30 May 2013
Endocrinology Absent in Choosing Wisely
When I read articles and press releases, I read with a concern or jaundiced eye to the factual information and what the strengths and weaknesses may be and may mean to the value of the information published. This is sometimes impossible or nearly so because of the information released. What is being hidden behind the pay wall and how accessible is a contact to receive a copy. As a patient, sometimes the information is easily available and at other times, extensive research is required. I don't mind the research, but at times, I find it a complete waste of time, as the full information is just as poor as the press release.
That is why when I read this; I almost did not believe what I was reading. A doctor writing an article about endocrinology that was not a study, but in fact was his opinion. The topic is well chosen and his observation is great, until he writes his list. I will not begrudge most of his efforts since he has chosen the low-tech side of the issue. Choosing wisely has for the most part been on the high tech side and is very interesting in the tests that we need to be watchful of letting our doctors and hospitals do too many of these tests when simpler or less expensive procedures will yield the same results.
I can agree with most of his low-tech reductions for cost savings. I will list his points and comment where I disagree – which I do on one item and I hope you will agree.
I would encourage you to read the entire article as Dr. Plotzker has some solid points.
My Top 5 List of Excessive Practices
1. Any test of any type that is already in an accessible record does not need to be repeated unless something has happened to that patient that might alter his or her medical status.
2. When a person comes in with weight loss and palpitations, a TSH should be measured before going on a tumor hunt or doing sophisticated cardiac studies.
3. A hemoglobin A1c measured a day or two after a packed red blood cell (RBC) transfusion misleads more than it contributes.
4. Many patients with diabetes test their blood glucose excessively, leading to overuse and unnecessary costs of test strips.
5. Finally, there's a phenomenon that I like to call consultorrhea, or excessive consulting.
I could nit-pick some points in all of Dr. Plotzker's points above, but the one that I feel he is wrong about is number 4. He does have a decent grasp on the topic, but with the problems many people with all types of diabetes encounter in obtaining a sufficient number of test strips, he should not be another one. I feel this doctor is one more obstacle to overcome by patients that should be allowed more test strips.
The example he chooses to use may be true, but there are those people in the early months following diagnosis that need to be able to test, test, and maybe retest quite often. I finally located my testing records from the first year, and I was a little shocked at how often I did test. The first four months I averaged eight tests per day on two oral medications. And yes, when I transferred to insulin, I continued but my average increased to 10 times per day. Then in the fifth month of using insulin, my average decreased to eight times and then I leveled off at about five times per day. I had several times a month that I would be at 10 or more in a day and I was happy to see my notes. A couple of times when I knew I would have a low because of a mistake, either in over estimating carbs, or injecting too much insulin. Other times the extra testing was because I added a new to me food and wanted to check my results for several days to be confident in the quantity I was eating. Thankfully, I had my food logs as well.
Because of Medicare and their testing strip limit, many type 2 patients cannot obtain extra test strips when they need them and most insurance companies follow the lead of Medicare. Our own American Diabetes Association and Joslin Diabetes Center may have much to do with the limits on test strips when they state that certain type 2 patients probably don't need to test. They ignore the fact that most oral medications can cause hypoglycemia and that is when extra test strips become invaluable. I don't have that many episodes of hypoglycemia, but I can use a lot of test strips when I do have an episode, especially on insulin.
I have no evidence and only speculation, when I say that it is possible that many elderly deaths may be caused by hypoglycemic episodes. Because these elderly often live alone, their deaths are listed as heart failure and no mention is made for secondary causes.
Recently, a ten member panel of “experts” in different aspects of hypoglycemia, five from the ADA and five from The Endocrine Society. I have not finished my blog on this yet, but it does recognize hypoglycemia from oral medications. It also has advice for clinical use.