March 15, 2014
Finally! Finally! Finally! Maybe something will happen to stem the diabetes epidemic! However, the disappointing side of this news is that the United States is not a participant. The cities of the world will soon have the opportunity to be officially designated “diabetes aware” cities.
This new program is being created by the International Diabetes Federation (IDF) and the European Connected Health Alliance (ECHAlliance). This is to be launched on World Diabetes Day, November 14, 2014. The IDF and ECHAlliance want to create a global network of “diabetes aware” cities using mobile health tools to promote diabetes awareness and support.
The cities accepted as “diabetes aware” will demonstrate that all sections of the community are committed to creating a healthy urban environment. These cities must demonstrate that local public services, businesses, and institutions understand the challenges faced by people with diabetes and those at risk for diabetes. Examples include providing appropriate nutritional information in restaurants and city authorities ensuring green spaces for safe and accessible space for exercise.
The IDF and ECHAlliance will have an expert group established to draw up the program. Representatives from business, mHealth, and other sectors will be included. Using mobile health tools and apps, key stakeholders in city life will be able to target diabetes aware options for those at risk of diabetes and those with diabetes.
Dr Petra Wilson, IDF's Chief Executive says, "People in urban areas will be particularly vulnerable. Socially and economically, this diabetes epidemic will be very costly. It is important that we find new ways of working across all sectors to provide people with targeted information on healthier lifestyle options."
“Brian O'Connor, Chair of the ECHAlliance welcomed the new partnership, "Providing people with mobile information on healthier places to eat, shop and exercise in cities is the first step toward making the healthy choice the easy choice. Information is the key to enabling healthy choices."
With about 10 months to work on this, I sincerely wish them well and ask that those of us in the United States find ways to apply pressure to our organizations to participate. There are a few feeble attempts and often misguided attempts in a few cities in the United States that hardly serve as examples of the needs to serve our citizens.
March 14, 2014
Patient-centered medical homes (PCMHs) are supposedly here to stay under two laws. This is a critical part of almost every aspect of the Affordable Care Act and HITECH. However, cultural attitudes, fears and logistical obstacles hold back the reform set up by these laws.
The medical news has been full of this story for much of the prior week, but I think there is more about this than we are receiving. The facts as reported from a 3-year study of 32 small and medium sized primary care practices and multi-payer pilot:
- A PCMH demonstration project could not significantly reduce costs and utilization or improve quality of care.
- A PCMH model didn't reduce hospitalizations, emergency department use, ambulatory services, or costs.
- The practices showed improvement in only one of 11 quality measures -- nephropathy screening in diabetes patients
“Thomas Schwenk, MD, dean of the University of Nevada School of Medicine in Reno, wrote in an accompanying editorial. "Widespread implementation of the PCMH with limited data may lead to failure." Instead, the study should remind the healthcare community that providers' focus should be on high-need patients, he said.” Bold is my emphasis.
“A quarter of all medical care is consumed by 1% of the population, according to the Agency for Healthcare Research and Quality. And nearly half is consumed by 5%. It's those patients who would benefit from extra care management and oversight that are usually trademarks of PCMHs, Schwenk wrote.”
Now there has more to the article, but I have some questions about the study. The one editorial by Dr. Schwenk above about high-need patients make me wonder what is being hidden by the study and why he would chose this term to emphasize about PCMHs. Are they considering reducing the consumption of the 1% and 5% patients and to what extent? Could it be the doctors in the study were not willing to short-change the treatment of high-need patients?
The last question leads me to another article in Government Health IT. Here Dr. Russell Kohl states that physicians should start learning to dance with their patients, instead of wrestling with them.
I can relate to the analogy Dr. Kohl uses to emphasize his point. When we consider that there are 525,600 minutes in a year and if a doctor sees a patient four times a year for a generous 30 minutes per visit, the doctor might get to spend 120 minutes a year with each patient. Doctors think that the 120 minutes as the most important in patient engagement.
The patient, on the other hand, does not consider them the most important of their year. How do doctors leverage the rest of the time to help patients take care of themselves? This means moving away from doctors knowing everything and bestowing care upon their patients to help patients take care of themselves. The patients do have 525,480 minutes to devote to that.
These are my thoughts. This means that doctors would actually have to communicate with the patients which doctors are ill equipped to do, as they only understand patient engagement. For many doctors, the word communication is a foreign language reserved for their family and not patients.
Dr. Kohl believes many patients are already active in their own care, and “grandma” surprises everyone by being the most actively engaged using patient portals. Whoa, most doctors are afraid of the portals. Doctors view patient portals as an opportunity for patients to drain them of their time. Dr. Kohl likes to show them how much time can be saved by emailing with their patients.
Dr. Kohl also has other tools for building the kind of relationship necessary for a patient-physician partnership. He says this includes home visits, personal written notes that help patients see the progress they are making in improving their health, even if it is a very small improvement.
The last question is why are doctors so reluctant to use true communication. My favorite blogging doctor, Dr. Rob Lamberts says, “Communication isn’t important to health care, communication is health care.”
March 13, 2014
Recently Allen and I ran into each other at the grocery store. I was on an errand for the wife and he was picking up supplies for the weekend. We stopped and talked briefly and while we were talking, another individual that neither of us knew overheard something I said about working on a blog about a book I had ordered. He interrupted us and asked if I was the person writing a diabetes blog.
When I asked the name of the blog, he had the name of my blog correct, so I acknowledged that I was the author. Then both of us had to listen to a string of profanity and him telling me that I could stop blogging, as I didn't know what I was talking about. Allen asked him what he talking about before I could.
He said testing and I asked for some specifics. He said any testing. Allen said I have different types of blogs on testing. He finally said telling people to test so often to learn what different foods do their bodies. He continued that his doctor says all he needs in a quarterly A1c test to learn what is needed. I asked why he believed his doctor.
The answer was that his doctor was his father and his father followed the ADA. Allen said if that is the case, we could not teach him anything. I said I have one question. What is his father's advice on nutrition? The answer was a total shock. The fellow said his father believed in not eating any whole grains, or starches. He said his father believed in low carb, low to medium protein and high fat.
Good, said Allen. We have that much in common. Next, Allen asked what medication he might be taking. Metformin was the reply and Allen asked how many years he had type 2 diabetes. The fellow answered about six years. I knew where Allen was heading with his question and Allen asked him if his father was testing him for vitamin B12 deficiency. The fellow answered that he had just had a test for vitamin B12 and vitamin D. He explained that his vitamin D was low and he had a shot for that and he was taking a supplement. The vitamin B12 was still in the suggested range, but on the low side. He said his father had suggested that he eat more liver, eggs, and salmon, plus beef and pork. Then in about 10 months, he would be tested again.
I asked what his last A1c had been and he said that after diagnosis of 12.0%, he was consistently between 5.0 to 5.8%. He continued that he was only taking 500 mg per day of metformin. I said he was fortunate that his father could monitor him and advise him on nutrition as it had helped him.
Allen stated that not everyone was as fortunate and received an education about diabetes, as he had been receiving. Then the secret came out. He stated that his mother was a doctor of nutrition and he had her for guidance. Allen and I said almost in unison, “No wonder you don't need to test.” He agreed and asked why I was pushing testing.
Allen said that not everyone receives the education and can have family available to help. Most of us need to learn on our own and testing is about the only avenue to available to help us learn.
I said I would continue to emphasize testing because without it, most are operating in the blind and would have no idea if they were improving or if their blood glucose numbers were becoming worse. I said he could ask his mother how hard it was for many people that believed the high carb, low fat doctrine that has been preached for so many decades.
I said I had to leave. Allen told me later that they had talked for almost an hour more. He said that the follow was a lot more positive when he left. He was in town visiting his sister and lived about three hours distant.
March 12, 2014
The other f-word you ask. That would be fear. Then you add the d-word – diabetes – and people can develop brain freeze and do nothing – the other d-word - denial. Then we have the s-word – secrecy - that seems to take over and people just don't want to take care of themselves or allow family members to help.
The above is a prescription for trouble and letting the complications gain the upper hand. This is happening more often than it should and several of our diabetes support group have lost friends in this situation. Allen has lost two friends in the last year and now A.J. has lost a relative.
Tim had heard the news and suggested we have a meeting about this. Everyone agreed and we had a short meeting on Saturday afternoon, March 8. Everyone was present and Susan was welcomed as a member. A.J. thanked us for our support, as he was not sure what to do, as he had not been able to make a difference in his cousin's life. His cousin's wife had asked for his help and he had tried.
Then Brenda said she had lost a friend about 6 months ago and had not said anything. Tim said that is why he had asked for the meeting. He said we need to figure out how we as a group can support each other and at the same time use intervention to help these people. I said we need to explore several avenues. I said that Dr. Tom would be here shortly and we should start with his recommendations.
Allen said that would be a good place to start. I added that there was another person that could help and I would see what Dr. Tom thought about that. I said this is a person, who specializes in interventions and he may be able to teach us what we need to learn or what we should do.
At that point, Dr. Tom arrived and Tim filled him in about the problems we were encountering. Dr. Tom said he was not sure how to handle this and I suggested the doctor I had spoken about earlier. Dr. Tom said this was probably the only person we should consider. I said I had a question since I felt he wanted to charge us for any help. Dr. Tom asked if he could call him and we agreed. He excused himself, stepped outside the room, and called.
When he came back, he said I was right and he would charge us for teaching us how to do a proper intervention. Even Dr. Tom seemed upset and said to give him a few days and he would see if there was anyone else that would help us. He said that this should be something that should be done without charge. He said that since he had talked to the doctor, several names had come to him that may be of use and he wanted to check them out before we talked to them.
Tim said this was okay, but we felt that the sooner the better as three of the group has lost friends and relatives. I then added that I had lost three friends that had stopped dialysis when their kidneys had caused dialysis. I said that I was not familiar with what had caused one to arrive at his condition until at that point. The third had gone into denial, his kidneys became bad, and he just refused to go to dialysis after the first time. One was not from diabetes, but from an auto accident, which I was told after his death.
Dr. Tom said let him see what he could do and if there was anyone that would speak to us without charging. Allen said we should consider bringing in the other groups and everyone agreed. Dr. Tom said this would be good and was needed and now he would work to find someone to speak to the groups. Dr. Tom asked Tim to call him late Friday if he or Allen had not received a call.
Tim thanked everyone for coming on short notice and for considering this important. He said to keep time available, as this would probably be our March meeting if Dr. Tom was successful. Dr. Tom asked if March 22 or 29 would be acceptable – depending on weather. Everyone agreed and the meeting ended.
March 11, 2014
Over the last 10 full years that I have had type 2 diabetes, if you had asked me what my feelings were about Joslin Diabetes Center, I would probably have answered in a very positive way. However, over the last 15 months, I have become very disenchanted with Joslin.
Before people that have had positive experiences at Joslin become too vocal, I do believe Joslin serves the type 1 diabetes community reasonably well. Even having stated this, there are times when some of the “experts” employed at Joslin have expressed opinions that should make us wary of their sincerity.
Since I am a person with type 2 diabetes and have never been to the Joslin Diabetes Center, I can only speak about what I have read from the Joslin's Diabetes Deskbook, the Joslin blog, and other printed sources. Some information is excellent and some makes me wonder about why it was written.
One of the earliest Joslin blogs I linked to is this one about a better way to give an insulin injection. The author is identified and should be proud of her blog as I felt it was timely and people injecting insulin could learn good pointers by reading it. My latest blog on about Joslin blogger anonymity accurately expresses my frustrations.
While the Joslin Deskbook was reasonable, the more I review it, the more I am finding that I am in disagreement with some of the chapters and the policies that are not supported by the American Diabetes Association (ADA) or what I have read in other sources. Granted, I don't follow everything put out by the ADA, but I know that you need to start at some point until you realize that there are other facts and that one-size-does-not-fit-all solutions.
I had thought to do more blogs on the Deskbook (and I may), but in reviewing what I have written, I need to change my attitude as I developed a very negative attitude and really don't like to pass this on to my readers. An occasional venting can sometimes be beneficial, but not a series.
How do I know this? I had two of the more level heads in our support group read them. Both said I was too far on the negative side. They agreed with what I had written, but wisely suggested that I stick to more facts and let the reader evaluate the facts and keep my opinion to myself. They admitted that a couple of the blogs were going to be difficult because they agreed with what and how I had stated a couple of ideas.
They asked if I would attach them to an email and they would make notes in the blogs and suggest a few different ideas. It has been a week now and one of the two said he had read and reread the extract and then tried to write something. He became very frustrated because he felt like me that they did not pull things together as they should have, their ideas were too fragmented, and did not agree with an area in ADA 2013 guidelines. He asked how soon I needed them and I said I could wait and I had more to work on. If I had a better idea by mid-April that would be good.
March 10, 2014
This is about a book and the reviews are very explicit. I do not disagree. Over the last few years, I have been learning about low carbohydrate food plans, Paleo food plans, and a few other food plans promoted away from the media.
Our news media today just doesn't report anything that they can't sensationalize, or to cause (events, especially in newspaper reports) to seem more vivid, shocking, etc, than they really are. They will parrot (to repeat or imitate without thought or understanding) from a press release and overstate this in the headline. They like sexy headlines and seem to care less about the truth of what they report.
Now some of our medical news sources are doing the same and this is becoming disgusting. I will admit that there have not been many interesting facts to report about diabetes in the last month or even health news.
Therefore, it is with some reluctance that am blogging about a book that I have ordered before reading it. The title of the book is Eat the Yolks by Liz Wolfe and is available only from Amazon. Yes, there is a Kindle edition.
Stone Hearth News just parroted the review from Amazon, which shows how lazy their reporters are. They do this for every article they publish, but often I can find other sources, which confirm what they parrot. I seldom use them for a source because of this. If I am interested in something they report, I wait until I find the information in other sources that are not parroting the same press release. Or, I email the corresponding author for a digital copy of the study. If I can't locate one and nothing further is released, the delete key does the rest.
I liked the review, which is why I ordered the book.
I will do a proper review after I have read the book.
March 9, 2014
I am not sure this will happen or when, but this is what is reported in MedPage Today back in December 2013. “Medicare officials and members of Congress are taking steps to expand the use of telemedicine services by dropping -- or proposing to drop -- restrictions on their use.”
I was not sure so I have held this until I could hear back from my representative. He was not aware of this and had not seen any proposed legislation. He did state that it could be part of the 'doc-fix' bill that is currently stalled, but he had not reviewed it and would not until it became actionable.
The MedPage Today article said the following, “Both the 2014 Medicare physician fee schedule and legislation to repeal the program's sustainable growth rate (SGR) payment formula have provisions designed to improve access to telemedicine.”
"Many of the states [through Medicaid] do a much better job of using telehealth than does the Medicare program," Gary Capistrant, senior director of public policy at the American Telemedicine Association, told MedPage Today. "Medicare may be the last to move forward."
Currently only 20 states and the District of Columbia require that private insurers cover telehealth the same as they cover in-person services. When Medicare started paying for services delivered through telemedicine systems, it was limited to patients in rural, underserved areas who had a Medicare provider present with them. This was very restrictive and limiting.
Medicare's Sustainable Growth Rate (SGR) restricts the growth of telemedicine and technology's use. Even if Congress passes the doc-fix and repeals the SGR, the government will still need to get out of the way and allow providers to perform their duties.
Until the bills are passed, we will have no improved method for the expansion of telemedicine. There are still barriers in the current laws and Congress is not currently considering removing these barriers. Capistrant says, "We need to move rapidly to a system where we're just talking healthcare, and not special restrictions on the use of technology for health."
I am concerned that Congress will work piecemeal at fixing the barriers to telemedicine, thereby making telemedicine not effective for several years.
Note: Unless this is separated from the SGR, it is basically a dead issue for this year.
Note: Unless this is separated from the SGR, it is basically a dead issue for this year.