1. Disparities in Pre-Diabetes Winston Wong, MD, MSKaiser PermanenteMedical Director, Community BenefitDirector, Disparities Improvement and Quality InitiativesJuly 12, 2010

2. A Family at Risk: America at Risk

3. The Burden of diabetes • End stage renal disease prevalence: • 3.2 cases per 1000 people years among Caucasians • 4.5 cases among Latinos • 4.6 cases among Asian Americans • 6.8 cases among African Americans

4. Prediabetes results in early CVD death • Prediabetes is associated with a 2 – 3X additional risk for cardiovascular disease • 75% of hospitalizations among diabetic patients are related to cardiovascular disease

5. Why are individuals and communities at risk?

6. Behind closed doors • African Americans are more likely to have worse control of HgbA1c, control of blood pressure and control of “high cholesterol” • Latinos are less likely to “self monitor blood glucose” • All non-white population groups were less likely than Caucasians to be “intensified” in treatment for poorly controlled for elevated HgbA1c

7. Systems are at play • When patients burden of costs increase for management, adverse outcomes are more likely • Among African Americans, missed medications are associated with worsening diabetes, blood pressure and lipid control • Poor health literacy is associated with poorer outcomes

8. What do we know that is effective?

9. Environmental > Systems >Evidence Based Practice The burden of disease must be addressed NOW • Anti-Platelet Trialists • HOT • HOPE • EUROPA • 4S • HPS Yusuf, S. Lancet 360: July 6, 2002

10. Steno-IICVD Events Combining ALL reduces CVD by nearly 50% over 8 years Hazard ratio .47, p=.008 NEJM 2003:348:383-93

11. “A.L.L.” Community Intervention Focused intervention of low income, vulnerable populations in the community

12. Excellent Enrollment Trends Across 5 Pilot Clinics NCHS: North County Health Services VCC: Vista Community clinic CHC: Comprehensive Health Center SDFC: San Diego Family Care LM: La Maestra

13. Impact of ALL: Number of Cardiovascular Events Prevented Kaiser Permanente, Oakland California/ United States Lancet. 2002 Jul 6;360(9326):23-33. N Engl J Med. 2000 Jan 20;342(3):145-53.

14. Disparities in Prediabetes management: bridge strategies Community engagement Sick-care Disease Management Chronic Condition Care Public Health