Evaluating the Implementation of the Diabetes Prevention Program in an Integrated Health System

High rates of obesity and prediabetes among older adults pose a substantial personal and
societal burden. Among U.S. adults age 60 and older, 35% have obesity and 50% have
prediabetes, placing them at substantial risk for diabetes, cardiovascular disease, certain
types of cancer, and impaired mobility, as well as significantly elevated health care costs.
Implementation of a practical and effective diabetes prevention program at the population
level could have major public health benefits and could also save costs.

DPP intervention was effective in reducing weight and risk for diabetes among older adults.
The Diabetes Prevention Program (DPP) clinical trial conclusively demonstrated that
participation in an intensive behavioral lifestyle intervention consisting of nutrition,
physical activity, and behavioral counseling was more effective in reducing the incidence of
type 2 diabetes and producing clinically significant weight loss than were metformin or
placebo. Participants on average lost 6.8 kg and more than one-third lost 7% or more of their
initial weight at one year follow-up. DPP was particularly effective among participants age
60 and older, in which there was a 71% reduction in the incidence of diabetes compared to 58%
in the larger sample (mean age of 51).

Centers for Medicare & Medicaid Services (CMS) will cover DPP for Medicare beneficiaries. CMS
funded YMCA of the USA to test whether DPP could be successfully delivered by non-physician,
community-based organizations to Medicare beneficiaries diagnosed with prediabetes. Among the
5,696 Medicare beneficiaries who attended four or more sessions, there was a mean weight loss
of 5.27 kg (~5% loss of initial weight) at one year and an estimated savings of $2,650 for
each beneficiary enrolled in the pilot over a 15-month period. In addition, a recent study
demonstrated that DPP delivered using an online program was also effective for Medicare
beneficiaries, who lost, on average, 7.3% of their initial weight over 26 weeks.

Based on these findings, Medicare plans to cover DPP delivered in clinical and non-clinical
settings, including remotely (by web or phone) beginning in 2018. Medicare will reimburse
organizations that implement the Medicare DPP program, a 12-month program that uses the
Centers for Disease Control and Prevention (CDC) approved National Diabetes Prevention
Program curriculum and consists of 16 core sessions delivered over 16-26 weeks and the option
of monthly core maintenance sessions over 6 months if the Medicare beneficiary achieves and
maintains a minimum 5% weight loss of their initial weight.

Feasibility of implementing DPP on a large scale is still unclear. The YMCA and DPP online
studies document the success of community-based DPP programs once people are enrolled.
However, attracting individuals to the DPP and similar lifestyle change interventions remains
a significant challenge. The scalability of both in-person and online programs is also less
certain, particularly in the context of a large health care system hoping to offer Medicare
DPP to potentially tens of thousands of patients. Reach in the YMCA demonstration project
appeared quite high (82.9%); however, this was calculated as the number of participants
attending four or more sessions divided by the number of participants who attended at least
one session. Therefore, only the total number of individuals initially engaged was accounted
for and not the total number at risk for diabetes in the population. Although effective and
possibly easy to scale up, the reach of an online DPP program in an older adult population is
also unknown. Since there was no randomization in the demonstration projects, there is
potential bias in the weight outcomes and retention rates reported. Furthermore, participant
motivation for enrolling or continuing participation was not assessed in the previous
projects and the proposed payment model for Medicare DPP has not been vetted by health care
systems, both of which could have significant implications for the expansion and
sustainability of Medicare DPP.

Inclusion Criteria:

1. Age ≥ 40

2. BMI ≥ 30; and

3. HbA1c 5.7-6.4%.

Exclusion Criteria:

1) Diagnosis of diabetes prior to the study's recruitment efforts