05 July 2013

Physicians Want Cut-and-Dried Answers

Forget individualizing HbA1c goals, physicians want cut-and-dried answers to the question of what level of HbA1c lowing yields the most benefit and the least risk. More and more studies are being commissioned to attempt to find this answer, but to date, they have been unsuccessful.

To me this means the physicians are putting numbers on our backs and treating us as numbers rather than as people that are patients. As long as they continue to do this, a satisfactory treatment will continue to be elusive and we as patients will continue to be harmed. We know that the young (below 19) and the elderly (above 64) are discriminated against now, but to put numbers on us is even more discriminatory and an insult to us as patients.

Everyone forgets that we are unique and what works for one patient may not work for another patient. Some of us may do well by lowing our A1c's more than the next person, yet doctors are looking for a one-size-fits-all solution. Until doctors and researchers realize that there is more than one type 2 diabetes, that there are several subclasses, and that each needs different treatment, researchers will continue to have problems finding a one-size-fits-all answer.

Dr Gregory Nichols (Kaiser Permanente Center for Health Research, Portland, OR) understands that glycemic burden is intuitively appealing, but it is not straightforward to calculate, and . . . was not a substantially better predictor of CVD risk than mean A1c. Dr. Nichols also believes other covariates such as age, systolic BP, cholesterol, presence of CAD or heart failure, well-established risk factors, were much better predictors of a CVD hospitalization than all of the different HbA1c measures. One exception, he noted is if an HbA1c "ever rising above 7%" was found to be a powerful predictor of CVD and that increased their risk of a CVD hospitalization by 39% when compared to those who never went above 7%.

Other studies have indicated studying different subgroups may yield better analysis for each subgroup. This is important and indicates that some researchers are seeing value in moving away from a one-size-fits-all solution. The resistance is coming from doctors that still believe in the one solution for everyone.

04 July 2013

Research More Interested In Treatments, Not Prevention

This is the hard part of doing information research for diabetes. Most everything is focused on drug therapy and not prevention. “Research for diabetes is far more focused on drug therapies than preventive measures, and tends to exclude children and older people who have much to gain from better disease management, according to a Duke Medicine study.” The previous quote from this Science Daily article is the problem today. Researchers today are only interested in diabetes patients that are between the ages of 21 to 64, and they discriminate against the young and the elderly.

Jennifer Green, M.D, associate professor at Duke University School of Medicine and member of the Duke Clinical Research Institute was the lead author in this study. Dr. Green states, "It's important that clinical trials enroll patients who are representative of populations affected by diabetes and its complications."

Dr. Green and colleagues analyzed trials from ClinicalTrials.gov and found 2484 trials related to diabetes and from October 2007 to September 2010.

#1. 75% focused on diabetes treatment.
a. 63% involved a drug.
b. 12% were behavioral.

#2. 10% were designed to test a preventive measure.

#3. 15% were not specified.

The researchers found that most clinical trials enrolled small numbers of patients at a small number of sites. Most were completed in less than two years. Most did not represent a geographically broad mix of patients and excluded young patients and elderly patients.

According to the research group, older people were explicitly excluded from 31 percent of trials, and were the main focus of only 1 percent of the studies. Similarly, just 4 percent of diabetes trials were aimed at people ages 18 and younger. The research group also found that only small numbers of diabetes trials were designed to assess the effect of interventions upon events such as heart attack, stroke, or death.
We will see many more such trials in the future, given the recent emphasis on assessing diabetes medications for cardiovascular safety," Green said.

In their conclusion the authors' state, “The majority of diabetes-related trials include small numbers of participants, exclude those at the extremes of age, are of short duration, involve drug therapy rather than preventive or non-drug interventions and do not focus upon significant cardiovascular outcomes. Recently registered diabetes trials may not sufficiently address important diabetes care issues or involve affected populations.”

For those that want the details of the study, it may be found at this link. Then a scroll down the page to this description, “Are current clinical trials in diabetes addressing important issues in diabetes care? by W. C. Lakey, K. Barnard, B. C. Batch, K. Chiswell, A. Tasneem, J. B. Green” At the bottom of the discussion is the link to download the PDF file. This study will eventually scroll off the page. Then you will need to do a search for the article in volume 56, issue 6 and this title - Are current clinical trials in diabetes addressing important issues in diabetes care?

03 July 2013

Telehealth, Telemedicine, mHealth - ????

With the explosion of technology today, it is difficult to see what is in store tomorrow much less five or ten years from now. Yet many people are attempting to predict and declare what will happen in the next five to ten years. This is because of their obsession with having order in their lives and direction in what they do. I can understand and appreciate this, but as I grow older, I just want to wake up tomorrow and then I will worry about what I do and what will happen. Oh, yes, I have plans, live by a budget, but all these dreams are mote if I don't wake up tomorrow.

The definitions of the terms used today are complex and often confusing. I am not sure that I have them right, but I have asked three doctors and received three different answers. And in their own professional groups, each has their points and they all differed. Digital health technology seems to be accepted more than any other term and in some instances, this may be true, but then we need to think about the other terms that are gaining acceptance. And when talking about digital health and digital healthcare, there is not a national organization, that I am aware of existing.

Telemedicine, telehealth, mhealth, (Mhealth, m-health, mobile health all apply to the use of mobile health devices), are just a few of the terms being used widely. In a search of the internet, only one of these terms relates to a national organization and that is the American Telemedicine Association. At present, and I say this cautiously, this is the only group to have a national association and as such I need to consider this the overarching organization for all other terms.

Be careful and don't confuse this with telecommunications as this is represented by at least two national groups – the National Telecommunications Cooperative Association (NTCA) and the National Rural Telecommunications Cooperative (NRTC). The NTCA and the Organization for the Promotion and Advancement of Small Telecommunications Companies (OPASTCO) merged and beginning on March 1, 2013, the new organization will be called NTCA, The Rural Broadband Association.

Back to the use of terms in the health arena.
The term “eHealth” is often used, particularly in the U.K. and Europe, as an umbrella term that includes telehealth, electronic medical records, and other components of health information technology. As this is a term more common to the European Union, I will leave it alone.

Another term similar to telemedicine is the term "telehealth," which is frequently used to denote a broader definition of remote healthcare not always involving active clinical treatments. Telehealth and eHealth are at times incorrectly interchanged with telemedicine. Telemedicine often refers only to the provision of clinical services while the term telehealth can refer to clinical and non-clinical services involving medical education, administration, and research.

Telehealth is not popular in some areas, but one company still pushes this. And remember, it does not take a national organization to drive definitions, but it helps.  Reading about the different terms in wikipedia can be of some help, but there is still confusion. I find it interesting just trying to wrap my head around all the terms. I may misuse them, but to me telemedicine will be for me the overarching term and may include some of the other terms as part of telemedicine.

02 July 2013

Elderly and Rehospitalization

This is a real problem and applying all sorts of names to it will not make it change. Why hospitals consistently think they can just push patients off on skilled nursing facilities (SNF) without proper care instructions is a mystery. This attitude is about to start causing them penalties and then they will begin severe rationing of health care on the elderly. This in turn will cause legal problems and calls for large settlements.

Hospitals are short of staff because they have been cutting costs by reducing staff instead of creating healthcare efficiencies. Hospitals in turn are blaming SNF for the readmissions when in fact; it is the lack of poor care coordination and discharge planning by the hospitals. Maybe the authors of this article are correct in calling these readmissions a “bounce back” to the hospital. This is being documented more and more for Medicare patients and it is estimated that one of four patients are being re-hospitalized within 30 days of discharge to a skilled nursing facility.

Yes, I could lay some blame on the SNF, but the hospitals must shoulder most of the blame for their lack of communications with the SNF. Occasionally a SNF will not exist near the hospital and the nursing homes do not have qualified medical staff available and do not follow through with the few instructions they do receive. These are the sad situations.

Medicare should also shoulder some of the blame for their mixed up payment rules which puts burdens on the patient, SNF, and the hospitals.

Then we must look at the patients themselves. A good portion of the patients in SNFs have limited functional capabilities and are often dependent on skilled nursing care. The following are patients' characteristics:

#1. The average age is close to 80 years,

#2. One-third of the patients are affected by cognitive diseases,

#3. 50% of SNF residents have at least three to six limitations in their basic activities of daily living,

#4. One-half of the residents are being managed for five or more chronic diseases - many that are considered terminal.

When looking at the above list, we need to be concerned about the type of care these people are receiving. I must wonder if they are receiving aggressive and unnecessary care or if they need palliative care instead. If they are truly in the last stages of life, then why are the physician, hospitals, and SNFs playing the aggressive roulette to milk money from Medicare and Medicaid when palliative care may be the best treatment? Probably because palliative care reimbursements are so low from Medicare.

A recent report published by the Institute of Medicine shows that this is happening more in some regions of the country than other regions. Unfortunately, there is no definitive answer about why this is occurring. We do know that advance care planning is inadequate. The inability of providers to correctly and actively counsel patients and their families in a dialog about the patients' prognosis and their goals of care should be a major concern. Yet this often does not happen.

Palliative care is not considered by the providers and too often, the patients are just told to have “do not resuscitate” (DNR) directives and “do-not-hospitalize” (DNH) directives on file and no further discussion about them. The patients and their families are then left wondering how these will be acted upon and when. There have been too many examples where these have been ignored, sidestepped, or aggressively adhered to when a discussion should have taken place. Therefore, is it any wonder many patients are concerned about having these directives on file when they are aggressively adhered to by uncaring doctors? A local example was a 45-year old that was having heart problems and his doctor refused to do anything because of a DNR in his file. Resuscitation was not the issue and an operation to repair a valve problem would have meant quality of life for possibly many years. It is no wonder when he passed in 24 days that the doctor had no DNR defense and the jury returned a hefty judgment for the family.

Is it any wonder that patients become concerned when doctors request these at younger and younger ages? Patients are becoming smarter and making them unenforceable below certain ages without family consent. Yet, even here, a doctor choose to ignore this and claimed that the DNH allowed him to avoid liability even if the patient was under the age of 50 and had operable cancer. The jury declared a huge financial award to the patient's family.

Then on the good side, there is a doctor that has this discussion when a patient passes a fiftieth birthday. The doctor is very open about all possibilities and family involvement is something that he feels should be considered and encouraged. This doctor discusses everything from acute care, palliative care, and hospice care to minor care. This doctor correctly feels advance care planning is often times neglected at nursing facilities and can lead to distressing end-of-life experiences for the patients and their families.

During the last few months of life, comfort measures may be more appropriate than aggressive life sustaining interventions at the hospital ICU. Under current Medicare rules, Medicare reimbursements provide a financial incentive to nursing homes to hospitalize Medicaid nursing home residents, who are receiving long-term care. In addition, since Medicare reimburses nursing homes a higher rate for skilled services, patients who transition to the hospice care benefit are not considered “favorable” patients and must pay for room and board out of pocket or through enrollment in Medicaid, for which many patients are not eligible.

Therefore, once in either a hospital or skilled nursing facility, patients can be caught in the profit game and are rotated endlessly between the two facilities and receive aggressive and expensive care procedures which may not be in the best interest or care of the patient.

01 July 2013

'Data Mining' May Work To Improve Patient Care

This is another instance of physicians learning that patients are good learners and there is definitely a change taking place in the doctor-patient relationship. I will admit that even in my own experience, the standard was the doctor prescribed and I followed his orders. As I have gained knowledge, I have done some push back on this in recent years. Some of my doctors have accepted this and are working with me, and at least one doctor has not accepted this. As a result, I am no longer a patient in that office.

This article in Medscape is from the TEDMED 2013 conference and two physicians spoke about the changes taking place. Both physicians felt that the opportunities for patients' involvement are becoming greater with the advent of the fast changing technology. Susan Desmond-Hellmann, MD, MPH, chancellor at the University of California, San Francisco, “Explained that she is part of a growing movement to empower patients through digital health initiatives and precision medicine. The goal is to cross-reference a patient's health data with a global "knowledge network" to deliver more targeted care.”

Doctor Desmond-Hellmann was cautious when she talked about, “There are situations where patient participation is not possible or is severely limited, such as in trauma, emergency surgery, or acute illness. Sometimes the best that can be done is informed consent. But when it comes to prevention, wellness, and chronic illnesses — these are perfect opportunities for healthcare consumers to get involved." I would prefer the change of “healthcare consumers” to the word patients.

This is something I can relate to and I feel that doctors that understand this will do more conscientious work knowing that patients in emergency situations cannot participate and will be asking many questions once they are on the road to recovery, provided they are able to communicate.

I whole heartedly agree with Dr. Desmond-Hellmann when she states, “If healthcare records all become electronic and the patients do not have access, that is defeating the purpose. These are wonderful new tools, but we need to use them to bring patients closer to their caregivers, in more of a partnership."

The other speaker following much the same thoughts was Dr. Roni Zeiger, founder and CEO of Smart Patients. He believes that technology is, “Helping patients move from being recipients of information to becoming experts — specifically, microexperts.  In many cases, we have patients who aren't just experts in what they feel or experience, but in the science of their disease." Read about Dr. Zeiger at this link.

I appreciate these thoughts and especially when Dr. Zeiger says, “We have a culture that is just ready to embrace this notion of a real peer-to-peer collaboration." We need more doctors that embrace this philosophy of peer-to-peer work and make use of it in clinical practice. I know in the case of diabetes, this could be part of what stops the epidemic of diabetes. This would also help in the education so badly needed by people with diabetes.

Since this not a priority on the agenda of the American Association of Diabetes Educators (AADE), and its members, maybe it is time for endocrinologists to select patients who are microexperts and give additional training where needed and then work with other primary care physicians (PCPs) to have them assist with education. This could be especially valuable on the areas of sparse doctors and probably no CDEs.