January 2, 2016

Excellent Tips on Patient and Employee Communication

Why would the Center for Healthcare Communication want to confuse the issue on improving patient and employee engagement. When it comes to communication, even the most sincere organizations cannot communicate and try to cloud the issue. What I do not understand is why communication is so utterly impossible and why they need to confuse the issue by using other terms to hide behind.

If they would use the tips they have promoted for engagement and apply them to honest communications, they could improve their organization dramatically.
This is obviously written for doctors and the way they should treat patients. The second part is also for doctors and how they should treat their employees.

#1. “Patients expect doctors to be nice. When they enter a healthcare facility, they expect people to be pleasant and friendly. Does this create good experiences? Yes. Does this create great experiences? Not necessarily. To create great experiences, you must exceed expectations. Here are some ways to exceed expectations.
  • Use empathy. Everyone always talks about empathy, but not many people consistently use this powerful tool. Stop the talking, start the doing!
  • Use the patient's preferred name. How do you know the desired name? Ask!
  • Do something special. For example, if a patient feels anxious, together take a few deep breaths with him or her. Patients do not expect this behavior from a professional, so you have created an exceptional experience.
  • Ask the patient his or her goals. Many healthcare professionals are busy telling the patient their suggested medical plan without asking the patient what they actually want.”
#2. “At a recent healthcare meeting, I spoke to an attendee and asked her a question about the hospital where she is employed. She said, "I'm not sure about that topic, I am just one of their nurses." JUST one of their nurses? It is obvious how she feels about her role in the hospital. To avoid the "just" comments, make employees feel a part of the organization rather than apart from the organization. Top tips to help:
  • Involve staff in the early stages of any new initiative as opposed to telling them about it after you have made all the decisions.
  • Constantly survey employees. Get their feedback on everything.
  • Focus on encouraging, not discouraging. If an employee has a suggestion that you don't feel will work, do not brush him or her off. Say to the person, for example, "Thank you for the suggestion. We tried that last year and unfortunately, it was not successful. However, I would like to hear your spin on it."
Yes, positive communications are important and will often put patients at ease and make office staff more attentive. Communications make an office more positive and this will reflect in the staff communications with patients. It is my hope that the term engagement will be relegated to talking about what happens to young couples in contemplation of marriage.

January 1, 2016

Getting the Most Out of Our Meters and CGMs

Integrated diabetes management [IDM] requires programs that must be willing to listen to patients, but learn from them as well.

Some would argue that this is why integrated diabetes management is needed, as it not only collects and transmits data, but it provides for an easy interaction between the patient and their healthcare team. It is the healthcare team that is doing all the date analytics and all that the patients need to do is collect the data. This focus on data can actually make a patient tune out even when they are getting good advice. This should not happen under any circumstance.

The Livongo and TelCare meters are two of many that transmit data to the cloud and also sends messages to the patient on their meter. Now in theory these messages are meant to help the patient better manage their diabetes. Yet these constant messages can also be annoying. What both systems lack is a sense of balance and perspective. Solid diabetes management is a marathon and not a sprint. And as any marathon runner can attest, races are filled with multiple variables. For some, the goal is to finish with a certain time. For other runners, the goal is merely to cross the finish line. The same is true for managing diabetes. For some, the goal is to keep their glucose levels in a tight range, while for others it’s just achieving an HbA1c of 7 or below. What’s lacking in most of the IDM programs we have seen is understanding these different patient perspectives and understanding that diabetes management is not one size fits all.

The survey did not cover this, but one reason patients don't download or review this data regularly is that for the majority of patients, managing their diabetes is just one more thing they must do each day. That, as we have said countless times, the vast majority of patients want to live their lives with diabetes, not for their diabetes.

Most patients want diabetes management to fit into their life, not run their lives. If IDM is ever to take hold, the approach must be more nuanced, more patient.
The fact is most of these programs, instead of learning from the patient, make assumptions about the patient. Perhaps the biggest assumption they make is that these patients actually care what their A1c is, that they want to do all the work to achieve good outcomes. While we wish this was true, sadly for the vast majority of patients, this just isn’t true, not even close.

IDM will only be impactful if it works with the patient as a partner, not as a dictator. It should understand the demands of diabetes management and it must learn from the patient before offering advice. For IDM to be truly impactful, it must not be a one size fits all approach. This will just cause patients to tune out. Yes, there is hope for IDM, but this hope only goes as far as IDM programs being willing to not just listen to the patient, but learn from them as well.

December 31, 2015

2016 ADA Guidelines for the Elderly

ADA terms us Older Adults and I use elderly. Maybe I am not politically correct, but I use the term(s) I am comfortable with and I don't always worry about being politically correct.

Diabetes is an important health condition for the aging population. The ADA says 26 percent of patients over the age of 65 years have diabetes and this number is expected to increase rapidly in the coming decades. Older individuals with diabetes have higher rates of premature death, functional disability, and coexisting illnesses, such as hypertension, coronary heart disease, and stroke, than those without diabetes – and the list goes on. Older adults with diabetes have more geriatric syndromes, such as polypharmacy, cognitive impairment, urinary incontinence, injurious falls, and persistent pain.

Screening for diabetes complications in older adults also should be individualized and periodically revisited, since the results of screening tests may impact therapeutic approaches and targets. Older adults are at increased risk for depression and should therefore be screened and treated accordingly. Diabetes management may require assessment of medical, functional, mental, and social domains. This may provide a framework to determine targets and therapeutic approaches. Particular attention should be paid to complications that can develop over short periods of time and/or that would significantly impair functional status, such as visual and lower-extremity complications.

Diabetes increases the incidence of all-cause dementia, Alzheimer disease, and vascular dementia when compared with rates in people with normal glucose tolerance. The effects of hyperglycemia and hyperinsulinemia on the brain are areas of intense research interest. Poor glycemic control is associated with a decline in cognitive function, and longer duration of diabetes worsens cognitive function. Older adults with diabetes should be carefully screened and monitored for cognitive impairment.

It is important to prevent hypoglycemia to reduce the risk of cognitive decline and to carefully assess and reassess patients’ risk for worsening of glycemic control and functional decline. Older adults are at higher risk of hypoglycemia for many reasons, including insulin deficiency and progressive renal insufficiency. In addition, older adults tend to have higher rates of unidentified cognitive deficits, causing difficulty in complex self-care activities - glucose monitoring, adjusting insulin doses, etc.. These deficits have been associated with increased risk of hypoglycemia and with severe hypoglycemia linked to increased dementia. Therefore, it is important to routinely screen older adults for cognitive dysfunction and discuss findings with the caregivers. Hypoglycemic events should be diligently monitored and avoided, whereas glycemic targets and pharmacological interventions may need to be adjusted to accommodate for the changing needs of the older adult.

At least they do make the following statements. For patients with advanced diabetes complications, life-limiting comorbid illness, or substantial cognitive or functional impairment, it is reasonable to set less intensive glycemic target goals. These patients are less likely to benefit from reducing the risk of microvascular complications and more likely to suffer serious adverse effects from hypoglycemia. However, patients with poorly controlled diabetes may be subject to acute complications of diabetes, including dehydration, poor wound healing, and hyperglycemic hyperosmolar coma. Glycemic goals at a minimum should avoid these consequences.

There is more that can be read at this link.

December 30, 2015

Doctors Can Help People with Diabetes

I often see people coming to the diabetes forums wondering what they can do. Most are very discouraged by their diagnosis and wondering where they can learn how to manage their diabetes. Most are not too polite in describing what their doctor said to them. Many feel that their doctor was accusing them for their diabetes and others felt their doctor was ridiculing them and a few felt that they were being bullied by their doctor.

This is often quite a bit to overcome, but most answers to their questions do their best to allay their guilt and encourage them to conquer their fears and then suggest following links to some very positive messages. Others tell them that they have experienced similar problems, but the people on the forum could help them and they would learn as well.

Varun Iyengar and Adam Brown describe in the diaTribe newsletter what Dr. Bill Polonsky said when he gave a talk on diabetes distress at the recent IDF World Diabetes Congress in Vancouver. He covered what this emotional state looks like, how and why it occurs, and simple strategies for addressing it. This reflects his research dedicated to one big question: how can we help people with diabetes feel motivated to succeed?

Dr. Polonsky stressed that doctors and other providers often communicate the wrong message, rather than hope, patients hear negatives and feel fear. The reason for vigilant management is not to live a long and healthy life, but to avoid complications. That framing makes a difference, as people with diabetes often go on to develop distress: an attitude of feeling defeated by diabetes.

Dr. Polonsky shared what “diabetes distress” sounds like in practice:
  • “Diabetes is taking up too much of my mental and physical energy every day”
  • “I am often failing with my diabetes regimen.”
  • “Friends or family are not supportive enough of my self-care efforts.”
  • “Diabetes controls my life.”
  • “I will end up with serious long-term complications no matter what I do.”

How common is diabetes distress? (You are not alone!)

The rate of diabetes distress is far greater than is often appreciated; 39% of type 1 and 35% of type 2 patients experience significant levels of diabetes distress at any given time. This distress cannot be treated with depression medications because…it is not depression! Rather, it requires a greater focus on acknowledging and addressing the emotional and behavioral obstacles associated with diabetes.

This statement by Dr. Polonsky is the way he turns a negative into a positive, “Well-controlled diabetes is the leading cause of nothing!” This is how Dr. Polonsky stresses the need to adapt the messages people with diabetes hear from doctors, providers, and caregivers, moving away from “blame and shame” to a new message, positive in nature.

Varun Iyengar and Adam Brown had much more to say about Dr. Polonsky's talk and I hope that the above link works, as it is very interesting.

December 29, 2015

Statins May Increase Kidney Disease

This should make everyone take notice. Long-term statin use may increase kidney disease. While we are all familiar with statins increasing the risk of type 2 diabetes, this is somewhat of a surprise, but seems logical. Many of the drugs of today have more and more side effects and many can cause harms to patients.

Considering that statins have no proven cardiovascular disease prevention or life lengthening effects, it seems that the statins all have more harm causing properties than health improving properties.

In a December 1, 2015 issue of the American Journal of Cardiology, lead author Dr, Tushar Acharya of the University of California, San Francisco, said an 8-year retrospective study with a median 6.4 year follow-up associated long-term statin use with an increased risk of kidney disease. Statin users, compared with case-matched controls that didn't use statins, showed a 30% to 36% greater prevalence of kidney disease during follow-up.

Senior author Dr. Ishak A Mansi, University of Texas Southwestern, Dallas, said, “Patients who are taking statins should not stop taking them based on this study. Our study did not examine whether the benefits outweigh the risk, as it was not designed for that. Still, this study shows that despite the use of statins for more than a quarter of a century, there are aspects about its long-term effects in noncardiac diseases that we do not know very well. We are missing more extensive, real-world data of the effectiveness of statins on total morbidity and all-cause mortality, and we need further studies specifically focusing on long-term outcomes in primary prevention."

Dr. Mansi continued, “The new [ACC] guidelines . . . are projected to increase statin use to many more hundreds of millions of healthy people, and before we do that we better make sure that we are not causing harm. Our paper says to scientists, physicians, funding agencies, [and] policy makers: 'Watch out, [it] seems that we still do not know enough about the long-term effects of these drugs on [the] overall well-being of patients.'"

The overall cohort comprised 43,438 individuals: 13,626 statin users and 29,812 nonusers. The most commonly prescribed statin was simvastatin (73.5%), followed by atorvastatin (17.4%), pravastatin (7%), and rosuvastatin (Crestor, AstraZeneca) (1.7%); 38% of the statin users received high-intensity doses. The statin users took the drugs for a mean of 4.65 years.

The researchers matched 6342 statin users in the overall cohort with 6342 nonusers, according to baseline demographics, comorbidities, and presence of renal disease, healthcare utilization, and medication use. In this matched cohort, patients had a mean age of 56, and 45% were women.

"The findings of this study, though cautionary, suggest that short-term [randomized controlled trial] may not fully describe long-term adverse effects of statins," Acharya and colleagues conclude. Statins lower the risk of cardiovascular disease and cardiovascular death, but "on the other hand, statins increase the risk of incident diabetes and possibly kidney diseases, both of which paradoxically increase long-term morbidity and mortality," they continue.

December 28, 2015

ADA 2016 Guidelines – Summary of Revisions

The new American Diabetes Association 2016 guidelines are now posted and the ADA is apparently attempting to be politically correct. The word diabetic will no longer be used to describe patients, but will only be used as an adjective when describing something like diabetic neuropathy. OH -WOW! And, there are more examples of political correctness through out the guidelines.

Strategies for improving care has been revised – including recommendations on tailoring treatment to vulnerable populations with diabetes, including recommendations for those with food insecurity, cognitive dysfunction and/or mental illness, and HIV, and a discussion on disparities related to ethnicity, culture, sex, socioeconomic differences, and disparities.

The support for only diagnosing based on HbA1c has been diminished and includes fasting plasma glucose, 75-gram oral glucose tolerance test, and the A1c test, with no preference to one test. The screening recommendations have now been revised to test all adults beginning at age 45 years, regardless of weight.

Two sections were combined – Initial Evaluation and Diabetes Management Planning and Foundations of Care: Education, Nutrition, Physical Activity, Smoking Cessation, Psychosocial Care, and Immunization from the 2015 Standards were combined into one section for 2016 to reflect the importance of integrating medical evaluation, patient engagement, and ongoing care that highlight the importance of lifestyle and behavioral modification. The nutrition and vaccination recommendations were streamlined to focus on those aspects of care most important and most relevant to people with diabetes.

Many people will be happy to see this - Because of the growing number of older adults with insulin-dependent diabetes, the ADA added the recommendation that people who use continuous glucose monitoring and insulin pumps should have continued access after they turn 65 years of age. Now we will need to push out congressional representatives to pass a bill to force Medicare to do this.

“Atherosclerotic cardiovascular disease” (ASCVD) has replaced the former term “cardiovascular disease” (CVD), as ASCVD is a more specific term.
A new recommendation for pharmacological treatment of older adults was added. To reflect new evidence on ASCVD risk among women, the recommendation to consider aspirin therapy in women aged greater than 60 years has been changed to include women aged 50 years and greater. A recommendation was also added to address antiplatelet use in patients aged less than 50 years with multiple risk factors.

A recommendation was made to reflect new evidence that adding ezetimibe to moderate-intensity statin provides additional cardiovascular benefits for select individuals with diabetes and should be considered. A new table provides efficacy and dose details on high- and moderate-intensity statin therapy.

“Nephropathy” was changed to “diabetic kidney disease” to emphasize that, while nephropathy may stem from a variety of causes, attention is placed on kidney disease that is directly related to diabetes. There are several minor edits to this section. The significant ones, based on new evidence, are as follows:
Diabetic kidney disease: guidance was added on when to refer for renal replacement treatment and when to refer to physicians experienced in the care of diabetic kidney disease.

Diabetic retinopathy: guidance was added on the use of intravitreal anti-VEGF agents for the treatment of center-involved diabetic macular edema, as they were more effective than monotherapy or combination therapy with laser.

The scope of youth section is more comprehensive, capturing the nuances of diabetes care in the pediatric population. This includes new recommendations addressing diabetes self-management education and support, psychosocial issues, and treatment guidelines for type 2 diabetes in youth.

The recommendation to obtain a fasting lipid profile in children starting at age 2 years has been changed to age 10 years, based on a scientific statement on type 1 diabetes and cardiovascular disease from the American Heart Association and the ADA.

There is more and I may cover some of this separately at a later date. Find the Table of Contents here.

December 27, 2015

What Is Happening at ACDE?

I am confused and I am not sure what is happening. I used to be able to access the Academy of Certified Diabetes Educators website, but since the tenth and maybe the ninth of December, I have not been able to access it by the main page, and this is the message I get on the screen. The URL is this - http://www.academycde.org/ .

The website you are attempting to access cannot be found

There is no website configured at the address you have provided.

Please try the following:
  • If you typed the page address in the Address bar, make sure that it is spelled correctly.
  • Contact the organziation to see if the address is correct.
  • Search Google for the website's correct address.

ERROR - URL not found
Internet Information Services

Technical Information (for support personnel)

I for one did not believe they are out of business and after several experiments, I have found another way into the website on 14 December. It is this URL - https://academycde.site-ym.com/?page=OfficersAndBoard .

In exploring the site further, I had to wonder why some places look like nothing is being done. The newsletter area only shows archived newsletters through July and I remember that normally it was three months after when it was archived. They may not have issued newsletters for August and September.

The last area that surprises me is in the Calendar of Events. After having a meeting on June 7, 2015, I would have thought a future meeting would have been posted for ACDE. I do need to be concerned about why they are pulling the main page of the website and what they are attempting to cover up. If the company that does the web page, “Professionally Managed by Capitol Consultants, Inc.” is that inept then their must be real problems or the ACDE has not paid the fee due Capital Consultants, Inc.