A Call To Action
In Monday’s issue of the Archives of Internal Medicine, the issue features a group of studies on patients who stopped taking their medications. One of the studies reviewed medical records of 11,532 diabetes patients. It found that those who didn’t take their drugs–hypoglycemics, blood pressure drugs and statins–had higher rates of hospitalization and death. The link was not as pronounced as in the heart attack research, but was still significant.
While the results of this study are disturbing they are hardy surprising and speak volumes about a major unaddressed problem when treating diabetes. Diabetic Investor has written extensively on the lack of patient education for adults with diabetes, in particular those with type 2 diabetes. Numerous studies have concluded that patients who receive even a small amount of education show better outcomes. Still little is being done to pressure insurance companies or the government into making diabetes education a priority. As we pointed out in our September issue it is far easier for physicians to prescribe a pill than it is for patients to find the time to exercise or change their eating habits. The same is true for education. While the benefits of education are clear what isn’t clear is what is the best way to get the education to the person who needs it most; namely the patient.
Far too often the debate over diabetes education focuses on cost or lack of reimbursement. While Diabetic Investor agrees that better reimbursement is needed in this area, money alone won’t solve the problem. Lost in this debate are some fundamental problems:
1. Adults with type 2 diabetes do not live their lives in a void where controlling their diabetes is their only concern. Unlike children with diabetes who have their parents available to supervise and assist with their treatment regimen, adults are less accepting of such assistance feeling they can manage just fine on their own.
2. Out of control patients are not aware of any problems until it’s too late. Unlike a person with chronic back pain, an out of control type 2 patient does not feel pain.
3. Education will only work when the patient is willing to change their behavior and habits. Achieving good control does not happen by accident and requires a fair amount of work by the patient. Take for example the simple process of checking glucose levels. Currently non-insulin using patients check their glucose less than twice a day. For years Diabetic Investor has stated that the major reason why these patients don’t check their glucose levels more frequently is they did not understand what the numbers meant and there was no action step that needs to be taken after the test. For a patient using oral medications the amount and frequency of their medication is set by their physician and not by what their glucose levels are. Why then would a patient check their glucose levels when the results are meaningless?
Contributing to the lack of glucose testing is what Diabetic Investor calls the “diabetes vanity factor.” Patients with diabetes, adults in particular, keep their diabetes a secret. When these patients do check their glucose levels it’s often in a private setting, typically at home once in the morning when they wake-up and again at night before they go to bed. To check their glucose levels throughout the day would require them to carry their meter and supplies. It would also require performing the test in public setting. Worse in the mind of the patient checking glucose levels is a constant reminder that they have diabetes.
4. Just when in their busy schedule will patients find time for education? Even if the education was paid for by their insurance or employer, time is not a renewable resource.
5. Finally other than statistical measures such as a lower A1C will education make the patient feel better? Unlike someone on a diet who can see the tangible benefits of weight loss, the benefits of better controlling their diabetes are far less tangible and more long term oriented. This is one reason why even those patients who do receive education often fall off the wagon. Diabetic Investor recently interviewed a newly diagnosed type 2 adult. Like the majority of newly diagnosed patients in the first few months after he was diagnosed he checked his glucose levels regularly and took his medication. Unlike many newly diagnosed patients his physician referred him to a Certified Diabetes Educator (CDE) who helped him deal with his diabetes. When asked if he was still checking his glucose levels on regular basis he replied, “Not really my last A1C was 6.7 and I feel fine.” The only thing about that statement that’s unusual is that he actually knew his A1C level, other than that his behavior is typical of an adult with type 2 diabetes who uses oral medications to treat their diabetes.
The bottom line is all the money in the world won’t change these fundamental problems. Diabetic Investor has reviewed several companies who believe that by providing patients with the tools and fancy software they can better control their diabetes. Typically these systems take the information gathered by the patient download it into a software program which then sends the data to the physician or educator. The general pitch is that armed with this information the patient, physician and educator can design the optimum treatment regimen which should lead to better control. Let’s ignore for the moment just who will pay for this data analysis and consider what is being asked of the patient, in particular adult patients. In essence you’re asking the patient to change their behavior and habits. A difficult task when the tangible benefits of better control are not immediately apparent.
To fully appreciate the difficultly that lies ahead one only needs to look at the efforts made to stop people from smoking cigarettes. Millions of dollars has been spent to get people to stop smoking. Warning labels have been on cigarette packages for years, cigarettes ads have been banned from television, most major cities around the globe have banned smoking in public places and the economic benefits of quitting are well known. While great strides have been made and the number of smokers has decreased dramatically the fact remains that here we are in 2006 almost 50 years since the Surgeon General’s report on smoking and millions of people still smoke.
Everyone knows that diabetes is not just a healthcare crisis but an economic crisis as well. Until a major effort is made to increase public awareness on the benefits of better control diabetes will remain a problem. Spending more money by itself is not the answer. Nor should anyone be deluded into thinking that there are any easy answers. It’s time for everyone to stop talking about the problem. As the old saying goes; talk is cheap.