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Diabetes poses a significant challenge to health care providers across the country. According to the Centers for Disease Control and Prevention (CDC), approximately 29.1 million Americans have diabetes (9.3% of the U.S. population), including an estimated 8.1 million Americans with undiagnosed diabetes (CDC 2014). Each year, 1.4 million new cases of diabetes are identified (CDC 2014), with type 2 diabetes (T2DM) accounting for 90-95% of all cases (ADA 2017). Based on recent trends, cases of diabetes are predicted to rise by approximately 165% in the U.S. by the year 2050 (Beltran-Sanchez 2013; Boyle 2001) at which point an estimated 1 in 3 adults in the U.S. will have diabetes (CDC 2010). Moreover, due to the associated microvascular and macrovascular sequelae leading to cardiovascular, ocular, and renal complications, the economic burden of diabetes is great with the most recent national figures estimating yearly expenditure reaching $245 billion and rising (ADA 2013).
Moreover, the “Diabetes/Obesity Belt”, encompassing approximately 15 states in the South and Southeastern U.S., has the highest rates of diabetes and obesity with 11.7% of the population diagnosed with diabetes, compared with 8.5% in other regions of the country (Beltran-Sanchez 2013). According to the Behavioral Risk Factor Surveillance System (BRFSS), in 2015 the South also had the highest prevalence of adult self-reported obesity, ranging between 30% and 35% by state (CDC 2016). These findings suggest a confluence of overlapping risk factors that lead to high rates of obesity, diabetes, and cardiovascular disease in southern regions of the U.S.
The diverse and complex nature of diabetes and its associated cardiometabolic risk necessitates the delivery of evidence-based medical education which emphasizes knowledge, competency and practical translation into clinical practice. Furthermore, primary care providers (PCPs) are uniquely positioned to improve the care of their patients with diabetes since PCPs deliver approximately 90% of diabetes care (Frei 2010). This comprehensive Southern Diabetes Initiative (SDI) approach has been shown to enhance the clinical skills of primary care providers (PCPs) so that they can better prevent, diagnose and manage diabetes, obesity, cardiovascular disease and other diabetes related complications while also addressing the clinical needs and high risk factors often seen in populations such as the elderly, Hispanic, and African-American populations in the Southern region of the U.S.
For over 20 years Pri-Med has been the trusted source for diabetes education for health care professionals across the country. The comprehensive Southern Diabetes Initiative has been a core part of Pri-Med’s educational programming for over 7 years and continues to provide PCPs with diabetes education relevant to their scope of practice and geographic region. Each year this programming is highly anticipated by clinicians who remain eager to learn the newest developments in the diagnosis and management of diabetes and cardiometabolic disease. All activities are developed, created and reviewed in collaboration with world-renowned experts and implemented based on established gaps in knowledge and competence in order to provide high quality content and superior educational experiences which are clinically impactful.
Pri-Med’s clinical team has broad knowledge and experience in virtually all clinical areas of medicine, with significant experience in the area of diabetes education. While Pri-Med’s principal audience includes PCPs and specialists, it also considers the importance of coordinated and integrative care when developing education to meet a multidisciplinary health care team. As such, these educational activities also can target NPs, PAs, pharmacists, nurses and other healthcare professionals as well.
For the past 7 years, the Southern Diabetes Initiative has educated over 25,000 clinicians. In 2016 alone, Pri-Med educated over 58,000 clinicians through multiple channels including live in-person conferences and online at Pri-Med.com. In addition, Pri-med.com realizes over 50,000 visits per month.
By focusing this education on prevention, early assessment and diagnosis, current guideline recommendations and novel and emerging therapies, we thrive in equipping our learners with evidence-based and cutting-edge knowledge that is easily translated into practice so as to improve patient care and health outcomes.
Based on extensive literature search, expert KOL input, analysis of the clinical landscape, and outcomes assessments from previous SDI educational activities, Pri-Med has identified the following gaps:
u PCPs are not alerting patients of their risk of diabetes and are not fulfilling screening recommendations for many diabetes-related complications. Furthermore they often delay making a diagnosis of prediabetes or diabetes
u Sedentary lifestyle and obesity are the main drivers of the increased prevalence of diabetes in the Diabetes Belt, yet PCPs have difficulty addressing obesity issues with their patients
u With annual updates to management guidelines for T2DM, PCPs struggle to incorporate these evidence-based recommendations into the care of patients with T2DM which leads to difficulty in getting patients to glycemic target goals
u With the increasing number of therapeutic agents now available to treat diabetes, PCPs continue to struggle to remain current on how and when to best incorporate these agents into their clinical strategies to better manage diabetes and associated risks
u PCPs continue to struggle to overcome barriers to initiating and intensifying insulin and combining insulin with other antihyperglycemic agents to better meet glycemic target goals
u Prevention and management of cardiovascular and cardiometabolic comorbidities associated with diabetes is suboptimal in the primary care setting, negatively impacting patient health outcomes
Upon completion of this educational activity, participants should be able to:
z NEEDS ASSESSMENT & GAP ANALYSIS
The Centers for Disease Control and Prevention (CDC) estimates that approximately 29.1 million Americans have diabetes (9.3% of the U.S. population), including an estimated 8.1 million people with undiagnosed diabetes (CDC 2014). Each year, 1.4 million new cases of diabetes are identified (CDC 2014) with type 2 diabetes (T2DM) accounting for 90-95% of all cases (ADA 2017). In recent years, T2DM prevalence has substantially increased alongside risk factors, such as advanced age, obesity, and related lifestyle factors. Based on recent trends, cases of diabetes are predicted to rise by approximately 165% in the U.S. by the year 2050, with the largest increases expected among the elderly and African-American community (Beltran-Sanchez 2013; Boyle 2001).
Diabetes is a critical component of cardiometabolic risk and prediabetes is directly related to the development of metabolic syndrome—a combination of abdominal obesity, insulin resistance, hypertriglyceridemia, hypercholesterolemia, and hypertension. The diverse nature of diabetes and cardiometabolic risk necessitates the delivery of competency and performance in practice-based education to enhance the skills of primary care providers (PCPs) since PCPs deliver approximately 90% of diabetes care (Frei 2010). In particular, providers must address the clinical needs of diverse populations of patients at high risk for diabetes and its complications, including elderly patients, Hispanic, and African-American populations in the Southern region of the U.S.
The CDC previously identified a “Diabetes Belt” consisting of 644 counties in 15 states located mostly in the South and Southeastern portion of the U.S. Within this Diabetes Belt, 11.7% of the population has a diagnosis of diabetes, compared with 8.5% elsewhere in the country. People in the “Diabetes Belt” are also more likely to be non-Hispanic African American (23.8% vs. 8.6% in the rest of the U.S.), obese (32.9% vs. 26.1%), and have a sedentary lifestyle (30.6% vs. 24.8%) (Barker 2011). Importantly, the current “Diabetes Belt” overlaps with the “Stroke Belt,” first described in the 1960s as a region of high age-adjusted stroke mortality rates (Liao 2009) as well as the “Obesity Belt”, where there is an alarmingly high prevalence of obesity and overweight. The most recent Behavioral Risk Factor Surveillance System (BRFSS) survey shows that the South has the highest prevalence of adult self-reported obesity, ranging between 30% and 35% by state (CDC 2016). These findings suggest a confluence of overlapping risk factors that lead to high rates of obesity, diabetes, and cardiovascular disease (CVD) in southern portions of the U.S.
Role of Glycemic Control in Preventing Complications of Diabetes
Glycemic control has always been the foundation of effective diabetes care, and studies suggest that intensive efforts to control blood sugar can alleviate or mitigate the numerous health consequences of diabetes. The landmark United Kingdom Prospective Diabetes Study (UKPDS) demonstrated that intensive glycemic control prevents or delays microvascular complications in diabetic patients (UKPDS 1998) in addition to improving macrovascular outcomes (UKPDS 1998). Long-term follow-up data studies from the UKPDS have demonstrated that early intensive glycemic control can reduce the risk of myocardial infarction and all-cause mortality (Holman 2008). Meta-analyses of the ACCORD, ADVANCE, and VADT trials have shown that intensive glycemic control is associated with a reduced risk of nonfatal myocardial infarction as well (Macisaac 2011; Tandon 2012).
Vascular inflammation, which is associated with prediabetes and diabetes, plays a major role in the development of CVD. The significance of these findings, especially on cardiovascular health, cannot be underscored enough since CVD accounts for approximately 50% of deaths in those with diabetes (Holden 2014). Adults with diabetes have heart disease and stroke death rates that are two to four times higher than those of adults without diabetes (Chiha 2012). These macrovascular complications of diabetes are in addition to the significant morbidity and mortality created by the microvascular complications of diabetes. Diabetes is the leading cause of end-stage renal disease, new cases of blindness among adults age 20 to 74 years, and non-traumatic lower-limb amputations in the U.S. (CDC 2014; UKPDS 1998). These alarming data support the need for interventions in the Diabetes/Stroke/Obesity Belt regions to address the macro- and micro-vascular complications of patients with diabetes and cardiometabolic risk.
Despite a strong focus on diabetes management in the U.S., epidemiologic and clinical studies continue to show that fewer than half of patients with diabetes achieve recommended hemoglobin A1c (HbA1c) goals (ADA 2017). According to the national State of Health Care Quality Report about 35% to 39% of adults between 18 and 75 years of age diagnosed with diabetes had their HbA1c level under optimal control, defined as <7% for a selected population (NCQA 2015). The proportion of individuals whose HbA1c levels were uncontrolled, defined as >9.0%, ranged from 24.9% to 43.6%, depending on the insurer data evaluated (NCQA 2015). Multiple studies have shown that HbA1c control rates are even lower among ethnic populations in the U.S., including Hispanics and African Americans (Egede 2011; Heisler 2007).
While intensive glycemic control has been a common focus, newer approaches to diabetes management stress a more personalized or individualized approach to patient management instead of a "one-size-fits-all" strategy. This has been emphasized in the American Diabetes Association (ADA) guidelines, including the most recent update to the Standards of Medical Care in Diabetes—2017 (ADA 2017) as well as the American Association of Clinical Endocrinologists (AACE) and American Association of Endocrinology (ACE) 2017 Comprehensive Type 2 Diabetes Management algorithm (Garber 2017).
Diabetes and CVD are closely related conditions that share many of the same risk factors. Taken together, the findings above suggest that a comprehensive approach that includes improved treatment of diabetes and its complications, careful attention to cardiovascular risk factors such as obesity, hypertension and dyslipidemia, and interventions to improve modifiable risk factors such as poor diet and lack of physical activity could substantially improve the health of individuals living in the Diabetes/Obesity Belt of the Southern U.S. The following needs assessment describes knowledge, competence, and practice gaps that contribute to less-than-optimal care for individuals with diabetes and cardiometabolic risk or disease. Education that addresses these gaps, directed towards those who most often treat these conditions, will improve patient health outcomes and quality of life for this growing and vulnerable population.