gms | German Medical Science

Background: Preventable chronic diseases such diabetes impose a high burden on patients and are a major threat for the financial sustainability of many European health care systems. The US diabetes prevention program (DPP) study and subsequent translational trials have shown that a 16-lesson lifestyle intervention focused on weight loss and physical activity reduces the diabetes incidence substantially and that this effect is sustained over more than 15 years. Economic analyses have further shown that these programs are highly cost-effective or cost-saving in the long-term. Despite this robust evidence on the DPP’s feasibility, effectiveness and cost-effectiveness lifestyle programs were rarely translated into clinical and public health practice. With the National Diabetes Prevention Program the US Centers for Disease Control and Prevention (CDC) initiated a strategy to implement lifestyle based diabetes prevention in communities across the country.

Research Question: Goal of this study is to analyze the NDPP in the US, the context of diabetes prevention in Germany, and the potential of translating the US NDPP to the German health care system.

Methods: I reviewed published studies and repots, as well as governmental webpages and other online sources concerning data and information related to the NDPP in the US and the policy context for diabetes prevention in Germany. Subsequently, I synthesized information on the NDPPs’ implementation history and strategy, its content, spread and reimbursement as well as general barriers of implementation on the US side and the policy context and pilot projects related to life-style based prevention approaches in Germany.

Results: Driven by the clinical evidence on the effectiveness of life style intervention in the US the CDC started in the 2000ers to partner with potential payers and providers of life style programs and drafted a framework for a national implementation program. Under the Prevention and Public Health Fund of the Affordable Care Act the US Congress mandated and funded the CDC to launch the National Diabetes Prevention Program. The NDPP is a national public-private partnership connecting providers, payers, health systems, local health departments and physicians to upscale the delivery of DPP-based lifestyle interventions in community settings. It is based on four pillars: training of workforce for efficient delivery in communities, a recognition program that audits and certifies DPP sites for quality assurance, the development of intervention sites and a health marketing program to support program uptake. The life-style programs are predominantly delivered in person by non-medical organizations in community settings such as the Young Men’s Christ Association. Until 2018, the intervention was delivered to more than 160,000 people at more than 1,600 CDC recognized sites. Data from the NDPP registry suggests that the achieved weight loss is comparable to the one in the major trials and that uptake is highest in non-Hispanic white. Currently, several employers, private payers and some State Medicaid programs pay for the DPP and Medicare will start to pay April 2018. The biggest barriers for large scale implementation are the reluctance of many payers to reimburse for the DPPs, the lack of structured referral mechanisms to non-medical proviers and the contracting between public and private payers and non-for profit, non-medical delivery organizations.

In Germany, diabetes self-management training for people with diabetes but not diabetes prevention programs is reimbursed by statutory health insurances. Recently, a DPP-like lifestyle program has been pilot-tested by three large sickness funds and the Association of Statutory Health Insurance Physicians Schleswig Holstein, but hasn’t been launched on a population level. With the numerous certified diabetes coaches and diabetes assistants a trained workforce would be available to deliver preventive life-style programs in medical and non-medical settings. Several ongoing trials such as the Prevention Lifestyle Intervention Study (PLIS) will further provide evidence on the feasibility and (cost-) effectiveness of lifestyle-based diabetes prevention in the German health care system.

Discussion: The US NDPP shows successfully that the integration of lifestyle based chronic disease prevention into a complex health care system is feasible, but that it requires political buy-in, sufficient funding and a national strategy. The ‘German national diabetes plan’ requested by the “Bundesrat” (upper house) and expected to be passed in the current legislation period might provide a leverage for a comprehensive, more prevention oriented diabetes strategy.

Practical Implications: Given the available evidence from the US-NDPP, the integration of life-style programs for chronic disease prevention should be considered as an important add-on to the discussed environmental and fiscal prevention strategies.