Clinical Identification and Referral of Adults With Prediabetes to a Diabetes Prevention Program

Christopher S. Holliday, PhD, MPH; Janet Williams, MA; Vanessa Salcedo, MPH; Namratha R. Kandula, MD, MPH


Prev Chronic Dis. 2019;16(6):e82 

In This Article

Abstract and Introduction


Purpose and Objectives: Community programs to prevent or delay the onset of type 2 diabetes are effective, but implementing these programs to maximize their reach and impact remains a challenge. The American Medical Association (AMA) partnered with the YMCA of the USA, as part of a Centers for Medicare and Medicaid Innovation demonstration project, to develop, implement, and evaluate innovative quality improvement strategies to increase routine screening, testing, and referral of Medicare patients with prediabetes to diabetes prevention programs (DPPs) at local YMCAs.

Intervention Approach: AMA recruited 26 primary care practices and health systems in 17 US communities to implement point-of-care and retrospective methods (or a combination of both) for screening, testing, and referral of Medicare patients with prediabetes.

Evaluation Methods: We assessed changes in rates of referral and enrollment of patients among participating practices. We used a mixed-methods pretest–posttest evaluation design to determine if use of certain tools and resources, coupled with systems changes, led to increased screening and referrals.

Results: Practices referred a total of 5,640 patients, of whom 1,050 enrolled in a YMCA DPP (19%; range, 2%–98%). Practices (n = 12) that used retrospective (ie, electronic medical record [EMR]) systems to identify eligible Medicare patients via a registry referred more people (n = 4,601) to the YMCA DPP than practices (n = 10) that used a point-of-care method alone (n = 437 patients) or practices (n = 4) that used a combination of these approaches (n = 602 patients). All approaches showed increased enrollment with point-of-care methods being most successful.

Implications for Public Health: Lessons learned from this intervention can be used to increase diabetes prevention in the United States and support the Centers for Medicare and Medicaid Services (CMS) decision to expand Medicare coverage to include the DPP for all Medicare beneficiaries.


Type 2 diabetes, a highly prevalent and costly disease in the United States, affects more than 25% of the Medicare population, and its prevalence is projected to increase approximately twofold for all US adults aged 18 to 79 by 2050 if current trends continue.[1] An estimated 84 million US adults, about 34% of the population, have prediabetes, but only 12% know they have it.[2,3] Almost half (48.3%) of adults aged 65 or older may have prediabetes.[2,3] Among those with prediabetes, the risk of developing type 2 diabetes may be 5% to 10% annually and 70% over a lifetime.[4] The burden of prediabetes, including its associated risk for heart attack, stroke, and increased medical expenditures, suggests the need for population-based clinical strategies to identify and manage this common metabolic disorder.[5] Thus, the US Preventive Services Task Force recommends diabetes screening for adults aged 40 to 70 who are overweight or obese.[6] Adherence to this recommendation will identify millions of patients with prediabetes who could benefit from a program to prevent or delay type 2 diabetes.

The landmark 2002 Diabetes Prevention Program, a randomized controlled trial, found that an intensive lifestyle change program focused on diet, physical activity, and weight loss reduced the risk of developing type 2 diabetes by 58% among adults aged 18 or older and by 71% among adults aged 60 or older compared with adults on placebo and that the program was significantly more effective for reducing diabetes risk than metformin.[7] The Centers for Medicare and Medicaid Services announced in 2016 that it would begin covering diabetes prevention programs that were part of the Centers for Disease Control and Prevention (CDC) National Diabetes Prevention Program (DPP) for all Medicare beneficiaries beginning in April 2018.[8]