December 28, 2016

The Whole Patient Finally Considered

The American Diabetes Association's2017 Standards of Medical Care include a new focus on assessment of the social, psychological, and financial circumstances in patients' lives that affect their ability to self-manage their diabetes, with the emphasis being on helping those with the condition to live as normal lives as possible. This means caring for the whole patient and not just part of the situation that the patient encounters.

For 2017, the ADA advises assessment of nonmedical factors that influence patients' abilities to self-manage their diabetes, including issues around access to care, financial barriers, and food insecurity, along with psychological or psychiatric disorders.

A new chapter called "Promoting Health and Reducing Disparities in Populations" provides guidance for promoting patient-centered care aligned with the Chronic Care Model, team-based care, and referral to local community resources for further support.

"You need to be aware of issues that impact self-management.… It doesn't do the patient or clinician any good if the clinician writes a prescription for an expensive branded medication and the patient can't afford it," Dr Ratner noted.

New recommendations for psychosocial assessment and intervention were published in a separate document November 22 in Diabetes Care. We're not just managing glucose, we're managing a human being who's trying to live a normal life.

These include evaluation for symptoms of diabetes distress, depression, anxiety, and disordered eating and of cognitive capacities, using appropriate standardized tools at initial visits, periodic intervals, or if the patient experiences any changes that merit concern, with the inclusion of family members when appropriate. Any problems found should be addressed via follow-up visit or referral.

In particular, depression is extremely common in both type 1 and type 2 diabetes and doubles the cost of care if left untreated, Dr Ratner said. "The idea is that we're not just managing glucose, we're managing a human being who's trying to live a normal life, and it's hard.… Ultimately, the person with diabetes is their own primary caregiver, and we need to be able to support them in doing that very difficult job," he said.

This seems to be the first time that the ADA has advocated anything like this. I am not aware of anything in the last seven year, but this may have been partially advocated before and fallen out of practice.

This is a good practice and may have come at the right time.

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