A Call to Improve Patient and Public Health Outcomes of Diabetes through an Enhanced Integrated Care Approach

Abstract
The incidence of diabetes mellitus in the United States is skyrocketing. Diabetes is one of the leading causes of morbidity and mortality in the country. Furthermore, one in three adults in the United States have prediabetes, and 7.3 million (2.8% of the U.S. population) are unaware that they have diabetes. Early detection and prevention, based on lifestyle and nutritional changes, are the most effective methods to manage diabetes. Comprehensive multisystem examinations are essential in the prevention of onset and the cessation of progression of diabetes. APHA recommends a series of action steps to increase access to and coverage of timely, comprehensive, high-quality dental care, vision and eye care, podiatric care, and medical management of patients with diabetes; to inform policy and program development; to increase public education; to increase access and funding for underserved and at-risk populations; and to improve data collection for prioritization of evidence of improved quality of care

Relationship to Existing Policy Statements
There is no active existing policy statement that addresses the public health problem identified in this statement. APHA Policy Statement 20002 (Reducing the Incidence of Blindness, Lower Extremity Amputation, and Oral Health Complications in Minority Populations Due to Diabetes) addressed several topics incorporated in this statement but was archived in 2019. This newly proposed policy statement applies to a broader patient population and includes more updated, comprehensive, and actionable policy recommendations than the archived statement. Several existing APHA policy statements address the need for improved access to dental care, eye care, and/or medical care in certain patient populations, but this is the only statement that specifically addresses diabetes. These existing policies include the following:

• APHA Policy Statement 20023: Support of Healthy Aging through Health Promotion and Prevention of Disease and Injury
• APHA Policy Statement Statement 200910: Improving Access to Vision Care in Community Health Centers
• APHA Policy Statement 20109: Health Literacy: Confronting a National Public Health Problem
• APHA Policy Statement 201011: Reforming Primary Health Care: Support for the Health Care Home Model
• APHA Policy Statement 20116: Reducing Barriers and Increasing Access to Children’s Vision Care Services
• APHA Policy Statement 20161: Access to Integrated Medical and Oral Health Services
• APHA Policy Statement 20189: Achieving Health Equity in the United States
• APHA Policy Statement 20191: Coordinated Nationwide Approaches to Promote Eye Health and Reduce Vision Impairment
• APHA Policy Statement 20203: Improving Access to Dental Care for Pregnant Women through Education, Integration of Health Services, Insurance Coverage, an Appropriate Dental Workforce, and Research
• APHA Policy Statement 20204: A Call for Adult Dental Benefits in Medicaid and Medicare

Problem Statement
Diabetes mellitus is a systemic, noncommunicable, metabolic disease characterized by chronic elevations in blood sugar (hyperglycemia) caused by irregularities in insulin production (type 1 diabetes) or insulin regulation/action (type 2 diabetes) of the pancreas. Type 2 diabetes is the most common form of diabetes in the United States, comprising approximately 91% of all individuals with the disease.[1] As a major public health problem in the country, diabetes has a significantly greater rate of medical disability among affected individuals relative to those without diabetes.[2] Statistically, diabetes is a leading cause of death in the U.S. population.[3] Cases of diabetes in the population are rapidly increasing, which creates a greater burden on all aspects of society. According to the U.S. Centers for Disease Control and Prevention (CDC) Diabetes Surveillance System, 34.2 million people of all ages (10.5% of the U.S. population) had diabetes as of 2018. Of additional concern, 7.3 million adults (2.8% of all U.S. adults) 18 years and older were not even aware that they had diabetes.[4] Furthermore, individuals with type 2 diabetes are at greater risk of severe illness and death from COVID-19.[5]

The best way to avoid diabetes-related disease is to prevent its onset when possible. Prediabetes—when blood sugar levels are elevated but not high enough for a diagnosis of diabetes—will convert to diabetes in approximately 70% of cases.[6] The diagnostic criteria for prediabetes vary slightly among organizations such as the American Diabetes Association (ADA) and the World Health Organization but are commonly based on hemoglobin A1c (HbA1c or A1c) values, fasting plasma glucose levels, and/or oral glucose tolerance testing. Recently published survey data over a 25-year period (1988–2014) show that the prevalence of prediabetes continues to rise in the United States. More than 50% of individuals with prediabetes have comorbid cardiovascular or renal disease.[7] During the survey period, members of racial/ethnic minority groups and those of low socioeconomic status had higher proportional increases in rates of prediabetes than non-Hispanic White or socioeconomically advantaged individuals.[7] Awareness of prediabetes in the United States is quite low across the entire population, and awareness in underserved populations is even lower; these underserved populations are less likely to know that without weight loss and physical activity, 15% to 30% of people with prediabetes will develop type 2 diabetes within five years.[8] The National Center for Chronic Disease Prevention and Health Promotion of the CDC works to reduce the four main risk factors for preventable chronic diseases such as prediabetes and diabetes: tobacco use, poor nutrition, lack of physical activity, and excessive alcohol use.

People with diabetes are generally unaware of the reciprocal nature of periodontal disease, eye disease, and foot and ankle disease and their strong association with diabetes.[9] Trends are corroborated by a large United Kingdom study that revealed a 37% prevalence of comorbid microvascular disease among individuals newly diagnosed with diabetes during 2004 to 2017.[10] Through early and routine in-person examinations and consultations, dental care providers, eye doctors, pharmacists, and podiatrists can identify, detect, modify, and manage lifestyle programs and medical treatment to reduce conversion to a diagnosis of diabetes and can increase the quality of life of those who have progressed to all levels of disability. Timely and routine evaluations for lifestyle modification and maximizing appropriate medical therapy are critical. In addition to their primary role, health care providers can educate individuals on fundamental lifestyle strategies such as decreasing blood pressure and stress, limiting alcohol use, quitting smoking, and improving sleep quality. These early interventions will lead to more effective diabetes management, reductions in health care expenses, and prevention of the development of diabetes-related disease. Early intervention and prevention of disease are significantly less expensive than managing complications of the disease.[11] Disseminating information regarding publicly available programs can help this cause. For example, the National Diabetes Prevention Program is a partnership of public and private organizations working to prevent or delay type 2 diabetes. Integrated care and partners make it easier for people at risk of type 2 diabetes to participate in evidence-based lifestyle change programs to reduce their risk.[12]

The ADA recommends a team-based approach to managing a patient’s diabetes, such as via the Chronic Care Model, which emphasizes person-centered team care, integration of long-term treatment approaches to diabetes, ongoing collaborative communication, and goal setting between all team members.[13] In addition, the ADA recognizes the association between social and environmental factors and prevention of diabetes. Risk-based screenings for prediabetes after the onset of puberty or after 10 years of age are also recommended. Patients with prediabetes have an elevated risk of pain and loss of function of the body’s nerves (diabetic peripheral neuropathy [DPN]) before the onset of diabetes, and patients with DPN have an elevated risk of metabolic syndrome and its component metabolic abnormalities.[14] Because diabetes initially affects the microvasculature of the body, a variety of different systems are affected. Early signs and symptoms of dysfunction from diabetes may include but are not limited to frequent infections of the skin and gums, blurry vision, and complications related to the toes and feet such as diabetic ulcers, blisters, and fungal infections. Screening for DPN in the feet should be performed via simple clinical tests such as vibration perception, pressure sensation, assessment of ankle reflexes, and pinprick sensation. At the opposite end of the body, the eye is a privileged organ in that it is the only place where internal components (vascular and neurological systems) can be directly viewed without cutting into or imaging inside the human body. For individuals with prediabetes, annual, in-person, comprehensive eye examinations play a pivotal role in preventing progression of the disease through early recognition of microvascular changes. Because the rate of conversion from prediabetes to diabetes is so high, it is critically important to identify the earliest signs of disease progression. In this case, medications to lower blood glucose can begin, increased diet modifications can be implemented, and nutritional educational programs can be initiated.

Annual in-person, comprehensive eye examinations are necessary for all individuals, regardless of diabetes status. These annual examinations are especially important for people who are prediabetic and diabetic, including those with gestational diabetes as they have a greater probability of developing postpartum diabetes.

The prevalence and incidence of diabetes are increasing,[15] yet only slightly more than half of the U.S. population receives an annual eye examination. Diabetic retinopathy, the most common microvascular complication of diabetes, is a leading cause of new cases of vision impairment and blindness among people 20–74 years of age in the United States and many other developed countries.[16] Diabetic retinopathy is characterized by increased vascular permeability (bleeding in the retina), vascular closure (hypoxia of the retina), and proliferation of new blood vessel growth on the retina and posterior surface of the vitreous. Intensive treatment to maintain blood glucose concentrations close to the normal range has been shown to reduce the risk of development of diabetic retinopathy and to decrease the risk of its progression among individuals with type 1 or type 2 diabetes.[17–19] In addition, early intensive glycemic control appears to have a lasting protective effect on diabetic retinopathy progression and severity due to “metabolic memory.”[20,21]

Because early detection and lifestyle modifications are among the most effective methods to manage diabetes, routine, comprehensive multisystem examinations are essential to prevent the onset and arrest the progression of diabetes and its complications. The complications of diabetes can be debilitating and thus will negatively affect an individual’s mental health. People with diabetes may be reluctant to visit a health care provider and share relevant information due to fear of a disease diagnosis and stigma.[22]

Federal, state, and local policymakers must promote population eye and vision health, oral health, podiatric health, and appropriate medical management, including nutritional education. It is imperative to implement strategies to minimize preventable and correctable diabetic progression, maximize early detection and integrated care referrals, and achieve greater health equity. Thus, primary care providers such as family physicians, internal medicine physicians, physician assistants, nurse practitioners, and public health advocates must be aware of the importance of integrated care referrals for comprehensive assessment, management, and treatment. Specifically, it is critically important for primary care practitioners to identify and refer individuals with comorbid diabetic conditions that can be addressed early in the disease process. Patient outcomes can be improved through the use of integrated care teams.

The integrated care team approach leads to improved care and outcomes for individuals with diabetes.[23] Because of the complexity of diabetes management, continuous management from a variety of health care professions is necessary.[24] These collaborative teams work together to mitigate further complications of type 2 diabetes.[25] Integrated care teams serve as improved sources of patient-centered access to health care, including monthly or quarterly trips to the pharmacy, biannual visits to the dentist, and yearly visits to the eye doctor and podiatrist. These integrated care touch points increase opportunities for early disease prevention and identification, especially in rural areas where access to care may be limited.[26]

Inclusion of podiatry in integrated care teams for individuals with diabetes can reinforce best practices for disease control and educate patients on preventive foot care, yet podiatrists are not always included in these teams.[27] Along with foot examinations, podiatrists provide education, foot care strategies, offloading, wound care, infection control, and surgical interventions. Podiatrists present a unique opportunity to reduce progression of diabetic complications. During a comprehensive foot exam, podiatrists perform assessments that include footwear and vascular, neurological, dermatological, and musculoskeletal systems. Regular follow-up with a podiatrist allows for monitoring of risk factors for diabetes and prevents the progression of diabetic foot ulcerations to infections that would require amputation.[28] Despite the importance of these follow-ups, the most recent survey data available suggest that fewer than 50% of individuals with diabetes currently receive regular foot screenings.[29] Collaboration inclusive of podiatry and other health care professionals who manage the risks and complications of diabetes is beneficial to early recognition and management.[27,28]

Maintaining a diabetes referral network among all relevant health care providers is essential to manage the increasing diabetes population, including gestational and prenatal providers if indicated. This is especially true of those health care professionals who are visited most frequently by patients. As the third-largest group of health care professionals in the United States after physicians and nurses, pharmacists are well positioned to fill gaps in health care and are trained extensively in their service expansion beyond traditional medication dispensing. However, pharmacists remain underused as providers in preventing type 2 diabetes, partly because many entities do not consistently consider pharmacists to be integral members of health care teams.[30] While pharmacists frequently care for patients at high risk for type 2 diabetes, they do not reach a large number of Americans in underserved areas despite data showing that 92% of U.S. residents live within 1.6 miles of a pharmacy and that patients see their pharmacist more frequently than their primary care physician.[31] Increased patient access to pharmacists who can play a larger role in the prevention and management of diabetes may improve outcomes.

Dental care providers can play a critical role in the detection and management of diabetes due to the close association between oral pathology and diabetes. One common diabetic comorbidity is periodontitis (advanced gum disease). Diabetes contributes to poorer periodontal (gum) health, and poorer periodontal health contributes to poorer glycemic control among individuals with diabetes.[32] People with type 1 diabetes, type 2 diabetes, or prediabetes have poorer periodontal health than their counterparts without diabetes.[32] Evidence suggests that periodontitis may contribute to the development of type 2 diabetes and worsening of complications of diabetes such as retinopathy, diabetic nephropathy, neuropathic foot ulceration, cardiovascular complications, and death.[33,34]

Studies have described disparities in dental care use among different groups of the U.S. population with diabetes, as follows:

• Dentate adults with diabetes report fewer dental visits over the preceding year than those without diabetes.
• Disparities in dental care among racial or ethnic groups and among socioeconomic groups are greater than those for any other type of health care visit, with smaller proportions of Latinx individuals and African Americans having had dental visits.
• Among four types of diabetes health care visits compared (visits to providers for foot care, eye care, and dental care and pharmacy visits), dentate adults with diabetes are least likely to report having a dental care visit in the preceding year.
• Disparities in health care visit rates across race/ethnicity, poverty status, education, and private insurance categories are most pronounced for dental care.[32]
• The prevalence of untreated tooth decay is two to three times higher among non-Hispanic Blacks, Mexican Americans, those who are poor or near poor, and current smokers than among non-Hispanic Whites, those who are not poor, and adults who have never smoked.[35]

Because millions of eye examinations are performed every year in the United States, eye doctors are commonly the first to detect diabetes and refer to primary care physicians or endocrinologists for initial systemic evaluations and medical management of disease progression. Also, eye doctors can easily refer to other subspecialties (such as dental care providers and podiatrists) for additional disease detection. Early diabetic eye disease is painless and commonly has no warning signs. Patients are frequently unaware that they have the condition, and the longer a person has diabetes, the greater the risk of sight-threatening diabetic eye disease. One of the more devastating complications of diabetes is diabetic retinopathy. Once vision is lost, it often cannot be restored. Preventing progression of diabetic complications is critical to maintaining a lifetime of high-quality vision. Unfortunately, an estimated 10% to 25% of people with diabetes do not know that they have the disease.[4,36] For some people, signs of diabetes found during an eye examination may be the initial indication of the presence of the disease.[37] Furthermore, 20% to 40% of those with type 2 diabetes already have retinopathy at the time of first diagnosis of diabetes.[38]

An annual, in-person, comprehensive dilated eye examination is the most effective way to detect the earliest signs of diabetes. Once evidence of diabetic eye disease has been detected, more frequent eye examinations may be required. Early detection, timely treatment, and appropriate follow-up care can reduce a person’s risk for severe vision loss from diabetic eye disease by 95%.[39] The very fine internal elastic laminae of the blood vessels are the first to be affected by diabetes. The earliest clinical signs of diabetes (microaneurysms) can be viewed in the eye. These microaneurysms, which are seen only in the retina, are typically smaller than 50 microns (thinner than a human hair).[40] Diabetes is a systemic vascular condition; it must be clinically assumed that diabetic vascular disease visualized in the eye is also occurring in the blood vessels/microvasculature throughout the entire body. As previously discussed, the eye is also a very privileged organ as it is the only part of the body where internal components can be viewed without cutting or imaging. The status of the arteries, veins, central nervous system, and half of the 12 cranial nerves can be assessed through an in-person comprehensive eye examination. Because the retinal assessment is so important to understanding the overall systemic health of individuals with diabetes, many in the biotech sector are attempting to utilize technology via telemedicine to image and evaluate the prediabetic and diabetic retina. As technology is continuously improving, telemedicine has improved basic retinal screenings. However, because telemedicine cannot currently be used to perform many components of an eye examination that evaluates individuals for diabetic complications, the role of telemedicine in the care of people with diabetes is still being assessed. Screening for specific eye health issues with technology for direct-to-patient eye- and vision-related applications, based on current technologies and uses, should not be used to diagnose eye, health, and vision conditions and should not be used as a substitute for a comprehensive dilated eye exam. Screenings with high sensitivity and specificity may help identify risk, but only an in-person comprehensive eye examination can begin to evaluate, mitigate, and/or address this risk.[41] The critical role that eye doctors play in the diabetes care team is underscored by federal government agencies. The CDC recommends that people receive a dilated eye examination from an eye doctor at least once a year.[42]

For individuals with diabetes, routine examinations and lifestyle discussions regarding proper diet and physical exercise have been shown to involve the greatest risk reduction.[43] Once an individual is diagnosed with diabetes, these multisystem examinations become a necessary part of the diabetic health exam. However, personal health information can be confusing to patients unless it is presented in plain language and is culturally appropriate. Patients will need to formulate a plan for how to obtain this newly identified and needed care, which health care professionals to visit, and how to choose a health plan that will best help the management of their diabetes.

People with diabetes can take action to lower their risk for heart attack, stroke, and other diabetes complications by controlling the risks outlined in the American College of Cardiology’s ABCDE of Primary Prevention: Lifestyle Changes and Team Based Care. Specifically, they should follow an individualized meal plan, engage in regular physical activity, avoid tobacco use, and take medicines as prescribed.[44]

In addition to self-management responsibilities to lower risk, self-management support is a partnership between patient and health care provider. It also involves increasing the health literacy of the health provider and the patient. It includes collaborative goal setting, problem solving, and individualized behavior change plans that address concerns identified by the patient as highest priority. All health care providers can offer self-management support, reinforcing patient problem-solving skills and delivering consistent, proactive health care messages.

Self-management support relies on principles of self-efficacy, short-term action plans, realistic goal setting, and proactive identification of barriers to optimal diabetes control. It involves asking the person with diabetes to identify an accomplishable action to be taken in changing a behavior (e.g., walking 10 minutes a day before dinner, starting tomorrow) rather than telling the individual what to do. Self-management support also includes troubleshooting with individuals about missed appointments; establishing routines around daily activities such as brushing and flossing their teeth and gums, foot care, and blood glucose testing; and helping them overcome barriers to receiving regular screening exams for oral, eye, and foot health.

Communication is essential between the health care team and organizations that share data for quality assurance. Health care technology allows multiple channels to streamline communications among the health care team, including electronic health records, secured e-mails, text messages, regularly scheduled virtual meetings, and telephone conversations. The frequency and timing of communications can be determined in advance and/or as dictated by state laws and regulations. Any scheduled communications should not supersede immediate reporting of new or unusual individual complaints and/or worsening of the individual’s condition.

Improved care from insurance claim submissions can be monitored and shared with patients via the Healthcare Effectiveness Data and Information Set (HEDIS). HEDIS measures were established by the National Committee for Quality Assurance (NCQA) and can be used to assess the quality of health plan coverage. One of the required measures is comprehensive diabetes care. HEDIS results from a collaborative study with the NCQA and the Centers for Medicare & Medicaid Services (CMS) can be used to alter health plan coverage and guide treatment recommendations for improved diabetic care. A variety of information from integrated care diabetic examinations is collected. One of the metrics evaluated and required to meet the HEDIS measures is a diabetic retinal examination. The study results showed that ongoing dental care was associated with better adherence to seven of the 11 HEDIS metrics relative to an otherwise similar population that did not receive dental care. This is evidenced by the population who received dental care and then went on to show higher rates of compliance with diabetic retinopathy screening, improved blood pressure control, and a greater likelihood of good glycemic control.[45] Analyses of insurance claim data consistently support the significant contribution of regular dental care, especially routine nonsurgical periodontal treatment, to lower overall health care costs. These lower costs are driven primarily by fewer hospitalizations and emergency department visits in privately insured populations who have diabetes and receive periodontal therapy (and, in some studies, other types of routine dental care as well) than in populations not receiving periodontal therapy.[46] Another indicator that would improve quality of care, support equitable care, and reduce lower extremity amputations would be the inclusion of an annual diabetic foot examination under the comprehensive diabetes care HEDIS measure.

Foot ulcers and amputations, which are consequences of DPN and peripheral artery disease, are common and represent major causes of morbidity and mortality among people with diabetes; they also carry significant financial costs.[4,41] Of all complications, DPN is responsible for the highest number of hospital admissions and is the leading cause of foot ulcers. The lifetime incidence rate of diabetic foot ulceration is 19% to 34%, with a yearly incidence rate of 2%.[28] The total medical cost for managing diabetic foot disease in the United States is $9 to $13 billion in addition to the cost for management of diabetes alone.[47] Long-term, uncontrolled diabetes is associated with higher rates of diabetic foot ulcerations and infections that result in lower extremity amputation.[48] Of recent note, diabetes-related major and minor amputation risk has increased during the COVID-19 pandemic.[49] Cost of care increases when diabetic foot ulcerations are not well managed.[50] The five-year mortality rate is approximately 40% following a first-time ulceration and 52% to 80% after a major amputation.[51]

Current guidelines from the International Working Group on the Diabetic Foot recommend annual foot exams for low-risk individuals with diabetes who do not have significant comorbidities.[52] For high-risk patients such as those with loss of protective sensation, peripheral artery disease, a history of prior ulceration or amputation, and/or end-stage renal disease, the frequency of foot exams should increase to once every one to three months.[52] Diabetic foot disease can result in a complex syndrome characterized by dysfunction of the nervous, vascular, and immune systems and should be monitored by a number of specialists, including podiatrists. Delays in symptom recognition may result in the development of diabetic foot infections and amputations. The assembly of a motivated integrated care team can help manage symptoms and successful limb preservation.[27,53] Foot care services that involve the trimming of toenails and reduction of skin calluses have historically been categorized by Medicare as “routine” services and not covered by insurance except when certain conditions exist such as diabetes. These exemptions for diabetes, in conjunction with other clinical conditions, allow individuals to receive Medicare benefits for foot care services with frequency limits applied. Such exemptions also require medical management of diabetes by a primary care provider every six months. Other types of health insurance often mirror Medicare foot care service policies, but there is variability.

Another Medicare benefit available to individuals with diabetes who clinically demonstrate medical necessity is therapeutic shoes and inserts. Use of specialized therapeutic footwear is recommended for high-risk patients with diabetes, including those with severe neuropathy, foot deformities, ulcers, callous formations, poor peripheral circulation, or a history of amputation.[54] Yet, access to foot care and therapeutic shoes or inserts varies, with rural locations having fewer providers. Efforts to improve and promote health equity in a variety of professions are ongoing. Programs that encourage education of all forms so that patients can gain an improved understanding of diabetes are essential to prevention of progression. Without education, patients are unaware of the complications of diabetes or even the existence of the disease itself.

Eye doctors may be the first health care practitioners to examine a patient with undiagnosed diabetes or ocular manifestations of diabetes such as refractive error shifts, glaucoma, diabetic macular edema, and cataracts. These conditions, all leading causes of vision loss in the United States, are significantly more common among individuals with diabetes.[55] CMS finalized a Medicare Merit-Based Incentive Payment System (MIPS) improvement activity in 2019 to encourage greater patient education efforts nationwide in terms of in-person, comprehensive eye examinations. CMS recognized the value of eye examinations, stating that “because comprehensive eye examinations are relatively low-cost interventions and early detection of conditions that can be identified through an eye exam may reduce more costly treatment later, we believe this improvement activity will not unnecessarily increase expenditures for public programs and the target population.” Overall, CMS noted that the improvement activity “will have a positive impact on patient care and promote health equity.”[56] Any physician who educates patients on the value of comprehensive eye examinations can earn Medicare MIPS improvement activity credit. This incentive is especially beneficial for doctors caring for individuals with prediabetes and diabetes.

Attention must also be paid to the relationship between providers and patients. Racial and ethnic diversity among health care professional results in increased access and improved health among underserved populations. Black and Hispanic health care providers practice more often in Black and Hispanic communities than do other health care providers but are underrepresented relative to the U.S. population. Blacks make up 12% of the U.S. population but only 4% of dentists, 5% of physicians, 5% of pharmacists, and 11% of other health practitioners. In 2018, more than half of dentists, optometrists, and physicians were male.[57] Creating a workforce that is more diverse will help improve the health of these communities.

Opposing Arguments/Evidence
In the United States, we struggle with epidemic levels of diabetes, which is not only a public health concern but an economic one as well. There are several important barriers that have stifled implementation of integrated care programs in the past and therefore warrant consideration. These barriers include, but are not limited to, operational complexity, regulatory challenges, unclear financial attribution, and cultural inertia.[58]

For individuals with diabetes, cost of care is a major issue and limiting factor. Opponents of a public health approach to preventing diabetes are concerned with the increasing costs of care in integrated care settings, the most expensive of which occur at the later stages of the disease. A single practitioner does not have the ability or in-clinic time to care for the comorbidities of diabetes on his or her own. This issue is magnified in rural and poor urban areas where there is less access to primary and tertiary care providers. Because diabetes produces multiple organ system dysfunction, patients are required to visit multiple health care providers; this in turn increases expenses to the system, but these expenses can be mitigated by increasing early in-person evaluations and examinations through an integrated care approach. However, once the disease begins to run its unrelenting course, the demand of required increased expenses and increased provider visits is inevitable. Many patients lack the long-term financial resources and time, resulting in increased rates of failure of integrated care.

Inequitable treatment and care of racial and ethnic minority and low-income people of color with diabetes have been documented for decades. These populations are at a disproportionately increased risk of diabetes complications and mortality. Systemic and institutionalized racism are at the core of inequities in socioeconomic status, neighborhood and physical environments, food environments, health care, and social contexts (also known as social determinants of health), which all contribute to health and wellness, particularly among those with diabetes.[59] Human DNA is 99.9% identical irrespective of race, further highlighting the nonmedical determinants of health. Diabetes is predominantly a preventable lifestyle disease; the focus on singularity of care seems inadequate and ineffective. The social determinants of health are nonmedical factors that influence health outcomes. Health inequities—the unfair and avoidable differences in health status seen within and between countries—are greatly influenced by social determinants of health.[60] A balanced, integrated care approach to the management of diabetes is a critical component of success in diabetes care and prevention of complications.

Action Steps
Federal Level

• APHA calls on accreditation bodies for dental care providers, eye doctors, pharmacists, and podiatrists to require curricular content on diabetes early detection, prevention, management, and integrated care.
• APHA recommends that the American Dental Association, the American Dental Hygienists Association, the American Optometric Association (AOA), the American Academy of Ophthalmology (AAO), the National Pharmacy Association, the American Pharmacy Association, and the American Podiatric Medical Association promote integrated care and early referrals for people at risk for diabetes and associated diabetic complications, including testing for associated diabetic risk factors, to decrease morbidity and disability.
• APHA calls on the Health Resources and Services Administration to support and advocate for integrated electronic health records throughout health care systems for improved patient care and a better-informed clinical care team.
• APHA calls on CMS to expand access to dental care services and eye examinations in the Medicaid and Medicare programs for individuals with diabetes.
• APHA calls on the Department of Health and Human Services (DHHS) and its agencies to provide patient and practitioner education on the importance of nutrition in reducing obesity and the risk of diabetes in the Medicaid and Medicare programs for individuals with diabetes.
• APHA recommends that DHHS and its agencies collect survey data such as HEDIS measures on the frequency of diabetic oral, foot, and annual comprehensive eye examinations.
• APHA calls on the U.S. Congress to increase access to preventive dental, eye, and foot care for vulnerable populations by eliminating prior authorization requirements and cost-sharing co-payments and to implement sustainable reimbursement schedules.

State/Local Level

• APHA strongly recommends that all educational programs for primary care providers (family practice physicians, internal medicine physicians, physician assistants, nurse practitioners, and other public health practitioners) include information on when and how to refer individuals with diabetes for dental, foot and ankle, eye, and glycemic control examinations, as well as to whom they should be referred.
• APHA urges dental care providers, eye doctors, pharmacists, and podiatrists to educate the public on the need for regular glycemic evaluation and control and annual in-person comprehensive eye examinations, foot and ankle evaluations, and dental examinations for individuals at risk for or living with diabetes.
• APHA recommends that dental care providers, eye doctors, pharmacists, podiatrists, and relevant health organizations provide self-management support to reinforce patients’ problem-solving skills with respect to their disease.
• APHA recommends that all dentistry, optometry, medicine, pharmacy, and podiatry clinical education programs stress self-efficacy, short-term action plans, realistic goal setting, and proactive identification of barriers to optimal diabetes control.
• APHA urges schools of dentistry, optometry, medicine, podiatry, and pharmacy to increase their racial and ethnic student diversity to better mirror the U.S. population.
• APHA strongly recommends that all health care organizations promote intervention models such as the joint National Diabetes Education Program and CDC Pharmacy, Podiatry, Optometry, and Dentistry Program to engage providers from each of these disciplines in actively identifying and treating patients with diabetes in a team-based care approach.
• APHA urges the AOA and the AAO to advocate for in-person, annual, comprehensive eye examinations.
• APHA recommends recommends that all health care providers educate individuals with diabetes about the potential threat of oral health complications, diabetic vision loss, and foot and ankle diseases.
• APHA calls on all health care providers to increase awareness among individuals with diabetes of the bidirectional nature of periodontal disease given that those with periodontal disease have a greater prevalence of diabetic eye and retinal disease and diabetic foot and ankle disease
• APHA calls on all relevant member sections to work together to foster integrated care for individuals with prediabetes and diabetes and to meet at the annual APHA meeting.

References
1. Centers for Disease Control and Prevention. Prevalence of diagnosed diabetes in adults by diabetes type—United States, 2016. Available at: https://www.cdc.gov/mmwr/volumes/67/wr/mm6712a2.htm. Accessed February 4, 2021.
2. Centers for Disease Control and Prevention. Disability and health related conditions. Available at: https://www.cdc.gov/ncbddd/disabilityandhealth/relatedconditions.html. Accessed February 4, 2021. 
3. Centers for Disease Control and Prevention. Leading causes of death. Available at: https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm. Accessed February 4, 2021. 
4. Centers for Disease Control and Prevention. National diabetes statistics report 2020. Available at: https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf. Accessed February 4, 2021.
5. Centers for Disease Control and Prevention. People with certain medical conditions. Available at: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html#:~:text=Having%20type%202%20diabetes%20increases,and%20insulin%20as%20usual. Accessed February 4, 2021. 
6. Tabák AG, Herder C, Rathmann W, Brunner EJ, Kivimäki M. Prediabetes: a high-risk state for diabetes development. Lancet. 2012;379(9833):2279–2290.
7. Ali MK, Bullard KM, Saydah S, Imperatore G, Gregg EW. Cardiovascular and renal burdens of prediabetes in the USA: analysis of data from serial cross-sectional surveys, 1988–2014. Lancet Diabetes Endocrinol. 2018;6(5):392–403.
8. Centers for Disease Control and Prevention. About prediabetes and type 2 diabetes. Available at: https://www.cdc.gov/diabetes/prevention/about-prediabetes.html. Accessed February 4, 2021. 
9. Oguntimein O, Butler J 3rd, Desmond S, Green KM, He X, Horowitz AM. Patients’ understanding of the relationship between their diabetes and periodontal disease. J Am Board Fam Med. 2020;33(6):1004–1010.
10. Palladino R, Tabak AG, Khunti K, et al. Association between pre-diabetes and microvascular and macrovascular disease in newly diagnosed type 2 diabetes. BMJ Open Diab Res Care. 2020;8(1):e001061.
11. Centers for Disease Control and Prevention. Cost-effectiveness of diabetes interventions. Available at: https://www.cdc.gov/chronicdisease/programs-impact/pop/diabetes.htm. Accessed August 10, 2021. 
12. Centers for Disease Control and Prevention. National Diabetes Prevention Program. Available at: https://www.cdc.gov/diabetes/prevention/index.html. Accessed August 10, 2021. 
13. American Diabetes Association. Improving care and promoting health in populations: standards of medical care in diabetes. Diabetes Care. 2019;42(suppl 1):S7–S12.
14. Stino AM, Smith AG. Peripheral neuropathy in prediabetes and the metabolic syndrome. J Diabetes Investig. 2017;8:646–655.
15. Centers for Disease Control and Prevention. National diabetes statistics report. Available at: https://www.cdc.gov/diabetes/data/statistics-report/index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fdiabetes%2Fdata%2Fstatistics%2Fstatistics-report.html. Accessed February 4, 2021. 
16. Ting DS, Cheung GC, Wong TY. Diabetic retinopathy: global prevalence, major risk factors, screening practices and public health challenges: a review. Clin Exp Ophthalmol. 2016;44(4):260–277.
17. Fong DS, Aiello L, Gardner TW, et al. Retinopathy in diabetes. Diabetes Care. 2004;27(suppl 1):S84–S87.
18. Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329(14):977–986. 
19. UK Prospective Diabetes Study Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet. 1998;352(9131):837–853.
20. Aiello LP. Diabetic retinopathy and other ocular findings in the diabetes control and complications trial/epidemiology of diabetes interventions and complications study. Diabetes Care. 2014;37(1):17–23.
21. Holman RR, Paul SK, Bethel MA, Matthews DR, Neil HAW. 10-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med. 2008;359(15):1577–1589.
22. Papaspurou M, Laschou V, Partsiopoulou P, et al. Fears and health needs of patients with diabetes: a qualitative research in rural population. Med Arch. 2015;69(3):190.
23. Szafran O, Kennett SL, Bell NR, Torti JMI. Interprofessional collaboration in diabetes care: perceptions of family physicians practicing in or not in a primary health care team. BMC Fam Pract. 2019;20(1):44.
24. Almutairi K. Quality of diabetes management in Saudi Arabia: a review of existing barriers. Arch Iranian Med. 2015;18(12):816–821.
25. Madden J, Barnard A, Owen C. Utilisation of multidisciplinary services for diabetes care in the rural setting: diabetes care in the rural setting. Aust J Rural Health. 2013;21(1):28–34.
26. 2019 National Healthcare Quality and Disparities Report. Rockville, MD: Agency for Healthcare Research and Quality; 2020.
27. Blanchette V, Brousseau-Foley M, Cloutier L. Effect of contact with podiatry in a team approach context on diabetic foot ulcer and lower extremity amputation: systematic review and meta-analysis. J Foot Ankle Res. 2020;13(1):15.
28. Schmidt BM, Wrobel JS, Munson M, Rothenberg G, Holmes CM. Podiatry impact on high-low amputation ratio characteristics: a 16-year retrospective study. Diabetes Res Clin Pract. 2017;126:272–277.
29. Institute for Preventive Foot Health. National Foot Health Assessment. Available at: https://www.ipfh.org/resources/surveys/national-foot-health-assessment-2012. Accessed November 11, 2020. 
30. Centers for Disease Control and Prevention. Pharmacists in federally qualified health centers: models of care to improve chronic disease. Available at: https://www.cdc.gov/pcd/issues/2019/19_0163.htm. Accessed February 7, 2021. 
31. Berenbrok LA, Gabriel N, Coley KC, Hernandez I. Evaluation of frequency of encounters with primary care physicians vs visits to community pharmacies among Medicare beneficiaries. JAMA Netw Open. 2020;3(7):e209132.
32. Borgnakke WS, Genco RJ, Eke PI, Taylor GW. Oral health and diabetes. In: Cowie CC, Casagrande SS, Menke A, et al., eds. Diabetes in America. 3rd ed. Bethesda, MD: National Institutes of Health; 2017.
33. Genco RJ, Graziani F, Hasturk H. Effects of periodontal disease on glycemic control, complications, and incidence of diabetes mellitus. Periodontology. 2020;83(1):59–65.
34. Borgnakke WS, Ylöstalo PV, Taylor GW, Genco RJ. Effect of periodontal disease on diabetes: systematic review of epidemiologic observational evidence. J Periodontol. 2013;84:S135–S152.
35. Centers for Disease Control and Prevention. Leading causes of death reports, 1981–2019. Available at: https://webappa.cdc.gov/sasweb/ncipc/leadcause.html. Accessed December 3, 2020. 
36. Selvin E, Wang D, Lee AK, Bergenstal RM, Coresh J. Identifying trends in undiagnosed diabetes in U.S. adults by using a confirmatory definition: a cross-sectional study. Ann Intern Med. 2017;167(11):769.
37. Schaneman J, Kagey A, Soltesz S, Stone J. The role of comprehensive eye exams in the early detection of diabetes and other chronic diseases in an employed population. Popul Health Manage. 2010;13(4):195–199.
38. Harris MI, Klein R, Welborn TA, Knuiman MW. Onset of NIDDM occurs at least 4–7 years before clinical diagnosis. Diabetes Care. 1992;15(7):815–819.
39. National Eye Institute. Prevention of vision loss. Available at: https://www.nei.nih.gov/sites/default/files/2019-06/diabetes-prevent-vision-loss.pdf. Accessed February 4, 2021. 
40. Dubow M, Pinhas A, Shah N, et al. Classification of human retinal microaneurysms using adaptive optics scanning light ophthalmoscope fluorescein angiography. Invest Ophthalmol Vis Sci. 2014;55(3):1299.
41. American Optometric Association. Position statement regarding telemedicine in optometry. Available at: https://www.aoa.org/AOA/Documents/Advocacy/position%20statements/AOA_Policy_Telehealth.pdf. Accessed February 4, 2021. 
42. Centers for Disease Control and Prevention. Diabetes and you: healthy eyes matter. Available at: https://www.cdc.gov/diabetes/ndep/pdfs/149-healthy-eyes-matter.pdf. Accessed February 4, 2021. 
43. American Optometric Association. Eye care of the patient with diabetes mellitus. Available at: https://www.aoa.org/AOA/Documents/Practice%20Management/Clinical%20Guidelines/EBO%20Guidelines/Eye%20Care%20of%20the%20Patient%20with%20Diabetes%20Mellitus%2C%20Second%20Edition.pdf. Accessed February 4, 2021. 
44. American College of Cardiology. The ABCs of primary cardiovascular prevention: 2019 update. Available at: https://www.acc.org/latest-in-cardiology/articles/2019/03/21/14/39/abcs-of-primary-cv-prevention-2019-update-gl-prevention. Accessed July 28, 2021. 
45. Mosen D, Pihlstrom D, Snyder J, Smith N, Shuster E, Rust K. Association of dental care with adherence to HEDIS measures. Perm J. 2016;20(1):33–40.
46. Alfano MC. Economic impact of periodontal inflammation. In: Glick M, ed. The Oral-Systemic Health Connection. Batavia, IL: Quintessence; 2019.
47. Rice JB, Desai U, Cummings AKG, Birnbaum HG, Skornicki M, Parsons NB. Burden of diabetic foot ulcers for Medicare and private insurers. Diabetes Care. 2014;37(3):651–658.
48. Acar E, Kacıra BK. Predictors of lower extremity amputation and reamputation associated with the diabetic foot. J Foot Ankle Surg. 2017;56(6):1218–1222.
49. Casciato DJ, Yancovitz S, Thompson J, et al. Diabetes-related major and minor amputation risk increased during the COVID-19 pandemic. J Am Podiatr Med Assoc. 2020 [Epub ahead of print].
50. Hicks CW, Canner JK, Karagozlu H, et al. The Society for Vascular Surgery Wound, Ischemia, and Foot Infection (Wifi) classification system correlates with cost of care for diabetic foot ulcers treated in a multidisciplinary setting. J Vasc Surg. 2018;67(5):1455–1462. 
51. Thorud JC, Plemmons B, Buckley CJ, Shibuya N, Jupiter DC. Mortality after nontraumatic major amputation among patients with diabetes and peripheral vascular disease: a systematic review. J Foot Ankle Surg. 2016;55(3):591–599.
52. Bus SA, Lavery LA, Monteiro‐Soares M, et al. Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2019 update). Diabetes Metab Res Rev. 2020;36:e3269.
53. Albright RH, Manohar NB, Murillo JF, et al. Effectiveness of multidisciplinary care teams in reducing major amputation rate in adults with diabetes: a systematic review and meta-analysis. Diabetes Res Clin Pract. 2020;161:107996.
54. Khan T, Shin L, Woelfel S, Rowe V, Wilson BL, Armstrong DG. Building a scalable diabetic limb preservation program: four steps to success. Diabetic Foot Ankle. 2018;9(1):1452513.
55. National Institutes of Health. Diabetic eye disease. Available at: https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/diabetic-eye-disease. Accessed February 4, 2021. 
56. Federal Register. Revisions to payment policies under the physician fee schedule and other revisions to Part B for CY 2019. Available at: https://www.federalregister.gov/documents/2018/11/23/2018-24170/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other-revisions. Accessed February 4, 2021. 
57. Kaiser Family Foundation. Disparities in health and health care: 5 key questions and answers. Available at: https://www.kff.org/racial-equity-and-health-policy/issue-brief/disparities-in-health-and-health-care-5-key-question-and-answers/. Accessed August 3, 2021. 
58. Maruthappu M, Hasan A, Zeltner T. Enablers and barriers in implementing integrated care. Health Syst Reform. 2015;1(4):250–256.
59. Hill-Briggs F, Adler NE, Berkowitz SA, et al. Social determinants of health and diabetes: a scientific review. Diabetes Care. 2021;44(1):258–279.
60. World Health Organization. Social determinants of health. Available at: https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1. Accessed August 10, 2021.