November 4, 2013

Endocrinologists and “Choosing Wisely”

When comparing the “Choosing Wisely” pronouncements of the Society of General Internal Medicine (SGIM) with the American Association of Clinical Endocrinologists (AACE) and their educational arm, the American College of Endocrinology (ACE) both are out of line to my way of thinking, but the AACE/ACE is more reasonable.

To review, the SGIM stated, “Don't recommend daily home finger glucose testing in patients with Type 2 diabetes mellitus not using insulin.” The AACE/ACE states, “Avoid routine multiple daily self–glucose monitoring in adults with stable type 2 diabetes on agents that do not cause hypoglycemia.” If for no other reason than many oral diabetes cause hypoglycemia, this is less threatening to people with type 2 diabetes. Plus they left themselves some wiggle room with the words multiple daily. The members of SGIM clearly stated no daily home finger glucose testing unless on insulin.

Obviously, Dr. Alan Garber was not made part of the selection committee or we would be relying on only the A1C results and be completely in the dark. The ACE president, Daniel Einhorn, MD, medical director of the Scripps-Whittier Diabetes Institute, La Jolla, California is a lot more thoughtful and maybe more patient oriented. He said of “Choosing Wisely”, “The whole Choosing Wisely campaign is to alert physicians to be thoughtful and for patients to also question when something is ordered or suggested."

Dr. Einhorn explained how the endocrine societies came up with their recommendations. "The list reflects the observation of a group of experts who've seen people order certain tests that are just not necessary. Other items could have been chosen, but these were felt to be perhaps the most common mistakes made. The recommendations are likely to evolve over time as more is learned." I do not appreciate being termed a common mistake just because I have diabetes.

Dr. Einhorn is right about vitamin D. Many doctors do use the incorrect test for vitamin D deficiency. Many doctors use the 1,25-dihydroxyvitamin D when they should use the 25-hydroxyvitamin D test. This test is less expensive and valuable for vitamin D deficiency. The 1,25-dihydroxyvitamin D is correct for use in patients with hypercalcemia or end stage kidney disease.

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