Friday Five – Data-Driven Insights Are Closing Diabetes Gaps in Population Health
By LuAnn Kimker, RN, MSN, Senior VP of Clinical Innovation, Azara Healthcare
LinkedIn: Kendra Obrist
LinkedIn: Azara Healthcare
Diabetes affects over 38 million Americans, disproportionately impacting underserved communities where access to consistent, quality care can be a challenge. Effective diabetes management and prevention are critical to closing care gaps, and data-driven insights are reshaping how healthcare professionals identify, track, and manage at-risk populations. In observance of National Diabetes Month, here are five powerful ways data-driven insights are transforming diabetes care by enabling more proactive, efficient and community-centered approaches.
Proactively Identifying At-Risk Populations
Data-driven insights empower care teams to identify, track and prioritize individuals most at risk for developing diabetes or experiencing complications. By analyzing clinical data, patient history and social drivers of health (SDOH), these insights can stratify populations, helping care teams tailor interventions, screenings and programs to those who would benefit most.
Why It Matters: Nationwide, over 38 million people have diabetes but nearly 98 million have prediabetes. Early identification allows for timely intervention, slowing disease progression and preventing costly complications. With an estimated annual cost of $412.9 billion, proactive, targeted identification not only improves patient outcomes but also reduces the long-term burden on healthcare systems.
Enhancing Routine Screening and A1c Tracking
A1c testing is a key measure of blood sugar control, essential for managing diabetes and identifying prediabetes. Population health analytics platforms help healthcare teams monitor A1c levels and other critical screenings, like retinal eye and foot exams, across patient populations, sending alerts when tests are overdue or when results indicate a need for intervention. Automated reminders ensure that screenings are not overlooked, supporting consistent monitoring and quick responses to abnormal findings.
Why It Matters: Diabetes-related costs increased by $80 billion over the past decade, with medical expenses 2.6 times higher than those without the condition. Regular screening and routine A1c tracking helps prevent undetected progression and supports better disease management. With insulin costs rising year over year, efficient, preventive diabetes management can help lessen the financial strain on patients and the healthcare system alike.
Providing Comprehensive Risk Stratification for Targeted Outreach
Data-driven tools go beyond basic screenings, allowing healthcare providers to assess both clinical and social risk factors through predictive analytics. With insights from patient history, SDOH, and lifestyle risk factors, healthcare teams can segment populations and create targeted outreach plans that provide tailored support for high-risk groups.
Why It Matters: Diabetes disproportionately affects underserved communities, where social and economic factors can limit access to preventive care and complicate disease management. Comprehensive risk stratification enables healthcare teams to address these disparities by identifying high-risk individuals in vulnerable populations and delivering targeted, culturally relevant interventions that bridge gaps in care and advance equity.
Improving Care Coordination with Real-Time Alerts
Data-driven analytics platforms facilitate better care coordination by centralizing patient information and providing real-time alerts on significant health changes, missed appointments, or critical lab results. Care coordinators can quickly respond to these alerts, ensuring that all members of the care team are informed and able to act promptly on new developments.
Why It Matters: Real-time alerts help prevent lapses in care by ensuring immediate follow-up for at-risk patients, which is crucial for managing a chronic condition like diabetes. Effective care coordination reduces complications and promotes adherence to treatment plans, improving patient outcomes and the efficiency of care delivery.
Supporting Preventive Education and Patient Engagement
Education and engagement are vital to empowering patients in diabetes prevention and self-management. Data-driven solutions help healthcare teams identify patients who could benefit from diabetes self-management education and remote patient monitoring and enable targeted outreach to increase participation. By equipping patients with knowledge and self-management resources, healthcare professionals foster proactive health behaviors that lead to better outcomes.
Why It Matters: Engaged, informed patients are more likely to follow treatment plans and adopt preventive lifestyle changes. Beyond direct medical costs, diabetes has a massive economic impact on worker productivity and absenteeism, accounting for $106.3 billion in annual indirect costs. By empowering patients to manage their condition, preventive care can help mitigate complications, improve health and support employee productivity.
National Diabetes Month is always a rewarding opportunity for the Azara team to reflect on the importance of data-driven insights in addressing diabetes care gaps. As healthcare continues to evolve, we believe intelligent analytics platforms stand at the forefront of population health efforts, providing critical support in the fight against diabetes.
ICYMI – Our other Friday Fives.
