July 9, 2016

Tips for Medications when Traveling

When planning for traveling, do not wait until the last minute to make sure you have enough medications and a carrying case for the medications. Often you will need to discuss this with your insurance company as they often refuse to pay for the extra medication amount you may need.

Be prepared to give the itinerary of travel destinations, how long you plan on being gone, and how many days of medication you currently have. This becomes very important when traveling overseas.

Using insulin will require special attention especially when traveling in different climates. If traveling in the hot summer make sure you have a cooler for ice packs and/or Frio packs/wallets that are cool when watered.

If your insurance company will not authorize additional medications, then you will need to find out where to obtain medications while traveling. You will also need to know, if traveling in the United States, the prescribers that are allowed in each state. Even though more states are allowing nurse practitioners (NPs), some states do not allow prescriptions from NPs. A few states also will not allow physicians assistants to prescribe and they are not accepted in other states.

If this is the case, make sure that you have a prescription from a doctor (MD). Prior investigation prevents problems and makes for more relaxed traveling. Some of the following will require action by your doctor.
  1. Take nothing for granted. Even though using a national chain pharmacy, not all prescriptions are transferable. Ask patients to call ahead of travel to make sure their prescriptions and prescribers are covered in the state(s) they are traveling to and will need to receive medications.
  • Know the state law. Since laws are constantly changing, best for the doctor to contact the state where their patient(s) are traveling to find out if prescription can be transferred from one state to another. Know “whose” prescriptions will be accepted. Be proactive to make sure the prescriptions are written by a prescriber whose prescriptions will be accepted.
  • Get active. Help to unify prescribing laws in all states.
  • Back to basics of travel and diabetes. Bring more medications and supplies than needed for the time away. In many cases, insurance will cover if given enough notice. Teach yourself to call early and make arrangements.

Don't be caught procrastinating. This could ruin your travel! One word of advice, never put medications in your luggage, but carry them in a case that will be carried on the plane, a train, or even a bus.

July 8, 2016

Reasons Our Medical System Is Harming Us

I have always enjoyed reading the Saturday Healthline posts by Wil Dubois, but the one on July 2 was a very profound post. When Wil says, “On this marking of our country’s 240th anniversary of independence — that I feel like I’m losing mine. I’m being manipulated by people in power. I’m being robbed of choice — and by association, of my humanity,” he expresses the feelings of many of us with diabetes.

He continues, “It’s not a king on a throne in a distant land that’s oppressing me. It’s men in the shadows right here in my own free country who hide in high-rise buildings on Wall Street, looking at me as a number, not a human being with a beating heart and a vibrant soul. Men who make decisions on what I can do, and can’t do, based on lining their own pocketbooks. I’m talking about the oppression of the insurance formulary.”

In this, Wil is correct. Why else would many heads of insurance companies be receiving large six and some seven figure incomes when they -
  1. Can rip diabetes supplies away from us
  2. Limit the supplies we can receive
  3. Substitute inferior quality of diabetes supplies
  4. Negotiate deals for cheaper supplies that don't meet our needs
  5. Constantly change the formulary to prevent us from managing our diabetes efficiently

The insurance cartel follows the Centers for Medicare and Medicaid Services (CMS) lock-step and even does more to harm patients when they won't allow patients to make use of the medications and tools that will help them manage their diabetes.

Wil then says, “Diabetes, left unchecked, is a slow and expensive killer.” I agree as I have seen what happens to patients that are prevented from testing as often as they should. They can have hypoglycemia, not have sufficient testing supplies, and end up in the hospital. This is more expensive than the test strips that could have helped them prevent the hypoglycemia from becoming worse.

Often many type 1 diabetes patients are forced to choose between insulin and food. Many type 2 diabetes patients are forced to do without the medications they know help them because the insurance company constantly changes their formulary and also prevents them from using the tools to manage their diabetes.

The medical insurance cartel needs to be broken up and prevented from harming patients. The doctors should not have to justify every medication they prescribe, especially when the medication has worked for the patient in the past.

Please take time to read the post by Wil Dubois in the first link above.

July 7, 2016

Test Strip Accuracy Matters – Part 2

Health authorities, but not the FDA, in the United States and in other countries recognize the importance of accuracy for self-monitoring of blood glucose. The American Association of Clinical Endocrinologists/American College of Endocrinology Clinical Practice Guidelines for Developing a Diabetes Mellitus Comprehensive Care Plan (2015) state that “self-monitoring of blood glucose (SMBG) is an important tactic to help patients document hypoglycemia, although it is essential that the glucose meter meet accuracy standards.”

In 2013, the International Organization for Standardization (ISO) tightened accuracy standards for BGMS to require analytical accuracy be within ±15 mg/dl when glucose concentrations are less than 100 mg/dl, and within ±15% for samples with glucose concentrations greater than or equal to100 mg/dl. According to the FDA’s 2014 draft guidance accuracy standards for BGMS, 95% of results should be within ±15% and 99% of results within ±20% across the entire glycemic range.

Even within the boundaries of these standards, considerable differences exist in the performance of commercially available systems, especially in the low glucose range. Even the Centers for Medicare and Medicaid Services is forcing BGMS of very poor quality on Medicare beneficiaries in an effort to reduce costs, the beneficiaries be damned.

These performance differences can potentially have a major impact on the risk for missing detection of hypoglycemic events and thus adequately identifying and treating them. (See Figure 1.) For example, fewer than 1 in 100 hypoglycemic events will be missed via self-monitoring of blood glucose at 10% error level; at 20% error level, the risk increases more than 10-fold, to 1 in 10 hypoglycemic events missed.

Meters that have only a ±20% level of accuracy are still on the market and in patients’ homes. Help your patients understand that the accuracy of their blood glucose meter matters, more than they might think.

July 6, 2016

Test Strip Accuracy Matters – Part 1

Blood glucose meters and their test strips are again coming under scrutiny. This time it is the American Association of Clinical Endocrinologists advising other endocrinologists and doctors about the accuracy.

They say that the accuracy of your patient's blood glucose meter (actually it is the test strips) matters – more than you might think. This is very true and it is a shame that the FDA does not do any checks on accuracy and as of yet has not set new standards for test strips. Mainly this is for insulin users, but must also include people with type 2 diabetes on medications that can also cause hypoglycemia.

Some important words and their acronyms for you to remember.
  1. Blood glucose monitoring system (BGMS). This includes #3 below.
  2. Self-monitoring of blood glucose (SMBG)
  3. Continuous Glucose Monitor (CGM)
We need accuracy in our test strips to be able to detect actual hypoglycemic events. This will allow us to treat these events accurately and in a timely manner. Helping to prevent hypoglycemia by delivering accurate blood glucose readings that provide the basis for patients to calculate and administer the appropriate insulin dose, blood glucose monitoring systems (BGMS) play a key role in reducing the impact of hypoglycemia.

In patients with Type 1 diabetes, a study shows when the margin of error of BGMS increases 2-fold, there is more than a 10-fold increase in the risk of missing hypoglycemic events.

Despite accuracy standards for strip-based BGMS, important performance differences exist among commercially available BGMS currently and previously approved by the FDA.

Self-monitoring of blood glucose (SMBG) by persons with diabetes, especially those who are on insulin therapy, is an important tool for helping patients to manage their disease and maintain optimal management of blood glucose levels. For example, the results obtained from a blood glucose monitoring system (BGMS) help guide patients’ insulin dosing. Measuring preprandial glycemic influences the prandial insulin dose, which in turn affects postprandial glycemic excursions. Therefore, the accuracy and precision of patients’ BGMS can minimize errors in insulin dosing. Accurate dosing not only affects clinical outcomes but also potentially impacts economic outcomes, such as direct and indirect health care costs.

Hypoglycemia, one of the most common and most severe complications of insulin therapy, contributes to considerable morbidity and mortality in persons with diabetes. Hypoglycemia limits successful metabolic control of the disease and may prevent both patients and their health care providers from initiating appropriate insulin therapy and achieving optimal glycemic control as early as possible in the battle with diabetes.

The average person with Type 1 diabetes experiences approximately 2 episodes of symptomatic hypoglycemia each week, a figure that has remained essentially unchanged for 20 years. More than three quarters of people with Type 2 diabetes have experienced self-treated hypoglycemia, with 36% experiencing an episode within the last month.

Hypoglycemia is also associated with substantial economic burdens. One study simulating the additional annual risk of hypoglycemia due to BGMS errors showed that use of more accurate BGMS can help prevent nearly 300,000 additional severe hypoglycemic episodes in Type 1 diabetes patients. This can also save more than 100,000 severe hypoglycemic episodes in Type 2 diabetes patients, with potential savings for the US health care system of more than $500 million per year.

An analysis of the economic impact of hypoglycemia in a cohort of patients with Type 2 diabetes mellitus from 2003 through 2008 estimated the mean costs for outpatient treatment of a hypoglycemic event at $285 and mean costs for a patient with a hypoglycemia event treated initially in the emergency room and then admitted as an inpatient at more than $10,000.

July 5, 2016

Good Reasons to Use Telehealth

This is not something many doctors or patients consider, but telehealth is coming whether they want it or not. I have recently talked to several doctors and asked them about using telehealth. Most are very negative in their answers and clearly showed no interest. One doctor (a hospital employee) said the hospital would not allow it and another said the head of the clinic he was part of was against telemedicine of any kind.

The hospital doctor said they would allow doctor-to-doctor consultations if it became necessary, but not doctor to patient. I did give a printout of this article and he read it. He said this would be something he would present at the next meeting with the administration and the fact that a doctor was talking would be good. He was impressed with the first two points and felt that these should be good for all the hospital doctors.

He gave me his home email address and asked me to send any more information I could find, which I have done for three other articles.

Peter Antall, MD says, “Telehealth is here to stay — consumers want it, health systems are adopting it, health plans are reimbursing for it, and frankly, there’s already a lot of great work being done by innovators like Cleveland Clinic.”

At the same time, there are a few, specific reasons why you’d want to practice telehealth. Here are five: (as listed by Doctor Antall)
  1. Get paid for things you’re probably already doing for free. A lot of doctors spend time throughout the day making phone calls, answering secure messages to patients, as follow-up, or regarding new conditions. What’s great about telehealth is that you can conduct this type of outreach over video, have a more robust visit, and get reimbursed for the care that you deliver. Why not monetize these phone or text-based interactions through telehealth while providing a service that your patients want and need? You should be getting paid for the hard work you do and with telehealth, you can.
  1. Improve access to care. The use of telehealth allows you to offer improved access for acute problems both during and after office hours. You and your colleagues can provide the staffing, or you could work with an online medical partner to augment your services. Patients who are unaccustomed to the experience of being able to see a board-certified physician in the wee hours of the night when dealing with a sudden issue will be thrilled to have on-demand care, provided by you. This also improves continuity as these acute conditions are all cared for under your practice and brand, rather than by the ER or local urgent-care center. This naturally builds loyalty to you and your practice, and more importantly, keeps your patients with minor conditions out of the ER.
  1. Make better use of mid-level and support staff. Telehealth can vastly improve your triage services – video can be utilized by your nurse or medical assistant when assessing new complaints. These patients can then be triaged to home care, a telehealth visit with a provider or a brick and mortar visit. Telehealth can also be used for pre- and post-procedure consultations. A good example is a conversation I recently had with a pediatric surgeon. When the surgeon asked me, “Why should I do telehealth?” my answer to him was easy — you can do more procedures. You can let your physician assistants and nurse practitioners do the pre- and post-op follow-up by video, leaving you more time in the operating room.
  1. Enjoy real care coordination without all the hassle. Telehealth can also be used to show specialists and other allied providers right into your office. Increasingly telehealth is being used for provider-to-provider consults or to facilitate team-based care. Instead of giving a patient a referral to go see a certified diabetes educator, dietician or specialist in the area, hope they follow your guidance and hope that you will get a report back. With telehealth, you can invite these providers to see the patient right in your office.
  1. Make your patients' lives easier (and improve compliance) by eliminating unnecessary in-person visits. Visits for medication management are particularly amenable to telehealth. These visits are not reimbursed when performed by phone and it seems silly to drag patients into the office — with transportation, parking, and the usual wait in the waiting room — when these visits can easily be done through telehealth. Why bring in an ADHD patient to talk about how school is going when you can see them remotely, in their home, on their couch? Elderly patients who may suffer from limited mobility can have a visit for medication adjustment without having to make travel arrangements.

Other more obvious benefits to practicing telehealth in and outside the clinical setting include better work-life balance, differentiation for your practice, the ability to take on disease management, increased geographic range, and the ability to build new programs.

Many medical practices are losing money when they refuse to consider this and ignore the desires of their patients. Plus, when another practice starts using telehealth, these patients will transfer.

July 4, 2016

Medicine – Increasing Causes of Death!

Peter C. Gøtzsche is a Danish physician, medical researcher, and leader of the Nordic Cochrane Centre at Rigshospitalet in Copenhagen, Denmark. So when he says the prescription drugs are the third leading cause of death after heart disease and cancer, I know he is talking about Denmark. What this translates to in the USA, I am not positive. The closest this translates to anything in the US is a report by a UK firm that says, medical errors have been ranked as the third highest cause of death in the US.

He states, “Based on the best research I could find, I have estimated that psychiatric drugs alone are also the third major killer, mainly because antidepressants kill many elderly people through falls. This tells us that the system we have for researching, approving, marketing and using drugs is totally broken.”

Yes, I can agree that this is horrible when the vast majority of the deaths can easily be prevented. Non-steroidal, anti-inflammatory drugs (NSAIDs) carry a huge death toll, primarily by causing bleeding stomach ulcers and myocardial infarction, and most of those who die could have done well without drugs or by taking paracetamol. The idea that NSAIDs have an anti-inflammatory effect has been disproven by placebo-controlled studies.

He says, “Antidepressant drugs are another major killer that people could do well without. Their effect on depression is questionable. The standard outcomes are highly subjective, e.g. a score on a depression scale, and it is therefore important that the trials are adequately blinded, but they aren’t. Most patients and doctors can guess whether the drug is active or placebo because of the drugs’ conspicuous and common side effects, and if atropine is added to the placebo to blind the trials better, the effect disappears. Many other drugs that likely have no true effect, e.g. anticholinergic drugs for urinary incontinence and anti-dementia drugs, also have cerebral side effects and can kill patients.”

Most of the deaths are invisible. People get myocardial infractions and hip fractures even without drugs, and general practitioners have no idea that they on average kill one of their patients every year.”

Peter C. Gøtzsche ends by saying, “There are simple solutions to our deadly drug epidemic. Make fewer diagnoses, prescribe fewer drugs and tell the patients to read the package insert on the Internet. Then they might never take the drug. Many years ago I did research on naproxen and when I read the package insert and realized in how many different ways this drug could kill me, I decided never to take an NSAID.”

“A life without drugs is possible for most of us most of the time.”

This is a problem for many of us with diabetes and polypharmacy is more the rule, even if we would prefer a life without prescription drugs. While some people with type 2 diabetes are able to become free of drugs, they need to test on a regular basis to not let diabetes get the upper hand.

July 3, 2016

Epsom Salts, Safe for People with Diabetes? - Part 2

Continued from the prior blog.

Infection is the prime cause of foot problems and people with diabetes need to be aware of this. This is also why a daily foot inspection is necessary and if any cuts happen or infection is noticed, they should call their doctor. Infection signs and symptoms include pus, redness, increasing pain, and warm skin.

Diabetes causes changes to the skin of the foot. People with diabetes may notice that their feet are extremely dry, and the skin may start to peel and crack. The nerves that control the oil and moisture in the feet stop working, leading to overly dry skin.

People with diabetes may develop poor circulation, which makes it hard to fight infection and to heal properly. This problem is known as peripheral artery disease. The blood vessels in the feet and legs also narrow and harden.

When an infection becomes too severe or doesn't heal properly, it can cause gangrene. If gangrene develops, the skin and tissue around the sore dies. The area turns a blackish color and develops a bad smell. In addition to pain, nerve damage can also lead to food deformities. Hammertoes or collapsed arches may be a problem.

Doctors say soaking the feet is not recommended for people with diabetes. Soaking the feet can dry out the skin, which can further irritate foot issues. People with diabetes tend to have dry feet and the Epsom salt bath may only make the condition worse. Prolonged soaking can also open small cracks that may be present in the skin, allowing germs to enter.

Again, while an Epsom salt foot soak may sound good, no type of foot soak is recommended for people with diabetes.

There are things that people with diabetes can do to ensure the health of their feet. Daily foot care as well as controlling blood sugar levels is essential not only for the feet but overall health.
  1. Check the feet daily. The feet should be carefully examined for any potential sores, blisters, cuts, scrapes, bruises or anything else abnormal.
  2. Wash the feet. Lukewarm water and mild soap are recommended. Oversoaking is not recommended because it can dry out your skin.
  3. Dry the feet. Special attention should be given to the area in between the toes. Excess moisture between the toes is a breeding ground for fungus.
  4. Moisturize the feet all over. A moisturizing lotion can help keep the skin from drying out so quickly. Do not put moisturizer between the toes.
  5. Always make sure to wear properly fitting shoes and socks. Shoes that are too tight can make pressure points on the feet that can eventually break down and lead to additional problems.

An emery board can be used to file rough toenail edges, and a pumice stone can help get rid of calluses. People with diabetes should never burst blisters or pick at sores. It is important to keep toenails regularly trimmed. If an ingrown toenail develops, a podiatrist should be seen.

People with diabetes should always contact a doctor as soon as possible, if they have an injury to their foot or an area does not seem to be healing. Prompt attention can help ward off infections or other foot complications.