May 7, 2013

Our Meeting about the AACE Algorithm

The PDF is currently available here.
Note:  If you have not downloaded the algorithm from the AACE site, you may not be able to now.  In trying to establish links for this blog, I was receiving the following message - "AACE Members can view the NEW COMPREHENSIVE DIABETES MANAGEMENT ALGORITHM FOR TREATMENT OF DIABETES AND PREDIABETES PATIENTS."  along with site address for members.  This tells me that they have been taken to task and many people are unhappy with their algorithm.

Our group had many emails about the algorithm when it appeared and several wanted to have a meeting about it, as they were not following it. Brenda asked how many would be able to attend and then said we should have it at her place. Ten of us attended and with Tim's digital projector, we all had good seats. Max and Rob had the main questions, as they were not following the progress of the algorithm.

Because Tim had requested them to bring a pad of paper and complete beforehand their body mass index (BMI), their ideal weight, and list their other medical problems we were ready to go. Other medical problems include, blood pressure, cholesterol, any of the complications, and comorbid conditions they know they have. I knew that this part could get personal, therefore I opened by saying that I was asking everyone to be honest with themselves, but if they felt it necessary to keep information from the rest of us, that was their business.

I had expected to have someone qualify under the BMI of 25 to 26.9, but no one did without having one qualifier to drive them into the complications side. On that side, only two of us had BMIs greater than 27. Now we needed to look to the last page. I knew then that we had a problem. Except for Max and I, none of the rest qualified for the algorithm. Everyone else had BMIs under 25. Looking at the algorithm, they did not fit the examples or the usage. In addition, all of us were on insulin and that did not compute for the flow of the algorithm. Even Max and I have A1c's below the target of the algorithm. Max's latest is 6.1% and my latest is 6.3%. Everyone else is below 6.0% with Sue having the current lowest at 5.2%.

Okay, I know. The algorithm is for newly diagnosed patients and creates an entry point. Still, this could drive doctors crazy. Even at that, I knew I would have to use hypothetical examples. I selected a man with blood pressure and cholesterol problems with a BMI of 33. I added that his A1c was 9.8% at diagnosis. Moving forward we determined that he probably would fit the “medium” or “high” stage severity of complications. We chose “medium” for the example. This would mean that this person would follow the arrow down and have the MD/RD counseling, and next have the medication therapy.

Since this person had diabetes, the Prediabetes Algorithm is bypassed. At the Goals for Glycemic Control we would need to follow the A1c greater than 6.5% box and this person's goals would be individualized. This is where people were having problems so we continued to the Glycemic Control Algorithm. With the diagnosis A1c of 9.8% and two complications, this person would continue at the far right side. This would mean a weight loss pill, basal insulin (long acting), and two or three oral medications.

Although not stated on this page, point 9 on the last page does verify that this person has three months to improve or go to “add or intensify insulin. What is not said is if this person is able to bring the A1c down below 6.5%, it does not say which direction the person would go. The other factor is the BMI which does not give a clue about what medication factor the person would b e taking.

Point 9 on page 10 of the algorithm is a long point, but basically says everything affecting diabetes is in play. Effectiveness of therapy must be evaluated frequently (every three months) until stable using multiple criteria. This includes A1c, SMBG records including fasting and post-prandial data, documented and suspected hypoglycemia, and monitoring for other potential adverse events (weight gain, fluid retention, hepatic, renal, or cardiac disease). The following is to be monitored, co-morbidities, relevant laboratory data, concomitant drug administration, diabetic complications, and psycho-social factors affecting patient care.

The group discussed this and felt that the person would start on the left side of the algorithm and proceed down that side. And then to the next page for the CVD (cardiovascular disease) Risk Factor Modifications Algorithm. Going through this example cleared many of the questions. The group felt that somehow we were the lucky ones and had been allowed to set our own goals and work toward them with help from the rest of the group.

Allen said that he now understood why I was so negative about the algorithm in my first blog here. Brenda chimed in that she agreed with my first blog and wondered why the authors were so shortsighted in so many areas. John said now he understood why I commented on so many points missing and why the authors are so sure that prediabetes and even diabetes can't be stopped in its tracks and not become progressive. He continued that this is probably the most depressing set of guides he has seen. It is as if they want people to go from prediabetes to diabetes and stuff them full of medications when people are able to manage prediabetes and diabetes and stop taking medications. The authors do not even make allowances for this and left this out of the notes.

Max said they don't even allow for people to switch to a full regimen of insulin like we were able to do. He added it will be interesting talking to our endocrinologists at our next appointment. 

Tim said he would send out notes and thanked me for working with him to get the information captured and into a Powerpoint presentation. Brenda thanked both of us and the presentation really brought home the good points and the not so great items.

Everyone wanted to hear about the projector Tim had used, so the meeting was adjourned. Tim said he had it on loan and that he was thinking about investing in one for himself and using it for our meetings. Brenda asked why the other four were missing and Allen said they had other commitments, but they were going to be sorry after what Tim had used. Tim said he is short on the amount necessary to purchase one for himself, but in another few months it may be possible. He then said that the one he had on loan would be available several more months.

Rob asked how difficult it was to capture the images we had used. I said I have a program that is a few versions older than the latest, but that it works for our needs. I said if someone has something for a program that can be made into images, that I would do it beforehand like I did for this and have them saved to a Powerpoint presentation and sent as an attachment to the person and to Tim. Tim said it does take some time because of all the capture and proofing, so don't wait until the night before the meeting. I told Tim thank you and said that operator inefficiencies are to blame. I used to be able to do this easily, but since that was on a version older than I have now, I am still learning the update. Max asked who had it and I said I would email the information to those that wanted it.

No comments: