APHA issues call for team approach to 'skyrocketing' diabetes cases

The American Public Health Association (APHA) has issued a call for a “multisystem” approach to the care of patients with diabetes mellitus, a disease with “skyrocketing” cases that is posing a public health crisis, according to the authors behind its new public health policy.

With the potential to improve patient outcomes, that multisystem or integrated approach means that health care providers—specifically eye doctors, dentists, pharmacists and podiatrists—should team up to manage the care of patients in order to get the best outcomes.

The APHA recommends 17 action steps in its policy statement, which was adopted by its Governing Council in October 2021, following a rigorous approval process. Its adoption was the result of an 18-month collaboration by health care professionals in the various disciplines cited in the public policy statement. The statement, “A Call to Improve Patient and Public Health Outcomes of Diabetes through an Enhanced Integrated Care Approach,” was published online Jan. 7 by APHA.

The APHA’s mission is to improve the health of the public and achieve equity in health status.

“Through early and routine, in-person examinations and consultations, dental care providers, eye doctors, pharmacists, and podiatrists can identify, detect, modify and manage lifestyle programs and medical treatment to reduce conversion to a diagnosis of diabetes and can increase the quality of life of those who have progressed to all levels of disability,” the policy says. “Timely and routine evaluations for lifestyle modification and maximizing appropriate medical therapy are critical.

“In addition to their primary role, health care providers can educate individuals on fundamental lifestyle strategies such as decreasing blood pressure and stress, limiting alcohol use, quitting smoking and improving sleep quality,” the policy adds. “These early interventions will lead to more effective diabetes management, reductions in health care expenses and prevention of the development of diabetes-related disease. Early intervention and prevention of disease are significantly less expensive than managing complications of the disease. Disseminating information regarding publicly available programs can help this cause.”

Annual comprehensive eye examinations were promoted in the policy statement.

Andrew Morgenstern, O.D., was the lead author on the proposed policy statement researched and hammered out by 11 APHA-member health care providers, representing dentistry, pharmacy, podiatry and eye care over an 18-month period. That diverse group of policy writers includes two other AOA members: Andrea Thau, O.D., former AOA president, and Glen Steele, O.D., professor of pediatric optometry, Southern College of Optometry. Dr. Thau served as section councilor and policy chair of the APHA Vision Care Section and helped guide the collaboration and resulting proposed policy statement from start to finish, even casting a vote to pass it as governing councilor.

“All of our professionals (among the proposed policy makers) are saying if we have a patient with diabetes, for best care of the patient, we are going to be on the lookout for problems and refer to other specialists accordingly,” Dr. Morgenstern says. “The goal with diabetes is to find the problems as early as possible and to manage them as rigorously as possible.”

Adds Dr. Thau: “Doctors of optometry play an important role in the battle against diabetes. In 2019, doctors of optometry detected signs of diabetic retinopathy in over 431,000 individuals without a prior diagnosis.”

Grounds for intense concern and response

Diabetes is a major public health concern and a leading cause of death in the U.S. The Centers for Disease Control and Prevention reported that 34.2 million people had been diagnosed with diabetes by 2018 with millions more unaware they have diabetes. Although prediabetes is preventable, public awareness is low, presenting a challenge to care and 70% of cases convert to diabetes, the policy says.

That’s not all patients with diabetes are unaware of.

“People with diabetes are generally unaware of the reciprocal nature of periodontal disease, eye disease, and foot and ankle disease and their strong association with diabetes,” the policy reads.

Action steps

The APHA advocates the action steps, on the federal and state levels, that would lower risk factors for diabetes if adhered to, including:

Federal level

• The APHA calls on accreditation bodies for dental care providers, eye doctors, pharmacists and podiatrists to require curricular content on diabetes early detection, prevention, management and integrated care.
• The APHA recommends that the American Dental Association, the American Dental Hygienists Association, the AOA, the American Academy of Ophthalmology (AAO), the National Pharmacy Association, the American Pharmacy Association and the American Podiatric Medical Association promote integrated care and early referrals for people at risk for diabetes and associated diabetic complications, including testing for associated diabetic risk factors, to decrease morbidity and disability.
• The APHA calls on the Health Resources and Services Administration to support and advocate for integrated electronic health records throughout health care systems for improved patient care and a better-informed clinical care team.
• The APHA calls on the Centers for Medicare & Medicaid Services to expand access to dental care services and eye examinations in the Medicaid and Medicare programs for individuals with diabetes.
• The APHA calls on the U.S. Congress to increase access to preventive dental, eye and foot care for vulnerable populations by eliminating prior authorization requirements and cost-sharing co-payments and to implement sustainable reimbursement schedules.

State/local levels

• The APHA strongly recommends that all educational programs for primary care providers (family practice physicians, internal medicine physicians, physician assistants, nurse practitioners and other public health practitioners) include information on when and how to refer individuals with diabetes for dental, foot and ankle, eye and glycemic control examinations, as well as to whom they should be referred.
• The APHA urges dental care providers, eye doctors, pharmacists and podiatrists to educate the public on the need for regular glycemic evaluation and control and annual in-person, comprehensive eye examinations, foot and ankle evaluations, and dental examinations for individuals at risk for or living with diabetes.
• The APHA recommends that dental care providers, eye doctors, pharmacists, podiatrists and relevant health organizations provide self-management support to reinforce patients’ problem-solving skills with respect to their disease.
• The APHA recommends that all dentistry, optometry, medicine, pharmacy and podiatry clinical education programs stress self-efficacy, short-term action plans, realistic goal setting, and proactive identification of barriers to optimal diabetes control.
• The APHA urges the AOA and the AAO to advocate for in-person, annual, comprehensive eye examinations.

“Seeing four organizations work together on weekly Zoom calls and have a document approved by the (APHA) Governing Council is a huge accomplishment,” Dr. Steele says. “This is a testament to Andy Morgenstern for his lead in writing the policy. Many do not understand the strict requirements to have a policy approved by APHA, and the work of this group led to policy approval.”