Clinical results from the initial 16-month pilot include:
- Median drop of A1C by 1.4 percentage points at three
- Increased diabetes self-management goal-setting at
all sites, a key element of diabetes care to decrease
diabetes-related complications and improve quality of
- Improved clinical performance measures at some sites,
such as blood pressure control and screening exams
- CDEMS adaptation for the Pacific region's unique
screening needs for diabetic comorbid issues, for example
betel nut use in addition to tobacco use, and
- Educational materials/resources
updates including culturally-relevant information for
diabetics and their families
In January 2018, a learning session was held. Additional
accomplishments and innovations noted by the teams are:
- Tracking of patients lost to follow-up
- Update of clinical indicators by endocrinology
- Progress in one-stop clinics and
In 2019, 11 multidisciplinary teams, representing the
region's USAPI health care systems, participated in the
Pacific NCD Collaborative. Teams reporting at the
bi-annual Collaborative Learning Sessions demonstrated
continued diabetes registry database improvements that
allows individual patient and physician tracking of
preventive care practices, benchmarking, and population
management across the participating healthcare teams.
These registries expanded to also include individuals
previously lost to follow-up as well as the newly
Teams continued to use Plan-Do-Study-Act cycles for the
upcoming year and aim for continued improvement in
aggregate A1c average,
diabetic foot screening, depression screening,
self-care goal documentation and blood pressure control.
Teams also demonstrated improvements from using
evidence-based preventive practices. Several examples
- A median drop of A1c of almost 1 percent in Pohnpei,
- Improvements in documentation of:
- Blood pressure control
- Depression screening (Kosrae, FSM, Palau)
- Foot exams (Ebeye, Majuro, RMI, Palau)
- Self-care goal (Majuro, Pohnpei, Yap, FSM, Palau)
- Dental exams (Palau)
An increased number of partnerships continue to share the
care model by outreach and expansion. For example, in
partnership with the Health Resources and Services
Administration (HRSA) National Hansen's
Disease Program, a train-the-trainer model addressed
lower extremity amputation prevention skills for 12
healthcare professionals working in the region. Another
example is the development of culturally relevant
diabetes self-management education (DSME) resources, such
Navigating the Course of Diabetes Self-Care
Guidebook, which increases access to DSME and
encourages individuals living with diabetes and their
families to work with their healthcare teams to prevent
complications and promote health.
As of 2020, regional healthcare system involvement
increased from eleven to twelve multidisciplinary teams.
Diabetes patient registries continue to expand to include
those lost to follow-up or previously undiagnosed.
Established evidence-based practices that prevent or
delay diabetes-related complications and promote health
have continued in their use.
Due to the COVID-19 Public Health Emergence (PHE),
mid-year 2020 virtual sessions have increased local NCD
team member participation. Feedback demonstrated that
virtual venues have strengthened collaboration.
For more detailed program results:
Hawley, N.L., Suss, R., Cash, H.L., Aitaota, N., Ayers,
B., McElfish, P.. (2019).
Diabetes Prevention and Care Programs in the
US-Affiliated Pacific Islands: Challenges, Innovation,
and Recommendations for Effective Scale-Up.
Current Diabetes Reports, 19 (5) 24.
Hosey, G. M., Rengiil, A., Maddison, R., Agapito, A. U.,
Lippwe, K., Wally, O. D.,... Satterfield, D. (2016).
U.S. Associated Pacific Islands Health Care Teams Chart a
Course for Improved Health Systems: Implementation and
Evaluation of a Non-communicable Disease Collaborative
Model. Journal of Health Care for the Poor and
Underserved, 27(4A), 19-38.
Hosey, G., Ichiho, H., Satterfield, D., Dankwa-Mullan,
I., Kuartei, S., Rhee, K., Belyeu-Camacho, T., deBrum,
I., Demei, Y., Lippwe, K., Luces, P. S., & Roby, F.
Chronic disease surveillance systems within the US
Associated Pacific Island jurisdictions.
Preventing chronic disease, 8(4), A86.
Hosey, G., Aitaoto, N., Satterfield, D., Kelly, J.,
Apaisam, C. J., Belyeu-Camacho, T., deBrum, I., Luces, P.
S., Rengiil, A., & Turituri, P. (2009).
The culture, community, and science of type 2 diabetes
prevention in the US Associated Pacific Islands.
Preventing chronic disease, 6(3), A104.