Type 2 Diabetes Case Study

Evidence-Based Practice
Nationally, Type II Diabetes has increased to epidemic proportions. In 2010, it was the seventh leading cause of death in the United States. According to the National Diabetes Statistics Report of 2014, “29.1 million people or 9.3% of the US population have diabetes, with 8.1 million of them being undiagnosed.”1 In addition, the comorbidity conditions associated with diabetes include: high blood pressure, high LDL cholesterol, heart disease/stroke, blindness/eye problems, kidney disease, amputations and other related problems such as: hearing loss, nerve disease, and pregnancy complications. The national financial burden of this disease is impressive. In 2012, the CDCs’ estimated costs of diabetes in the United States were broken down as follows: Direct – medical costs of $176 billion; and Indirect costs: (work

loss, disability, etc.) of $69 billion.

The prevalence and financial burden of diabetes is apparent on a State and local level as well. In 2000, the Wyoming Department of Health commissioned a project to assess the annual cost of diabetes. State-wide the direct costs (medical care) of diabetes were more than $31 million annually and the indirect costs (premature mortality and lost productivity) totaled more than $68 million. With the staggering costs, on the national, state and local level there is a clear benefit to improve diabetes care including a significant costs saving to communities and more importantly an increase in the quality and length of life for people with diabetes. In the past ten years, the number of adult diabetics in Wyoming has almost doubled. In response to this increase, the Wyoming Department of Health created the Diabetes State Strategic Plan 2010-2015. Their official mission statement is to: “Improve the quality of life for those at risk or affected by diabetes in Wyoming.” The five year

objectives of the plan include:

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1. Partner with agencies and organizations to increase awareness of diabetes in those who
have not been diagnosed.
2. Provide diabetes education to patients, families, and the public through at least one public
media avenue per year.
3. Encourage healthy food choices and physical activity to prevent diabetes and reduce
risks of complications.
4. Promote planning, construction and use of community infrastructures that support
healthy lifestyle behaviors.
These goals are supported with the Wyoming Department of Health’s’ current Medicaid program called “Choice Rewards”. “The program offers diabetes-focused education, one-on-one support for living with diabetes, as well as tools to help clients learn how to self-manage the disease. Adult Wyoming Medicaid clients are eligible and can receive a $25 incentive card for every three months of the program they complete.” 2
Evidence based recommendations of diabetes prevention are proven. According to the Diabetes

Journal: “Randomized controlled trials have shown that individuals at high risk for developing

type 2 diabetes (IFG, IGT, or both) can significantly decrease the rate of diabetes onset with

particular interventions. These include intensive lifestyle modification programs that have been

shown to be very effective (∼58% reduction after 3 years).”3 These lifestyle modifications
include nutrition education, monitoring of diet, and a routine exercise program. This type of low-

cost treatment, that relies on behavior change, requires no up-front planning or expense on the
part of the patient and the effects can be substantial. While there are some proactive efforts to reduce the incidence of diabetes on the State level, there is not the same type of response on a local or county level.

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Clinical Preventative Services and Health Promotion
The county hospital recently decided to stop doing their own Health Fairs (leaving only a State-wide organizations’ annual health fair for blood draws for diabetic screening). This is an unfortunate loss of an opportunity to educate the public on many relevant health care issues including diabetes prevention. If reinstituting the hospitals’ health fair is not negotiable, then it is imperative to provide alternative regular, diabetes prevention educational services (and other prevention services) to help keep the citizens of the community well. Managing diabetes effectively is complex and requires a team approach. Currently, there is not a multidisciplinary team approach to patient care, and that includes diabetes prevention. Implementing this type of approach to diabetic prevention could incorporate the same standards and methods used by the professionals that provide education and support to patients with the disease There does exist one diabetic educator through the Wellness Department of the hospital (and she is retiring) and a Diabetes Support group in a nearby town - both for current patients, but no community prevention. In order to effectively address the educational needs of the community with regards to diabetes prevention regular health screenings need to be performed. A possible suggestion for replacing the retiring diabetic educator could be the addition of a Diabetes Prevention Coordinator (also known as a lifestyle coach) in the Wellness Department. The CDC has already created a list of responsibilities and roles for a coordinator position and ways of screening potential patients and educating those that are detected through their Diabetes Prevention Program. A Diabetes Prevention Coordinator could work with other Health Care providers to screen and educate the community using such things as the CDCs’ Prevention Program Pre-Diabetes screening quiz (that is only seven questions long). The Diabetic Prevention
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Coordinator could provide these short quizzes to other community health care providers that share a stake in diabetes prevention and could be a resource for screening potential patients include: Dentists, Eye doctors, Pharmacists and Podiatrists. These professionals are sometimes the front-line or first encounter for patients with suspicious symptoms. A dry mouth, a blister or sores on a foot that won’t heal and retinopathy - all should be investigated further.
Population Health and Community Aspects of Practice.

Communicating information with the public is usually one of the barriers to the delivery of health care services in general. In rural communities there are even more challenges to disseminating information to patients or the public in general, and this includes Converse County. Developing a team approach to diabetes prevention in the community would have to include the use of media. Some media options could be in the form of workshops, informal lectures or presentations in addition to media such as flyers, billboard, newspaper, and radio advertising. It is also imperative to use more current methods of information delivery including social media such as blogs and the Hospital’s own Facebook page; especially since the average age of diagnosis for diabetes is between 45 and 64. One such screening tool that could be applied to the hospitals websites includes the CDC’s free “Diabetes risk widget” which allows individuals to access their own risk of diabetes. Diabetes Prevention is a matter of managing risk reduction. Whether or not a person develops diabetes is a combination of genetics and environment and there are a large number of people in the community that have some of the environmental risk factors including: being overweight or obese and being sedentary. This may
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seem contradictory in a setting where most employment options seem like physical labor (in the oil and gas industry), but most employees run equipment or machinery for 12 hours a day and don’t perform any manual labor. This employee behavior is related to the field of occupational health. Most local employers provide their employees the opportunity to participate in health screenings, including diabetic prevention. These screenings have the potential to help reduce sick days and disability related illness and can be a cost savings to the local companies. The problem is the community connection to education and the necessary behavioral management changes are nonexistent. This could be another opportunity for the hospitals’ ‘Lifestyle Coach” to bridge the gap and provide local employers and employees the venue to change their lives and make healthy choices. Diabetes and its causes have become an international issue as well. According to the World Health Organization: “The number of people with diabetes will more than double over the next 25 years, to reach a total of 366 million by 2030. Most of this increase will occur as a result of a 150% rise in developing countries.”4 The prevalence of diabetes worldwide has a huge socioeconomic global impact as well. This burden makes it more difficult for developing countries to prosper and develop strong economies and ultimately affects our own country and its economy. Diabetes affects people of all races, genders, and socioeconomic status, and although it has grown into a global issue – the first place to affect change and make a difference is in our own communities.
Reflection
The answer to disease and the burdens it places on society and individuals is prevention. Reflecting on my role as a PA-S (and in the future as a Physician Assistant), I feel my role as

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part of an integrated team includes facilitating the creation, implementation and utilization of prevention services to the people of this community. I have been meeting with the Assistant Administrator of the hospital, the Wellness Department, and the Dietician to discuss the possibility of having her incorporate the CDC’s National Diabetes Education program into the Wellness Departments community agenda. This assignment has provided me with an opportunity to present some of my ideas to the staff and I hope to be a participating partner, not only in increasing prevention education in the clinic setting, but also track our progress to prove to the administration and other healthcare providers that it works and benefits us all.