Diabetes

1. 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 foot—or any organ, etc, for that matter—has been performed (rather than an "unacceptable exam"?)
2. 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.
3. 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.
4. 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.
5. 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 this area.
6. 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.
7. 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.
8. Comments on specific objectives:

1. 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 others.
2. 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.
3. Objects should be grouped by topic, e.g. 11, 12 and 19 of the present draft of HP 2010 should be sequential.
4. 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 country!"
5. 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.
6. "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.
7. 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.
8. 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.
9. 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.