Designing a Natural Experiment to Evaluate a National Health Care–Community Partnership to Prevent Type 2 Diabetes

Navigate This Article

Ronald T. Ackermann, MD, MPH; Ann M. Holmes, PhD; Chandan Saha, PhD

Suggested citation for this article: Ackermann RT, Holmes AM, Saha C. Designing a Natural Experiment to Evaluate a National Health Care–Community Partnership to Prevent Type 2 Diabetes. Prev Chronic Dis 2013;10:120149. DOI: http://dx.doi.org/10.5888/pcd10.120149

PEER REVIEWED

Abstract

To address the growing incidence of type 2 diabetes in the United States, UnitedHealth Group, the YMCA of the USA, and the Centers for Disease Control and Prevention have partnered to bring a group-based adaptation of the Diabetes Prevention Program lifestyle intervention to a national scale. Researchers at Northwestern and Indiana universities are collaborating with these partners to design a robust evaluation of the reach, effectiveness, and costs of this natural experiment. We will employ a quasi-experimental, cluster-randomized study design and combine administrative, clinical, and programmatic data from existing sources to derive reliable, timely, and policy-relevant estimates of the program’s impact and potential for sustainability. In this context, evaluation results will provide information about the unique role of a health care–community partnership to prevent type 2 diabetes.

Top of Page

Introduction

An estimated 79 million Americans have prediabetes and are at high risk for developing type 2 diabetes in the next 5 to 10 years (1,2). Intensive population-based efforts are needed to reduce the development of type 2 diabetes, over a short time, among people who have prediabetes (3). To help address this issue, UnitedHealth Group (UHG), the YMCA of the USA (the Y), and the Centers for Disease Control and Prevention (CDC) have partnered to create a low-cost, group-based adaption of the Diabetes Prevention Program’s (DPP’s) lifestyle intervention for implementation on a national scale.
The DPP clinical trial demonstrated the efficacy of a behavior-based lifestyle intervention to prevent or delay more than half of new cases of type 2 diabetes among adults at high risk (4). Because the DPP promotes healthful diet and moderate increases in physical activity to achieve modest weight loss, it also has benefits beyond diabetes prevention, such as improving other cardiovascular risk factors, reducing health care expenditures, and enhancing well-being (5–9). The DPP’s high programmatic costs and the frequency of ongoing face-to-face visits have made it challenging to implement routinely in the real world (10).
Community delivery of adapted versions of the DPP have demonstrated promise for achieving weight losses consistent with the DPP trial for about one-eighth the cost of the original intervention design (11–13). In 2010, UHG partnered with the Y and CDC to develop 1) standards for recognition of community organizations that offer a program consistent with the DPP; 2) new infrastructures for the training of a nonclinical diabetes prevention workforce to deliver such a population-based program; 3) processes targeting employers, health professionals, and high-risk health plan enrollees to identify people with prediabetes in the general population; and 4) initiatives to encourage such high-risk people to enroll in a community-based DPP intervention. UHG and the Y also collaborated to develop a payment structure that encourages maximal attendance and achievement of at least a 5% weight loss goal for each participant. By combining new analytic and outreach procedures with performance-based payments for the DPP, UHG has constructed a novel preventive-health benefit design that aims to expand the reach and cost-effectiveness of the diabetes prevention programming that the Y offers nationally.
The success of this initiative depends on the efficient identification of high-risk adults in the population and the willingness of those adults to enroll and maintain participation in the program (13). However, the optimal mix of strategies to maximize program participation is unknown, and the potential for financial sustainability of the program depends on whether the health improvements achieved by greater participation in the DPP are associated with reductions in future health care expenditures. Learning whether the costs and benefits of the program are distributed equitably among all high-risk people in the population, regardless of age, race, culture, or economic context, is also important.
UHG, the Y, and researchers at Northwestern and Indiana universities have partnered to design an evaluation of this natural experiment that will be both pragmatic and rigorous. Our aims are to evaluate whether 1) UHG efforts to identify and engage high-risk adults can efficiently promote use of the Y program; 2) participation in this model for DPP delivery results in meaningful weight loss; 3) use of the program reduces the need for medications to treat diabetes, high blood pressure, or high cholesterol; and 4) DPP participants have lower overall health care use and costs.