October 11, 2014

Aids to Help Prevent Prescription Errors

In our meeting last evening, requested by Brenda, we had everyone in attendance plus several from Dr. Tom's group and Dr. Tom. Brenda was still agitated about what had happened and very vocal about what should be done.

Tim started the meeting by showing the slides I had prepared from my blogs and this article. Please read the link to the article as this blog would be too long if I included all the discussion.

First, when you have a hard-copy prescription, if it's hand-written, make sure you can read it.

Second, when you pick up a prescription, check the name to make sure it's for you.

Third, make sure that you are paying the lowest price available.

Fourth, if your doctor is changing your dosage, or changing your prescription in any way, be particularly careful to look at the pill bottle when you receive it.

Fifth, every time you receive a new prescription, or a new refill of any drug, look carefully at the bottle to confirm that the information on the label matches up with what you know you were prescribed.

Sixth, read the pharmacy insert, and know the fillers, dyes, and ingredients used in the medication you are taking.

Then from this blog, I had this list of tips. Read the blog at your convenience.

Keep a list of your current medications with you at all times.

Cross-check and update your medicine list with your provider at every visit.

Ask for an updated list of your medications and prescriptions before leaving your doctor's office.

If you're tech savvy, use the practice patient portal.

Cross-check every medicine after you pick it up against the prescription your provider wrote.

Don't hesitate to speak up if you think a prescription is wrong.

Finally, don't forget that so called "natural" supplements are medicines too.

To the above points or tips, I had added the following:

#1. If the doctor e-prescribes, ask for a copy of what was sent to the pharmacy.

#2. If there are questions, please talk to the doctor before leaving.

There was a lot of discussion on the points and tips provided and I had printouts available and handed them out.

Dr. Tom then made several comments and had Tim go through the slides a second time. He said he appreciates patients that ask questions about their medications and what the side effects are. He said that sometimes he is not fully aware of all the side effects and will hand write the name of the medication(s) so that the patient can look them up on the computer. He also gives them the URL for the WebMD site and at least one other site. He also gives them one or two other medications that can be substituted so that they can look them up.

He does ask them to call him back within 48 hours (during office hours, of course) and discuss the medication(s) they would use. He did say that sometimes he tells the patient that they should start the medication(s) immediately because of the injury or illness and to call if they have questions after starting the medication(s).

He then asked which pharmacies were being used and there were five different pharmacies. He understood the VA pharmacy because of the veterans in the group and the second pharmacy because Medicare recommends people on Medicare use this pharmacy. He then stated the second pharmacy will provide a list of medications used by each patient served by them if asked.

The other three he was not sure they would provide a list except at year end, but it would not hurt to ask if needed.

He commented on Brenda's situation and stated that computers can lead to errors when doctors do not use care and close other patient's accounts and make sure they are in the correct patient for e-prescribing. He said he made this embarrassing error one time and has since made sure he was in the correct account before hitting the send key. He admitted that some doctors are in such a hurry that they don't check the account. He then asked how many used or had access to their patient portal. Only nine of us did and Dr. Tom said this was less then he would like to see.

Dr. Tom concluded that he appreciated the discussion about prescriptions and prescription errors and hoped this topic could be had again in about 18 months. Or he said could include more groups as he felt the topic was needed. Errors do happen and everyone needs to be aware of this.

Tim asked if there was anything that needed discussion and said the meeting was over. Discussions continued and Tim put the slides back up for a few that had questions.

Dr. Tom asked Tim and me to talk with him before leaving. He had heard about our meeting in November with a group about a half hour's drive south of us. He had been asked to come and had told the doctor that he would since he knew the people that would be presenting to his group. He asked Tim if he could read the information that would be presented as he knew the doctor and wanted to be prepared if the doctor had questions. He said the doctor follows the ADA a little closer than he possibly should, but he knew we did not and felt this would be a good time to teach the doctor a few good pointers.

Dr. Tom asked if the topic we had presented could be added. Tim said the material already may be too long, but we could check. Tim then suggested that maybe we could invite them to meet with the groups in a meeting next April and have this be one of the topics. Dr. Tom said he would bring this up after our meeting with them in November. Tim said the topics should be ready in another week and he would let him review them. With that, we closed the room for the night.

October 10, 2014

Managing Diabetes When Money Is Limited

Many people just do not understand how to manage diabetes when money is very limited. This doctor, writing for the Empower Our HealthMagazine of the American Association of Clinical Endocrinologists starts the topic off on the right note, but fails to cover many possibilities. I will cover what the doctor says and then in other blogs cover some of the many points she ignores.

For a doctor on a fellowship that says she was focusing on how to help the low-income, uninsured persons struggling to maintain their health, I don't understand why she totally ignores some points. Then she makes some statements that I am sure time and experience will correct. She says that even on limited income, there are many cost-effective ways to control diabetes, high blood pressure, and high cholesterol. I have no disagreement so far, but when she says increasing physical activity, I have to wonder why there is no precaution of with the doctor's permission.

The other statement is one that I have a constant complaint with all doctors and that is the salt debate. It seems this is so standard and not reflective of many recent studies.  It is obvious that the doctor does not know diabetes and does not make any precautions about blood glucose levels safe for exercising. This also seems standard for most doctors, as even simple precautions are seldom included in any discussion.

I am surprised in her cost-saving tips for medications, but apparently, she is not aware of programs available from drug manufacturers that can help save money. There is nothing wrong with generics, but sometimes there is none that can be used. This is when manufacturer programs can be valuable.

I have no complaints about her discussion of treating high blood pressure. While some of the foods listed need to be avoided by people with diabetes, the rest of her advice should be followed. Of course, the salt should be moderate and this debate is still on going.

Exercise, minimizing salt in your diet, losing weight and minimizing stress are important ways to prevent as well as treat high blood pressure. The same exercises used for treatment of diabetes can be used for hypertension. Foods such as tamarind drink, spinach, beans, sunflower seeds, bananas, spinach, squash, cantaloupe, garlic, celery, lemon, honey, ginger, cumin seeds, and cayenne pepper may help to reduce blood pressure because they are rich in magnesium and potassium. Also, avoid over indulging in alcohol — it can increase blood pressure. For those requiring medication, splitting higher dose pills to get a smaller prescribed dose is another means for cost savings, but this should not be done with pills marked as “extended release” or “slow release.””

When Dr. Noorhasan talks about cholesterol, she does not push statins, yet. Again, she promotes exercise, herbs, and foods which can reduce cholesterol. These include dandelion root, pumpkin seed, oats, sunflower seeds, whole grain breads, broccoli, cabbage, carrots, oranges, and salmon. Of course, whole grain breads, oats, carrots, and oranges need to be limited or avoided by people with diabetes.

There is much research needed for more blogs, but I will eventually have more.

October 9, 2014

Self-Monitoring of Blood Glucose, Lessons - P2

This is a continuation of the last blog. I have some concerns about the high blood glucose levels usedfor examples, but at the same time I can understand that the examples are not generally numbers that persons with type 2 diabetes would like to see. However, I am shocked by the number of blood glucose readings that are this high or higher by type 2's that are not managing their diabetes.

Both James and Jerry have admitted to having readings in the 400's a few times before they received help. Both are now having blood glucose readings of 160 mg/dl or less and we know from talking to them that they are working on having readings of 140 mg/dl or less. Jerry seems to be really taking to his food plan. A.J reports that most of his readings the last two weeks have been under 125 mg/dl postprandial with readings less than 100 mg/dl for morning fasting and preprandial readings. He has only one excursion under 70 mg/dl and that was 66 mg/dl.

A.J reports that Jerry has taken to cooking and is really preparing some meals that have surprised A.J with how tasty the food has been. Jerry has even borrowed two of my cookbooks with the nutritional data for each recipe and then adapts them. By that I mean to have them fit the approximate carbohydrate to fat and protein levels that A.J and he are comfortable eating. Jerry says that even he is surprised at what he is learning by using the recipes and a food scale with the desired information on nutrients. He admits that it takes extra time and effort, but with A.J's encouragement and the two of them cooking together on the weekends, there is less cooking needed during the week.

Jerry says he has a lot to learn yet, but he is looking forward to his next VA appointment and what his A1c will be. Jerry and Allen spend quite a bit of time together when A.J is working and Allen says he is a fast learner. Both Allen and A.J have expressed their appreciation for Jerry because he always wants to cover his costs and not sponge off of others.

A.J has asked for my inflatable mattress for this weekend, as Jerry's son will be home after hearing that his mom and dad were separated. Jerry said he expected this, but is happy that his son wants to stay with him. He said they will have a lot to talk about, as he was sure that his son knew his mother was having mental problems before the separation. They have asked several of us to come for the evening on Saturday.

October 8, 2014

Self-Monitoring of Blood Glucose, Lessons - P1

This is a continuation of previous blogs on self-monitoring of blood glucose (SMBG). In rereading several, I realized that they were okay, but not as complete as they should have been. In the blog over at DiabetesMine on September 27, 2014, Will Debois wrote about a few points I have been taught, but forgot about. Two of my fellow support group members, Allen and Tim called me after reading that blog and asked when I was going to write about it. I urge you to read the DiabetesMine blog at the link above.

Yes, I have talked about testing before meals and then after meals, but I have not been the best at explaining some of the reasons. So, here goes! The points I want to cover include are:

#1. Dr. William Polonsky of the Behavioral Diabetes Institute who came up with the concept and coined the accurate term “testing in pairs” to make it easy to understand.  Why you need the preprandial (before meal) and postprandial (after meal) blood glucose tests.

#2. The reason I can avoid the guidelines of the ADA and AACE.

#3. Facilitating the development of an individualized blood glucose profile, which can then assist health care professionals in treatment planning for an individualized diabetic regimen?

The purpose or goal of SMBG is to collect information about blood glucose levels at different times during the day to assist you in creating a more level blood glucose. You will use this information to adjust your regimen in response to the blood glucose values. This will mean adjusting your food intake, physical activity, and possibly medications with your doctor’s direction.

This is the reason for testing in pairs. One reading postprandial is worthless and tells you nothing. It does not tell you what the increase may have been from the food consumed, or even if you need to reduce your food consumption. Okay, if the preprandial dinner reading was 105 mg/dl and at 90 minutes postprandial, the reading is 148 mg/dl, then this means that the increase was 43 mg/dl. Now this says something and depending on the goals you have set, you can make adjustments. Do you need to reduce your food consumption (the carbohydrates), do more physical activity, or if on insulin adjust the dosage injected?

If on oral medications then the readings may mean that the physical exercise needs to be increased or the food consumed needs to be reduced. If the person is on no medications, then the person needs to consider medications or less food.

As Will explained, it does depend on whom you work for as to the guidelines followed. The ADA guidelines are the most lax and the AACE guidelines are somewhat better. When it comes to fasting blood glucose levels, I agree with Will that anything below 70 mg/dl causes concern and should be discouraged. I have had readings lower and being on insulin, I was very concerned. I do not work and am retired and as such only answer to myself. I can set my own ranges for my goals and if I don't meet them, then I have only myself to blame. Yes, all doctors try to set goals for me and I generally tell them that the goals are not realistic (an A1c above 7.5% - because of my age) and thus I will use my goals (6.5% and lower).

Yes, I am not cooperating with my doctors and am in the process of finding another so I am not facilitating number 3 above.

October 7, 2014

Prevent Prescription Errors

I will ask for your forgiveness now as I could easily go into a rant, but I will attempt not to become too verbose or use profanity. Yes, I am upset and angry even though this did not happen to me. It happened to Brenda, a member of our support group. She had been to the doctor for her quarterly diabetes check up, the doctor had e-prescribed one new medication, and Brenda had agreed.

When she arrived at the pharmacy, she was totally surprised at the amount of her bill for the medicines. She asked what medicines were in the sack. She had expected the insulin; however, neither of them were what she was using and the new medication was not the same that she and the doctor had talked about, plus there were two other medications she had not heard about.

When she asked the pharmacist assistant to look at the name on the prescriptions, the assistant assured her they were for her. She asked the assistant to call the doctor and check if he had prescribed those medicines for her. At that point, the pharmacist looked at the prescriptions and when she saw the name, said they should not have been for Brenda and she would call the doctor immediately.

It turns out the doctor had the wrong file open when he sent the e-prescription and yes, he agreed that the medications were not for Brenda. He told the pharmacist that
he would e-prescribe the correct medicines. Twenty minutes later, Brenda had her prescriptions and an apology from the assistant for not looking at the name on the container label. This time she knew that the bill was correct and the pharmacist let her look at the medication containers to verify that they were hers.

On her way home, Brenda stopped at Tim's and said we needed a meeting on drug errors and mistakes doctors and pharmacists make. Tim agreed and said we need to include mistakes patients make. Then Tim called me and I said I had a couple of blogs already and an article from October 6 that could be helpful. While Tim was on the phone, I could hear Brenda say she wanted the meeting this Saturday, Oct 11. I reminded Tim of our invitation to meet Jerry's son on Saturday.

Tim asked Brenda if Friday would work and Brenda said okay. Tim said he would send out emails and asked me to put the program together.

October 6, 2014

This Is Interesting about the ACDE

I will quote from the Academy of Certified Diabetes Educators (ACDE) to avoid errors and then consider comments.

Advocate, through support and awareness, for the professional recognition and advancement of the certified diabetes educator credential, acknowledging the credential’s multi-disciplinary composition, through shared expertise and partnership.

Recognition of certified diabetes educators by health professionals, government and the community as the expert standard of education and care of people living with diabetes, through raising standards, innovation and awareness.

The Academy is organized exclusively for education, scientific and advocacy purposes to support the provision of Diabetes Self-Management Education/Training (DSME/T) provided by Certified Diabetes Educators.”

The mission is laudable, but nothing new. Now the vision would be more valuable if there wasn't so few CDEs. They serve mostly people with type 1 diabetes which is great, but they serve very few people with type 2 diabetes because there are too few CDEs to manage this.

The purpose of the ACDE may give us some insight into the organization and the word “exclusively” may be what we need to pay attention to, as this is the motto of another organization that is working hard to promote their being exclusive to the detriment of other professionals. The other disturbing fact in the purpose is DSME/T. This means that they are not recognizing the change to Diabetes Self-Management Education/Support (DSME/S). This was developed by a Task Force from the American Association of Diabetes Educators (AADE) and the American Diabetes Association (ADA).

For the ACDE to ignore this means more mandates, mantras, less education, and probably little or no support. To ignore these national standards has me concerned.

The membership categories is also of concern. I will quote them to avoid confusion on my part.

"ACTIVE MEMBERSHIP in the Academy is open to healthcare professionals who are certified by and in good standing with the National Certification Board for Diabetes Educators.

ASSOCIATE/EMERGING EDUCATOR MEMBERSHIP in the Academy is open to healthcare professionals holding a current, active, unrestricted license, registration, or certification from the United States or its territories, or a master’s degree or higher in social work from a United States college or university accredited by a nationally recognized regional accrediting body and who do not meet the requirements for Active Membership.

AFFILIATE MEMBERSHIP in the Academy is open to individuals who provide products and/or services related to the provision of DSME/T who do not meet the requirements for Active or Associate Membership.

STUDENT MEMBERSHIP in the Academy is open to those individuals currently enrolled in an accredited higher education program leading to a degree in one of the NCBDE recognized disciplines or graduate degrees. After one year following graduation from an accredited higher education program, student members must transfer membership to either Associate or Affiliate Membership."

The exclusive requirements I feel will be the downfall of the ACDE and the AADE should be a better education/support organization once they have the non-licensed category of peer-to-peer groups helping them. People with diabetes helping other people with diabetes should be a success. I believe this as I see this in our support group and we have no training.

October 5, 2014

First Blood Test for Depression May Be Available Soon

Things are looking up for people with depression. In my previous blog on tests for depression this came to light - if depression could be detected via a blood test or urine test, it would clearly be in the realm of ‘medical illness’ and therefore a real problem that is not due to individual weakness or other equally stigmatizing reasons. Now we have a blood test for diagnosing severe or major depression and it has been developed by Northwestern Medicine® scientists.

This they claim is a breakthrough that provides the first objective, scientific diagnosis for depression. Apparently, they have not followed the information from my blog link above. The test identifies depression by measuring the levels of nine RNA blood markers. RNA molecules are the messengers that interpret the DNA genetic code and carry out its instructions.

Besides helping diagnosis of depression, the blood test will also predict who will benefit from cognitive behavioral therapy based on the behavior of some of the markers. Individualized therapy for people with depression will become more effective and individualized.

The research also showed that the test showed the biological effects of cognitive behavioral therapy, the first measurable, blood-based evidence of the therapy’s success. The levels of markers changed in patients who had the therapy for 18 weeks and were no longer depressed.

Eva Redei, co-lead author of the study, had previously developed a blood test that diagnosed depression in adolescents. Most of the markers she identified in the adult depression panel are different from those in depressed adolescents. Redei developed the test and is a professor of psychiatry and behavioral sciences at Northwestern University Feinberg School of Medicine.

Co-lead author David Mohr, a professor of preventive medicine and director of the Center for Behavioral Intervention Technologies at Feinberg says, “This study brings us much closer to having laboratory tests that can be used in diagnosis and treatment selection.”

The current method of diagnosing depression is subjective and based on non-specific symptoms such as poor mood, fatigue, and change in appetite, all of which can apply to a large number of mental or physical problems. A diagnosis also relies on the patient’s ability to report his symptoms and the physician’s ability to interpret them. But depressed patients frequently under report or inadequately describe their symptoms.

Eva Redei says, “This test brings mental health diagnosis into the 21st century and offers the first personalized medicine approach to people suffering from depression.”

It is time for science to catch up with all forms of depression and provide scientific evidence to blunt the stigmatism often attached to depression.