ACTIVITIES OF MEMBER ORGANIZATIONS
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Agency for Healthcare Research and Quality (AHRQ)		National Institute of Allergy and Infectious Diseases (NIAID)
Center for Scientific Review (CSR)		National Institute of Biomedical Imaging and Bioengineering (NIBIB)
Centers for Disease Control and Prevention (CDC)		National Institute of Child Health and Human Development (NICHD)
Centers for Medicare & Medicaid Services (CMS)		National Institute of Dental and Craniofacial Research (NIDCR)
Department of Health and Human Services (DHHS) • Office of Minority Health (OMH)		National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)
Food and Drug Administration (FDA)		National Institute of Environmental Health Sciences (NIEHS)
Health Resources and Services Administration (HRSA)		National Institute of General Medical Sciences (NIGMS)
Indian Health Service (IHS)		National Institute of Mental Health (NIMH)
National Center for Complementary and Alternative Medicine (NCCAM)		National Institute of Neurological Disorders and Stroke (NINDS)
National Center for Health Statistics (NCHS), CDC		National Institute of Nursing Research (NINR)
National Center for Research Resources (NCRR)		National Institute on Aging (NIA)
National Center on Minority Health and Health Disparities (NCMHD)		National Institute on Alcohol Abuse and Alcoholism (NIAAA)
National Eye Institute (NEI)		National Institute on Deafness and Other Communication Disorders (NIDCD)
National Heart, Lung and Blood Institute (NHLBI)		National Institute on Drug Abuse (NIDA)
National Human Genome Research Institute (NHGRI)		National Library of Medicine (NLM)
		Veterans Health Administration (VHA)

Agency for Healthcare Research and Quality (AHRQ)
http://www.ahrq.gov

The Agency for Healthcare Research and Quality continues to be involved in a broad range of activities related to improving the quality of health care, reducing its costs, improving patient safety, decreasing medical errors, and broadening access to essential services related to diabetes. These activities include the support of research and collaborations with others in the public and private sectors to improve outcomes for those with diabetes and to prevent the condition across the population.

Current AHRQ Activities
U.S. Preventive Services Task Force (USPSTF).. Through numerous outreach activities (e.g., presentations in scientific meetings, consumer outreach via articles in lay language, and media interviews), AHRQ has increased awareness and understanding of the 2003 USPSTF recommendations for screening adult type 2 diabetes and gestational diabetes. Monitoring of literature continues for future updating of the recommendations. The Task Force is currently reviewing the literature on gestational diabetes. Plans are to update recommendations in the next 6 months.

Improving Diabetes Care in Communities Collaborative (IDC3). AHRQ has established a learning collaborat ive of regional business coalitions on health and a state health department on diabetes quality improvement. The learning collaborat ive includes: the Greater Detroit Area Health Council, Memphis Business Group on Health, Mid-Atlantic Business Group on Health, and Vermont Department of Health. The learning collaborat ive grew out of a partnership established between AHRQ and the National Business Coalition on Health (NBCH), which offers expertise in employer-driven quality improvement in health care and access to the trademarked tool “eValue8” that regional business coalitions can use to assess performance of health care plans. The Vermont Department of Health, which like the business coalitions is pursuing a community-based approach to quality improvement in diabetes, was invited to join the learning collaborat ive to exchange its experience and resources with the coalitions.

Overview of Activities:  In each of the communities, AHRQ is helping learning collaborat ive participants develop tailored quality improvement goals and strategies that build on their strengths and local opportunities:

• In the mid-Atlantic region, AHRQ is working with employers to identify opportunities to improve health plans' diabetes management performance using eValue8 data and to build diabetes management performance guarantees into their contracts.
• In Memphis, AHRQ is working with the coalition to design a local team-based approach to managing diabetes and to develop a tool to help employers select and evaluate disease management vendors.
• In Southeastern Michigan, AHRQ is helping the coalition to build the diabetes component of a communitywide multistakeholder Save Lives Save Dollars initiat ive to improve health care quality and reduce health care costs.
• AHRQ is partnering with the state of Vermont to support the Vermont Blueprint for Health, a chronic care initiat ive focusing initially on enhancing diabetes care statewide. AHRQ is advising Vermont on evaluating the initiative, assessing its return on investment, and spreading its successes and lessons learned to other states.

During FY 2005-2007, AHRQ is implementing a knowledge transfer initiative designed to result in better care for Medicaid beneficiaries with chronic care needs. The focus of the initiative is on quality improvement and performance measurement in Medicaid care management (which includes programs such as disease management, primary care case management, and enhanced primary care case management). AHRQ has established a pilot learning network of six state Medicaid agencies (Arkansas, Kansas, Oklahoma, Pennsylvania, Virginia, and Washington). Several of these states are focusing on diabetes in their care management programs, and others may be considering diabetes as a focus. The aims of the learning network include: development of a defined and effective measurement strategy, enhanced/expanded interventions, improvement in one or more measurement issues, capacity building for infrastructure and system change, and learning and sharing knowledge among states and the nation. AHRQ will emphasize decreasing health care disparities through various activities of the Medicaid Care Management Learning Network. State faculty assistance is being provided by the Indiana and North Carolina Medicaid agencies and contractor support from The Lewin Group and the Center for Health Care Strategies. Representatives of the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC, among others) are serving on the Learning Network’s project expert resource team.

National Health Plan Collaborative To Reduce Disparities and Improve Quality in Diabetes Care. This collaborative brings together nine of the nation’s largest health insurance plans: Aetna, Cigna, Harvard Pilgrim, HealthPartners, Highmark Inc., Kaiser Permanente, Molina, UnitedHealth Group (Ovations and AmeriChoice), and WellPoint Inc. Over a 2-year period, these plans seek to: improve the capacity to collect and analyze data on race and ethnicities; link data to quality measures; develop quality improvement interventions to close gaps in care; and produce results that can be replicated by plans serving commercial, Medicare, and Medicaid populations nationally. With funding and guidance from The Robert Wood Johnson Foundation and AHRQ, the Center for Health Care Strategies (CHCS) and the Institute for Healthcare Improvement (IHI) are partnering to coordinate the collaborative and to provide assistance in quality improvement and evaluation. The RAND Corporation provides additional expertise in the area of data collection and analysis. America’s Health Insurance Plans (AHIP) also is a contributing partner in the work of the collaborative. Participating plans receive one-on-one assistance to develop, implement, and evaluate quality improvement efforts to improve diabetes care and reduce health disparities. The plans are using Health Plan Employer Data and Information Set (HEDIS) measures to track their progress. Participants are adopting a flexible learning model that was created from experience with the BCAP Quality Framework and The Chronic Care Model. This model incorporates:

• Increasing availability of race and ethnicity data to better identify members with the highest risk of complications due to poor access, lack of compliance, etc.;
• Designing and testing provider- and member-targeted activities;
• Conducting organizational assessment and training in cultural competency and cultural sensitivity; and
• Implementing a community strategy.

The best practices and lessons learned from this collaborative will be disseminated through a toolkit and National Quality Summit in 2006.

Improving the Quality of Care for Cardiovascular Disease—Using National Managed Care Performance Data To Investigate Gender Differences in HEDISâ Measures Related to Heart Disease and Diabetes. This a 3-year contract between AHRQ and the National Committee on Quality Assurance to investigate gender differences in HEDIS measures related to heart disease and diabetes. The overall goal of this project is to investigate gender differences in quality of care (prevention and treatment) related to cardiovascular disease (CVD) and its risk factors, as measured through HEDIS® performance measures related to CVD in a national sample of managed care plans. This information will be used to inform the development of recommendations for improving quality of care and eliminating gender differences in cardiovascular care.
Goals are:

• Examine gender differences in health plans’ performance on HEDIS® measures related to CVD in a nationally representative sample of health plans. 
• Explore critical organizational and process-of-care variables that may account for the potential gender differences in health plans’ performance on the HEDIS® measures related to CVD identified in Phase 1, using qualitative interviews in a small sample of health plans that do and do not exhibit gender differences.
• Develop and disseminate recommendations for reducing gender disparities and improving the quality of cardiovascular care.

Preliminary analyses of Phase 1 results show that, on six of the nine quality indicators for cardiovascular disease, performance was higher for males within a health plan compared to females within that plan by more than 2 percentage points. The largest differences were seen in cholesterol control measures (% with LDL-C level < 100), with an average 7.8-point difference between males and females within a health plan for the acute cardiac events patients and 5.6 points for diabetic patients. Gender disparities in performance were large within some health plans. For example, for cholesterol control among patients with acute cardiac events, nine plans had disparity scores of more than 4 percentage points that favored men, and five of these had disparity scores of at least 10 percentage points. Small numbers of eligible populations limit the reportability of several measures, particularly measures that focus on care for patients with acute cardiac events. During Phase 2 of this project, additional analyses will be completed with 21 plans that reported plan level data and more than 20 reporting units that are submitting patient-level data. These analyses should provide additional evidence about the prevalence of gender disparities and the relationship of disparities to plan performance and other characteristics.

diabetes in five safety net health centers in San Francisco. The project is seeking to establish the reach and effectiveness of an automated telephone diabetes management system and group medical visits through a three-arm randomized controlled trial. (See details below under Research Grants Funded by AHRQ.)

Centers for Education Research and Therapeutics (CERTs).

• The University of North Carolina is conducting studies on the following topics in diabetes: (a) Prevalence of Type 2 Diabetes in Childhood: measuring fasting blood glucose in frozen serum samples obtained in 1997 from 638 9th-& 10th-grade students to determine undiagnosed glucose intolerance; and (b) Safety and Efficacy of Continuous Subcutaneous Blood Glucose Monitoring: systems in the management of type 1 diabetes in children, providing better and more detailed data for diabetes management.
• The University of Arizona is studying the Effects of Herbal Remedies in Diabetic Hispanic Women in the Southwestern United States: includes qualitative evaluation, development of a clinical tool, and chart review.

Medical Expenditure Panel Survey (MEPS) Database. The MEPS diabetes patient self-assessment questionnaire will pilot test a question concerning the delivery of self-management support in 2006.

• Diagnosis, Prognosis, and Treatment of Impaired Glucose Tolerance and Impaired Fasting Glucose. Released September 2005. AHRQ Publication No.05-E026-2.
• Preliminary activities have been developed toward an initial evidence report under the Medicare Modernization Act format. A project being conducted by Johns Hopkins University will use large databases to examine treatment patterns for newly approved diabetes drugs and to address how to use real-world data from drug databases to examine the effectiveness and safety of these new drugs relative to existing therapies.

Effect of Navajo Interpreters on Diabetes Outcomes. Investigators led by an American Indian researcher are evaluating how formally trained diabetes medical interpreters affect diabetes outcomes and health care use patterns compared with the usual-care interpretation with no formal medical interpreter or diabetes knowledge training. By probing linguistic, cultural, and regional language issues—including a possible lack of word-for-word translatability—in translating an apparently simple questionnaire (the Michigan Diabetes Knowledge Test) from English into Navajo, the translators have been able to articulate approaches that can be used in explaining diabetes management in an appropriate cultural context. (Principal Investigator: Melvina McCabe, University of New Mexico; Grant HS10637, 9/30/00-9/29/05)

Ongoing studies funded under the Primary Care Practice-Based Research Networks (PBRN):

• Evaluating a Patient-Centered Diabetes Registry; University of Colorado at Denver and Health Sciences Center, Aurora; Grant No.: 1R21HS014871-01; Project Duration: 09/30/2004–09/29/2006.
  
  The purpose of this project is to study the feasibility of implementing a patient-centered registry for improving diabetes care in primary care. Unlike typical, passive diabetes registries designed to monitor only those services initiated by clinicians, investigators plan to test a bidirectional registry in which both patients and practices can enter data and receive tailored information about guideline-concordant diabetes care and self-management. A multistep translational research framework is proposed to guide testing, implementation, and ongoing evaluation of the intervention.
  
  
• Improving Diabetes Efforts Across Language and Literacy (IDEALL); University of California at San Francisco (UCSF), Grant No.: 1R21HS014864-01; Project Duration: 09/30/2004– 09/29/2006.
  
  This is a three-arm randomized controlled trial of a communication technology-based intervention (automated telephone diabetes management) to an interpersonally oriented intervention (group medical visits) in a UCSF Collaborative Research Network-affiliated safety-net health system, the Community Health Network of San Francisco (CHNSF). The study aims to (1) expand exposure of these self-management support strategies to more patients and providers in a total of 4–5 primary care practices within the CHNSF; (2) compare the relative effects of these two interventions with respect to each other as well as to usual primary care; and (3) explore contextual factors that moderate both the effects of the interventions on patient outcomes and the success of implementation and maintenance. This study presents an opportunity to assess the degree to which results of efficacy studies can be translated into improvements in health status for priority populations within a safety-net delivery system, as well as to identify characteristics of the complex patient-clinician-practice-organization ecology that influence effectiveness for the target population.

Extramural Research—Ongoing Studies on Information Technology:

• Santa Cruz County, CA, Diabetes Mellitus Registry (DMR); Pajaro Valley Community Health Trust; Grant No.: UC1 HS15362; Project Duration: 09/30/2004–09/29/2007.
  
  In this project, the Santa Cruz County Diabetes Mellitus Registry builds on collaboration among the county’s public, private, and not-for-profit health sectors; with two physician organizations, the county’s Medicaid HMO, the health department, a local community college, and a local philanthropy form the project team. The clinical entities have agreed to share encounter/claim, laboratory, and pharmacy data to populate a countywide diabetes registry. The immediate goal of the Santa Cruz DMR project is to extend the existing registry to as many county providers as possible. This will be accomplished in phases, by customizing training, reaching agreements among the organizations about sharing data, and piloting and launching the registry in increments. This in turn will make it possible not only to improve the level of diabetes care within individual offices, but to make a higher standard of care consistent across the county. In addition, the registry will make it possible to track the county’s diabetes population in the aggregate, to identify trends in key indicators of care and control of this preventable but potentially devastating—and costly—disease.
  
  
• Trial of Decision Support To Improve Diabetes Outcomes; Case Western Reserve University; Grant No.: R01 HS15123; Project Duration: 09/30/2004–08/31/2007.
  
  This is a 2-year cluster-randomized trial of 22 primary care practices, 197 primary care physicians (PCPs), and their 13,000 adult diabetics across two health systems experienced in using the same commercial electronic medical records (EMR) system. Four clusters of similar practices will be assigned randomly to EMR-based disease management (EMR-DM 2), web portal-based patient empowerment (EMR-PE), both approaches (EMR-Both), or EMR alone. The aims of the study are to compare the incremental effects of the interventions on primary outcomes (quality of care/patient safety, and utilization), adjusting as necessary for baseline prognostic differences and clustering and using an intention-to-treat analysis; to estimate intervention effects in prespecified subgroups; to describe specific features of patients and PCPs that are associated with different types and levels of adoption of the interventions; and to describe general and intervention-specific unintended consequences of the interventions. Results will be of critical value to providers and their patients with chronic illnesses, to payers and insurers, to policymakers, and to those seeking to better understand EMR-based decision support, its adoption, and its usefulness for improving quality and safety in patient care.

Extramural Research—Ongoing Previously Funded Studies:

• Computerized interviews to assist secondary prevention in diabetes care (2003–2005)
• Evaluation of culturally appropriate primary health care, with particular attention to diabetes (2003–2004)
• Efficiency examination in diabetes care (2003–2004)
• Home care outcomes of expanded home health aide roles, with particular attention to diabetes (2003–2007)
• Collaborative Management of Diabetes in Blacks (2003–2006)
• Partnership for achieving quality home health care (learning collaborative involving diabetes) (2002–2006)

Intramural Research and Publications:

• Correa-de-Araujo R, McDermott K, Moy E. Gender differences across race and ethnicity in the quality of care for diabetes. Accepted for publication in Women’s Health Issues.
• Bernard DM; Encinosa W; Banthin J. Health care expenditure burdens among adults with diabetes in 2001. Accepted for publication in Medical Care.
• Norris SL. Health-related quality of life among adults with diabetes. Curr Diab Rep, 2005; 5:124-130.
• Jiang HJ, Andrews R, Stryer D, Friedman B. Racial/ethnic disparities in potentially preventable readmissions: the case of diabetes. Am J Public Health. 2005 Sep;95(9):1561-1567.

Current Partnership Activities

HRSA Health Disparities Collaborative—Changing Practices, Changing Lives: Assessing the Impacts of the HRSA Health Disparities Collaboratives. The Health Resources and Services Administration (HRSA)/Bureau of Primary Health Care (BPHC) Health Disparities Collaboratives (HDC), is a multiyear initiative to improve the quality of care and to eliminate health disparities in populations served by federally funded health centers. This large-scale initiative involves partnerships with state primary care associations, the IHI, the National Association of Community Health Centers, and other federal agencies including AHRQ as well as the CDC, Substance Abuse and Mental Health Services Administration, and National Cancer Institute. The approach involves an active learning process tied to system change, infrastructure and leadership at the state and national level to support positive change, and models of evidenced-based care management and quality improvement. AHRQ, in partnership with BPHC/HRSA and the Commonwealth Fund-funded projects at the University of Chicago and Harvard University has cooperative agreements under the Changing Practices, Changing Lives: Assessing the Impacts of the HRSA Health Disparities Collaboratives Request for Applications. The following are ongoing studies under this initiative:

• University of Chicago (Marshall Chin, M.D., M.P.H., Principal Investigator): The evaluation consists of in-depth chart reviews and surveys of patients with diabetes in participating health centers in the Midwest and West Central clusters. In addition, it includes semistructured interviews of key staff at selected health centers and two rounds of surveys with people from each of 155 health centers in the Midwest and West Central clusters, and study of five health centers to examine the cost effectiveness of collaborative participation.
  
  The specific aims of the project include: (1) to determine if the Health Disparities Collaboratives (HDC) have improved the quality of care and outcomes of patients over the 6-year span of the initiative; (2) to determine ways to enhance the effectiveness, sustainability, and spread of the HDC, with a special emphasis on seeking to understand and improve incentives and assistance for both leaders and other staff at the health centers; (3) to evaluate the costs and cost-effectiveness of the HDC to assess whether quality of care improvements that are effective, sustainable, and capable of spread are also viable financially from health center and societal perspectives.
  
  
• Harvard University (Bruce Landon, M.D., M.B.A., Principal Investigator). This project has two specific aims: (1) to evaluate whether participation in an HDC leads to improved processes and outcomes of care; and (2) to identify the characteristics of health centers, improvement teams, and improvement methods that are associated with positive change in quality of care.

Endorsement of AHRQ’s Diabetes-Related Prevention Quality Indicators

The National Quality Forum (NQF) has endorsed 29 national voluntary consensus standards for diabetes care for internal quality improvement (QI) and community-level monitoring. The voluntary consensus standards represent the consensus of the more than 270 organizations that are members of the NQF. The measures that address complication-related admissions are based on four of AHRQ’s Prevention Quality Indicators (PQIs):

• Admissions for uncontrolled diabetes or short-term complications, per 100,000 population (PQI 1—Diabetes Short-Term Complication Admission Rate and PQI 14— Uncontrolled Diabetes Admission Rate)
• Admissions for diabetes long-term complications, per 100,000 population (PQI 3—Diabetes Long-Term Complication Admission Rate)
• Admissions for lower-extremity amputation among patients with diabetes, per 100,000 population (PQI 16— Rate of Lower-Extremity Amputation Among Patients With Diabetes)

Future Activities

AHRQ’s Women’s Health and Gender-Based Research Programs and CDC’s Division of Diabetes Translation are currently planning a project that will look into the quality of comprehensive care provided to women across life stages.

Starting on October 1, 2004, AHRQ implemented a new policy due to limitations on available grant funds, the new budget limit of $300,000 total (direct and indirect) costs per year for large (R01, R18) grant applications. For large conference grant applications (R13), AHRQ is implementing a total cost budget limit of $100,000 per year. The existing budget limits of $100,000 total costs for small research (R03) grant applications and $50,000 direct costs for small conference (R13) grant applications remain unchanged.

AHRQ is also expecting a budget cut this fiscal year, but no additional information is available currently to indicate how this will affect any of the ongoing and planned diabetes activities.

The Center for Scientific Review is a Center within the National Institutes of Health (NIH) in which a majority of investigator-initiated applications in diabetes and obesity areas are reviewed. The mechanisms of application support are the investigator-initiated individual project applications (R01s), High Risk/High Impact Pilot grant applications (R21s), Small Business Innovation Research Applications or Technology Transfer (SBIR/STTR), and Individual Fellowship Applications: Predoctoral (F31 and F30), Postdoctoral (F32), and Senior Fellowships (F33).

These applications are reviewed in several Integrated Review Groups (IRGs) within which individual subcommittees (study sections) are located. Each of these subcommittees (study sections) has definite expertise to review specific areas relevant to diabetes and obesity. Thus, the mission of CSR to activities of DMICC is central and pivotal through help in maintaining the quality of diabetes and obesity research in the Nation. The knowledge gained through these NIH-supported projects would help control/treat type 1 diabetes and type 2 diabetes and obesity in areas of the world in which these diseases are prevalent.

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Centers for Disease Control and Prevention (CDC)
http://www.cdc.gov

There are more than 21 million Americans with diabetes and approximately 41million Americans with pre-diabetes. One in three Americans born in 2000 will develop diabetes during their lifetime. The Centers for Disease Control and Prevention’s Division of Diabetes Translation (DDT) is a science-driven program focused on preventing and controlling diabetes and its complications. The following are key program activities and strategies used to accomplish our mission:

• Defining the diabetes burden—public health surveillance
• Conducting applied translational research
• Developing and maintaining National and State-based diabetes control programs.
• Supporting the National Diabetes Education Program

Current Activities

The Diabetes Prevention Collaborative: Established in 2002, the Diabetes Prevention Collaborative is an interagency, public-private partnership that includes the Health Resources and Services Administration (Bureau of Primary Health Care), CDC (Division of Diabetes Translation), and Institute for Health Care Improvement. The project builds on the partnership and infrastructure established in the National Diabetes Collaborative, established in 1999. This pilot represents an effort to translate the science established in clinical trials conducted around the world that have demonstrated that lifestyle modification in the form of physical activity and weight loss can prevent or slow the progression from pre-diabetes to diabetes. Though results are inconclusive at this time, the interventions are promising and may be playing a role in slowing the progression from pre-diabetes to diabetes.

The Diabetes Systems Modeling Project: This project purports to accelerate the diffusion of analytic methods from the field of systems dynamics into routine public health practice, with an initial focus on those chronic diseases that are marked by dynamic complexity (e.g., diabetes, obesity, heart disease).

National Diabetes Surveillance and Public Health Epidemiology Activities: DDT's Surveillance and Public Health Epidemiology programs provide data on the current state, trends, and forecasts for diabetes, its risk factors and complications, and their control. During the past year, these activities contributed to major presentations and publications that drew national attention and policy interest.

Diabetes Health Economics Program: Over the past decade, DDT has evolved a national/international program in diabetes economics. DDT collaborates with the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) providing expertise to cost-effectiveness studies alongside several major multicenter randomized controlled trials. DDT also has developed a sophisticated computer model of the complex natural history of diabetes and its complications; this model has been used to estimate the cost-effectiveness of a variety of interventions (e.g., screening, control of cardiovascular disease risk factors). During the past year, this program made contributions in two high-impact areas: (a) publication of the results, in collaboration with NIDDK’s Diabetes Prevention Program (DPP) Group, of the cost-effectiveness of primary prevention of diabetes; and (b) completion of a data and science-driven article on diabetes control priorities for the National Institutes of Health (NIH)/World Bank textbook, Disease Control Priorities for Developing Countries.  

• The Association of American Indian Physicians
• The Black Women’s Health Imperative
• The Khmer’s National Cambodian American Diabetes Project
• The National Alliance for Hispanic Health’s “Juntos Contra la Diabetes” program (JCD-United Against Diabetes)
• The National Association of School Nurses
• The National Latina Health Network
• The National Medical Association
• Papa Ola Lokahi

Future Activities

CDC will continue to support Diabetes Prevention and Control Programs (DPCPs) and other partners to improve diabetes care and prevent type 2 diabetes. CDC will strive to build a stronger national program to take on primary prevention and to address complications such as vision loss and kidney disease.

CDC's priorities for expansion in the future include:

• Increasing primary prevention
• Continue and expand efforts to translate diabetes prevention science into public health action.

• Expanding surveillance
• Identify new directions for diabetes surveillance to better monitor and understand the increasing public health problem diabetes presents.

• Expanding the NDEP
• Build on lessons learned and develop materials and tools to help communities and providers improve diabetes management and reduce the morbidity and mortality from diabetes and its complications.

• Expanding the National Vision Program
• Continue to assess and monitor the burden of vision impairment and blindness and to partner with key nonprofit, government, and voluntary organizations to develop and refine vision surveillance programs, services, and policies.

• Establish the National Kidney Program
• Develop a national surveillance system that will identify gaps in data, trends, and priority areas; convene an expert panel to assist with the development of a national kidney plan; and study the economic cost of chronic kidney disease.

Diabetes activities at the Centers for Medicare and Medicaid Services fell into several broad categories: evaluation of the quality of care provided to Medicare beneficiaries, national and State-level quality measurement and improvement projects designed to improve care for Medicare beneficiaries, beneficiary educational campaigns, and research to support quality diabetes care.

Current Activities

Physician Focused Quality Initiative: The Physician Focused Quality Initiative builds upon ongoing CMS strategies and programs in other health care settings in order to: (1) assess the quality of care for key illnesses and clinical conditions that affect many people with Medicare such as diabetes, (2) support clinicians in providing appropriate treatment of the conditions identified, (3) prevent health problems that are avoidable, and (4) investigate the concept of payment for performance.

The Physician Focused Quality Initiative includes the Doctor’s Office Quality (DOQ) Project, the Doctor’s Office Quality Information Technology (DOQ-IT) Project, and several Demonstration Projects and Evaluation Reports.

• The DOQ Project has two goals. The first goal is to describe quality of care in the ambulatory setting in three domains: clinical performance, practice system assessment survey, and the patient experience of care survey. The second goal is to assess the feasibility of collecting doctors’ office quality-of-care data.

• The goal of the DOQ-IT Project is to encourage physician offices to adopt electronic health record systems.

• CMS has a number of disease management and physician-focused demonstrations underway aimed at improving the quality of care and helping people with diabetes and other diseases manage their diseases. The Demonstration Projects study the impact of new payment approaches and new types of services on beneficiaries, providers, health plans, and States; and the Evaluation Reports validate the research and demonstration findings.

Quality Improvement Organizations (QIOs): The Quality Improvement Organizations (QIOs) have been working to improve diabetes care in the following areas:

• Annual hemoglobin A1c testing.
• Biennial lipid profile.
• Biennial eye examination.

In their last contract, which ended in 2005, the QIOs implemented quality improvement projects in physician offices to improve diabetes care for the above measures on a statewide basis as well as working intensively with approximately 5 percent of the physicians in their State to improve diabetes care by implementing interventions such as office system changes, patient care management registries, and flow sheets or reminder cards.

Improving diabetes care remains a focus for the QIOs in their new contract cycle, the eighth Scope of Work. QIOs are working with physician offices to implement electronic health records to measure and report on quality-of-care in the outpatient setting, including diabetes performance measures on select diabetes measures approved by NQF.
 
Quality Assurance and Performance Improvement Projects (QAPI): In prior years, Medicare Advantage (formerly M+C) plans were required to participate in National Quality Assurance and Performance Improvement Projects (QAPI), which focused on topics selected by CMS. In 1999 and in 2004, the topic chosen by CMS for the National QAPI project was Diabetes. Beginning in 2006, Medicare Advantage plans will begin annually conducting multiyear Quality Improvement (QI) projects on self-selected topics determined to be clinically relevant to the particular plan's Medicare enrollees. In addition to this requirement, Medicare Advantage plans are required to implement and report on a Chronic Care Improvement Program. Both of these requirements will be audited by CMS as part of routine compliance audits, thus encouraging plans to improve care for conditions prevalent in Medicare Advantage plans and monitor health outcomes for Medicare beneficiaries. CMS expects that diabetes will continue to be a topic of focus for the Medicare Advantage plans. More information about the QAPI Clinical Health Care Disparities projects of 2003 and the 2004 QAPI National Diabetes Project can be found at www.cms.hhs.gov\healthplans\quality.

Methods for Increasing Communications With People With Medicare: The Center for Beneficiary Services has an agreement with the National Diabetes Educational Program (NDEP) to promote preventive services for people with Medicare. Current promotional efforts include the Power To Control Diabetes Is in Your Hands brochures, posters, Community Kits, and Practitioner Kits. We have also prepared a new fact sheet that will advise people with diabetes about the new self-monitoring benefit and the medical nutrition benefit to supplement the Power To Control campaign. The fact sheet uses the existing cleared language from CMS Publication #11022, Medicare Coverage of Diabetes Supplies & Services.

Diabetes Self-Management: Medicare covers services to help people with diabetes manage their condition so they can prevent or reduce the severity of diabetes-related complications. Medica re approves certain diabetes self-management training services to help beneficiaries successfully manage their disease. Currently, two organizations have been granted deeming authority by CMS.

Future Activities

Section 721 of the Medicare Modernization Act of 2003 (MMA) authorized development and testing of a voluntary chronic care improvement program, now called Medicare Health Support, to improve the quality of care and life for people living with multiple chronic illnesses, including diabetes. The Medicare Health Support Program currently is being phased in in regions across the country.

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Department of Health and Human Services (DHHS)
http://www.dhhs.gov

The Office of Minority Health (OMH) within the Office of Public Health and Science (OPHS) seeks to improve the health of racial and ethnic minority populations through the development of health policies and programs that address health disparities and gaps. In FY 2004, OMH continued funding diabetes projects under the following three grant programs and continued diabetes activities under one cooperative agreement. Two of the grant programs funded new partners in FY 2004.

1.The Bilingual/Bicultural Service Demonstration Grant Program funds projects that use promotores (lay health educators) to conduct education and outreach to the target population by: providing diabetes screening in community settings such as churches, schools, and work sites; fostering case management to assist individuals with diabetes; conducting workshops that encourage physical fitness and better nutrition; and developing bilingual health education materials. The projects also reach health care providers to enhance the quality of care delivered to minorities with limited-English-proficiency (LEP) through cultural competency training and providing health care facilities with interpreters for LEP patients. In FY 2004, four diabetes projects ended their grant cycle. In FY 2004 the Bilingual/Bicultural Service Demonstration Grant Program was competed and four new grants were awarded that had diabetes as one of the top three priority health issue areas. Of these four, two grants also have obesity/overweight as one of the top three priority health issue areas. Two other projects solely address obesity/overweight as their health issue area.

2.The Health Disparities in Minority Health Grant Program is intended to demonstrate the merit of using local, small-scale programs to address health problems and issues that affect the health and well-being of local minority populations. Several of the projects within this program address diabetes prevention education, self-management education, and access to health care for defined minority populations. Of the projects continuing in FY 2004, four have diabetes and two have obesity/overweight among the top three priority health issue areas.

3.The Community Programs to Improve Minority Health Grant Program fosters the use of a community coalition approach to health promotion and risk reduction as a means of reaching targeted minority populations. Project activities seek to improve the delivery of comprehensive diabetes care in the community through a patient-based care management model, patient education, health care provider education, and telemedicine technology. In FY 2004, five projects that included diabetes and two projects that included obesity/overweight as health issue areas ended. During FY 2004, OMH recompeted the Community Programs to Improve Minority Health Grant Program and funded 11 new partners who have diabetes as one of the top three priority health issue areas. Seven of the diabetes projects also address obesity/overweight as one of the three priority health issue areas.

4.The American Indian Higher Education Consortium (AIHEC) Cooperative Agreement in FY 2004 continued activities under the “Honoring Our Health: Tribal Colleges and Communities Working Together to Prevent Diabetes” project. This project is a collaborative effort between AIHEC, OMH, Centers for Disease Control and Prevention, the Indian Health Service Diabetes Program, and 10 Tribal Colleges and Universities. The project seeks to:

• Develop infrastructure for diabetes education and community mobilization;

• Establish diabetes-related curricula;

• Connect diabetes prevention to land preservation, aquaculture, gardens, and bison restoration;

• Develop diet-related curricula;

• Increase education, awareness, and the opportunity to practice good health behaviors;

• Support community health and wellness centers;

• Foster faculty development in diabetes-related fields; and

• Stimulate capacity building for health-related research.

In November 2001, OPHS, in collaboration with the Office of the Secretary, initiated a partnership with the ABC Radio Networks to inform minority communities of ways to achieve better health and close health gaps with the rest of the U.S. population.

During FY 2004, HHS conducted its third annual Closing the Health Gap campaign, featuring consumer information on diabetes and other key health disparities issues affecting racial and ethnic minority populations. More than 550 community and national organizations joined the campaign and conducted more than 280 Take a Loved One to the Doctor Day events in September 2004, with screenings, health fairs, and publicity intended not only to raise awareness of health issues but to bring people to care. Nationally syndicated radio personality Tom Joyner served as national chair for the third year, kicking off the campaign with HHS Secretary Tommy Thompson in Washington, DC, in July. He publicized HHS and community efforts in the months leading up to the Doctor Day and devoted his full September 21 radio show to the event. ABC Radio Networks, a founding partner of the campaign, once again aired hundreds of HHS health messages and publicized activities through more than 200 local affiliates.

An additional HHS Closing the Gap effort, Celebra La Vida Con Salud, a Spanish language campaign, included 10 health fairs this year in Hispanic communities in Arizona, California, Florida, Illinois, New Mexico, New York, and Texas. The fairs were visited by more than 21,000 Hispanic consumers in search of health information and health screenings by local providers. Corporate partners including Nike helped draw consumers to the fairs. Health messages on partner radio stations in the 10 markets were supplemented by a national radio show. Dr. Elmer Huerta hosts “Prevenir es Salud” (prevention is health), and devotes 11 Spanish-language call-in shows on more than 40 stations in key Hispanic markets to health issues, including diabetes. The series continues through early January 2005. In addition, Spanish web portal Terra is running a series of HHS health articles on key consumer health topics. In addition to the people reached via health events and screenings, HHS estimates that the campaigns have resulted in more than 175 million audience exposures to HHS health messages.

The mission of the Center for Drug Evaluation and Research of FDA is to facilitate the clinical development and delivery into the marketplace of safe and effective drugs for human use. The Division of Metabolic and Endocrine Products works in collaboration with the pharmaceutical industry and academia in the area of drugs for the prevention and treatment of diabetes and its microvascular and macrovascular complications.

Current Activities

There are now available in the United States multiple insulin products, animal-sourced and recombinant, the latter category including native-sequence human insulins and insulin analogues with rapid-acting or long-acting pharmacokinetic/pharmacodynamic characteristics. In January 2006, the FDA approved a combination drug-device for inhaled regular insulin in type 1 and 2 diabetes.  

Other recently approved therapies include pramlintide, which is to be used as an adjunct to mealtime insulin in type 1 and 2 diabetes, and exenatide, which is to be used in type 2 diabetics who are taking metformin, a sulfonylurea, or a combination of the two.

There is continued interest in drugs that impact insulin responsiveness by primary transcriptional activation, the so-called PPAR (peroxisome proliferator-activated receptor) drugs, and FDA is committed to prudent developmental strategies, including preclinical and clinical studies, for new drugs in this class and others. While many new drugs show promise in effecting improvements on glycemic control, the challenge is establishing long-term benefits outweighing risks of monotherapeutic and combination therapeutic medical regimens, particularly with regard to the cardiovascular sequelae of pre-diabetic metabolic dysregulation and diabetes.

With the recognition of diabetes as a “risk equivalent” of coronary artery disease, the assessment of the effects of potential anti-atherosclerosis therapies on the natural history of the disease in diabetes and metabolic syndrome is important from the standpoint of understanding the totality of expected risks and benefits of these new drugs and, therefore, in guiding prudent, long-term, preventive therapeutic intervention strategies. The FDA is engaged in ongoing dialogue with industry and thought leaders in this area as new data emerge, in hopes of establishing scientifically rigorous methods for determining the cardiovascular benefits, if any, of primary anti-diabetic, anti-obesity, and other cardiovascular-risk-factor-modifying drugs.

As part of the U.S. Health and Human Services Department’s and FDA’s Diabetes Initiative, in May 2004, FDA and the National Institutes of Health/National Institute of Diabetes and Digestive and Kidney Diseases (NIH/NIDDK) co-sponsored the FDA/NIH Joint Symposium on Diabetes: Targeting Safe and Effective Prevention and Treatment, held on the NIH campus in Bethesda. This meeting brought together experts from academia and industry, as well as government scientists and regulators, to discuss recent developments, goals and promise for the future, and hurdles to progress in the prevention and treatment of both type 1 and type 2 diabetes and treatment of the complications of these conditions.

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Health Resources and Services Administration (HRSA)
http://www.hrsa.gov

The Health Resources and Services Administration manages several health care systems programs that include diabetes identification, education, prevention, or treatment.

Current Activities

Bureau of Primary Health Care

HRSA supports the Consolidated Health Center Program, a health system providing primary and preventive care to the underserved, which includes diabetes identification, education, prevention, and treatment. The health center program is managed in HRSA’s Bureau of Primary Health Care (BPHC).

Health Disparities Collaboratives

The Health Disparities Collaboratives (HDC), started in FY 1999, seeks to: (1) generate and document improved health outcomes for underserved populations; (2) transform clinical practice through new evidence-based models of care; (3) develop infrastructure, expertise, and multidisciplinary leadership to improve health status; and (4) build strategic partnerships.

The HDC program originally focused on diabetes mellitus—to delay or decrease disease complications—by implementing an evidence- and population-based model of care, which relies on knowing which patients have the illness and helps them participate in their own care. It has six basic elements: support of patient self-management, clinical decision support, delivery system redesign, a clinical information system, organization of health care, and strong partnerships with local government and community organizations. Additional clinical areas of focus have been added to the HDCs, including cardiovascular disease, asthma, depression, cancer, prevention, diabetes prevention, finance/redesign, and perinatal/patient safety.

• 542 health centers participated or are in the initial learning year of the HDCs with a focus on diabetes.

• After completing the year-long collaborative, health centers continue to receive support—to promote the model of care throughout their organizations, bring change to clinics, and measure its impact on the health of underserved patients.

• A website, http://www.healthdisparities.net/hdc/html/home.aspx, contains orientation and training materials as well as tools to assist with staff turnover at participating health centers. Health centers have integrated these tools in ongoing staff orientation programs, increasing sustained organizational changes.

• A software program, the Patient Electronic Care System (PECS), is used as a clinical information system.

• Depression screening is included in care of diabetes patients.

• Partnerships with other Federal agencies, e.g., the Centers for Disease Control and Prevention (CDC), National Institutes of Health (NIH), Agency for Healthcare Research and Quality (AHRQ), State diabetes control programs, and private-sector organizations grow stronger.

Outcomes (through October 2005)

• Health centers continue to report on the shared key goal that 90 percent of patients with diabetes will receive two HbA1c tests annually, at least 3 months apart. Starting in 2000, a shared health outcome measure was added to all of the diabetes collaboratives requiring them to report on control of glucose levels (average HbA1c), and a self-management support measure. Additional measures focus on prevention of cardiac as well as microvascular complications, the latter including eye, kidney, and lower extremity disease.

• There are more than 450,000 patients in the HDC registry that enables centers to track and better manage the delivery of health care. Of the patients in the registry, more than 235,635 persons have diabetes and are tracked for diabetes care.

• The average HbA1c is 7.82 for the more than 235,600 patients in the Diabetes registry.

Strategic Partnerships and Infrastructure Development

• Ten cluster directors and 15 information systems specialists are employed by the five lead Primary Care Associations.

• Thirty State-based staff provide additional support to the centers.

• The partnership with the CDC’s Division of Diabetes Translation (DDT) continues to be strengthened. BPHC partnered with the DDT beginning in 2003 to translate the CDC/NIH Diabetes Prevention Program (DPP) into practice in Health Centers by implementing a Diabetes Prevention Prototype Collaborative in five Health Centers.

• From 1999 to 2005, partnerships between State health department Diabetes Prevention and Control Programs (DPCP) and health centers working on the diabetes collaborative have grown from 15 to 48 programs.

• Since 2002 AHRQ has assisted with a program evaluation strategy. Results are expected in spring 2006.

Maternal and Child Health Bureau

The Maternal and Child Health Bureau (MCHB) administers maternal and child health (MCH) Block Grants to States to support programs that promote the health of all of the Nation’s mothers and children and ensure statewide systems of health care for the MCH population. Diabetes screening, education, prevention, and treatment programs may be supported through these grants.

Additional Title V activities, such as MCH research, training, genetic services, and MCH improvement projects, are supported under Special Projects of Regional and National Significance (SPRANS). Although these activities may not specifically target diabetes, core elements of community systems of care serving children with special health care needs are addressed by the Program for Children With Special Health Care Needs. The Healthy Start Initiative to significantly reduce infant mortality in targeted communities also includes services addressing diabetes in mothers and children. In addition, MCHB promotes diabetes detection and care through school-based and school-linked health programs. Finally, the MCH Training Program provides training grants to graduate programs and professional schools to support teaching, research, and service activities that focus on women and children. Its Leadership Education in Adolescent Health (LEAH), public health nutrition, and pediatric nutrition grantee programs include diabetes education, and the Indiana LEAH is nationally recognized for its work in diabetes.

Special Programs Bureau

HRSA’s Special Programs Bureau has been working with the Organ Procurement and Transplantation Network, the national system for matching donated organs with patients on the transplantation waiting list, to facilitate the allocation of pancreatic organs for use in pancreatic islet cell transplants in treating patients with type 1 diabetes. Approximately 30 investigational new drug (IND) applications are in effect for the use of islet cell transplants to treat type 1 diabetes.

Healthcare Systems Bureau

The Division of Transplantation in the Healthcare Systems Bureau oversees the operation of the Organ Procurement and Transplantation Network (OPTN), the national system for matching donated organs to patients on the transplant waiting list. The OPTN facilitates the allocation of pancreata for treating patients with type 1 diabetes who might benefit from such transplants. As of November 29, 2005, approximately 2,500 candidates were on the waiting list for a combined kidney-pancreas transplant, and 1,700 were on the waiting list for a pancreas transplant alone. The OPTN establishes criteria to ensure that transplant programs have the necessary expertise and ancillary services to safely and successfully conduct transplant procedures. All transplant programs in the United States must be OPTN members to perform organ transplants into humans. OPTN member transplant programs include 143 whole pancreas transplant programs and 32 islet transplant programs located across the United States. HRSA is working with the OPTN to improve the recovery and allocation of pancreata for whole organ and islet transplantation and is working with the Centers for Medicare and Medicaid Services (CMS) to resolve issues regarding reimbursement of islet transplantation that hinder progress in this developing field.

HIV AIDS Bureau

Derangements of glucose metabolism, including both glucose intolerance and frank diabetes, have been associated with the use of combination antiretroviral therapy to treat HIV infection. As part of comprehensive primary care, the Ryan White CARE Act-funded clinical programs provide monitoring, treatment, patient education, and nutritional counseling for this complication of HIV treatment. The AIDS Education and Training Centers provide education and training to clinicians regarding this complication of combination antiretroviral therapy and rapidly disseminate information on new treatment strategies as they evolve.

Office for the Advancement of Telehealth

During the period October 1, 2004 to September 30, 2005, the Office for the Advancement of Telehealth (OAT) funded 49 grantees that use telehealth technologies to provide a range of services for improving the clinical management of patients with diabetes. Among the projects funded in FY 2005 is one to the University of Tennessee to expand a pilot diabetes management telehealth project in the Delta region that specifically targets the gathering of evaluation data to assess outcomes. OAT also has funded the creation of a technical assistance document, A Guide to Getting Started in Telemedicine, that can be found on OAT’s website, http://telehealth.hrsa.gov. This document assists organizations in establishing programs that employ telehealth technologies in the management of diabetes.

Bureau of Health Professions

Division of Medicine and Dentistry (DMD)

Twenty-six funded programs in the Primary Care Medical Education Branch of the Division of Medicine and Dentistry were identified as having content related to diabetes.

Family Medicine Predoctoral Training in Primary Care Grant to the University of Massachusetts Medical School (D56HP00072): This 3-year grant that began in July 2004 has as its major objective expansion of the curriculum in Public/Community Health by developing a 4-year longitudinal curriculum. This will include several major interventions for enhancing curricula modules in Public Health topics (depression, diabetes, tobacco, oral health) in the third year core clerkship. These modules will be web-based and supplemented by the use of PDAs in the ambulatory setting. PDAs will be loaned to students during their clerkship. In addition to identified specific measurable objectives, evaluation of this objective will be facilitated by the use of tracking software implemented to provide information on the usability of the newer PDA methodology.

Family Medicine Predoctoral Training in Primary Care Grant to the University of Virginia School of Medicine (D56HP06547): This 3-year grant that began in September 2005 has five major objectives. The third objective of this grant is to enhance the students’ abilities to develop realistic strategies for health promotion and chronic disease management. Under this objective, the grantee will develop interactive web-based cases in chronic disease management focusing on diabetes and health promotion. The grantee also will develop two electives for fourth-year medical students in advanced health promotion and chronic disease management.

Family Medicine Predoctoral Training in Primary Care Grant to the University of Iowa (D56HP00160): This 3-year grant that began in July 2003 has four major objectives. The first objective is to develop curricular activities to prepare medical students for clinically and culturally competent care of underserved and high-risk patients, with a focus on geriatric, Latino, rural, geographically underserved, and economically disadvantaged patients. Sub-Objective 1.2 will develop curriculum for a half-day Ambulatory Practice Module (APM) session entitled, “Caring for Hispanic/Latino Patients in the Primary Care Office,” which will focus on Iowa’s Latino patients, including cultural issues, as well as relevant clinical issues such as diabetes, hypertension, obesity, and tuberculosis. The grantee will include an interactive session on medical Spanish terminology. All third-year medical students will participate each year of this 3-year grant.

Family Medicine Predoctoral Training in Primary Care Grant to the University of California at Davis (D56HP00043): This 3-year grant that began in July 2003 is designed to improve geriatric chronic illness care training for medical students by introducing chronic disease management and quality of care innovations and experiences into the longitudinal predoctoral curriculum. The Improving Chronic Illness Care (ICIC) model, the most widely implemented and evaluated of the new paradigms for redesigning chronic illness care, will be used as a reference point in developing curricular innovations. A particularly strong focus is placed on activities that allow students to experience first-hand the pivotal role that two elements of the ICIC model play in the optimal management of chronic illness: (1) longitudinal, collaborative, culturally sensitive provider-patient relationships; and 2) patient self-care. Diabetes will serve as one of the diseases around which this chronic care curriculum will be designed and evaluated with simulated patients.

Family Medicine Residency Training in Primary Care Grant to the Brody School of Medicine at East Carolina University (D22HP00156): This 3-year grant that began in July 2003 has as its major goal to develop a curriculum designed to increase the knowledge base, skills, and confidence of family practice residents in caring for high-risk patients by using the strategies of care management and group visits to improve clinical outcomes. Eastern North Carolina can be characterized largely as rural, poor, and minority. Much of the unnecessary premature mortality in this region is due to chronic disease and high risk factors such as obesity, diabetes, and poor nutrition. At the end of the curriculum, it is anticipated that the residents will understand effective strategies for managing chronic disease and high-risk conditions using care management and group visits.

Family Medicine Residency Training in Primary Care Grant to the Riverside County Regional Medical Center located in Moreno Valley, California (D22HP00394): This 3-year grant that began in July 2003 has three major objectives. The third objective of this grant is to develop and implement an interdisciplinary diabetes curriculum for the local uninsured Hispanic population. A curriculum initiative was implemented that involved some structural reorganization of patient care, with a major educational focus on diabetes care. There are seven components to this objective, to include a community coalition, group patient visits, and the development of a residency diabetes advisory group, improvement to the patient education curriculum, didactics, and a quality improvement project.

Family Medicine Residency Training in Primary Care Grant to the Sutter Medical Center located in Santa Rosa, California (D58HP000025): This 3-year grant that began in July 2003 has four major objectives, two of which deal with diabetes. The first objective of this grant is to train residents to provide excellent care for people with chronic conditions, diabetes being one of the major chronic conditions. The goal of this listed objective is to consolidate and extend the Chronic Care Model across the entire FPC so that every resident experiences high-quality training to care for those with chronic conditions such as diabetes. The second objective of this grant is to ensure that all residents learn to effectively support patient self-management and foster healthy behavioral change. The need for improved self-management support is demonstrated by the growing evidence that self-management abilities are critical determinants to successful improvement to chronic illnesses such as diabetes.

Family Medicine Residency Training in Primary Care Grant to the West Suburban Hospital located in Oak Park, Illinois (D22HP00249): This 3-year grant that began in July 2004 has one major project goal: to develop, test, and implement a population-based curriculum that enhances resident physician knowledge, attitudes, and skills so as to improve health care to an underserved, diverse and vulnerable inner city population. This is accomplished through six separate curricular areas. The second of these six curricular areas is disease prevention and health promotion among high-risk underserved populations. Under this specific curricular area, residents will demonstrate an increased knowledge about guidelines and their specific applications to address the more frequent diagnoses and complex health issues among patients in the hospital. Diabetes is among these listed for inclusion in the curriculum. 

Family Medicine Residency Training in Primary Care Grant to the University of California, San Francisco, Fresno Medical Education Program (D58HP00054): This 3-year grant that began in July 2003 proposed the development of a multidisciplinary educational and clinical program to improve diabetes care for disadvantaged populations. The primary objective of this grant is the establishment of a Comprehensive Diabetes Management Program (CDMP) to train family practice and other primary care residents in comprehensive diabetes care for underserved and disadvantaged populations. Another major focus for this grant is the development of a distance learning capability with a special focus on diabetes care. Even disadvantaged high school and college undergraduate students taking part in the Kids into Health Careers objective of this grant will participate in the CDMP activities.

Family Medicine Residency Training in Primary Care Grant to the Medical Center of Central Georgia (D58HP03199): This 3-year grant that began in July 2004 has three major objectives, all of which are focused solely around the Holistic Women’s Health Project. Georgia currently is experiencing an alarming increase in lifestyle-related illnesses such as obesity and diabetes. Two of the objectives for this grant focus specifically on improving residents’ knowledge of wellness behaviors and lifestyle choices and on the recognition of risks and benefits of complementary modalities frequently chosen by women.
Family Medicine Residency Training in Primary Care Grant to the Lancaster General Hospital, located in Lancaster, Pennsylvania (D58HP03373): This 3-year grant that began in July 2004 has three major objectives. Two of these objectives have a diabetes-related focus. Diabetes disproportionately affects members of the Latino community. This grant focuses on teaching residents how to take an adequate family history while at the same time identifying and referring patients who are deemed “at-risk” for diabetes based on their family history to a diabetes intervention program. The program will partner with a Latino community service organization to provide new curricula for culturally appropriate interventions for Latinos “at-risk” for diabetes. Residents will learn not only how to provide interventions in a cross-cultural context, but also the importance of referral to appropriate community organizations. 

General Internal Medicine Residency Training in Primary Care Grant to Emory University School of Medicine (D58HP05178): This 3-year grant that began in July 2005 contains eight important objectives. The major goals of this grant focus on new approaches to improving the declining health status of our Nation, particularly that of underserved communities. The General Internal Medicine/Primary Care Residency Program at Emory trains general internists, in a setting of culturally competent care, about the needs of underserved populations such as those cared for at Grady Hospital and its affiliated programs. One of the major objectives of this grant is to train the residents in improving diabetes management for underserved populations.

Family Medicine Residency Training in Primary Care Grant to Georgetown University, Providence Hospital Family Practice Residency Program (D58HP05135): This 3-year grant that began in July 2005 has four major objectives. The overall purpose of this project is to develop service-related learning experiences for residents in collaboration with Congress Heights, a Federally qualified Community Health Center located in the poorest Ward in Washington, DC. The program provides residents with effective tools for addressing health care disparities by providing high quality care for at-risk patients. The grant incorporates unique features to create a curriculum to teach residents how to track clinical outcomes to improve care to high-risk minority patient populations. It also addresses the regional need to develop effective nutritional treatment programs as well as programs to slow the increasing incidence of type 2 diabetes. 

Family Medicine Residency Training in Primary Care Grant to the University of Maryland (D58HP05145): This 3-year grant that began in July 2005 has three primary objectives, two of which directly relate to diabetes care and management. The first objective is to develop and implement a high-quality ambulatory training experience by implementing the Chronic Care Model, beginning with the management of diabetes. The second objective is to develop and implement a required Chronic Care Improvement block rotation that provides experiential learning in diabetes-related medical knowledge and team care of diabetes. This project will be facilitated by close collaboration with the University of Maryland’s Joplin Diabetes Center.

General Pediatric Residency Training in Primary Care Grant to the University of Medicine and Dentistry of New Jersey (UMDNJ) (D58HP05187): This 3-year grant that began in July 2005 has three major objectives. The first objective is to design, implement, and evaluate curriculum elements for pediatric trainees to address health disparities and promote health literacy for several Healthy People 2010 targeted areas. One of the areas to be targeted is diabetes.

Family Medicine Residency Training in Primary Care Grant to the Montefiore Medical Center, located in Bronx, New York (D58HP05173): This 3-year grant that began in July 2005 has two major goals, both of which require family medicine residents to demonstrate competence in the attitudes, knowledge, and skills that they will need now, and in the future, to provide high-quality care that contributes to improvement in Healthy People 2010 indicators. Specifically, this grantee is targeting smoking cessation and behaviors to improve health outcomes in people with diabetes. These goals will be accomplished through curriculum redesign and faculty development in quality improvement and assessment of effectiveness of a motivational interviewing approach to promote behavior change.

Family Medicine Residency Training in Primary Care Grant to the University of Oklahoma Medicine (D58HP05177): This 3-year grant that began in July 2005 has three objectives. As a note, Oklahomans die from chronic illnesses at a rate substantially higher than the national average, and although the death rate in the country as a whole has decreased in the last 5 years, the death rate in Oklahoma has increased. The prevalence of diabetes among Native Americans, who constitute 7.9% of the state’s population, has increased by 50%. Oklahoma lags behind the rest of the nation in the delivery and receipt of most preventive services. This 3-year initiative will include the development, implementation, and evaluation of a curriculum designed to teach family medicine residents in the three residency programs to use the Chronic Care Model (CCM) and Goal-Directed Health Care (GDHC) model to improve the care provided to patients with chronic illnesses and increase the delivery of preventive services. 

Family Medicine Residency Training in Primary Care Grant to University of California, Los Angeles (D58HP05136): This 3-year grant that began in July 2005 proposes to teach residents how to manage chronic disease using a group model as an innovative approach to the epidemic of chronic disease—diabetes, obesity, and asthma. The methodology is to adopt and modify the "Chronic Care Model" endorsed by the AAFP and developed primarily by Edward Wagner, M.D., Group Health in Seattle, Washington. The grantee plans to restructure the "resident in clinic" month that occurs in each year of the residency to include participation in an ongoing series of groups of patients with either diabetes, asthma, or obesity. The goal is to provide the residents with an example of how they might adapt such a group model to their next 35 to 40 years of practice by demonstrating the role of both physicians and nonphysicians as well as patient self-care in the group process.  

Family Medicine Residency Training in Primary Care Grant to Alameda County Medical Center (D58HP05142): This 3-year grant that began in July 2005 focuses on training residents in the skills necessary to interact with patients in a culturally competent manner and educating them about the impact of health literacy on patient self-management and medication safety. The 12 objectives of this project include two that relate to diabetes: development of a didactic curriculum for quality improvement in chronic disease management that is integrated into the primary care core curriculum; and design of a curriculum for urban underserved patients with chronic diseases using the principles and tools of the CCM and the Model for Improvement. In addition, residents will learn skills in health literacy, cultural competence, and interdisciplinary team care of chronically ill patients, including those with diabetes.

Family Medicine Residency Training in Primary Care Grant to Harbor-UCLA Medical Center (D58HP05179): This 3-year grant that began in July 2005 plans to address the need to improve chronic illness care for its patient population of poor and underserved by developing an innovative Chronic Care Curriculum. There are six objectives that include organization of residents, fellows, and faculty into Learning in Action teams that will be the vehicle to implement the Chronic Care Curriculum and development of a medical knowledge component of the Chronic Care Curriculum using evidence-based guidelines to teach prevention, diagnosis, and management of common chronic conditions. Support for this curriculum exists at all levels within the organization, from the Los Angeles County Department of Health Services to the Medical Center's director of ambulatory care as well as the director of graduate medical education. This project also will enable the Department of Family Medicine to have input into a countywide disease management initiative, to participate in planning and implementing a hospitalwide chronic care model, and to provide a curricular model to other training programs.

Physician Assistant Training in Primary Care Grant to Duke University School of Medicine (D57HP19168): This 3-year grant that began in July 2004 has six objectives. Two of the objectives include: (1) developing a curriculum in clinical preventive services (health promotion) and community aspects of practice, with emphasis on linkages with public health and cultural dimensions of practice; and (2) building on the existing clinical program with new curricula for care of chronically ill patients with a focus on skills needed to successfully partner with patients to manage diabetes, asthma, and other chronic diseases. 

Physician Assistant Training in Primary Care Grant to University of Texas Medical Branch (D57HP19139): This 3-year grant that began in July 2004 proposes to offer students the opportunity to train with unique population subsets (minority, disadvantaged, infants and children, uninsured and indigent, and elderly) so they better understand community-based, primary care medicine, and to continue to recruit and train minority students. With regard to training for care of the elderly, the grantee proposes to offer training using an interactive television communication and telemetry system to provide physician assistant (PA) students the capability to provide care to chronically ill elderly patients by telemedicine. The second technology venture will be to develop a home telemedicine project to follow up on 10 geriatric patients with diabetes using telemedicine and interactive communication units.

Physician Assistant Training in Primary Care Grant to Le Moyne College (D57HP05130): This 3-year grant that began in July 2004 proposes to meet the Healthy People 2010 goal of reducing health disparities by ensuring that PA graduates have the skills to care for multicultural, multiethnic, multilinguistic populations, and that graduates provide care for populations in underserved communities. This proposal focuses on the health disparities and special need for culturally competent care in obesity, diabetes, asthma, tobacco, low birth weight, lead poisoning, HIV/AIDS, sexually transmitted diseases, hypertension, and kidney disease. There are numerous health conditions that disproportionately affect individuals due to race, ethnicity, geography, or other factors: This project will train PA students who possess the knowledge and skills to provide culturally competent care and to contribute to the reduction of these health disparities.

Physician Assistant Training in Primary Care Grant to the Community Hospital of Roanoke Valley (D57HP19112): This 3-year grant that began in July 2003 continues the Program’s traditions of advocacy in addressing emerging problems, creative use of community-campus coalitions, and implementation of emerging technologies to solve the problems associated with rural health care. There are six objectives, three of which focus on implementing a chronic disease curriculum, to include diabetes, and one that addresses increasing students’ skills in caring for Hispanic and poor, rural Appalachian populations. Clinical year students will evaluate chronic disease among the populations served by the Program’s existing Community Health sites, develop community linkages for collaboration, recruit potential lay leaders, prepare a manual for health care providers on working with lay leaders, and establish hands-on training activities at a diabetes clinic and women’s cardiovascular clinic at Community Health rotation sites. 

Physician Assistant Training in Primary Care Grant to the University of Kentucky (D57HP10165): This 3-year grant that began in July 2003 has four objectives: (1) to revise the PA training program to fully integrate education in prevention of specific chronic medical conditions, to include diabetes, and to more effectively educate practicing providers in preventive medicine through an annual symposium; (2) to form partnerships with HRSA-funded Community Health Centers to establish model sites for PA students on clinical rotations to learn best practices in preventive medicine and optimal management of chronic care; (3) to establish a PA student outreach program for schools serving grades K-12 in Eastern Kentucky to introduce an at-risk Appalachian population to health-lifestyle as prevention for specific chronic medical conditions; and (4) to improve outcomes for the PA clinical year experience by expanding on the use of standardized patients in a training model.

General and Pediatric Dental Residency Training Grant to University of Massachusetts Medical School (D59HP05268): This 3-year grant that began in July 2005 has as its major objective the creation of a new residency training program in general and pediatric dentistry, with proposed program expansion in years 2 and 3. This application represents a unique opportunity to expand the oral health-general health interface by increasing interdisciplinary and coordinated care between primary care providers and dentists utilizing the medical school's extensive expertise in public health education resources and programs. To achieve these aims, the grantee plans in year 1 implementation of clinical placements at one collaborating community health center and expansion of placements in years 2 and 3 at two additional community health centers. Goal 2 is focused on curriculum development related to the oral health needs of medically compromised populations—i.e., those with diabetes, HIV/AIDS, and developmental disabilities, and the elderly.

DMD/Podiatric Primary Care Residency Program

University of Texas Health Science Center San Antonio/Bexar County Health System: This program partners with the Texas Diabetes Institute’s pediatric endocrinology group. The aim is to provide inner-city, at-risk youth populations with podiatric health and diabetic foot information. Materials are in development for both children and their parents, and the program has begun to disseminate information to families designed to help parents identify children with diabetes, learn how to obtain testing and treatment, and locate education about lifestyle modifications.

Barry University School of Graduate Medical Sciences, Miami Shores, FL: The program trained more than 111 primary care podiatric residents in underserved Miami communities and provided more than 300,000 medically underserved individuals with podiatric services in clinics for the homeless, elderly, migrant workers, and uninsured. Providing foot care related to diabetes, obesity, and peripheral vascular disease is a significant aspect of this project.

DMD/Graduate Psychology Education Program

Howard University, Washington, DC: This program has a special focus on training graduate students, interns, medical residents, and allied health students in psychology to address, in an integrated fashion, the behavioral and medical needs of African-American patients with diabetes. The goal of this interdisciplinary training is to attain greater treatment compliance, improved mental health, and improved quality of life.

Texas Tech University, Lubbock, TX: This project provides both exposure and intensive training for doctoral students in community-based behavioral health (psychology) integrated with primary care. Training sites designed for diabetic care include the Southwest (Lubbock, TX) Diabetes Center, a satellite location of the Texas Tech University Department of Internal Medicine and the East Lubbock Coalition for Obesity and Diabetes Prevention.

DMD-Congressional Earmark

The Drew Clinical Care Quality Enhancement Project: Charles R. Drew University of Medicine and Science. This program is receiving funding from October 1, 2005, through September 30, 2006. The Drew Clinical Care Quality Enhancement program is a newly designed project that will address several key health conditions and top health care priorities for the local community served by Drew University.The program is providing supplementary clinical faculty and related support for the delivery of quality health care to improve outcomes of patients with diabetes. The goals of this program are to: (1) enhance recruitment and retention of faculty dedicated to the care of patients with diabetes and diabetes-related conditions; (2) improve outcomes for patients with diabetes (e.g., blood sugar control, hypertension control) within the Drew Health Care System; and (3) dissemination of evidenced-based diabetes information to high-risk communities.

Division of Nursing

Nurse Education, Practice, and Retention. Four funded grants focused on diabetes care:

• Brazosport Memorial Hospital grant has a focus on enhancing diabetes care. They intend to coordinate and provide diabetes education with all clinical partners, develop a method to identify new onset diabetics, and obtain outcome measures of effectiveness of self-care. The project period is 9/1/03–6/30/06.

• University of California, San Francisco School of Nursing’s Nurse Managed Center grant has a focus on providing an increased number of undergraduate and graduate nursing students with clinical training in all aspects of the management of homeless clients with chronic diseases, particularly diabetes. The nursing students will provide annual screening and/or treatment to a medically underserved, high-risk, predominately homeless client population in San Francisco's Tenderloin District. The project period is 7/01/05–6/30/08.

• Driscoll Children's Hospital nurse residency grant has a focus on instructing new graduate nurses on how to effectively care for underserved pediatric patients with diabetes. The 31,000-square-mile region's population is markedly younger, sicker, and poorer than Texas and the United States, with alarming rates of childhood obesity, asthma, and diabetes. The residency program, offered twice yearly, will be open to recently graduated nurses who have passed their NCLEX exam, nurses with non-pediatric care experience, nurses re-entering the workforce, and foreign nurses. The project period is 7/2005–6/2008.

• University of Washington School of Nursing has a focus on Registered Nurses using evidence-based practices for diabetic patients in need of wound and ostomy management. The project period is 7/01/05–6/30/08.

Advanced Education Nursing. For FY 2005, 54 grantee programs prepare primary care nurse practitioners; the program curriculum includes content in diabetes management. The following two projects focus on diabetes:

• University of Alabama, Birmingham. Project Period: 7/01/02–6/30/07. This project prepares family nurse practitioners with an emphasis on the knowledge and skills needed to care for specific health problems disproportionately represented in Alabama, including diabetes, hypertension, obesity, lipid disorders, coronary artery disease, and asthma. Students will work toward obtaining Diabetes Educator Certification provided through the National Certification Board for Diabetes Educators.

• University of South Alabama. Project Period: 7/01/05–6/30/08. This project prepares Family Nurse Practitioner (FNP) graduates as dysmetabolic syndrome experts and as Advanced Diabetic Managers (ADM) who are able to provide quality care to all age groups in rural and underserved populations in the United States.

Division of State Community and Public Health

Area Health Education Center (AHEC) Program: Area Health Education Centers (AHECs) assist health professions schools to improve the distribution, diversity, and quality of health personnel in the health delivery service system by encouraging the regionalization of health professions schools. The AHEC Program assists schools in the planning, development, and operation of AHEC centers to utilize education system incentives to attract and retain health care personnel in areas in which critical shortages exist. By linking academic resources of the university health science center with local planning, education, and clinical resources, the AHEC program establishes a network of community-based training sites to provide educational services to students, faculty, and practitioners in underserved areas. In FY 2005, there were 51 AHEC programs contracting with approximately 200 affiliated AHEC centers. Of these AHEC programs, 43, or 84 percent, included diabetes as a topic in their curricula and/or continuing education courses. The range of trainees in the AHECs for FY 2004 included: 42,156 health professions students at community-based training sites; 315,820 local health providers receiving continuing education; and 36,314 students in grades 9–12 in health careers training. More than 4,500 practicing health professionals received continuing education on diabetes at AHEC sites. A full range of diabetes education and training programs have been carried out at university and community-based training sites by AHECs in 20 states: Arizona, Arkansas, Colorado, Florida, Georgia, Hawaii, Illinois, Louisiana, Maine, Missouri, New Hampshire, New Mexico, New York, Ohio, Pennsylvania, North Carolina, South Carolina, Texas, Virginia, and Wisconsin.

The Allied Health Project Grants (AHPG): Allied health project grantees provide training to allied health professional students and allied health professionals to become proficient in providing quality health care for the public. One of the topics under health promotion and disease prevention is diabetes. The AHPG implemented the following three projects concerning diabetes:

1.  University of Maryland Eastern Shore funded from July 1, 2004, to June 30, 2007 to implement the project called “An Interdisciplinary Approach to Reducing Obesity” to:

• Improve and strengthen the effectiveness of program directors, faculty, and local allied health professionals in providing education about the prevention of obesity and obesity-related diseases.

• Add and strengthen curriculum units in allied health programs to include knowledge and skills concerning health promotion and obesity-related disease prevention.

• Promote the effectiveness of allied health practitioners in health promotion and disease prevention assessment, education, and consultation through interdisciplinary training programs.

• Provide health promotion services to the community through a variety of community-based health education activities.

2.  University of Kentucky Research Foundation is funded from July 1, 2004, to June 30, 2007, to implement the project called “Allied Health Projects” to train clinical nutritionists and medical technologists in obesity and related comorbidities such as diabetes.

3.  University of Texas Medical Branch is funded from July 1, 2005, to June 30, 2008, to develop and implement interdisciplinary experiences for CLS and OT students in the areas of cultural competence and diabetes. Through collaboration with the University of Texas at Tyler, the University of Texas Health Center at Tyler, Lake Country Area Health Education Center, and the University of Texas Medical Branch Stark Diabetes Center, interdisciplinary training of these students in the areas of cultural competence and diabetes is provided.

Geriatric Education Centers Program: Geriatric Education Centers (GECs), collaborative arrangements involving several health professions schools and health care facilities, provide interdisciplinary training to health professional faculty, students, and practitioners in the diagnosis, treatment, prevention of disease, disability, and other health problems of the elderly. Projects supported by these grants must offer interdisciplinary training involving four or more health professions, one of which must be allopathic physicians, osteopathic medicine.

In FY 2005, the Geriatric Education Centers Program has 50 active GEC grants. Each grant is awarded for up to 5 years. Activities focusing primarily on diabetes include:

• The Stanford GEC at Stanford University provided technical assistance to the Indian Health Center (IHC) in Santa Clara Valley’s Support for Diabetes Prevention Program by helping facilitate the IHC Diabetes Community Advisory Committee. The Stanford GEC developed an educational videotape entitled, “Cultural Resources Available for Diabetes.” Additionally, the GEC developed a curriculum module on the mental health aspects of diabetes. The curriculum for health professionals “Mental Health Aspects of Diabetes in Elders from Diverse Ethnic Backgrounds” was completed by 12 members of the Stanford GEC core faculty. The 100-page curriculum includes sections on elders from African American, American Indian, Chinese American, Filipino American, Hmong American, Japanese American, and Mexican American backgrounds. Each section includes risks, culturally appropriate assessment, and culturally appropriate management of diabetes, depression, and cognitive loss/dementia, including sections on dietary education. A section also is included featuring information on emergency preparedness for ethnically diverse sensory impaired elders. It is available in hard copy in a binder and will available on CD ROM in the near future.

• The South, West & Panhandle Consortium GEC of Texas (SWAP-GEC) at the University of Texas Health Science Center at San Antonio produced, demonstrated, and replicated a training program for vision station staff to screen for diabetes, counsel clients on disease prevention behaviors, and detect those behaviors. Diabetes educators successfully presented diabetes prevention programs at six vision stations. These stations serve a particular minority or ethnic mix of known “at-risk” communities. The tremendous success is demonstrated by the increase of “at-risk” clients now attending classes. A survey of behavioral modification outcomes indicates clients are responsive to health care instruction and demonstration of appropriate meal preparation. Lab reports show a 6 to 9 percent reduction in glucose levels in the “at-risk” group. Plans are pending for the employment of bilingual diabetes educators or trainees to staff additional vision stations.

• The Washington Area GEC Consortium at George Washington University cosponsored a program with the District of Columbia Department of Public Health on January 10, 2005, for the District of Columbia Diabetes Initiative. This program was geared toward policy and program development with nationwide leaders in diabetes control.

• The Wisconsin GEC at Marquette University developed a web-based seminar entitled, “Implementing Diabetes Mellitus: Guidelines in a Heterogeneous Older Population Geriatric Practice.” The seminar targets primary care practitioners. The American Geriatrics Society endorses the online continuing medical education offering and provides one of the online “portals” for practitioners to access the program via their website (AmericanGeriatrics.org). The program is accessible through the Wisconsin GEC website (WGEC.org), Aurora Health Care’s Center for Urban Population Health website (CUPH.org), and on HRSA’s website at http://bhpr.hrsa.gov/geriatric/resources/HRSAdefault.asp. 
  

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Indian Health Service (IHS)
http://www.ihs.gov

The mission of the IHS Division of Diabetes Treatment and Prevention (DDTP) is to develop, document, and sustain a public health effort to prevent and control diabetes in American Indian and Alaska Native (AI/AN) people. The agency promotes collaborative strategies for the prevention of diabetes and its complications in the 12 IHS Administrative Service Areas (regions) through coordination of a network of 19 Model Diabetes Programs and 12 Area Diabetes Consultants. They in turn provide resource distribution, program monitoring, evaluation activities, and technical support to 36 federal hospitals, 63 federal health centers, 44 federal health stations, 13 tribal hospitals, 158 tribal health centers, 76 tribal health stations, 34 urban Indian health centers and 170 Alaska village clinics at the local level in the delivery of comprehensive health care to more than 1.5 million American Indians and Alaska Natives. The DDTP also disseminates current information about all aspects of diabetes surveillance, treatment, education, and prevention.

Current Activities

• Continued to develop and operate the Special Diabetes Program for Indians (SDPI) grant program, with 399 grantees in 35 states. Sixty-six new grantees were added in FY 2005 and focused on planning an intensive intervention in two areas: the primary prevention of diabetes and CVD risk reduction in AI/AN with diabetes. The IHS also submitted its second Report to Congress on the progress and outcomes of the SDPI.

• Updated 14 original diabetes-related Best Practice documents and added four additional Best Practice draft documents on depression, adult weight management, communication, and breastfeeding.

• Cosponsored with the Tribal Leaders Diabetes Committee and other partners the Prevention of Cardiovascular Disease and Diabetes in AI/AN conference in Denver, with more than 1,000 participants.

• Conducted the first IHS Summer Institutes training programs on diabetes in Portland, OR, and Albuquerque, NM.

• Using a workgroup of IHS providers, developed clinical treatment guidelines for prediabetes and metabolic syndrome, and made the guidelines available through the IHS diabetes network.

• Continued to coordinate a diabetes prevention initiative for Native American Boys and Girls Clubs located in 25 Tribal communities. The goal of this program is to promote healthy lifestyle choices that will prevent the onset of diseases such as diabetes, heart disease, and obesity.

• Continued to operate the Integrated Diabetes Education Recognition Program (IDERP), which allows Indian health diabetes education programs to become certified and thus seek Medicare reimbursement for providing diabetes education. Nineteen programs currently have received IHS Recognition.

• Continued to operate and expand the Joslin Vision Network Teleophthalmology Project.

• Continued to operate and enhance the Annual l IHS Diabetes Care and Outcomes Audit.

Future Activities

• Will oversee the launch of SDPI intensive interventions in 66 tribal communities for primary prevention of diabetes and CVD risk reduction in people with diabetes.

• Will conduct further in-depth evaluation, validation studies, and key informant interviews of SDPI grant program activities and will disseminate successful grant program strategies.

• Will continue to develop strategies and approaches to address childhood and adult obesity.

• Will launch a chronic disease initiative based on IHS success with its approach to diabetes.
  
  
• Will implement and refine culturally acceptable screening approaches for AI/AN communities.

• Will develop and provide more technical assistance and training (for health professionals, tribal leadership, administrators, paraprofessionals, and patients) and promote increased awareness regarding new diabetes prevention findings through the media, booklets, the Internet, and other avenues of communication.

• Will continue to promote data improvement by implementing an enhanced electronic medical record specific to diabetes IHS-wide, developing an electronic medical records audit, centralizing technical support for the Diabetes Management System of the IHS electronic medical record, and ongoing collaboration with the Tribal Epidemiology Centers.

• Will begin live use of the Diabetes Data Mart and Data Warehouse.

Significant Obligations Since 1998

The National Center for Complementary and Alternative Medicine explores complementary and alternative medicine (CAM) practices in the context of rigorous science, trains CAM researchers, and disseminates authoritative information on CAM. To achieve its objectives, NCCAM supports basic and clinical research on CAM, awards grants to train researchers in CAM, and sponsors a variety of outreach activities, including posting fact sheets and research reports on CAM and diabetes on the NCCAM website.

Current Activities

The study of diabetes and insulin resistance and their complications remains a priority for the NCCAM extra- and intramural research programs. For example, under a new round of awards in FY 2005, NCCAM, in collaboration with the National Institutes of Health (NIH) Office of Dietary Supplements (ODS), funded a Botanical Research Center for the study of botanicals and metabolic syndrome. The key scientific goal of this Center is to better understand the mechanisms by which certain botanicals, including Russian tarragon, Shilianhua (a Chinese herbal product), and grape seed, may prevent or reverse metabolic syndrome (i.e., obesity, insulin resistance, development of type 2 diabetes, and accelerated CVD). Information gained from this study will shed light on the processes associated with insulin resistance and diabetes and will inform future research on the potential of botanicals to address these conditions.

Other NCCAM-funded studies are investigating the effect of chromium on: (1) insulin resistance and glucose intolerance in HIV disease; (2) insulin-stimulated glucose uptake in a well-characterized population of nonobese, nondiabetic subjects with insulin resistance; and (3) whole-body energy balance, lipid metabolism; and cellular energy status in subjects with type 2 diabetes. Other examples of NCCAM-funded studies include research in animal models on supplementation with omega 3 fatty acid and alpha-lipoic acid for the prevention or delayed onset of type 2 diabetes and a pilot clinical study to assess the effects of certain therapeutic naturopathic diets on inflammatory markers, immune modulation, and diabetes. 

In NCCAM’s Intramural Research Program, the Diabetes Unit seeks to understand molecular mechanisms of insulin action and insulin resistance in the context of CAM modalities to diagnose, prevent, and treat diabetes, obesity, and CVD. Several clinical protocols are underway. One is developing simple methods to assess insulin sensitivity and insulin secretion in humans. Other clinical protocols are evaluating changes in insulin sensitivity and vascular function after oral vitamin C in subjects with type 2 diabetes, oral glucosamine in healthy and obese subjects, and dark chocolate in hypertensive subjects. The Diabetes Unit is also elucidating molecular mechanisms whereby the dietary supplements DHEA and EGCG modulate metabolic and vascular actions of insulin and adiponectin in adipose and endothelial cells. Other laboratory studies investigate cross-talk between inflammatory signaling pathways and metabolic insulin signaling to understand the molecular mechanisms of insulin resistance.

In July 2005, NCCAM published a new article in its series, NCCAM Research Reports. The new report, Treating Type 2 Diabetes With Dietary Supplements (http://nccam.nih.gov/health/diabetes/), summarizes the scientific evidence available to date on the effectiveness of certain dietary supplements as CAM treatment for type 2 diabetes.

Future Activities

NCCAM continues to encourage researchers to submit investigator-initiated applications related to diabetes and insulin resistance. Also, NCCAM, ODS, and the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) will evaluate the results of the chromium Program Announcement (PA), which has expired, prior to its re-issue or other related activity. NCCAM will also expand its continuing education series on CAM to other professions, such as psychologists.

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National Center for Health Statistics (NCHS), CDC
http://www.cdc.gov/nchs

The National Center for Health Statistics has continued to obtain, analyze, and disseminate needed health information on diabetes. NCHS has relied on its ongoing data systems, namely vital records, interview and examination surveys, medical records, and patient encounters to accomplish this effort. New projects also have been initiated to expand this effort.

Current Activities

During 2004, the following diabetes-related activities were completed at NCHS:

• Finalized the release of 2003 data for National Health Interview Survey (NHIS) on preventive health care among people with diabetes. The 1-year support for this information collection was provided by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).

• Released results from the 2002 National Survey of Family Growth (NSFG) (cycle 6), which include the latest national information on factors affecting the pregnancy experience of diabetic and non-diabetic women in the United States.

• Published a new national chartbook entitled Health Care in America: Trends in Utilization, which dedicated several chapters to trends in diabetes health care utilization and trends in the use of diabetes medications.

• Released 2002 National Vital Statistics data on diabetes-related mortality.

• Increased the number of States using revised birth certificates that distinguish between pre-pregnancy diabetes and gestational diabetes.

• Collaborated with the Centers for Disease Control and Prevention (CDC) Division of Diabetes Translation (DDT) to publish the first national findings on lower extremity disease among adults with diabetes from the National Health and Nutrition Examination Survey (NHANES).

• Provided technical support to health officials in New York City to begin an initiative to conduct the first NHANES-like local area survey that is obtaining diabetes-related information that can be compared to national diabetes health statistics.

• Developed the protocol to reintroduce oral-glucose tolerance testing (OGTT) data in the NHANES, which will permit a national assessment of factors related to pre-diabetes, which has been redefined in the United States.

• Prepared the first NCHS report on women’s health that included National and State-specific estimates for diabetes risk factors and diabetes mortality. The report was entitled Healthy Women: State Trends in Health and Mortality.

• The National Health Care Survey (NHCS) continues to obtain information from diabetes-related ambulatory care visits, hospitalizations, and nursing home stays.
  
  The National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS), which are NHCS components, contain trend data on utilization of care for diabetes; delivery of preventive care services, including counseling for diet/nutrition and exercise; use of diagnostic/screening services, such as blood glucose; and use of medications.

• Published peer-reviewed papers on a range of topics, including diabetes prevalence, obesity in diabetes, and health-related quality of life among people with diabetes.

Future Activities

• With support from NIDDK and CDC’s DDT, NHANES will begin to collect OGTT data in 2005.

• NCHS will publish study findings from NSFG data on the pregnancy experience among women with gestational diabetes.

• NCHS will link information from the Centers for Medicare and Medicaid Services with survey data from the NHIS and the NHANES. This linked file will permit followup analyses of these NCHS survey participants to assess health and subsequent healthcare utilization.

• In 2005, the NAMCS and NHAMCS will collect additional information on diabetes, obesity, hyperlipidemia, and use of disease management programs.

• NCHS will publish data for births occurring in 2003 from States using revised birth certificates that distinguish between pre-pregnancy diabetes and gestational diabetes.

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National Center for Research Resources (NCRR)
http://www.ncrr.nih.gov

The National Center for Research Resources provides laboratory scientists and clinical researchers with environments and tools that they can use to prevent, detect, and treat a wide range of diseases. This support enables discoveries that begin at the molecular and cellular level, move to animal-based studies, and then are translated to patient-oriented clinical research, resulting in cures and treatments for both common and rare diseases. NCRR connects researchers with patients and communities across the nation to bring the power of shared resources and research to improve human health. Selected highlights of NCRR-supported diabetes research activities and future plans that relate to diabetes are presented below.

Current Activities

Islet Cell Resource Centers (ICRs). During their first 4 years, the 10 NCRR-supported ICRs:

• Performed 290 isolations that were used to treat 148 patients afflicted with severe type 1 diabetes throughout the country. These islets were provided at no cost to either the patient or the clinical researcher.

• Established procedures through which more than 11 million human islets were provided in the past year at no cost to 55 qualified investigators engaged in approved basic diabetes research.

• Continued research to establish assays of islets that would predict clinical success via collaborative efforts between several groupings of ICRs.

• Continued to optimize culture, storage, and shipping conditions to increase the likelihood of successful transplantation.

• Demonstrated that islets retrieved from non-heart-beating donors can yield good transplant results.
  
  
• Enlisted the coordinating center to provide administrative, bioinformatics, and biostatistical support for laboratory studies and clinical programs that use ICR-generated islets nationwide.

• Established a web-based islet processing database to share information with the NIDDK-sponsored Collaborative Islet Transplantation Registry United Network for Organ Sharing (UNOS) to enable one-time data entry, decrease the reporting burden for investigators, and share data between researchers.

General Clinical Research Centers (GCRCs). The 78 GCRCs and their satellites provide