- Need greater definition of what constitutes an
"exam" or test, e.g. if the frequency of foot examinations is to be tracked,
what is an acceptable "exam of the foot?" Further, how will it be documented
that an acceptable examination of the footor any organ, etc, for that
matterhas been performed (rather than an "unacceptable exam"?)
- Information should be included that indicates what to do,
should an abnormal physical examination, historical information, or laboratory test be
found. For example, is an "abnormal at risk foot" is found following
examination; if a history of active smoking is determined; if an abnormal cholesterol
measurement is noted; etc., what should the next steps be? This recommendation was felt
relevant to many of the chapters in HP 2010.
- While the inclusion of "education" is good, the
concept of "education" needs to be broadened substantially to also include
health care professionals, large as well as individual purchasers of health care plans,
the general public, managed care plans, etc.
- Should be a separate "obesity chapter." Obesity is
becoming an epidemic in the U.S. and underlies many of the topics in HP 2010. Thus, it
deserves it's own separate chapter. At a minimum, there should be clear and easy
"directions" to other focus areas and/or objectives where obesity is discussed.
- Need to increase the public health dimensions to the
diabetes chapter in HP 2010. Most of the objectives are very clinical in nature, i.e.
refer only to activities that would take place in a one on one situation between the
health provider, esp. MD, and the patient. These are important, but insufficient, if there
is to be progress in diabetes. The environment where people work, live and play also must
be addressed in the diabetes chapter if a meaningful way if there is to be progress in
- Issues of policy, etc. should also be included in the
diabetes chapter of HP 2010. This comment relates to #5 above, but is very important and
at a minimum, should be discussed in the various background sections. Ideally, there
should be 1 or 2 objectives related to policy issues and diabetes mellitus, such as
provision of reimbursement for education, diabetes supplies, etc.
- There should be greater emphasis on objectives related to
morbidity and quality of life, than mortality. Consistent with the concept of
"compression of morbidity," most of the diabetes interventions will delay and
attenuate the extent of impaired quality of life, i.e. morbidity. These measures should
receive greater emphasis.
- Comments on specific objectives:
- Objectives should somehow be prioritized. This is a
general comment to all the chapters of HP 2010. Otherwise, people and organizations either
will not no where to "start," or will be overwhelmed, thinking that there is too
much to do. There should be some clear sense of which objectives are more important than
- The following objectives should be added: gestational
diabetes mellitus; influenza and pneumococcal vaccination; some measure of
"economics;" possibly some indicator of hypoglycemic rates associated with DM.
For each of these suggested additional objectives, there is evidence that they are
clinical and public health problems; as well as validated interventions that can reduce
the morbidity and mortality associated with them.
- Objects should be grouped by topic, e.g. 11, 12 and 19
of the present draft of HP 2010 should be sequential.
- Greater emphasis needs to be placed on "data
sources," i.e. where the data will come from; the use and development of new or
improved data collection systems; etc. "The government should be willing to make
investments in data systems if it really wants to know what is going on in the
- Regarding glycosylated hemoglobin assays, a test that
will increasingly be used to not only evaluate individual progress in diabetes, but also
capabilities of managed care plans, additional work needs to be done to achieve
standardization of the assays to measure this substance. Otherwise, it will not be
possible to make meaningful comparisons.
- "Population attributable risk" should be
included in all objectives in the diabetes chapter where it would be appropriate. It will
not be possible, for example, to reduce the rate of death from CVD in persons with DM
below the non-diabetic average. Thus, how much of the excess risk of CVD death in persons
with DM can really be attributed to DM? This information should be included in HP 2010 as
well as in the calculations of the goals of the objectives.
- Some of the objectives in the diabetes focus area may
be "in conflict." For example, it is very unlikely that the prevalence of DM
will in fact decrease if there is success in identifying previously unrecognized DM and/or
decrease mortality in persons with DM.
- For objective 4 and 5, there may be some confusion and
conflict when on the one hand, "underlying cause of death" is used; and in the
second case, "underlying and contributing" or any listing of death from DM, is
used. One "formula" should be used for both objectives.
- Terms in the diabetes focus area, as well as
throughout HP 2010 need to be standardized and consistent. For example, the phrases
"cardiovascular disease," "coronary artery disease," "ischemic
heart disease," etc. appear to be used interchangeably. Only one term should be used
by all the chapters, and there should be a general glossary of terms for HP 2010.