National Diabetes Prevention Program

Overview

The National Diabetes Prevention Program (NDPP) is a partnership of public and private organizations working to address the increasing burden of Pre-Diabetes and Type 2 Diabetes throughout the country. With support from the U.S. Centers for Disease Control and Prevention (U.S. CDC) and the National Association of Chronic Disease Directors (NACDD), the Maine Department of Health and Human Services (Maine DHHS), led by the Maine CDC, has applied a partner engagement model in the state focused on reducing the risk of Type 2 Diabetes among Mainers by increasing enrollment in CDC-recognized lifestyle change programs.

HealthInfoNet serves as one of the Maine CDC’s partners offering services to help increase clinical screening, testing, and referral efforts of people at highest risk for Type 2 Diabetes – especially those individuals enrolled in MaineCare (Medicaid). Using the HIE’s statewide clinical data set, HealthInfoNet is now generating the following measures on a daily basis in support of Maine’s DPP efforts:

Screening Recommendation for Pre-Diabetes and Type 2 Diabetes
Screened and Eligible for National DPP Participation
Risk for Developing Pre-Diabetes and Type 2 Diabetes

The following sections provide detailed specifications for each of these measures.

For questions about the NDPP measure specifications, please contact the Maine CDC at askdiabetes.cdc@maine.gov.

Screening Recommendation for Pre-Diabetes and Type 2 Diabetes

Specification	Description
Measure Steward	Maine Centers for Disease Control and Prevention (Maine CDC)
Measure Frequency	Daily
Measure Description	Patients 35 years of age or older as of the measurement date with a most recent BMI value of ≥ 25 kg/m^2and with at least one of the following criteria within the last 3 years as of the measurement date: Diagnosis of (a) Overweight or Obese, (b) Hypertensive, (c) Hyperlipidemic, (d) Family History of Diabetes Mellitus, (e) Metabolic Syndrome, (f) Polycystic Ovarian Syndrome, or (g) Non-Alcoholic Steatohepatitis; or, Prescription of an Anti-Psychotic Medication; or, Race of (a) Black, (b) American Indian or Alaska Native, (c) Native Hawaiian or Pacific Islander, (d) Asian, or (e) Multi (two or more races); or, Ethnicity of Hispanic. If Race of Asian then BMI value of ≥ 23 kg/m²; if Race of Unknown, then BMI value of ≥ 25 kg/m².
Measure Exclusions	Exclude patients with at least one of the following criteria: Diagnosis of (a) Pre-Diabetes, (b) Type 1 Diabetes, (c) Type 2 Diabetes, (d) End-Stage Renal Disease, (e) Palliative Care, or (f) Condition of Frailty at any time in the patient’s available medical history; or, Pregnancy within the last nine months as of the measurement date; or, Diagnosis of Gestational Diabetes at any time in the patient’s available medical history; or, Blood test results within the last year as of the measurement date corresponding to (a) fasting glucose, (b) plasma glucose measured 2 hours after a 75gm glucose load, or (c) HbA1c; or, Elevated glucose levels within the last year as of the measurement date.
Additional Notes	Anti-psychotic medications used in the generation of this measure are retrieved from the Surescripts pharmacy claims repository. Important notes pertaining to the limitations of this data source include the following: A patient’s medication information from Surescripts is refreshed if the patient has an Emergency Department visit at a participating hospital. A patient’s medication information from Surescripts is refreshed if they have a hospital-based MRN stored in the HIE and have been queried by a user within the Clinical Portal electronic health record system. A patient’s medication information is not available from Surescripts if the medications are paid by the patient with cash (i.e., self-pay). For these reasons, not all patients actively prescribed an anti-psychotic medication may be identified in the data source; and, At this time, the MaineCare pharmacy claims repository is not used as a supplemental data source to identify anti-psychotic medications.

Screened and Eligible for NDPP Participation

Specification	Description
Measure Steward	Maine Centers for Disease Control and Prevention (Maine CDC)
Measure Frequency	Daily
Measure Description	Patients 18 years of age or older as of the measurement date with a most recent BMI value of ≥ 25 kg/m^2within the last 3 years as of the measurement date and with at least one of the following criteria : Blood test results within the last year as of the measurement date corresponding to (a) fasting glucose of 100-125 mg/dl, (b) plasma glucose of 140-199 mg/dl measured 2 hours after a 75gm glucose load, or (c) HbA1c of 5.7-6.4; or, Elevated glucose levels within the last year as of the measurement date; or, Diagnosis of Gestational Diabetes at any time in the patient’s available medical history. If Race of Asian then BMI value of ≥ 23 kg/m²; if Race of Unknown, then BMI value of ≥ 25 kg/m².
Measure Exclusions	Exclude patients with at least one of the following criteria: Diagnosis of (a) Type 1 Diabetes, (b) Type 2 Diabetes, (c) End-Stage Renal Disease, (d) Palliative Care, or (e) Condition of Frailty at any time in the patient’s available medical history; or, Pregnancy within the last nine months as of the measurement date.

Risk for Developing Pre-Diabetes and Type 2 Diabetes

Specification	Description
Measure Steward	Maine Centers for Disease Control and Prevention (Maine CDC)
Measure Frequency	Daily
Measure Description	Patients' risk for developing Pre-Diabetes and Type 2 Diabetes based on calculating the following criteria: Screening Recommendation for Pre-Diabetes and Type 2 Diabetes measure result of '1' Age (as of the measurement date) 18-39 years = 0 point 40-49 years = 1 point 50-59 years = 2 points 60+ years = 3 points Sex (as of the measurement date) Female = 0 point Male = 1 point X = 1 point Unknown = 1 point Null = 1 point BMI (as of the measurement date) Null = 0 point 25-29.9 kg/m²= 1 point 23-29.9 kg/m² if Race of Asian = 1 point 30-39.9 kg/m²= 2 points 40 kg/m²+ = 3 points Diagnosis of Hypertensive (at any time in in the patient’s available medical history) = 1 point.
Measure Exclusions	Exclude patients with at least one of the following criteria: Screening Recommendation for Pre-Diabetes and Type 2 Diabetes measure result of '0' Age of Null or 17 years or younger; or, Diagnosis of (a) Type 1 Diabetes, (b) Type 2 Diabetes, (c) End-Stage Renal Disease, (d) Palliative Care, or (e) Condition of Frailty at any time in the patient’s available medical history; or, Pregnancy within the last nine months as of the measurement date.
Risk Calculation	Patients' risk can be interpreted based on the following translation: Total Points = 0 - Minimal Risk Total Points = 1-2 - Low Risk Total Points = 3-4 - Moderate Risk Total Points = 5+ - High Risk Patients excluded from the measure will have a result of ‘N/A’.

Frequently Asked Questions

Question

Answer

How does the Risk for Developing Pre-Diabetes & Type 2 Diabetes NDPP risk measure methodology differ from the Type 2 Diabetes predictive risk model?

Whereas the Risk for Developing Pre-Diabetes & Type 2 Diabetes measure is calculated based on a custom specification developed in collaboration with the Maine Centers for Disease Control and Prevention (Maine CDC) in support of the National Diabetes Prevention Program (NDPP), the Type 2 Diabetes predictive risk model is a measure calculated based on a proprietary machine learning algorithm developed by HealthInfoNet and its partners.

Furthermore, the NDPP measure is calculating risk for developing Pre-Diabetes and Type 2 Diabetes, whereas the predictive risk model is calculating risk for for developing Type 2 Diabetes only.

For more information about the Hypertension predictive risk model, download the Technical Appendix from the Predictive Risk Modeling section.

How does an elevated Risk measure result relate to the Screening Recommendation and/or Eligibility measures?

Based on the current measure specifications, users should not infer that patients with an elevated risk result for developing Pre-Diabetes and Type 2 Diabetes are also recommended for Pre-Diabetes and Type 2 Diabetes screenings and/or eligible for NDPP participation. For example, patients may have an elevated risk result based on a combination of their age and sex alone (e.g., all males over the age of 60 years are at High risk).