Worse, even when strong scientific consensus emerges about appropriate protocols and treatments, the health-care industry is extremely slow to implement them. For example, there is little controversy over the best way to treat diabetes; it starts with keeping close track of a patient's blood sugar levels. Yet if you have diabetes, your chances are only one-out-four that your health care system will actually monitor your blood sugar levels or teach you how to do it. According to a recent RAND Corp. study, this oversight causes an estimated 2,600 diabetics to go blind every year, and anther 29,000 to experience kidney failure.
Now, this seems like a rather extraordinary assertion: 3/4 of all diabetics are not instructed in monitoring their blood sugar? That's certainly a problem in the health care system, but can it really be true that the majority of the nation's primary care physicians regularly commit malpractice?
No, in fact, the Rand study he cites doesn't seem to quite say what he says. As far as I can tell, this is the study he references, and here's what it actually says:
People with diabetes received only 45 percent of the care they needed. For example, fewer than one-quarter of diabetics had their average blood sugar levels measured regularly. Poor control of blood sugar can lead to kidney failure, blindness, and amputation of limbs.There's no indication whether that's an access problem, a management problem, or a compliance problem. But compliance will be at the very least a big part of it, as compliance is a major problem with all chronic diseases, and diabetes is one of the nastiest diseases to control, between diet, exercise, and drawing blood. I very much doubt that the problem is a failure to "teach" diabetics how to monitor their blood sugar; I'm pretty sure it's going to be a combination of access barriers and low compliance rates.
Does this matter? It doesn't much undercut the general thrust of the piece, but yes, a health system that barely bothers to teach people to control their blood sugar is very different from a health system that cannot produce regular records of blood sugar levels. The latter is not ideal. But it's a lot better than the former.
Knowing what it's like to go through editing on a technical piece, I know how easy it can be for something to get snarled, so I don't necessarily think Longman garbled the stat, but still: awful statistic.
I work in this field and can say pretty confidently that a lot of it is about compliance.
From the standpoint of a managed care plan, it's really important to them that patients keep their blood sugar under control through monitoring, Rx therapy, etc., because drug treatment is way cheaper than hospitalizations, amputations, etc., that go along with adverse outcomes.
To that end, many plans have programs in place to promote adherence to therapy and monitoring. While lots of times, plans want to suppress usage of certain treatments because the link to better economic outcomes is unclear, diabetes is most profoundly not in that situation. It's all about patients taking better care of themselves... good luck to any health care payer who tries to do that - private or government.
I feel the need to comment and confirm this. My wife is a currently a first year medical resident in primary care. The majority of the patients she treats, are Medicaid patients who recieve their care for little or nothing.
Her biggest pet peeve is the Medicaid patients who come in to the clinic 3-4 times a month with the same medical issues and their effects (obesity, diabetes, pain, etc) every time and yet will not do anything she asks them to do.
They won't change their diet, excercise, monitor blood glucose or even take their insulin. If people won't comply with Drs orders, it doesn't matter what our health care system looks like or how many people have access to it, we will still have a lot of sick people.
Megan
But you don't actually know for sure anything you have written.
You strongly suspect that you found the correct RAND study, and you strongly suspect that the problem is mainly due to compliance, because "compliance will be at the very least a big part of it, as compliance is a major problem with all chronic diseases, and diabetes is one of the nastiest diseases to control...".
You may very well turn out to be right. But denouncing an error should require a bit more than a mere suspicion. Not very cricket.
The Rand study includes the exact items he cites--25% compliance, blindness, kidney disease. And it's from 2003. It is the only study from earlier than 2005 that comes up when you search on those terms. So maybe it's not the study, but it's very likely that it is.
Sounds good. A citation of the RAND study in question would be even better. Doesn't the Longman article provide one?
And how do you know that, in diabetes specifically, "...compliance will be at the very least a big part of it..."? It's a pretty bold statement, and you support it with an assertion about chronic illnesses in general.
Nimed, this isn't rocket science, it's a common disease that people have been looking into since the Renaissance. The causes, treatments, and problems associated with it are pretty widely understood these days. Given an opportunity to err on assuming either widespread failure by the medical community to act on one of its longest-known and most readily treatable malladies, or an errant quote by one person that is possibly explained by a compliance problem, which one does a reasonable person "suspect" as being more likely?
That doesn't negate the importance of the study -- it just means that a reasonable person can conclude that the study probably doesn't say what one person in a bizarre, isolated quote is claiming it to say. As Megan has now noted, she did go looking for the source study and her findings suggested that the Longman article had, in fact, somehow misrepresented it.
You're making the argument that a lot is known about how to best handle diabetes. Longman's argument is one of incentives.
It turns out that precisely because the VHA is a big, government-run system that has nearly a lifetime relationship with its patients, it has incentives for investing in quality and keeping its patients well--incentives that are lacking in for-profit medicine.
And diabetes patients under the VHA care perform better:
The Annals of Internal Medicine recently published a study that compared veterans health facilities with commercial managed-care systems in their treatment of diabetes patients. In seven out of seven measures of quality, the VA provided better care.
I'm sure the medical staff of VHA isn't particularly more knowledgeable about treatments of diabetes.
Dumping this on compliance is misleading. After all, why should VHA patients be more compliant than others? They go through the same hassle when monitoring blood sugar. OTOH, incentives for practitioners are different.
Now maybe you should go back and read Megan's previous post, where she addressed the contextual limitations and/or problems in some of the exact statements you just quoted.
You're being lazy. She doesn't address the things I just mentioned. To be precise, she addresses the incentives problem with a bad argument, and doesn't address the other points.
To repeat:
Dumping this on compliance is misleading. After all, why should VHA patients be more compliant than others? They go through the same hassle when monitoring blood sugar. OTOH, incentives for practitioners are different.
To quote somebody, this isn't rocket science.
I'll check for sources tomorrow, but in my personal experience in this area compliance is a major issue. Many patients dislike having to draw blood from themselves (which is why you see those infomercials all the time on new, less painful ways of drawing blood for glucose tests). Even with proper blood-glucose monitoring, many patients are non-compliant involving their diet.
Why are VHA patients more compliant? If you read her previous post, then I apologize for repeating one of her main points, that patients of the VHA are a different population from the general population. This would be true in many respects, but the important difference in this argument would be the ability to follow orders. I would think this would lead someone in the military to be more compliant than someone not in the military. Obviously I don't have a study supporting this, but it's at the very least a reasonable assumption.
Nimed, obviously he doesn't cite it, or I would know which study he was referring to; he does what most magazine writers (including me) do, which is to say "A Rand study". Print articles do not have hyperlinks or footnotes. But I did link the study that seems to be what he's referring to; you can go look for yourself.
To follow Nola Dawg's lead: the VA patient population is different. When I tell a VA patient to do something, the response is a barely-stifled SIR YES SIR. Now, he might have been a sergeant who creatively interpreted his lieutenant's and captain's orders to mean the opposite of what was said - this is the usual response to an order to quit smoking - but when it's immediate, and important, and is painful to do right, the VA excels. It's the perfect high-testosterone environment - "Yeah, my blood sugar never tops 130. I do 20 fingersticks a day. No pain." And all you have to do is mention the risk of permanent, non-Viagrable erectile dysfunction, and your diabetes problems just melt away...
Cricket, schmicket. One need not have a double Ph.D. in Econ and English to parse the Longman quote and find something odd in it. Diabetes and its maintenance have been known to the medical practice for a very long time; therefore, when reading a quote claiming that diabetes patients are only 1-in-4 likely to receive either direct sugar monitoring or instruction on how to monitor it, do you suspect the entire healthcare industry of having fallen off the turnip truck, or do you suspect that the arguer is misrepresenting the statistic? Seriously, what sniff test does that get past?
To repeat my point - denouncing errors and awful statistics requires more than suspicions.
Also, according to your argument, Megan wouldn't even have needed to look for the RAND paper. She could have just posted the passage from the Longman article and added "Can you believe this guy?"
I don't think Mouse is advocating that one criticize someone's fact-checking without doing some yourself. But searching for the study as best you can seems like a reasonable measure. Perfection should not be the standard here.
By the way, a GOP health care plan has just been analyzed by the CBO. Apparently, it sucks.
Now, of course the plan has essentially zero chance to pass, so it doesn't deserve the attention and scrutiny of the of the Democrats' proposals.
But hey - it is, after all, the document where we presumably will find the best ideas of the opposition. And it looks like the best ideas would leave 17% of Americans uninsured while doing a poorest job on the deficit.
So I was hoping for some libertarian "country down the drain, pox on both your houses, end of America as we know it" sort of despair. Where is it?
Re-posting, apparently a link alone maketh a comment not.
So what exactly does the plan in question suck at?
Hmm... Didn't I just say that? "And it looks like the best ideas would leave 17% of Americans uninsured while doing a poorer job on the deficit."
To be more specific:
- If we do nothing, the CBO projects that 17% of Americans will not have health care coverage in 2019.
- But if we only followed the GOP plan... 17% of Americans would not have health care coverage in 2019.
In addition, it reduces the deficit by less than the Dems' plan, which "only" leaves 4% of Americans without uninsured (yes, 4% is still bad).
So the question is more "what exactly does the plan in question not suck at?"
http://voices.washingtonpost.com/ezra-klein/2009/11/congressional_budget_office_th.html#comments
It costs $61 billion. Not splitting hairs over exact cost of the plethora of Dem's plans, there's at least an order of magnitude difference. 3-to-10% reduction in insurance premiums is certainly a bigger number over ten years than the projected cost. Sounds like a shot at fixing some of the problems with status quo without upsetting the entire system. Which, let me remind you, works for the majority of the population.
Oh, and don't bother reminding me that we dwell in different Universes. I very well remember it.
http://voices.washingtonpost.com/ezra-klein/2009/11/congressional_budget_office_th.html#comments
"According to CBO, the GOP's alternative will shave $68 billion off the deficit in the next 10 years. The Democrats, CBO says, will slice $104 billion off the deficit."
"Shave off the deficit" -- at the expense of extra taxes? Thank you, the tax bill is the biggest one I have by far already. The number I am interested in is what it costs.
Oh, and according to CBO the Rep's version will shave 8-10% (I am sometimes self-employed and sometimes work for small companies) off my insurance premium. Admittedly not much, but what are the Dems promising? Public option? Thanks again, I grew up in the Soviet Union.
Nimed, don't you think the gross cost numers are relevant? If I read the CBO numbers correctly, the Democratic bills are spending ~$1T to achieve ~95% coverage, while the Republican bills are spending ~$60B to achieve ~85% coverage. So the democrats are spending 16x as much to cover that last 10%.
The net cost (i.e. deficit) numbers are cerainly also interesting, but they represent a small different of two big numbers, and the revenue numbers are not strongly tied to the actual insurance. Small tweaks on the revenue side could easily eliminate (or double) the net cost number without effecting gross cost or coverage.
By the way, I haven't even glanced at the actual provisions of the Republican bill. I doubt either the Democratic or Republic bill contains the reforms I really want. I am just commenting on how one should evaluate the efficiency of coverage-boosting spending.
You're hilarious. You actually believe the mandatory cuts in the Pelosi health plan will be enacted. You actually believe the members who vote for this plan have any thought of enacting them. The Dems in Congress are pissing in your soup bowl, Nimed, and you're lapping it up like it's Campbell's Chunky. Too funny.
The GOP plan has no chance of passage, so I agree it's not worth much discussion now. But next year, if Obamacare is still hanging, it will be a different story.
Yes, you're right. The government should just give up making budgets and projections altogether. What's the point? It's all going to change somehow. So we might as well start comparing different proposals by reading tea leaves.
But this seems to contradict your philosophy:
So I take it some projections are worth discussing after all. They just have to come from the right party - meaning the one which has been consistently responsible for the largest deficits in the last 50 years.
Oh yes. We're reliving History here, that's how it all started. How could one forget the Great Public Option Revolution of 1917? If Congress passes the public option, it's really just a matter of time.
Seriously, whatever your opinions may be about the soundness of the public option, there's a whole non-communist world out there in which the state has a greater role in health care than the U.S.. And you know it. So why do you insist on comparisons with Mother Russia?
why do you insist on comparisons with Mother Russia
Because this is something I have seen. Your experience with the "whole non-communist world that..." is strictly theoretical.
So how's that "reducing deficit" doing? Think you can swing it without upping my bracket by another few percentage points?
Actually, you're wrong about that. I've lives almost half my life in Portugal, plus some years in Spain and one in France. Big role of the state in health care. No communism.
And this is besides the point. If your experience with a communist regime makes you label every single thing the government does as a step toward communism, it is obviously not helping you. For the deficit argument, see my response to John Thacker.
If "Sam Roberts"=="Nimed", then your response simply reminds me of those differences between our respective Universes. We do not seem to agree on what the real problems are.
The GOP plan is only "worse on the deficit" because it doesn't promise massive Medicare cuts and doesn't include higher taxes. I don't think that those Medicare cuts in the Democratic plan will happen, but it's certainly "not cricket" to pretend that the deficit savings from massive cuts in Medicare reimbursements are part of how the Democratic plan deals with the uninsured instead of something separately added to pay for the latter.
Both the Democratic taxes and the Medicare cuts could be added to the GOP plan separately to make it look better vis a vis the deficit, if you wished. The differences have nothing to do with the best ideas of how to deal with uninsured Americans, and entirely to do with the Democrats' plans for insuring the uninsured costing more (and covering more, granted) and thus being paid for with higher taxes and Medicare cuts.
Between this and your previous comment in this thread on statistics, Nimed, I've left wondering whether I should hope that you're as ignorant of statistics as you appear, or simply a deceitful partisan.
Hey man, you should obviously hope for whatever makes you feel better.
So let's see - the GOP proposal promises the same percentage of uninsured we would have without reform. So the growing number of uninsured are obviously not a problem for the GOP.
Yes, "the Democratic taxes and the Medicare cuts could be added to the GOP plan separately to make it look better vis a vis the deficit, if you wished". But, since the GOP plan has almost no effects, this argument is pretty disingenuous. Adding the Democrat parts would make it a plan to deal with our health care problems. How didn't you realize this? I wonder if you are merely ignorant in statistics or a deceitful partisan.
You seem to think that increasing taxes or cutting Medicare is cheating. But Medicare expenses are growing out of control. To deal with this, you can increase taxes, cut Medicare, or do both. But these measures are unpopular, so the GOP "plan" does none of the above.
Likewise, when it comes to the growing number of uninsured, the alternatives are again pretty simple - you can deny that it's a problem or spend money to cover more people.
Then there is a parallel discussion - is it possible that certain inefficiencies pervade our current health care system, so that cuts in the costs of current or future services can be achieved without decreasing health care outcomes?
I believe there is a case for that, but let's leave it aside for the moment. The fact is, if such costs exist, the GOP plan doesn't deal with them. What the plan does, if we take it at face value, is to reduce 2019 private insurance premiums between 3% and 10% relative to status quo. But private insurance premiums since the 1970s have been growing at a rate of 9.9%. So yeah, it's slightly better than nothing. But it leaves all the real problems unsolved.
The trend has been to use the term adherence over compliance. Whichever term one chooses, it definitely plays a role. Ask a pediatric endocrinologist about caring for teenagers with diabetes. The juxtaposition of patients who feel indestructible with a condition whose optimal care requires interventions that make them feel different from their peers poses enormous challenges.
Interestingly there are some data that the VA has better outcomes in standard diabetes quality measures than traditional managed care. One of the measures assessed, hemoglobin A1C, provides an estimate of blood sugar control over a longer period, thus the lower value among VA patients suggests better control.
Kaiser also does excellent work with chronic disease management, including diabetes.
It's possible to improve quality of care with better systems of care, both publicly and privately. Emphasis on systems; it can be hard for a harried private practitioner to do this in his or her office. I doubt it's mere coincidence that the VA and Kaiser have the best electronic health records systems in the country.
My wife is a Family Practice doc at a low income clinic with a large number of diabetes patients. They have a nurse whose full time job is diabetes education and compliance. The patients all get education, they get phone calls checking up on them, and the compliance is still terrible. However, you're mostly talking about people who are in terrible health through a combination of sedentary life style, excessive eating and often too much smoking and/or drinking. Is it really shocking that they don't have great compliance?
Obviously, I was talking about the Type II patients in that post.
A big component of type-II diabetes is hereditary. Behavior obviously matters, but you seem to be overgeneralizing there.
Fuck you. Type II is not hereditary, you ignorant baboon. You will say any lie to get your agenda across, you ignorant POS.
Err, Type II is actually more hereditary than Type I http://www.endocrineweb.com/diabetes/2diabetes.html
ElectronHayek, you should learn how to:
1) communicate in a civilized fashion;
2) read.
I wrote:
"A big component of type-II diabetes is hereditary."
http://www.endocrineweb.com/diabetes/2diabetes.html
Approximately 38% of siblings and one-third of children of people with type 2 diabetes will develop diabetes or abnormal glucose metabolism at some point.
Studies with identical twins showed that 90-100% of the time when diabetes developed in one it would also develop in the other compared with 50% in type 1 diabetes.
You seem to have convinced yourself that I was trying to con people into thinking that type 2 diabetes was really type 1. That's because you're a moron. Not entirely your fault - I heard that there is also a big hereditary component to that.
Way to "communicate in a civilized fashion", Nimed. First rule of advice is to take your own.
Tit for tat. Actually, a little less than that - no "POS" and "fuck you".
ElectionHayek, your comments are valued, but this is not okay. If you think Nimed is being unreasonable, just say that.
Seriously--you're a valuable contributor. Help me keep these threads civil, please, no matter how you feel you're being provoked.
Megan:
But calling people "teabaggers" is OK?
I hope calling somebody "whiner" is ok.
Fraggle Rock, stop being a whiner. Things are fine as they are, with Megan's interventions rare and effective. So quit pulling Megan's skirt.
Sam:
Shouldn't you have quit reading this blog since you whined that "all your [Megan's] today's posts kinda sucked".
You do know what "today" means, right?
What I didn't do, of course, was keep whining about it in the next days. You, OTOH, take every opportunity to whimper "B-b-but Megan, what about those meanies that say the word 'teabagger'? The world is so unfair!"
Grow a pair already.
http://stanford.wellsphere.com/healthy-eating-article/paleo-v-mediterranean-curing-type-2-diabetes/497407
type 2 diabetes can definitively be cured by diet changes and compliance with those diet changes.
sounds like the 'hereditary' angle is more confusion of environment/social variables with heredity.
the fact that just changing the food you eat can vanquish diabetes (and increasingly there is evidence that the same can be said for alzheimer's, considered by some to be diabetes type 3) and yet all patients are not prescribed such a diet is where the failure lies.
which is also an awful set of statistics.
Diabetes can be managed, not cured, with a combination of the right diet and exercise.
The Alzheimer thing is complete news to me. No offense, but are you sure about what those claims? A link would be really helpful.
@ Nimed:
the research suggests that diabetes type 2 can be cured via diet change if caught in the first decade and much more easily maintained if the dietary switch happens after that point.
eating paleo is very different than the classic diabetes maintenance diet. and it gets better results for broader groups of diabetics.
google 'alzheimer's insulin'. that will bring up a range of things ranging from mainstream to partisan-bloggy on the connection between insulin and alzheimer's.
eating a pre-industrial diet is pretty close to the 'right diet' for diabetics, the obese and those with other inflammatory ailments.
wibbles, many thanks for the Alzheimer suggestion. I'll definitely check out the original PNAS paper tomorrow!
I have Type II. I love the exercise requirement -- it ends a lot of "should I work more or go work out" arguments. I love the dietary restrictions, though I don't always follow them. I have lost a lot of weight in the past year. But I hate hate hate checking my blood sugar and I would say I have a compliance problem. It's not the little prick in my finger. It's seeing the bad news, when it's bad. I just don't want to know! I take my meds, I'm active, I eat differently than I used to, I get a blood test every two months and see a doctor about it. Do I really have to know all day what my blood sugar is???
Type II is more hereditary, but complications are completely eliminated in people who lower their BMI, increase exercise and monitor blood glucose closely. Both the points of view are correct. Type 2 is hereditary because obesity and sedentary behaviors are hereditary.
As a Type 1 diabetic whose kidneys have failed, the major barrier I see to compliance is mental health. People do not have the resources to change negative behavior pattern, and doctors and educators do not do a good job of evaluating low level mental health issues that allow a person to remain functional, but not to function at a a high enough level to closely monitor food, exercise, and glucose.
The point isn't whether or not DMII is hereditary or not, the point is whether or not people test their blood sugars and take their meds, once they've been diagnosed. The fact is that virtually everyone with diabetes will continue to decompensate, and most will face various neuropathies, infections, and other complications, even if they do everything right. However, many patients with diabetes don't do everything right. I'm not saying it's easy, or even that I'd be able to do it right, but there is indeed a notable lack of even minimum adherence to the tx plan, for some patients.
We have had patients in the hospital who have received multiple coaching sessions from RDs, nurses, medical students, interns, residents, and attendings, and they continue to present with HbA1C levels of 13, which is a definitive sign of poor long-term glucose control. I had one patient, for whom we tried in vain to obtain eligibility for a daily home health nurse for medicine management- this is because he is now legally blind from diabetic retinopathy, and can no longer even read the labels on the bottles. Unfortunately, for a number of reasons, he was ineligible, but we did schedule for him to visit the outpatient clinic at some obscene level of regularity, just so we can keep up with him. I do feel badly for my patients- diabetes sucks. But I don't feel that saying this negates the fact that patients can be partially at fault for poor management of the disease.
there is increasing evidence that switching to a paleo-type diet means no more bloodsticks, either. that is, just changing to the right kind of diet could mean less constant personal monitoring for diabetics and thus better compliance and fewer complications.
'did i eat enough steak this week' is a lot easier to comply with than 'did i do enough blood sugar tests today alone?'
There is no evidence that a majority of the population can comply with the avoidance of sugar laden sweets and junk food.
NO evidence at all.
yes there is. prior to the corruption of the food supply (before WW2 basically), only about 25-30% of the population was overweight (and this meant an extra 20-30 pounds tops, not the range we see nowadays of 20-200 extra pounds for 'overweight').
people were eating less sugary crap and junk food, even the 'fatties' of those decades.
[i do not know if you are being sarcastic or not.]
Interesting population you might look into as to diabetes problems due to compliance vs. due to medical care-licensed pilots with diabetes and medical special issuance. Seems they would have very good compliance since poor health could cost them there medical certificate. If compliance is a big deal, you'd likely see much better outcomes among this group than the general population. Wonder if anyone has studied it.
Anecdotally, I was diagnosed with Type-II about six years ago and my doctor at the time suggested that I "...you know, read all about it on the web." Yup, that was my education.
On my follow-up visit, she told me that I could have gotten my blood meter through my insurance company, but since I paid cash already "don't bother."
Two pearls of medical wisdom - lucky me!
I had to go through two more Primary Physicians before I found one willing to sit down and discuss what exactly my medication were doing, the latest dietary recommendations, the difference between Blood Sugar levels and A1C and what my goals were for both.
Don't presume that my experience says anything about our healthcare system - past or future. But, I would fall into that dreaded 3/4.
Anecdotally, I suggest that compliance for Type II diabetes isn't just difficult because "we don't like it". It's difficult because the docs and nutritionists have a) absolutely no idea what it feels like to be diabetic and have low blood sugar, and b) because the mechanisms for accurately assessing blood sugar are a joke.
I was diagnosed with gestational diabetes on my second pregnancy (that means Type II diabetes that comes on with pregnancy due, they think, to interaction of the placenta and the mother's biochemistry; the baby wants to make sugar to eat, and does so more than the mother's glycogen-insulin system can handle.)
First, to the blood sugar tests. The personal easy pin prick tests are badly inaccurate, systemically so. If you had diabetes (rather than prediabetes or syndrome X or whatever), reliance on these portable devices would be hazardous--could kill you.
Over 12 weeks (diagnosed at week 27 of gestation, to birth at 39) I received 4 personal meters, because the first three did not behave properly. I went through several bottles of "control solution" --that's the liquid sugar they give you to test if your meter is behaving in range--because they couldn't tell the meter was bad until they tested three bottles of control solution against it (how to know the control is in control, you see?) I went through bottles and bottles of test strips for the same reason--the system of test strip, control solution, and meter couldn't separately determine which was at fault, so you just keep trying more "random" samples.
The actual stated standard deviation on the meter was wide enough that the range numbers the nutrionist gave me were bunk. That is, I was required to keep my numbers within a range that was SMALLER THAN THE VARIANCE of the meter. That the nutrionists and other nurse enforcers didn't understand standard deviations or variance was not ever going to be fixed by me.
So, once you learn that your meter is garbage, that the test strips are garbage, that the control process is tainted, and that the numbers really aren't accurate enough to be meaningful, why would you comply?
Now, onto the bigger reason: the assumed directional causality that "these fatties" just ate and slothed their way into diabetes has not been established. Could be that it's the other way: something goes wrong in the body, causing people to feel HUNGRY, RAVENOUSLY HUNGRY all of the time. Simultaneously, nothing they eat satisfies their hunger, and all of the food is turned into fats and stored instead of being used to create energy.
If you have diabetes, you are STARVING often. And if you've ever been really hungry, you know it makes people cranky. Well, the meds that limit your sugar don't stop the starvation. THEY INCREASE IT, because they aren't addressing the whole biochemical process of whatever made your diabetic in the first place--they just soak up the sugars. And feeling starving makes you miserable.
For many people with type II diabetes, being "compliant" is to be in a mental state of depression or rage.
Given the choice between wanting to lash out at everyone in your life, or eat that muffin, I'd choose the muffin.
With the greatest respect Allison, I'm not sure you can compare your moods and behaviours while pregnant to those of a normal diabetic.
I speak as someone who has 3/4 grandparents with type II, my mother, and my sister just got gestational diabetes. Even my great grandfather died from it (6 months before insulin became available in Australia).
My take, which I've looked into somewhat, is that the tendency to type 2 is highly hereditary, but diet and low body fat can keep it at bay in most cases. (Unless you get pregnant.)
I think the author confused regular blood sugar readings with the A1C blood test. I can't believe that 75% of diabetics aren't instructed to monitor their blood sugar. I would completely believe that such a large percentage aren't getting the semiannual or annual check on their A1C, though. My understanding is that it's the A1C test that measures *average* blood sugar levels.
Average might not be the best term, but you're essentially correct. The home blood sticks measure an exact blood glucose level at that time (how much glucose is actually in your blood). The Periodic A1C measures refer to a more complex procedure measuring the number or percentage of Hemoglobin molecules that irreversibly complex with glucose when the glucose concentration in the blood is too long, so it measures (with less quantitative accuracy) if the glucose spike is recent or has been relatively high for the last couple of months.
I also agree the author might have been confused, or perhaps vague about the statistic. Were they not instructed at all, not instructed properly (what exactly does that mean? This isn't a hard test to do), or is this a measure of compliance (i.e. they weren't instructed as to the importance, so they didn't do it)?
However, I'm not sure how regular blood glucose measurement could be confused with the A1C test, which I was pretty sure had to be done at a physicians office (a little more complicated of a test and equipment is required).
I have just finished participating in a clinical trial at a major medical center for type 2 diabetes patients. I had extensive patient education and benefited from it enormously. It was the sort of counseling that no regular practice can offer including hours and hours of one-on-one conversations with experts in diabetes. It is a difficult disease to accept and to treat. There is a great deal of resistance from almost anyone to changes in basic behavior. And there is the stigma of it all. It is true that the test strips and finger pricking are not that reliable. The clinical trial relied solely on the A1C test. We need to get that test in a reliable homekit version. And test strips are expensive. Let's put all diabetes drugs and testing equipment in the generic category and see how much compliance increases. I have great A1C numbers, so I don't waste my money on test strips. And there are promising new drugs on the horizon. The new drug, Byetta, has been a godsend for me, controlling the A1C and suppressing my appetite. More $ for research!
@Eleanor Swain
"It was the sort of counseling that no regular practice can offer including hours and hours of one-on-one conversations with experts in diabetes."
Yep. Exactly the sort of thing that current fee for service medicine pay schedules don't really support.
@Megan, the issue is this
Most Family Docs do not have the time to become expert in managing diabetes (or other specialties). Not their fault, they are generalists. While specialists can write guidelines for them to follow, it is not that simple.
Many patients have difficulty accessing specialist endocrinologists whether for reasons of geography, insurance, compliance etc.
The procedure oriented fee schedules that determine physician compensation favor surgical procedures and for other specialists they compensate initial consultation more than followup. Diabetes management is all about the follow up. Fee schedules consistently undercompensate this. You spend 45 minutes trying to counsel a patient on diabetes management and you will be paid less than break even.
The fee schedules are set by bodies that are dominated by surgeons and reinforce the bias towards paying for one off procedures vs patient management or prevention. The logic of this structure is rooted in history and a mix of assumptions - both correct and incorrect - about the skills required, time involved, and impact on patient outcome.
Access to services of a dedicated diabetes care dietician - which is probably the single most valuable and cost effective adjunct to treatment - is often unavailable, again due to numbers, geography, insurance plans, and yes - compliance.
So if your family doc is diligent about continuing medical education in areas including endocrinology, located in a region with access to specialists for referral and consults, billing under insurance or part of an HMO that adequately compensates regular follow up visits that go beyond 15 minutes, can refer to adjunct care like specialist dieticians and clinics that have the time to educate and provide some point of contact for additional followup that also addresses compliance issues, you are probably okay.
And regarding the core statement:
"Yet if you have diabetes, your chances are only one-out-four that your health care system will actually monitor your blood sugar levels or teach you how to do it."
I suspect the real issue is not that people don't get taught how to monitor their blood sugar, it is they don't get taught what to do about it. And it is not that primary care physicians don't know how to monitor blood sugar levels, it is that they are not compensated for doing this and given the other challenges on their time and resources they may not be able to keep up with the specialist guidelines on what to do about it.
Megan, you love the economics and market solutions. Here is an easy one: Pay more to Family docs and Endocrinologists for diabetes care followup visits. When physicians get paid 4 times as much to spend 2 minutes lancing a boil as they do taking an hour to counsel a diabetic you dis-incent this care. You dis-incent physicians from even entering the field.
The not so easy ones, because they would require more perfect market knowledge or actual competition among health insurers, would involve competitive advantage fro providers who covered cost effective and outcome enhancing services like dieticians, specialist diabetes nurses and clinics for followup etc
Not a doctor but I play one on TV
Everyone wants to pay for quality instead of procedures (I mean, except the surgeons and the dermatologists). Two problems:
1) Quality is hard to measure and even easier than procedures to game
2) The surgeons are in control of the major medical lobbies.
Medicare is probably the worst offender in this regard, and no one has succeeded in changing it, despite 25 years of trying.
One more thing to add to this. Type 1 treatment is getting harder to come by. Technology has improved (continuous glucose monitors, the pump, long acting insulin), A1Cs have dripped, health impacts have gotten much better, and whaddaya know, if Type 1s don't get amputations and eye surgeries, they end up needing counseling and monitoring rather than expensive procedures, so clinics go out of business. Nice system.
Sorry to flood the comments here, but one more question:
How come it's ok to say this:
The procedure oriented fee schedules that determine physician compensation favor surgical procedures and for other specialists they compensate initial consultation more than followup. Diabetes management is all about the follow up. Fee schedules consistently undercompensate this. You spend 45 minutes trying to counsel a patient on diabetes management and you will be paid less than break even.
The fee schedules are set by bodies that are dominated by surgeons and reinforce the bias towards paying for one off procedures vs patient management or prevention. The logic of this structure is rooted in history and a mix of assumptions - both correct and incorrect - about the skills required, time involved, and impact on patient outcome.
...which is fine.
But then when Obama or someone else says doctors are doing extra tonsillectomies for profit, OMG EVERYONE FLIP OUT NOT TEH BELOVED DOCTORS THEY'RE ALL IN IT FOR THE GOOD OF SOCIETY!!!!
I've written in Megan's comments sections before on the need to evaluate moving toward a Mayo Clinic Model of physician compensation, one which is based on salaries and mandatory peer reviews with multiple specialists. It is an excellent system that, while somewhat difficult to implement, is not impossible, because it's already happening in several places.
Coming from someone in medical school, I think John Updike put it best when introducing The House of God by Samuel Shem (a novel written in the '70's, btw) "we imagine that their training and expertise and saintly dedication have purged them of all the uncertainty, trepidation, and disgust that we would feel in their position, seeing what they see and being asked to cure it. Blood and pus and vomit do not revolt them; senility and and dementia have no tremors... The House of God is a book to relieve you of these illusions; it does for medical training what Catch-22 did for the military life - displays it as farce, a melee of blunderers laboring to the murky purpose under corrupt and platitudinous superiors."
With that said, Obama's claims angered me for two reasons. I am much easier accepting criticism from someone who knows about which he speaks, but Obama obviously didn't. He picked tonsillectomies and amputations to diabetics. Tonsillectomies are still taught as a secondary intervention to children with chronic infections, because the tonsils are where the body takes any oral or throat infections, and if too many occur at once, the tonsils become over-infected to the point where the body can no longer effectively deal with it. This has been a medical practice for decades, does not cost much or make much money for surgeons, and has very few side effects. Diabetic amputations are also not well compensated (especially by medicare), so to imply that surgeons are taking money hand over fist (he claimed $30,000) and be at least 1 order of magnitude off (Medicare compensation to surgeons for an amputation is somewhere under $1,000) is almost as insulting as the implications.
There is a lot of waste and added expense in regards to unnecessary testing, from blood work to imaging (Cardiologists owning CT and Ultrasound imaging, for example), all go hand in hand with procedure based fees, which presents the (often unconscious) opportunity to over-test to ensure the best possible diagnosis. In medical school, we are often taught the "gold standard" of diagnosis in one ear, and taught that we can't hardly use it because it's too expensive in the other. There are also disease states with similar issues: we can recommend exercise and diet for obesity, or we can suggest the higher earning gastric surgery. The part no one seems to notice is that, and especially with the internet, none of these decisions occur in a vacuum. The public now also knows the gold standard and wants all the tests to discern from the minutiae found on WebMD. They also know the gastric bypass is easier than a change in diet and exercise (which can be almost impossible for many). The options for a physician to make extra procedure based money are too easy, because it's often what his patient wants as well. This, for me, is where reform needs to begin, and why I don't support current legislation, but that;s for another discussion.
All of that was said to get to this point: if physicians can do all these things (and if Obama had objected to them, I would have had little or no problem), why would he perform surgery on a child or remove a limb for what is likely not to be much money? He directly attacked physician decision making, labeling them mercenaries for whom lopping off a limb or carving on childrens' throats is no obstacle to the cash they get in return (which they don't get much of for these procedures).
Not only was it ignorant and offensive, but it's difficult enough to convince parents or diabetics to allow these surgeries. Obama's statement made physicians already difficult jobs tougher to score some political points.
Not to get too wordy here, but the other reason I don't have a problem with neumann's comment is because he or she wasn't necessarily saying physicians were getting paid too much, just that a different system of payment might be more beneficial for medical costs, health care, etc.
Unfortunately, the title of this post is all too fitting for the latest unemployment rate: 10.2% for October.
Not good.
Sure glad we passed the massive "stimulus" that Obama promised would keep unemployment below 8%.
NO!!!
fewer than one-quarter of diabetics had their average blood sugar levels measured regularly
Please note that this refers to AVERAGE blood sugar levels measured regularly.
This is DIFFERENT than just plain "blood sugar levels measured regularly".
When you test your blood sugar, you are measuring your blood sugar level.
When your DOCTOR orders an A1C, she is asking for an AVERAGE blood sugar level over the last about three months.
Megan, you wrote about the first. The RAND report and the quote seems to be about the second. Not to say that there aren't compliance issues with the second, but it's a test your doctor orders, NOT a test that you do or don't do 4-12 times a day.
My wife's a type 1 diabetic. So that's how I know.
The quote can't possibly be about the second, since no one gets taught to draw their own blood and send it off to Qwest.
I don't know what you're referring to here (who said mailing blood in?), but the RAND quote is unquestionably about testing average blood sugar levels, as I read it in context. It's also clear that Longman screwed up the reference, particularly by adding "or teach you how to do it."
My point here, which is a problem in your post too, is that there's a big difference between frequent testing of blood sugar, which you do at home, and monitoring of average levels, done by your doctor. The reason this distinction matters for your post is that, while issues of compliance, access, etc. apply to both, they apply in different ways to a frequent home test verses a (preferably) quarterly test done by a doctor.
And one more thing: Frankly, most people don't really understand anything about diabetes care -- including a LOT of doctors, particularly primary care doctors. It does not at all surprise me that many primary care doctors taking care of type II patients don't do enough blood sugar monitoring (though I have no experience in that specifically -- just in interacting with a whole bunch of doctors who don't seem to know squat about diabetes).
Daniel is right about the distinction between the two tests, but Longman still screwed up.
I have type 1 - and it seems clear to me that the RAND report was referring to tests that measure Hemoglobin A1c - which gives a rough average of glucose levels over the last 3 months or so. These are actually available for testing at home (they have been refined to require less blood than full-on venipuncture - you can find them on Amazon), but generally this is a test done at a doctor's office.
This is different from the kind of "snapshot" glucose testing that should be done anywhere from 6-15 times a day with the little handheld kits. It's inaccurate to conflate the two.
So I think Longman garbled the stat and was inaccurate in using it as a basis to draw inferences about whether the health care system is teaching diabetics to do the daily testing I mentioned above.
Speaking of awful statistics, the true 10-year cost of Obamacare is... $1.8 trillion.
A trillion in new taxes, $800B in new deficit spending (oh, excuse me, I mean "imaginary Medicare cuts that will never happen"). And the next ten years are going to be even worse.
Hello, second recession. It's like 1938 all over again...
I very much doubt that the problem is a failure to "teach" diabetics how to monitor their blood sugar; I'm pretty sure it's going to be a combination of access barriers and low compliance rates.
Can't we pass a law forcing them to comply? I'm pretty sure the Commerce Clause lets the government demand you do just about anything these days.
I think we can fix the compliance problem. Can't we penalize those that won't comply like we are going to penalize those who won't buy health care?
This post should really be titled "Megan's Gut versus Statistics part 117"
I am diabetic. When diagnosed I was told I needed to test my blood sugar and yet was never instructed on the right time (before or after eating) or how often (once/twice/four times/ day) Thank heavens for the internet.