[EQ] Public health approach - Tracking Diabetes

Tracking Diabetes: New York City’s A1C Registry

Shadi Chamany, Lynn D. Silver, Mary T. Bassett, Cynthia R. Driver, Diana K. Berger, Charlotte E. Neuhaus, Namrata Kumar, and Thomas R. Frieden
New York City Department of Health and Mental Hygiene; the Doris Duke Charitable Foundation; the New York City Health and Hospitals Corporation; the Centers for Disease Control and Prevention
The Milbank quarterly, Volume 87, Number 3, September 2009

Available online at: http://www.milbank.org/quarterly/8703feat.html

Context:
In December 2005, in characterizing diabetes as an epidemic, the New York City Board of Health mandated the laboratory reporting of hemoglobin A1C laboratory test results. This mandate established the United States’ first population-based registry to track the level of blood sugar control in people with diabetes. But mandatory A1C reporting has provoked debate regarding the role of public health agencies in the control of noncommunicable diseases and, more specifically, both privacy and the doctor-patient relationship.

Methods:
This article reviews the rationale for adopting the rule requiring the reporting of A1C test results, experience with its implementation, and criticisms raised in the context of the history of public health practice.

Findings:
For many decades, public health agencies have used identifiable information collected through mandatory laboratory reporting to monitor the population’s health and develop programs for the control of communicable and noncommunicable diseases. The registry program sends quarterly patient rosters stratified by A1C level to more than one thousand medical providers, and it also sends letters, on the provider’s letterhead whenever possible, to patients at risk of diabetes complications (A1C level >9 percent), advising medical follow-up. The activities of the registry program are similar to those of programs for other reportable conditions and constitute a joint effort between a governmental public health agency and medical providers to improve patients’ health outcomes….”

Conclusions:
Mandatory reporting has proven successful in helping combat other major epidemics. New York City’s A1C Registry activities combine both traditional and novel public health approaches to reduce the burden of an epidemic chronic disease, diabetes. Despite criticism that mandatory reporting compromises individuals’ right to privacy without clear benefit, the early feedback has been positive and suggests that the benefits will outweigh the potential harms. Further evaluation will provide additional information that other local health jurisdictions may use in designing their strategies to address chronic disease…..”

Commentary:
Beyond Historical Precedent
Amy L. Fairchild, Center for the History and Ethics of Public Health, Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University

Commentary:
A Legal Perspective on Diabetes Surveillance—Privacy and the Police Power
Michelle M. Mello and Lawrence O. Gostin
Harvard University; Georgetown University

“……….The New York City A1C Registry (NYCAR) program is an unusual and groundbreaking extension of the reach of public health law. It marks the first time that the government has mandated name-based reporting of a chronic, noninfectious disease not caused by an environmental toxin and where the data are given to patients and physicians. Although the program has generated deep social controversy, remarkably it has not been challenged in court.

Nonetheless, the law offers a useful lens through which to consider the program’s justification and legitimacy. In this commentary to the article in this issue by Chamany and colleagues (2009), we examine the state’s powers and responsibilities; patients’ rights to privacy and security of personal data; and physicians’ “privacy” rights…..”

Commentary:
Public Health and Health Care Quality Assurance—Strange Bedfellows?
Jonathan E. Fielding, Los Angeles County Department of Public Health

“….What is the role of governmental public health in ensuring the quality of medical care? With some notable exceptions, state and local public health departments have taken a passive role in medical care system quality assurance. Yet medical care can contribute much to improving the health of populations and at least some to reducing health disparities.

The article in this issue of The Milbank Quarterly by Chamany and colleagues describes one public health agency’s novel approach to the clinical management of adult diabetics: working with health care providers…………”

 

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