June 12, 2015

Diabetes Self-Management Education May Have Received a Boost

Can anyone say 'pipe dream'?  That was my first thought when I read this.  No, I am not kidding.  Yes, there are some advantages for some people with diabetes that live in some of the larger metropolitan areas.  Those people living in rural areas will still not have an advantage and may not even be able to utilize the increased educational opportunities. 

What is a surprise is that the joint statement by the American Diabetes Association (ADA), The American Association of Diabetes Educators (AADE), and The Academy of Nutrition and Dietetics (AND) focuses primarily on type 2 diabetes while the general principles apply to everyone with diabetes.  The joint statement is primed to fill the gap not covered by other guidelines addressing medication use and HbA1c targets. 

The joint statement calls for referrals to accredited diabetes education programs at four key points: at diagnosis of diabetes, on an annual basis, when new complicating factors (diabetes-related, or not) influence self-management, and at the time of transitions in care, such as from pediatric to adult or for an adult to nursing home.  The document provides detailed guidance for issues that should be addressed at each of those points.

It is noteworthy that the Academy of Certified Diabetes Educators is excluded from the joint statement.  Whether they will shirttail on the joint statement remains to be seen.  Either way, this still leaves the total number of CDEs way short of what will be needed to meet the goals of the joint statement, especially the people with type 2 diabetes. 

Other factors affecting the joint statement include:
     1.  Many CDEs do not live in largely rural areas.
     2.  Many doctors have had unfavorable encounters with CDEs and won't use them.
       3.  Many CDEs will not work with some doctors and contradict much of what the doctor has ordered creating additional problems.
     4.  Most CDEs do not want to work with people with type 2 diabetes that          are managing their diabetes well.
     5.  Many CDEs are also registered dietitians (RDs) and often will not work with the new nutrition guidelines, especially the low-carb/high-fat food plans.
     6.  Many RDs do not accept the exclusion of whole grains, again leaving many people with diabetes out of the education.  This is because the RDs often will not do any education for those of us excluding wheat.
     7.  Many doctors also promote low fat and whole grains because they still in believe Keyes and will not accept that he has been disproven.

The following is contrary to what the Society of General Internal Medicine (SGIM) promotes.  The SGIM does not believe in education for people with diabetes and follows statements made by prior influential people in the ADA and American Association of Clinical Endocrinologists advocating that people with type 2 diabetes, not on insulin rely on their HbA1c results to manage their diabetes.

Surprisingly, Martha M Funnell, RN, research scientist and adjunct nursing lecturer at the University of Michigan, Ann Arbor stated, "There is actually a substantial body of research on the value of education, including lowering hemoglobin A1c levels, reducing the onset or advancement of diabetes complications, improving lifestyle behaviors, reducing diabetes-related distress, and improving quality of life."

Ms Funnell continued, "The literature also shows that diabetes education is cost-effective, particularly in reducing hospital admissions and readmissions. Studies have also shown that patients who receive diabetes education are more likely to receive kidney and eye screenings."

Medication costs typically go up with diabetes education, "but that's because people are actually taking their medications and getting their prescriptions refilled. So, diabetes education works," Ms Funnell noted.

But despite the benefits, one recent study showed that among adults aged 18 to 64 years with diabetes, less than 7% had received formal diabetes education. "While less than 7% is a great A1c number, it's a really lousy number for the number of people who get education," Ms Funnell quipped.

June 11, 2015

The “Less Is More” Medical Campaign – Part 3

The latest campaign of "less is more" leaves a lot to be desired.  Doctors love to leave patients is the dark and ill prepared for medical procedures.  They claim that there is a fair amount of uncertainty about the potential benefits and risks of the vast majority of medical procedures.  In an ideal world, patients would learn about all the risks and benefits of a treatment and its alternatives, including doing nothing, through the process of informed consent and shared decision-making.

But, unfortunately, we have a fundamental problem with informed consent as it is practiced today.  What could be a platform to promote the idea of "nothing about me without me" has devolved into a perfunctory exercise by medical personnel to ensure that the "chart" has the proper paperwork.  Meanwhile, consent forms are often completed with patients being minutes away from a procedure, commonly supine, and even sometimes sedated.

This is not informed consent and smacks of decision by decree, often initiated by the doctor.  I have been fortunate with some of my doctors that actually took time to explain what would happen, what was expected to happen, and the worse case of what could happen.  Then I was questioned about what I wanted accomplished and if I agreed.  This was what happened before my gall bladder surgery and even though I knew my gall bladder removal was necessary, time was allowed in a meeting before the surgery to ask questions and have the procedure explained several days before the actual surgery.  I was given a sheet of instructions on eating and fasting to prevent potential problems and my diabetes regimen with changes was discussed. 

When the actual day of the surgery arrived, a brief discussion took place and I was allowed questions if I had any.  This was very reassuring and put me at ease for the surgery or anesthesia.  When I became aware after the surgery, a nurse was there to explain how the surgery had gone and that I would be allowed some broth after a few hours.  I was allowed water almost immediately and my CPAP was set up and made ready if I wanted to sleep. 

It is true that the consent form was a standardized form and it was readable by me even with a paragraph of medical jargon.  It is a shame that consent forms are not written for patients to understand and even more shameful that the consent process is not respected by surgeons and their staff. 

This is true because the medical culture has not promoted shared decision and the time allowed by the system is against this.  Then most patients do not easily understand the tools needed.  It is physicians' responsibility for elective procedures to be sure that patients understand their options and recognize their power to make choices.  The physicians need help to make this meaningful for the patients.

Patients need to know that there is a choice and they have permission to make a choice.  Patients should be made aware that the choice is not set in stone.  The patient's preferences are as important as the facts about risks and benefits.  Patients deserve personalized estimates of what the potential risks and benefits of various strategies may be.  They deserve information about the medical team's experience with different strategies and outcomes.  Patients deserve to know what a procedure will cost them out of pocket if everything goes well.  All of this information is vital and ought to be part of informed consent.  In fact, the obligation is that doctors need to ensure that patients know that two people presented with the same information may make different choices and still be right.

Finally, the informed consent should be taken out of the time just before the procedure and have time allowed for questions and answers.  Doctors should be prepared to teach their patients and know that the system supports the patients.

To be continued next week.

June 10, 2015

The “Less Is More” Medical Campaign – Part 2

Some people do the darnest things.  Dallas Mavericks owner Mark Cuban did a good one when he tweeted to his followers to have their blood tested "for everything available" every three months.  Naturally the media had a field day and jumped all over it saying that this could result in false positives, further testing, unneeded treatment, stress, and considerable costs.

The medical community did expose their true feelings when they described the "less is more" movement as a discussion to reduce overuse of "low-value" services.  They say that low-value services are screening, diagnostic tests, or treatments that are unlikely to help patients and post the risk of harm.

In general, they are referring to all screening which means much of the preventive care advocated by the Centers for Medicare and Medicaid Services (CMS).  Researchers have suggested the cost of wasted healthcare dollars, including from overuse of low-value services, makes up a third of the nation's $2.8 trillion healthcare bill.

The less in more campaign has been in the background over the last decade, but has gained a healthy traction with the 2012 Choosing Wisely campaign by the American Board of Internal Medicine (ABIM) Foundation.  The campaign enlisted clinician groups to help promote change by naming an evidence-based top 5 list of tests and procedures that physicians and patients should question because they offer little or no benefit and may cause harm.  Consumer Reports and other consumer groups have also signed on to help educate patients about how more medicine can be harmful.

In addition, some of the prominent diabetes organizations have adopted positions not friendly to those of us with type 2 diabetes.  I will admit that this has me upset and very much against the Society of General Internal Medicine (SGIM) for their stand on this - "Don't recommend daily home finger glucose testing in patients with Type 2 diabetes mellitus not using insulin."  It is not that the American Association of Clinical Endocrinologists did much better, they didn't.

But in an analysis reported last year, researchers at Dartmouth and Harvard pointed out that most of the tests and procedures selected by medical groups, especially "proceduralist societies," for their top 5 lists are either rarely done or are typically performed by clinicians in other fields.  One of the interpretations of this was that specialty societies weren't choosing things that affected their own revenue streams, they were choosing things that affected others' revenue streams.  This is how convoluted Choosing Wisely has become.

Moving away from payment systems that reward volume to those that reward value -- which is what Medicare is rolling out in the post-SGR era, may also help accelerate investment in clinical decision support linked to EHRs to reduce low-value care.  Right now, there is no financial reason for a physician group to invest in that kind of technology.  Risk-sharing arrangements such as accountable care organizations may create a kick in the pants for physician organizations to put things in place like what Cedars-Sinai is doing, providing financial reasons to invest, on top of the motivation to improve quality of care.

Whatever changes are needed to move the less-is-more movement forward, the idea
has staked its claim in the culture of medicine.  What's been accomplished is a cultural sea change, a cultural wave around safety issues and a cultural wave about overuse.  If this is true, why haven't we seen a dramatic decrease in adverse events, medical errors and hospital infections?  I think everything at present is lip service in hopes that the situation will improve.  That is another reason that the catchy phrases are not accomplishing anything, but giving the medical community a warm fuzzy.  It is time for actions to speak louder than catchy phrases.

June 9, 2015

The “Less Is More” Medical Campaign – Part 1

I have to wonder if doctors are really interest in practicing medicine.  When I see new terminology after new terminology being used, I know this is done to confuse an issue that they are uncomfortable talking about with patients.  This is also done to confuse and keep patients off guard. 

This latest is an outgrowth of the "Choosing Wisely" campaign started by the nefarious American Board of Medical Specialties (ABMS) and the American Board of Internal Medicine (ABIM).  There is some good being done, but at the same time, many things that harm patients were not listed on the procedures to be avoided.  There were some procedures and items listed that were adopted by various medical groups that are necessary to prevent patient harm and some that were left off that do patient harm. 

One of the problem patients need to be aware of is not over requesting tests.  This is what the hospitals want to hear, because they get paid more for tests and want the business, even when the test may harm patients.

There are other catchy phrases many doctors like to use that also do not mean anything.  They like to use these and think this is what the patients need to hear.  To these, I say BS (not blood sugar). 

There are five points to know when talking to doctors about tests or treatments:
1. Learn Clinical Guidelines If Possible, Ask The Doctors to Explain Potential Harms.  Patients need to be skeptical when doctors recommend a particular test or treatment.  Doctors will often withhold information about the test, the purpose, and that the hospital is recommending the test.

Unless this is an emergency, do not be afraid to ask for the name of the test and have the doctor spell it out.  Then ask for permission to return home and look it up on the internet.  This may help the doctor understand that you will not be bullied into the test.

If the doctor Points out the risks and unanticipated consequences of tests then this may be helpful because this makes it clear that the clinician is looking out for your interests.  It's also worth noting that a test can be done later, if circumstances change.

2. Elicit Unspoken Concerns About a Symptom or Illness.  Carefully asking a doctor about unspoken concerns is worthwhile because you may often fear the worst, such as cancer causing back pain.  Because misconceptions may arise from information you have read on the Internet or gleaned from conversations with friends or family, it may be helpful to ask specifically about some worst-case scenarios that commonly raise concerns.

3. Be Concerned and Look for Empathetic and Supportive Doctors. 
It's important to find empathy and support even if your request is not granted.  It is important that the doctor address your concerns to your satisfaction.  If this does not happen, find a different doctor.

4. Have the Doctor Summarize the Care Plan and Follow-up.  It's always important to receive a brief summary of the care plan, invite questions, and ask if you are in agreement with the plan.  A clearly laid out follow-up plan is also important, with instructions for you to contact the clinician if any "red flags" emerge.  Again, if you do not receive this, look for another doctor.

5. Make Sure the Doctor Provides Resources.  Newer decision aids (available either directly to clinicians or through insurance plans) are valuable for helping the doctors help you navigate the many gray areas in medicine, where reasonable people might make different choices.  These aids can make it clear that there are options, describe the full range of options, and lay out the key benefits and risks of each.

June 8, 2015

Charcot Foot, Diabetes Complication Increasing

Charcot foot is truly a diabetes complication that is increasing and is seldom recognized early enough to receive the proper treatment. Charcot foot develops as a result of neuropathy, which decreases sensation and the ability to feel temperature, pain, or trauma. Because of diminished sensation, the patient may continue to walk, making the injury worse.

The symptoms of Charcot foot may include:
  1. Warmth to the touch (the affected foot feels warmer than the other)
  2. Redness in the foot
  3. Swelling in the area
  4. Pain or soreness
Early diagnosis of Charcot foot is extremely important for successful treatment. To arrive at a diagnosis, the surgeon will examine the foot and ankle and ask about events that may have occurred prior to the symptoms. X-rays and other imaging studies and tests may be ordered. Once treatment begins, x-rays are taken periodically to aid in evaluating the status of the condition.

It is extremely important to follow the surgeon’s treatment plan for Charcot foot. Failure to do so can lead to the loss of a toe, foot, leg, or life.
Non-surgical treatment for Charcot foot consists of:
  1. Immobilization. Because the foot and ankle are so fragile during the early stage of Charcot, they must be protected so the weakened bones can repair themselves. Complete non-weightbearing is necessary to keep the foot from further collapsing. The patient will not be able to walk on the affected foot until the surgeon determines it is safe to do so. During this period, the patient may be fitted with a cast, removable boot, or brace, and may be required to use crutches or a wheelchair. It may take the bones several months to heal, although it can take considerably longer in some patients.
  2. Custom shoes and bracing. Shoes with special inserts may be needed after the bones have healed to enable the patient to return to daily activities—as well as help prevent recurrence of Charcot foot, development of ulcers, and possibly amputation. In cases with significant deformity, bracing is also required.
  3. Activity modification. A modification in activity level may be needed to avoid repetitive trauma to both feet. A patient with Charcot in one foot is more likely to develop it in the other foot, so measures must be taken to protect both feet.
In some cases, the Charcot deformity may become severe enough that surgery is required. The foot and ankle surgeon will determine the proper timing as well as the appropriate procedure for the individual case.

The patient can play a vital role in preventing Charcot foot and its complications by following these measures:
  1. Keep blood glucose levels under control can help reduce the progression of nerve damage in the feet.
  2. Get regular check-ups from a foot and ankle surgeon.
  3. Check both feet every day, and see a surgeon immediately if you notice signs of Charcot foot.
  4. Be careful to avoid injury, such as bumping the foot or overdoing an exercise program.
  5. Follow the surgeon’s instructions for long-term treatment to prevent recurrences, ulcers, and amputation.
Charcot foot often confines patients to wheelchairs, and in severe cases can require amputation. Charcot foot patients from around the country come to Loyola University Medical Center orthopedic surgeon Michael Pinzur, MD, for a surgical treatment that enables 91 percent of his patients to walk normally again. The technique secures foot bones with an external frame, made of stainless steel and aircraft-grade aluminum.