program was associated with an increase in knowledge of diabetes and more favorable attitudes toward diabetes as measured by the DAS. The DAS changes were subtly different for the physician group as compared with the allied health care provider group. These results suggest that the DAS can be a useful instrument for measuring the short-term impact of educational interventions.     

Analysis of changes in eating behavior and weight loss in type II diabetic patients. Which behaviors to change

To identify the behavior-change strategies that are most clearly related to weight loss, 106 patients with type II (non-insulin-dependent) diabetes completed the Eating Behavior Inventory (EBI) before and after participating in a behavioral weight-loss program and at 1-yr follow-up. The EBI is a standardized questionnaire that assesses behavioral strategies typically taught in a behavioral weight-loss program. Pretreatment scores on the EBI were not related to weight-loss outcome, but changes on the EBI in the direction of more frequent use of appropriate strategies were related to weight loss at both posttreatment and 1-yr follow-up. Specific strategies related to weight loss at both times were 1) eating foods that help in losing weight, 2) recording foods eaten, 3) refusing food offered by others, and 4) being able to stop eating when appropriate. However, few patients maintained frequent use of these strategies at follow-up. It is concluded that weight-loss programs should focus on the strategies most strongly related to weight loss and try to improve long-term use of these techniques.     

Antidepressant Medicine Use and Risk of Developing Diabetes During the Diabetes Prevention Program and Diabetes Prevention Program Outcomes Study

OBJECTIVE

To assess the association between antidepressant medicine use and risk of developing diabetes during the Diabetes Prevention Program (DPP) and Diabetes Prevention Program Outcomes Study (DPPOS).

RESEARCH DESIGN AND METHODS

DPP/DPPOS participants were assessed for diabetes every 6 months and for antidepressant use every 3 months in DPP and every 6 months in DPPOS for a median 10.0-year follow-up.

RESULTS

Controlled for factors associated with diabetes risk, continuous antidepressant use compared with no use was associated with diabetes risk in the placebo (adjusted hazard ratio 2.34 [95% CI 1.32–4.15]) and lifestyle (2.48 [1.45–4.22]) arms, but not in the metformin arm (0.55 [0.25–1.19]).

CONCLUSIONS

Continuous antidepressant use was significantly associated with diabetes risk in the placebo and lifestyle arms. Measured confounders and mediators did not account for this association, which could represent a drug effect or reflect differences not assessed in this study between antidepressant users and nonusers.Our earlier report from the Diabetes Prevention Program (DPP) (1) was the first to examine antidepressant medicine (ADM)-related diabetes risk in an overweight population with elevated fasting glucose and impaired glucose tolerance. We found in the placebo and lifestyle arms that when other factors associated with diabetes risk (age, sex, education, fasting plasma glucose at baseline, weight at baseline, weight change during the study, and depression symptoms at baseline and during the study) were controlled, baseline ADM use and continuous ADM use during the study (compared with no use) were associated with significantly increased diabetes risk; in the lifestyle arm, intermittent ADM use during the study was also associated with increased diabetes risk. Among metformin arm participants, ADM use was not associated with developing diabetes.The present study extends the duration of follow-up in our previous report by including 7 years of the Diabetes Prevention Program Outcomes Study (DPPOS) and providing a median 10.0-year (interquartile range 9.0–10.5) follow-up since randomization to the DPP.     

Translating the Diabetes Prevention Program Into American Indian and Alaska Native Communities: Results from the Special Diabetes Program for Indians Diabetes Prevention demonstration project

OBJECTIVE

The landmark Diabetes Prevention Program (DPP) showed that lifestyle intervention can prevent or delay the onset of diabetes for those at risk. We evaluated a translational implementation of this intervention in a diverse set of American Indian and Alaska Native (AI/AN) communities.

RESEARCH DESIGN AND METHODS

The Special Diabetes Program for Indians Diabetes Prevention (SDPI-DP) demonstration project implemented the DPP lifestyle intervention among 36 health care programs serving 80 tribes. A total of 2,553 participants with prediabetes were recruited and started intervention by 31 July 2008. They were offered the 16-session Lifestyle Balance Curriculum and underwent a thorough clinical assessment for evaluation of their diabetes status and risk at baseline, soon after completing the curriculum (postcurriculum), and annually for up to 3 years. Diabetes incidence was estimated. Weight loss, changes in blood pressure and lipid levels, and lifestyle changes after intervention were also evaluated.

RESULTS

The completion rates of SDPI-DP were 74, 59, 42, and 33% for the postcurriculum and year 1, 2, and 3 assessments, respectively. The crude incidence of diabetes among SDPI-DP participants was 4.0% per year. Significant improvements in weight, blood pressure, and lipid levels were observed immediately after the intervention and annually thereafter for 3 years. Class attendance strongly correlated with diabetes incidence rate, weight loss, and change in systolic blood pressure.

CONCLUSIONS

Our findings demonstrate the feasibility and potential of translating the lifestyle intervention in diverse AI/AN communities. They have important implications for future dissemination and institutionalization of the intervention throughout the Native American health system.Type 2 diabetes, a serious global public health problem, affects disadvantaged populations disproportionately, especially American Indians and Alaska Natives (AI/ANs) (1). In 2009, the age-adjusted prevalence of diabetes for adults eligible for Indian Health Service (IHS) was 16.1%—more than twice that of non-Hispanic white adults (1). Landmark clinical trials, such as the Diabetes Prevention Program (DPP), have showed that lifestyle interventions can prevent or delay the onset of diabetes for those at risk (2–5). In addition, DPP found no significant differences in the reduction of diabetes incidence by race/ethnicity, including in American Indians (4). While under well-controlled circumstances (e.g., clinical trials) lifestyle intervention may have equivalent efficacy across race/ethnicity groups, the effectiveness of implementing such programs in community-based settings among underserved populations remains underexplored. In particular, implementations of large-scale public health interventions in AI/AN communities are plagued by lack of resources, diverse health care settings, and the highly mobile population, all of which are challenges to the successful recruitment, retention, and effectiveness of translational efforts.Translating the DPP intervention into real-world situations has occurred in other settings (6–16), such as urban medically underserved communities (7), faith-based settings (8), YMCAs (9), work sites (10), and primary care practices (11–13). However, most of these were small studies implemented in relatively uniform settings; particularly, none of them included a substantial number of AI/ANs—the U.S. population that suffers most from diabetes (1,17). Given the significant economic and sociocultural diversity of AI/AN communities, it is important to determine the feasibility and effectiveness of such an intervention in a large sample of this population.Mandated and funded by Congress, the IHS implemented the Special Diabetes Program for Indians Diabetes Prevention (SDPI-DP) demonstration project and collected data that allowed an unprecedented investigation of the translational effectiveness of the DPP lifestyle intervention in preventing diabetes across 36 diverse programs, representing rural, reservation, and urban AI/AN communities. This article reports the primary and secondary outcomes of SDPI-DP participants after a follow-up of 3 years.     

The Diabetes Prevention Program: recruitment methods and results

The Diabetes Prevention Program (DPP) is a multicenter randomized controlled trial designed to test whether diet and exercise or medication can prevent or delay the onset of type 2 diabetes in persons with impaired glucose tolerance, who are at increased risk of the disease. This paper describes DPP recruitment methods, strategies, performance, and costs. The DPP developed an organizational structure for comprehensive management and continuous monitoring of recruitment efforts. The DPP utilized a variety of recruitment strategies, alone or in combination, and a stepped informed consent procedure leading to randomization. Studywide and clinic-specific recruitment data were monitored, analyzed, and used to modify recruitment approaches. DPP recruitment was completed slightly ahead of schedule, meeting goals for the proportion of women enrolled and nearly meeting goals for the proportion of racial/ethnic minorities. Clinics varied widely in the recruitment strategies they used, and these strategies also varied by participant age, gender, and race/ethnicity. Staff time devoted to recruitment averaged 86.8 hours per week per clinic, with the majority of effort by staff specifically assigned to recruitment. The number of staff hours required to recruit a participant varied by recruitment strategy. Recruitment cost (excluding staff cost) was about 1075 US dollars per randomized participant. The DPP experience offers lessons for those planning similar efforts: (1) a method for ongoing assessment and revision of recruitment strategies is valuable; (2) a range of recruitment strategies may be useful; (3) the most effective methods for recruiting potential subjects may vary according to the gender, age, and race/ethnicity of those individuals; (4) recruitment strategies vary in the amount of staff time required to randomize a participant; and (5) a stepped screening may make it easier to identify and recruit volunteers who understand the requirements of the study.     

Health plan responses to Medicaid managed care policy in New York City

Nearly all states in the United States have instituted managed care programs to serve Medicaid recipients and are developing policies to increase program participation. State practices regarding managed care contracting, premiums, and enrollment have implications for whether managed care plans will respond in a manner consistent with overall state policy objectives for the Medicaid managed care program. The experience of expanding the Medicaid managed care program in New York City, where the number of Medicaid beneficiaries exceeds the number in all but three states, has provided an interesting opportunity to look at the relationship between Medicaid managed care policy and plan enrollment. This paper analyzes trends in Medicaid managed care enrollment in New York City from January 1991 to September 1998, a period of critical changes in Medicaid managed care policy in New York.