Category: Health and Health Care

9 - Population Health Management of Prediabetes at the Miami Veterans Affairs Healthcare System

Prediabetes is often a transient condition, progressing to diabetes in most patients. In 2015, over 84 million US adults had prediabetes which will continue to fuel an increasing prevalence of diabetes, currently at 30.3 million US adults, and expected to reach 53 million by 2025.  Effective treatments can delay or prevent diabetes, but are not routinely utilized in Primary Care (PC).  To improve prediabetes management in PC at the Miami Veterans Affairs Healthcare System, we implemented and evaluated the effectiveness of a multi-layered, population-based intervention.

METHODS: Weekly reports generated by the Veterans Affairs electronic medical records (EMR) system identified patients with an upcoming appointment in PC and BMI ≥25 kg/m2, among other criteria. Patients without HbA1c tested in the previous 3 years had a lab order entered by the study team. The intervention targeted patients with high-risk prediabetes (HbA1c 6.1-6.4%) and included entering prediabetes ICD10 code in the EMR, redesigning of patient education materials and lab result notification letter, training of PC providers at staff meetings, electronic notifications, and a new clinical reminder in the EMR. We compared outcomes over one month, before and after the intervention.

RESULTS: 53 patients were diagnosed in the pre-intervention period (age 60.6 ± 9 years); 138 in the post-intervention period (age 59.5 ± 10 years). The intervention increased HbA1c testing and identification of high-risk cases within the target population (45% and 155%, respectively), documentation of prediabetes discussion (37% vs. 53%; p= .06) and discussion of metformin use (4% vs 20%; p= .006) in EMR. Compared to post-visit, a diagnosis entered prior to the PC visit increased documented discussion of prediabetes (77% vs. 30%, p < .001), discussion of metformin use (31% vs. 4%, p < .001), and active orders for metformin (21% vs. 2%; p= .004). 

CONCLUSIONS: This population health approach and, particularly, entry of prediabetes diagnosis before a clinic visit increased discussion of condition and use of metformin. Given risk of conversion to diabetes among high-risk patients, remedies to the treatment gaps in PC are urgently needed. We are currently expanding the program using Whole Health principles, assessment of social determinants of health, and proactive interventions by health coaches, nutritionists and clinical pharmacists.


Jason Dahn

Health Behavior Coordinator
Miami Veterans Affairs Healthcare System

Dr. Dahn is a psychologist interested on behavior changes to improve health.

Kenly Sullivan

Miami Veterans Affairs Healthcare System

Dr. Sullivan is a psychologist whose work focuses on promoting changes in health behavior

Violet Lagari

section chief
Miami Veterans Affairs Healthcare System

Dr. Lagari is an endocrinologist and chief of the endocrine section at the Miami VA Healthcare System.

Silvina Levis

physician investigator
Miami Veterans Affairs Healthcare System

Dr. Levis is an endocrinologist whose work focuses on healthy aging and on the health consequences of hormonal changes that occur with age.

Remberto Rodriguez

Associate Chief of Staff for Ambulatory Care
Miami Veterans Affairs Healthcare System

Dr. Rodriguez is an internist. As Associate Chief of Staff for Ambulatory Care at the Miami Veterans Affairs Healthcare System, he is interested in promoting programs that support health and well-being.

Dominick Rancatore

Miami Veterans Affairs Healthcare System

Mr. Rancatore is a practicing dietitian whose work focuses on weight management and diabetes prevention.

Ana Palacio

phsyician investigator
Miami Veterans Affairs Healthcare System

Dr. Palacio has expertise in remote and in-person behavior modification interventions and in the use of social determinants of health to improve outcomes within a healthcare system.