Enhancing access and impact of the Medicare Diabetes Prevention Program using telehealth: a narrative review

Introduction

Background

Diabetes affects 29% of adults aged 65 and older in the United States (US) (1). Another 49% of older adults, amounting to 26.4 million individuals, have prediabetes and are at heightened risk of progressing to type 2 diabetes without intervention (1,2). Both prediabetes and diabetes can damage blood vessels, which results in co-morbidities such as cardiovascular disease, cerebrovascular disease, and even cognitive decline (3,4). The high prevalence of prediabetes and diabetes among older adults demands population-level prevention strategies, including to reduce the high costs associated with diabetes care. For every older adult with diabetes, approximately $13,240 (in 2017 US dollars) is spent annually on diabetes-related medical care (5). This amount is nearly twice the cost of diabetes care for adults aged 45–64 years ($6,870 per person per year) (5). Moreover, the costs of medical care are 16 times higher for older adults with diabetes compared to older adults with prediabetes ($820 per person per year) (5). Thus, there is potential cost savings of $12,420 per person per year for every case of prediabetes that is halted from progressing to diabetes among older adults.

The National Diabetes Prevention Program (NDPP) is a yearlong, evidence-based lifestyle intervention that was launched by the Centers for Disease Control and Prevention (CDC) in 2010. The NDPP promotes modest weight loss through healthy eating and physical activity. Benefits include a 46% reduction in diabetes incidence (compared to no intervention) among adults of all ages (6). Older adults may fare even better—in the clinical trial that preceded the NDPP, there was an impressive 71% reduction in risk of developing diabetes among participants ≥60 years old (7). There were also significant reductions in medical spending among Medicare beneficiaries who participated in the NDPP (8). On average, $1,456 was saved per Medicare beneficiary within just 1 year of participating in the NDPP (8). In turn, the Centers for Medicare and Medicaid Services (CMS) began provisional coverage for the Medicare Diabetes Prevention Program (MDPP) in 2018 (9). The MDPP is an unprecedented opportunity for older adults to receive a diabetes prevention program (DPP) that is fully covered by Medicare (9).

The MDPP is an extension of the NDPP and uses the same curriculum, quality assurance recognition program, and lifestyle coach trainings (10). In addition to the CDC’s policy that governs the NDPP, the MDPP also requires adherence to CMS’s policy that is more restrictive. The CDC allows various modalities, including in-person group classes, online platforms (e.g., mobile applications), and distance learning (e.g., video-conferencing) (11). Yet, initially CMS only allowed in-person delivery of the MDPP after finding more limited evidence for other modalities at the time (9). CMS also targets ≥5% weight loss, whereas the CDC offers more potential benchmarks to demonstrate success (e.g., ≥0.2% A1C reduction). CMS predicted that over 65,000 Medicare beneficiaries would participate in the MDPP each year (9). However, only 4,848 total beneficiaries have participated after 4 years of coverage (12). Another concern is that most MDPP participants are white (77%) (12), yet racial and ethnic minority groups are in greater need of services to address diabetes disparities (1). The coronavirus disease 2019 (COVID-19) pandemic prompted a temporary shift to allow MDPP delivery through distance learning (13). Distance learning has the potential to increase reach, especially as 39% of all beneficiaries must travel more than 50 miles to attend a single session at their nearest MDPP location (12). However, while CMS initially mandated a return to in-person delivery by the end of 2023 (14), distance learning delivery will now be permitted through December 31, 2027 (15).

Rationale and knowledge gap

Inadequate uptake of the MDPP is concerning because the MDPP is not yet a permanent benefit and still falls within the CMS Innovation Center (16,17). Continued coverage likely depends upon demonstrating robust results in the near future, including to effectively address gaps in access and ensure high potential impact. The MDPP is the first Medicare-covered disease prevention program, and its success would likely prompt other payers to cover the NDPP and similar services. Expanding telehealth delivery may offer a promising solution to increase the reach and impact of the MDPP for older adults. However, there is a critical knowledge gap regarding the effectiveness, feasibility, and acceptability of telehealth delivery for older adults in the MDPP.

Objective

We aim to explore the role of telehealth on the accessibility and effectiveness of DPPs for older adults. The objective is to identify the factors that are likely to affect utilization of the MDPP when delivered through telehealth, as well as explore the potential benefits and challenges that are associated with this mode of delivery. We present this article in accordance with the Narrative Review reporting checklist (available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-23-37/rc).

Methods

This narrative review focuses on telehealth to deliver DPPs to older adults, specifically through distance learning. Distance learning is defined by the CDC, and endorsed by CMS, as live delivery of session content in which participants join through phone- or video-conferencing (11). We focused on distance learning delivery because it is the only virtual delivery method permitted by CMS (and only since the COVID-19 public health emergency). With the assistance of a health sciences librarian, we based our review on relevant literature from the online databases of MEDLINE, APA PsycInfo, CINAHL, and Academic Search Elite, in the EBSCOhost system. For efficiency of searching, we used Medline in the EBSCOhost system, which includes all the content of PubMed and also searches the full text of articles. We searched for the terms ((diabet* OR prediabet* OR “pre diabet*” OR “pre-diabet*” OR “metabolic syndrome”) N3 prevent*) AND ((telemedicine OR telehealth or telecare OR telenursing OR telerehab* OR “remote consult*” OR “distance learn*” OR “video conferenc*” OR videoconferenc* OR Zoom OR teleconferenc* OR Webex)) AND (Elderly OR MH “Aged+” OR “older adult*” OR “seniors” OR “senior citizen*”). We also conducted hand searches of reference lists.

Articles were included if they described DPPs among adults aged 55 years and older using distance learning delivery and described the clinical effectiveness, feasibility, and/or acceptability of the intervention. Using a lower age limit than 65 allowed for a more comprehensive search. Exclusion criteria included interventions that were delivered asynchronously online or through mobile applications, as these delivery modes are not permitted for the MDPP. To provide a synopsis of recent evidence, the literature was searched from January 2016 through September 2023. The online tool Covidence (Melbourne, Australia) was used to facilitate organization and screening of references. Two hundred and ninety-two articles were initially retrieved, and six duplicates were removed. After abstract review, 224 articles were not aligned with the topic and excluded. After full-text review of 62 articles and application of the eligibility criteria, eight articles were included to specifically describe outcomes associated with distance delivery of DPPs for older adults. Both authors reviewed the full text of the articles for inclusion; any disagreement between authors was resolved by re-reviewing and discussing eligibility criteria together. See Table 1 for the search strategy summary. We also incorporated information from relevant policy documents and online publications.

Results

Three key themes emerged from the literature on telehealth as it relates to DPPs for older adults: (I) clinical effectiveness of DPPs that are delivered via telehealth for older adults; (II) feasibility and acceptability of implementing DPPs for older adults via telehealth; and (III) future policy considerations to support greater public health impact of the MDPP through telehealth.

Clinical effectiveness

There is a growing body of evidence to suggest that older adults can do well in the MDPP when delivered via telehealth. The evidence comes largely from studies showing that (I) outcomes for in-person DPPs are favorable for older adults; and (II) outcomes for telehealth delivery are also favorable, albeit with calls for further research.

Favorable outcomes for in-person delivery of the MDPP with older adults

CMS initially piloted the MDPP from 2013–2015 with 6,874 mostly older adults who attended in-person classes at their local Young Men’s Christian Associations (YMCAs) (18). The average weight loss was 5.8% for older adults who attended for 4+ months (number not reported). After CMS began offering the in-person MDPP as a covered benefit in 2018, the first annual report stated that the average weight loss was 5.1% for the 1,359 Medicare beneficiaries who had attended at least two sessions (19). The second annual report was consistent in showing that average weight loss was also 5.1% for the 3,618 beneficiaries who attended at least two sessions (12). Each kilogram of weight loss with lifestyle intervention has been associated with a 16% reduction in diabetes incidence (20). Thus, it is encouraging to have consistent evidence that older adults achieve a clinically meaningful amount of weight loss in the MDPP. This suggests that the MDPP’s content is beneficial and could potentially lead to successful outcomes when translated from in-person to telehealth delivery.

Favorable outcomes for telehealth delivery with older adults

Recent reports have also described telehealth delivery of DPPs for older adults using distance learning. The BRIDGE study piloted a 6-week version of the DPP that was delivered through live webinars at a senior center with a small sample of 16 older adults (21). Average weight loss was 2.9% after the intervention and was expected to exceed 5% weight loss if the intervention was longer (i.e., average weight loss was 0.4% each week), as in the yearlong MDPP. CMS also reported on MDPP outcomes for beneficiaries who received most sessions through telehealth due to the public health emergency. Remarkably, the average weight loss was 6.1% for 221 beneficiaries who participated in at least two sessions in 2021 (12). This was the highest level of mean weight loss of any cohort since the MDPP began in 2018, offering strong preliminary evidence of clinical effectiveness through distance learning. Another study found no significant difference in weight loss between in-person (6.2%; n=278) and remote delivery (5.8%; n=191) of a 16-week DPP, although participants included adults of all ages (22). However, the authors found no significant effect of age on weight loss, such that the intervention may benefit older and younger adults alike.

Two other recent studies have also shown that distance learning DPPs implemented during the pandemic achieved better outcomes compared to in-person programs before the pandemic (23,24). In Minnesota, completing remote delivery of the NDPP resulted in greater weight loss (7.7%; n=31) compared to participants who completed the standard in-person NDPP (4.7%; n=47); the average participant age was 58 years (23). Moreover, in a population-based study from the United Kingdom, older adults appeared to have the most weight loss after 9 months of distance learning delivery of the National Health Service Diabetes Prevention Programme. For example, participants who were 60–69 years of age (n=11,987) had 2.7 kg of weight loss compared to 1.8 kg of weight loss for participants who were 18–39 years of age (n=2,636) (24). Delivery features, content, and evaluation standards of the National Health Service Diabetes Prevention Programme aligned with the CDC’s NDPP. Recommendations to further bolster weight loss with distance learning delivery include providing additional real-time behavioral support and extra personal communications (such as emails, texts, or phone calls). Interventions that incorporate such support have been shown to achieve 1% greater weight loss compared to remote interventions without added support (25).

Calls for additional evidence of clinical effectiveness

Further study of telehealth delivery has been called for to address several remaining knowledge gaps (26). Evidence is lacking on telehealth delivery of DPPs among diverse, underserved populations (27), but some recent evidence suggests effectiveness among economically-disadvantaged and ethnically-diverse adults (23). Diabetes disparately impacts racial and ethnic minority and low-income individuals (1), and ensuring equitable outcomes is important. Prior reports have focused on describing weight loss outcomes, yet more data is needed to understand glycemic outcomes and reductions in diabetes incidence from telehealth delivery in older adults. New research from the Longitudinal Epidemiological Assessment of Diabetes Risk (LEADR) study shows that DPPs that were delivered in-person to diverse adults of all ages (n=1,336) can prevent diabetes even without weight loss (6). Findings from the LEADR study (6) and other emerging research (28) suggest that the relationship between weight loss and diabetes prevention is not as strong as previously thought. Promisingly, the BRIDGE pilot study of telehealth delivery for older adults has been expanded to a large clinical trial, including both weight loss and A1C change as primary outcomes (clinicaltrials.gov #NCT05166785) (29). Results are expected in 2026. In a pilot of two distance-delivered sessions before the trial’s implementation, 87% and 94% agreed or strongly agreed that the video format was a good fit, and attending was easy, respectively (30). We also recommend that future studies clearly report outcomes for subgroups to ensure clinical effectiveness for priority populations (e.g., racial and ethnic minority groups, low-income individuals, and rural participants), as well as outcomes for all participants who attended at least one session, which is a commonly used attendance metric for the NDPP and MDPP.

Feasibility and acceptability of implementing the MDPP via telehealth

In addition to clinical effectiveness, successful large-scale implementation of the MDPP through telehealth requires high levels of feasibility and acceptability for both participants and MDPP suppliers.

Feasibility for participants

Both barriers and facilitators to telehealth adoption among older adults have been well-documented. Barriers include vision and hearing impairments, limited dexterity, and memory issues (31-34). In turn, recommended strategies to address vision impairments include increasing screen brightness and text and icon sizes, and avoiding ornate fonts that are more difficult to read (32,34). Issues with dexterity may be managed by simplifying tasks and allowing extra time (34). Hearing deficiencies may be addressed with adequate sound volume and closed-captioning (34). Strategies to address cognitive challenges include using simple instructions and logins; intuitive, pictorial information displays; fewer required “clicks”; and adequate time for processing material (32,34).

Other barriers can include limited computer use and digital literacy, low self-efficacy or disinterest in using technology, frustration with technological complexity, and privacy concerns (32,33,35,36). However, a recent report revealed substantial gains in technology use among older adults over the past decade (37). As of 2021, 75% of older adults are internet users, 64% have broadband internet at home, and 61% own a smartphone, up from only 13% of older adults owning a smartphone in 2012 (37). Nonetheless, strategies to address technology concerns include providing extra training on technical features, easy access to troubleshooting, positive reinforcement for acquiring digital skills, and explicit details on the precautions taken to protect information (32-34).

Acceptability for participants

The literature suggests that older adults are likely to accept (31,38) and be satisfied with telehealth (39-41). The BRIDGE pilot study held focus groups to assess intervention acceptability and found satisfaction with “most program components, especially the webinar group interaction and using physical activity trackers” (21). Participants had only minor recommendations for improved telehealth delivery, including to ensure a quiet environment and good sound quality. A study on diabetes self-management education classes that were mostly delivered to older adults (mean age of 62 years) (42) also included qualitative interviews about the pros and cons of distance learning (43). Illustrative quotes that help to describe the “real” experience of distance learning included:

• “It was online, which was a big deal for me because … I’m not going out these days.”;
• “I liked [distance learning] a lot because sometimes with depression, anxiety … it’s hard to go places and do stuff. That was helpful because it eliminated an excuse …”;
• “I found it all really distract[ing] because so many of the people were doing other stuff. I’m watching them fart around … A cat walks by, or somebody’s husband’s coming in …” (43).

The participants also reported that a virtual environment was more conducive to discussing sensitive topics and felt more private. Yet, participants also continued to receive social support from distance learning, with some even reporting that it felt equivalent to meeting in-person. The acceptability of telehealth interventions has also extended to older adults in rural areas, which is critical given the healthcare access and resource issues often experienced by those living in rural areas of the US (44). In another study that assessed the effects of a highly intensive weight loss intervention delivered through both live video conferencing and in-person sessions, participants reported high satisfaction with the telehealth components (38). For example, there were high satisfaction scores with the video-conferencing device itself (4.4 out of 5) and using video-conferencing to work toward their health goals (4.7 out of 5). Such levels of acceptability highlight the value of telehealth interventions to overcome the lack of close proximity to health promotion programs in rural locations (44).

Feasibility for suppliers

The majority (92.5%) of organizations delivering the NDPP exclusively provided in-person group classes as of 2019 (6). Yet, most organizations quickly transitioned to virtual delivery after the onset of the COVID-19 pandemic (12). This rapid transition indicates the high level of feasibility for providing distance learning services. As of June 2023, there were 155 NDPP suppliers registered with the CDC as providing the distance learning delivery mode who also have “preliminary” or “full” CDC-recognition (45), which is required by CMS to be an MDPP supplier. Only 15% (n=23) are currently MDPP suppliers. The remaining 132 NDPP organizations could readily expand to delivering the program via telehealth for Medicare beneficiaries as well. However, multiple MDPP suppliers have reported a desire for additional training and resources to better implement DPPs through distance learning (9,12). Because CMS mandated in-person delivery prior to the COVID-19 pandemic, some suppliers experienced challenges when switching to distance learning delivery, e.g., technological skills of staff, administrative intricacies of virtual delivery, and adherence to curriculum fidelity online (12).

Suppliers have reported difficulty recruiting for their remote classes, which diminishes feasibility. Recruitment is often a challenge even with in-person delivery of DPPs to participants of all ages (46), and this challenge has also applied when suppliers are recruiting older adults (18,47,48). Two studies that exclusively enrolled older adults in telehealth interventions similar to the MDPP noted difficulty with recruitment (21,38).

Nonetheless, there are recommended strategies to facilitate recruitment (46). A systematic process to refer patients to the MDPP is especially key (47,49). Electronic health record (EHR) systems can be used to identify patients with prediabetes (50,51), alert the healthcare provider, and link patients to an MDPP supplier (52), which could improve MDPP referrals and uptake. Referral protocols that are compliant with the Health Insurance Portability and Accountability Act (HIPAA) have been established, including by the American Medical Association (51) and the State of Colorado’s Office of eHealth Innovation (53). Importantly, provider-referred patients are more likely to enroll in DPPs (50,51), and go on to achieve more weight loss than those who were identified from other referral sources (5.4% vs. 4.8%) (12).

Acceptability for suppliers

A recent qualitative analysis reported on the perspectives of MDPP suppliers in Pennsylvania and found that telehealth delivery of the MDPP has become more appealing after the onset of the COVID-19 public health emergency. Although MDPP suppliers reported that older adults had initially hesitated when considering telehealth delivery, suppliers also perceived how telehealth facilitated access and social support for older adults during the pandemic (47). Suppliers in Los Angeles County also reported that telehealth delivery increased access for individuals who would otherwise have difficulty with in-person attendance in the NDPP (54). Interviewees further described examples of older adults and low-income participants who were “very tech-savvy” and “quickly able to adjust to telehealth” (54). However, as described in detail below, a remaining concern is that suppliers have reported needing better reimbursement rates for providing the MDPP.

Policy considerations to increase MDPP impact through telehealth

First, changing CMS policy to permanently allow continued delivery of the MDPP through distance learning appears warranted based on the newest evidence presented in this review. Telehealth delivery is especially needed because older adults living in rural areas with limited access have higher rates of diabetes (55) and diabetes-related mortality (56) than their urban counterparts. Although some knowledge gaps remain, it is reassuring that telehealth suppliers would still be required to demonstrate adequate fidelity and effectiveness of their programs, in accordance with the CDC standards for program delivery. Otherwise, most policy change recommendations are related to reimbursement to suppliers for providing the MDPP.

Cost-effectiveness considerations

Reimbursement rates for the MDPP are set by CMS. The gap between MDPP costs and reimbursement is well-documented (57,58) and has been identified as a challenge to MDPP implementation (48), including when the MDPP was delivered through telehealth. For in-person services, initial delivery costs were reported to be $553–800 with average reimbursement of only $108–190 per participant (57,58). CMS announced changes effective in 2022 to help with this financial shortfall. Reimbursement for participants who meet all the attendance and weight loss benchmarks increased from $468 to $705; for those who meet attendance but not weight loss benchmarks, payments increased from $203 to $455 US dollars (13). Yet, even higher reimbursement rates are likely needed and appear supported by the return on investment. The long-term medical cost savings of participation in the MDPP have been established (8,18,59), and outcomes should be similar (or even better) for telehealth based on the evidence of clinical effectiveness reported above. CMS could also survey the costs for telehealth delivery of the MDPP, which appear largely unknown. One small study reported a cost savings of $90 per participant when comparing in-person delivery to video-conference delivery among adults with a mean age of 50 and 53 years, respectively (60). Although distance delivery removes the necessity and cost of the physical space used for in-person programming, costs may be similar when accounting for staff time to provide additional technical support and other accommodations that older adults may require. Suppliers have also requested that CMS reduce payment wait times (47).

Another concern of low reimbursement rates is that MDPP suppliers may be dissuaded from entering markets with underserved populations who historically have been less likely to achieve performance payment milestones (58,61). In fact, severe shortages of MDPP sites were observed in states and territories with the largest populations of racial and ethnic minority beneficiaries (62). A recent analysis of suppliers revealed that states with a Medicare enrollment of ≥20% African American or Hispanic beneficiaries had fewer MDPPs, e.g., Mississippi had three sites, New Mexico had one (63). However, health equity goals may be achieved through policy changes that assure equitable payments for underserved beneficiaries who can have more barriers to achieving weight loss goals (58,64). For example, CMS could add reimbursement for A1C improvement, which is an indicator of risk reduction that can be less prone to disparities (28).

In turn, the overall impact of any changes in CMS rulemaking may be assessed by examining whether (and to what extent) there is a corresponding increase in the number of participating MDPP suppliers and beneficiaries. Evaluation of outcomes after CMS rulemaking changes could also include subgroup analyses to determine their effect on individuals from racial and ethnic minority groups, low-income backgrounds, and rural settings.

Strengths and limitations of this review

This review is limited by the small body of evidence that exists on telehealth delivery of lifestyle programs for diabetes prevention and weight loss among the older adult population, an issue that has been acknowledged by others (38,41). Additionally, many included studies were limited by small sample sizes, which restricts their generalizability. However, the evidence reviewed indicates that telehealth DPPs are feasible, acceptable, and effective for older adults. Further research is needed to better determine the cost-effectiveness of telehealth program delivery in the general population and among older adults.

Conclusions

Population-level strategies to prevent type 2 diabetes are urgently needed for the 26.4 million older adults with prediabetes in the US (1). Although the MDPP is a cost-free strategy for older-adult Medicare beneficiaries, it is largely unavailable and underutilized. This review revealed encouraging evidence that telehealth delivery of the MDPP is a useful method to increase its reach and impact, while also providing social support for older participants. Our findings from a limited body of evidence indicate that telehealth programs delivered via videoconferencing appear to be feasible, effective, cost-effective, and generally well-accepted by the population of older adults, summarized in Table 2. Clinically meaningful levels of weight loss were noted, and older adults were receptive to this form of programming, with some caveats. Adjustments for physical and cognitive limitations and modifications to the program to accommodate the needs of older adults were desired (21,29,32,34). Additional important components were the ability to interact with others for support (21,38) and technical help (32-34,38). Taken together, the evidence suggests that delivery of the MDPP via telehealth is a sound practice that should be embraced by CMS for the widespread use and benefit of this program.

A unique contribution of this review is the integration of the newest analyses that compare in-person to distance learning delivery during the COVID-19 pandemic (23,24). These data provide compelling information that telehealth delivery appears to be effective among those who are aged 55+ years. Additionally, we have focused on the policy implications of the evidence. The findings shed light on the challenges faced by the MDPP, including insufficient reimbursement, limited awareness, and low referral rates. This review emphasizes the importance of continued virtual delivery of the MDPP and provides evidence to support policy recommendations, such as using EHR systems to identify patients with prediabetes and facilitate referrals. The impact of policy changes on program enrollment and payment structures is also explored, underscoring the need for increased payments and reduced wait times to encourage broader participation. There is an urgent need for expanded virtual delivery options, considering the limitations posed by geographical barriers and the scarcity of MDPP suppliers. By leveraging telehealth technologies, the MDPP can reach underserved populations and help prevent type 2 diabetes among older adults. Policy recommendations derived from this review can inform future rulemaking by CMS to pave the way for the long-term sustainability of the MDPP and the coverage of other disease prevention programs.

Enrollment in Medicare is projected to increase by an average of 1.5 million beneficiaries each year from 2021 to 2029 (65), making uptake of the MDPP critically important. Moreover, as older Americans age into the Medicare system, they will have had much more experience with technology than previous generations. This evolution suggests an increased demand for more convenient, time-saving, and accessible programs will ensue. For millions of beneficiaries, conversion to diabetes could be prevented by MDPP participation, and produce substantial cost savings. Distance learning delivery facilitates participation, particularly for individuals living in rural areas and experiencing physical limitations. Policy makers are encouraged to consider the current evidence on telehealth effectiveness and recognize the importance of allowing MDPP delivery in this format. Scalable delivery via telehealth is essential to make a national, population-level impact for older adults receiving Medicare benefits.

Acknowledgments

Funding: This work was supported by the National Institutes of Health (Nos. R01DK119478 and R15HL163736).

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-23-37/rc

Peer Review File: Available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-23-37/prf

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-23-37/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Centers for Disease Control and Prevention. National Diabetes Statistics Report. 2022. Available online: https://www.cdc.gov/diabetes/data/statistics-report
2. Rooney MR, Rawlings AM, Pankow JS, et al. Risk of Progression to Diabetes Among Older Adults With Prediabetes. JAMA Intern Med 2021;181:511-9. [Crossref] [PubMed]
3. Gregg EW, Sattar N, Ali MK. The changing face of diabetes complications. Lancet Diabetes Endocrinol 2016;4:537-47. [Crossref] [PubMed]
4. Marseglia A, Fratiglioni L, Kalpouzos G, et al. Prediabetes and diabetes accelerate cognitive decline and predict microvascular lesions: A population-based cohort study. Alzheimers Dement 2019;15:25-33. [Crossref] [PubMed]
5. Dall TM, Yang W, Gillespie K, et al. The Economic Burden of Elevated Blood Glucose Levels in 2017: Diagnosed and Undiagnosed Diabetes, Gestational Diabetes Mellitus, and Prediabetes. Diabetes Care 2019;42:1661-8. [Crossref] [PubMed]
6. Campione JR, Ritchie ND, Fishbein HA, et al. Use and Impact of Type 2 Diabetes Prevention Interventions. Am J Prev Med 2022;63:603-10. [Crossref] [PubMed]
7. Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393-403. [Crossref] [PubMed]
8. Alva ML, Hoerger TJ, Jeyaraman R, et al. Impact Of The YMCA Of The USA Diabetes Prevention Program On Medicare Spending And Utilization. Health Aff (Millwood) 2017;36:417-24. [Crossref] [PubMed]
9. Centers for Medicare & Medicaid Services (CMS). HHS. Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2018; Medicare Shared Savings Program Requirements; and Medicare Diabetes Prevention Program. Final rule. Fed Regist 2017;82:52976-3371. [PubMed]
10. Albright A. The National Diabetes Prevention Program: From Research to Reality. Diabetes Care Educ Newsl 2012;33:4-7. [PubMed]
11. Centers for Disease Control and Prevention. Centers for Disease Control and Prevention Diabetes Prevention Recognition Program Standards and Operating Procedures. 2021. Available online: https://www.cdc.gov/diabetes/prevention/pdf/dprp-standards.pdf
12. Hoerger TJ, Jacobs S, Romaine M, et al. Evaluation of the Medicare Diabetes Prevention Program. 2022. Retrieved July 5, 2023. Available online: https://www.cms.gov/priorities/innovation/data-and-reports/2022/mdpp-2ndannevalrpt
13. Centers for Medicare & Medicaid Services (CMS), Health and Human Services (HHS). Medicare Program; CY 2022 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment Policies; Medicare Shared Savings Program Requirements; Provider Enrollment Regulation Updates; and Provider and Supplier Prepayment and Post-Payment Medical Review Requirements. Fed Regist 2021;86:64996-6031.
14. Centers for Medicare & Medicaid Services (CMS). HHS. Medicare Program; Extending the Medicare Diabetes Prevention Program's (MDPP) Expanded Model Emergency Policy Through CY 2023. Fed Regist 2023;88:27413-4.
15. Centers for Medicare & Medicaid Services (CMS), Health and Human Services (HHS). Medicare and Medicaid Programs; CY 2024 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; Medicare Advantage; Medicare and Medicaid Provider and Supplier Enrollment Policies; and Basic Health Program. Fed Regist 2023;88:78818-80047.
16. Diabetes Advocacy Alliance. Letter to CMS administrator Verma on MDPP. 2019. Available online: https://www.adces.org/docs/default-source/advocacy/daa-letter-to-verma-on-mdpp-021519.pdf?sfvrsn=2
17. Centers for Medicare & Medicaid Services. Medicare Diabetes Prevention Program (MDPP) Expanded Model. 2023. Available online: https://innovation.cms.gov/innovation-models/medicare-diabetes-prevention-program
18. Hinnant L, Razi S, Lewis R, et al. Evaluation of the Health Care Innovation Awards: Community Resource Planning, Prevention, and Monitoring, Annual Report 2015. Awardee-Level Findings: YMCA of the USA. 2016. Available online: https://innovation.cms.gov/files/reports/hcia-ymcadpp-evalrpt.pdf
19. Hoerger TJ, Jacobs S, Romaine M, et al. Evaluation of the Medicare Diabetes Prevention Program. 2021. Available online: https://www.cms.gov/priorities/innovation/data-and-reports/2021/mdpp-firstannevalrpt
20. Hamman RF, Wing RR, Edelstein SL, et al. Effect of weight loss with lifestyle intervention on risk of diabetes. Diabetes Care 2006;29:2102-7. [Crossref] [PubMed]
21. Beasley JM, Kirshner L, Wylie-Rosett J, et al. BRInging the Diabetes prevention program to GEriatric populations (BRIDGE): a feasibility study. Pilot Feasibility Stud 2019;5:129. [Crossref] [PubMed]
22. Ciemins EL, Coon PJ, Coombs NC, et al. Intent-to-treat analysis of a simultaneous multisite telehealth diabetes prevention program. BMJ Open Diabetes Res Care 2018;6:e000515. [Crossref] [PubMed]
23. Welshons KF, Johnson NA, Gold AL, et al. Diabetes prevention program outcomes by in-person versus distance delivery mode among ethnically diverse, primarily lower-income adults. Digit Health 2023;9:20552076231173524. [Crossref] [PubMed]
24. Barron E, Bradley D, Safazadeh S, et al. Effectiveness of digital and remote provision of the Healthier You: NHS Diabetes Prevention Programme during the COVID-19 pandemic. Diabet Med 2023;40:e15028. [Crossref] [PubMed]
25. Joiner KL, Nam S, Whittemore R. Lifestyle interventions based on the diabetes prevention program delivered via eHealth: A systematic review and meta-analysis. Prev Med 2017;100:194-207. [Crossref] [PubMed]
26. Golovaty I, Ritchie ND, Tuomilehto J, et al. Two decades of diabetes prevention efforts: A call to innovate and revitalize our approach to lifestyle change. Diabetes Res Clin Pract 2023;198:110195. [Crossref] [PubMed]
27. AuYoung M, Moin T, Richardson CR, et al. The Diabetes Prevention Program for Underserved Populations: A Brief Review of Strategies in the Real World. Diabetes Spectr 2019;32:312-7. [Crossref] [PubMed]
28. Ritchie ND, Alshabani N, Cervantes L. Patient-centered goal setting to advance health equity in diabetes prevention. ADCES in Practice 2023;11:14-9. [Crossref]
29. Beasley JM, Johnston EA, Sevick MA, et al. Study protocol: BRInging the Diabetes prevention program to GEriatric Populations. Front Med (Lausanne) 2023;10:1144156. [Crossref] [PubMed]
30. Beasley JM, Johnston EA, Costea D, et al. Adapting the Diabetes Prevention Program for Older Adults: Descriptive Study. JMIR Form Res 2023;7:e45004. [Crossref] [PubMed]
31. Eze ND, Mateus C, Cravo Oliveira Hashiguchi T. Telemedicine in the OECD: An umbrella review of clinical and cost-effectiveness, patient experience and implementation. PLoS One 2020;15:e0237585. [Crossref] [PubMed]
32. Kebede AS, Ozolins LL, Holst H, et al. Digital Engagement of Older Adults: Scoping Review. J Med Internet Res 2022;24:e40192. [Crossref] [PubMed]
33. Wilson J, Heinsch M, Betts D, et al. Barriers and facilitators to the use of e-health by older adults: a scoping review. BMC Public Health 2021;21:1556. [Crossref] [PubMed]
34. Searcy RP, Summapund J, Estrin D, et al. Mobile health technologies for older adults with cardiovascular disease: current evidence and future directions. Curr Geriatr Rep 2019;8:31-42. [Crossref]
35. Coley N, Andre L, Hoevenaar-Blom MP, et al. Factors Predicting Engagement of Older Adults With a Coach-Supported eHealth Intervention Promoting Lifestyle Change and Associations Between Engagement and Changes in Cardiovascular and Dementia Risk: Secondary Analysis of an 18-Month Multinational Randomized Controlled Trial. J Med Internet Res 2022;24:e32006. [Crossref] [PubMed]
36. Cajita MI, Hodgson NA, Lam KW, et al. Facilitators of and Barriers to mHealth Adoption in Older Adults With Heart Failure. Comput Inform Nurs 2018;36:376-82. [Crossref] [PubMed]
37. Faverio M. Share of those 65 and older who are tech users has grown in the past decade. 2022. Available online: https://www.pewresearch.org/short-reads/2022/01/13/share-of-those-65-and-older-who-are-tech-users-has-grown-in-the-past-decade/
38. Batsis JA, Petersen CL, Clark MM, et al. Feasibility and acceptability of a technology-based, rural weight management intervention in older adults with obesity. BMC Geriatr 2021;21:44. [Crossref] [PubMed]
39. Robert C, Erdt M, Lee J, et al. Effectiveness of eHealth Nutritional Interventions for Middle-Aged and Older Adults: Systematic Review and Meta-analysis. J Med Internet Res 2021;23:e15649. [Crossref] [PubMed]
40. van Middelaar T, Beishuizen CRL, Guillemont J, et al. Engaging older people in an internet platform for cardiovascular risk self-management: a qualitative study among Dutch HATICE participants. BMJ Open 2018;8:e019683. [Crossref] [PubMed]
41. Marsh Z, Nguyen Y, Teegala Y, et al. Diabetes management among underserved older adults through telemedicine and community health workers. J Am Assoc Nurse Pract 2021;34:26-31. [Crossref] [PubMed]
42. Nederveld AL, Gurfinkel D, Hosokawa P, et al. The Psychosocial Needs of Patients Participating in Diabetes Shared Medical Appointments. J Am Board Fam Med 2022;35:1103-14. [Crossref] [PubMed]
43. Ritchie ND, Gurfinkel D, Sajatovic M, et al. A Multi-Method Study of Patient Reach and Attendance in a Pragmatic Trial of Diabetes Shared Medical Appointments. Clin Diabetes 2023;41:526-38. [Crossref] [PubMed]
44. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; et al. Achieving Rural Health Equity and Well-Being: Proceedings of a Workshop. Washington (DC): National Academies Press (US); 2018.
45. Centers for Disease Control and Prevention. Diabetes Prevention Recognition Program Application. Registry of All Recognized Organizations. 2023. Retrieved June 28, 2023. Available online: https://dprp.cdc.gov/Registry
46. Ritchie ND, Baucom KJW, Sauder KA. Current Perspectives on the Impact of the National Diabetes Prevention Program: Building on Successes and Overcoming Challenges. Diabetes Metab Syndr Obes 2020;13:2949-57. [Crossref] [PubMed]
47. Turk MT, Ritchie ND, Jakub K. Stakeholder analysis: Medicare Diabetes Prevention Program awareness and implementation. Am J Manag Care 2023;29:308-12. [Crossref] [PubMed]
48. Gruß I, Firemark A, Papajorgji-Taylor D, et al. Challenges with implementing the Diabetes Prevention Program for Medicare beneficiaries in an integrated health system. Am J Manag Care 2021;27:e400-3. [Crossref] [PubMed]
49. Tseng E, Meza K, Marsteller JA, et al. Engaging Payors and Primary Care Physicians Together in Improving Diabetes Prevention. J Gen Intern Med 2023;38:309-14. [Crossref] [PubMed]
50. Ritchie ND, Swigert TJ. Establishing an effective primary care provider referral network for the National Diabetes Prevention Program. AADE in Practice 2016;4:20-5. [Crossref]
51. Holliday CS, Williams J, Salcedo V, et al. Clinical Identification and Referral of Adults With Prediabetes to a Diabetes Prevention Program. Prev Chronic Dis 2019;16:E82. [Crossref] [PubMed]
52. Public Health Institute at Denver Health. CRISPeR-Community Resource Inventory Service for Patient e-Referral. 2018. Available online: https://www.phidenverhealth.org/-/media/dph-files-and-docs/health-info-and-reports/crisper-projectoverview-20190911.pdf
53. State of Colorado, Office of eHealth Innovation. Working action plan and environmental scan report: support care coordination in communities statewide. 2019. Available online: https://oehi.colorado.gov/sites/oehi/files/documents/Care%20Coordination%Environmental%Scan%Action%Plan%Final_V4.pdf
54. Bullock SL, Menendez T, Schwarte L, et al. Transitioning to telehealth during COVID-19: experiences and insights from diabetes prevention and management program providers in Los Angeles County. Diabetology 2023;4:46-61. [Crossref]
55. Coughlin SS, Clary C, Johnson JA, et al. Continuing Challenges in Rural Health in the United States. J Environ Health Sci 2019;5:90-2. [PubMed]
56. Callaghan T, Ferdinand AO, Akinlotan MA, et al. The Changing Landscape of Diabetes Mortality in the United States Across Region and Rurality, 1999-2016. J Rural Health 2020;36:410-5. [Crossref] [PubMed]
57. Parsons AS, Raman V, Starr B, et al. Medicare underpayment for Diabetes Prevention Program: implications for DPP suppliers. Am J Manag Care 2018;24:475-8. [PubMed]
58. Ritchie ND, Gritz RM. New Medicare Diabetes Prevention Coverage May Limit Beneficiary Access and Widen Health Disparities. Med Care 2018;56:908-11. [Crossref] [PubMed]
59. Alva ML. How Much Does Attendance Impact Weight Loss and Health Care Spending in a Diabetes Prevention Program Serving Older Adults? Am J Health Promot 2019;33:1067-72. [Crossref] [PubMed]
60. Vadheim LM, McPherson C, Kassner DR, et al. Adapted diabetes prevention program lifestyle intervention can be effectively delivered through telehealth. Diabetes Educ 2010;36:651-6. [Crossref] [PubMed]
61. Ritchie ND, Havranek EP, Moore SL, et al. Proposed Medicare Coverage for Diabetes Prevention: Strengths, Limitations, and Recommendations for Improvement. Am J Prev Med 2017;53:260-3. [Crossref] [PubMed]
62. Ritchie ND, Sauder KA, Gritz RM. Medicare Diabetes Prevention Program: where are the suppliers? Am J Manag Care 2020;26:e198-201. [Crossref] [PubMed]
63. Yan A, Chen Z, Wang M, et al. Accessibility of Medicare Diabetes Prevention Programs and Variation by State, Race, and Ethnicity. JAMA Netw Open 2021;4:e2128797. [Crossref] [PubMed]
64. Formagini T, Brooks JV, Jacobson LT, et al. Reimbursement Policies for Diabetes Prevention Program (DPP): Implications for Racial and Ethnic Health Disparities. Kans J Med 2021;14:234-7. [Crossref] [PubMed]
65. The Commonwealth Fund. Medicare Data Hub. 2020. Available online: https://www.commonwealthfund.org/sites/default/files/2020-10/Medicare%20Data%20Hub_October.pdf