December 20, 2014

Support for Other Bloggers

Every once in a while, something comes along that gets to you and gives you a swift kick in the backside. The eighteenth was one of those times, the person I respect was the bearer of the message, and he does not even know it until now. In his blog here about Dr. Bernstein’s diabetes university, David Mendosa said, “Medicine is finally coming around to recognize that carbs, not fats, are the enemy of diabetes...”

I often ignore statements like this, but recently I had a doctor ask me what type of food plan I was using. When I said low carb, medium to high fat, I did not receive the usual lecture about fats being bad, just an okay and with no gallbladder, be careful. That should have registered at the time, but I gave it no more thought until I was reading David's post.

On the nineteenth, I called the doctor and asked him why he had changed away from the lecturing about eating low fat. I about fell out of my chair at his answer. He said, “I am learning from my patients and more are going medium to low carb and medium to high fat.” He continued that if they were not afraid to tell me that, then what was I missing. He said I went on a search and found other doctors saying the same thing and then I came across several diabetes bloggers that were writing about this. The final convincing came in a blog a patient of mine wrote about an interview with Adele Hite. He said her reference to Dr. Eric Westman was the information I needed as I had been reading about some of his work and this sent me back to research his work.

I accepted this and decided that I had better listen to Dr. Bernstein’s diabetes videos or classes on YouTube. Yes, they were interesting and included some interesting American Diabetes Association history. This confirmed for me why the ADA is always behind the times and research. They are afraid of making changes and will only change when the preponderance of evidence forces the change. While I can agree that change is not always best, the ADA is way behind the times and seems to wait until many doctors have already made the change, then they claim the credit when they make the change.  He now has four videos posted.

Please take time to read David's blog as he makes some great points. I had wanted to comment on his blog, but when I thought more about it, I felt this blog would be better and I did not want to curb my thoughts.

December 19, 2014

Sleep Apnea in the US Threatens Public Health

New studies highlight the destructive nature of obstructive sleep apnea and benefits of CPAP therapy. Public health and safety are threatened by the increasing prevalence of obstructive sleep apnea, which now afflicts at least 25 million adults in the U.S., according to the National Healthy Sleep AwarenessProject. Several new studies highlight the destructive nature of obstructive sleep apnea, a chronic disease that increases the risk of high blood pressure, heart disease, Type 2 diabetes, stroke, and depression.

Public safety is only given a mention, but needs more emphasis as it is unknown how many accidents are caused by people being drowsy or asleep while driving. I have even seen drivers asleep at the when at stoplights. Sometimes other drivers sit and honk at them, but most just drive around them.

Data published previously in the American Journal of Epidemiology shows that the prevalence rates of obstructive sleep apnea have increased substantially during the last two decades, most likely because of the obesity epidemic. The latest estimates predict that 26 percent of adults between the ages of 30 and 70 years have sleep apnea.

Obstructive sleep apnea is destroying the health of millions of Americans, and the problem has only gotten worse over the last two decades. The effective treatment of sleep apnea is one of the keys to success as our nation attempts to reduce health care spending and improve chronic disease management.

Findings from new studies emphasize the negative effects of sleep apnea on brain and heart health. These health risks can be reduced through the effective treatment of sleep apnea with continuous positive airway pressure (CPAP) therapy.
  1. A neuroimaging study in the September issue of the journal Sleep found that participants with severe, untreated sleep apnea had a significant reduction in white matter fiber integrity in multiple brain areas, which was accompanied by impairments to cognition, mood, and daytime alertness. One year of CPAP therapy led to an almost complete reversal of this brain damage.
  2. A study published online ahead of print Sept. 21 in the journal NeuroImage found functional and anatomical changes in brainstem regions of people with sleep apnea.
  3. A study in the October issue of Anesthesiology shows that diagnosing sleep apnea and prescribing CPAP therapy prior to surgery significantly reduced postoperative cardiovascular complications - specifically cardiac arrest and shock - by more than half.
  4. A study published online ahead of print Sept. 19 in the Journal of Hypertension found a favorable reduction of blood pressure with CPAP treatment in patients with resistant hypertension and sleep apnea.
  5. A Brazilian population study published online ahead of print Sept. 23 found that nocturnal cardiac arrhythmias occurred in 92 percent of patients with severe sleep apnea, compared with 53 percent of people without sleep apnea. The prevalence of rhythm disturbance also increased with sleep apnea severity. “

Common warning signs for sleep apnea include snoring and choking, gasping, or silent breathing pauses during sleep. The American Academy of Sleep Medicine, Centers for Disease Control and Prevention, Sleep Research Society, and other partners in the National Healthy Sleep Awareness Project urge anyone with signs or symptoms of sleep apnea to visit this website to pledge to "Stop the Snore" and talk to a doctor about sleep apnea.

If you suspect you have sleep apnea, follow the directions above and see a doctor specializing in sleep problems. I use a CPAP machine daily and find that I have not had more problems with sleep and am generally rested when I awake in the morning.

December 18, 2014

More Activities to Help a Member

Allen called me the next evening and said he did not seem to be getting through to the new member even after our session the prior day. I suggested that Allen should talk to Tim about using this as a topic for our January meeting. Or I said that we should at least explore the idea and see how many would be in favor of this as a topic. Allen agreed that most of the old members would know the importance and maybe we should do one for the new members.

Allen said he would call Tim and to be ready for Tim to call. About 30 minutes later, Tim did call and said I must have some thoughts since Allen mentioned we had been together and talked about this. I said that we needed to do something and consider the importance since others may be operating under similar methods and these were bad habits that need to stop. I suggested that Tim send an email to the old members to explain this and ask if they would accept a meeting on this topic. I also said we needed to talk to Dr. Tom and find out what can be done to change the person from a Medicare supplier to a local pharmacy.

Tim said now we were getting somewhere and that we had something that may help more of our members when they went on Medicare. He said he would talk to Dr. Tom and get back to me the following day.

Tim called me the next evening, Thursday, and was perplexed. Dr. Tom said there was not much he could do or recommend to help the former patient. He was not listening to anything he was telling him and had his own way of doing things and he doubted he would listen to any of us. I said it sounds like an intervention is not in order, but we should keep lines of communication open. I continued that seven of the new members were obtaining VA assistance and an eighth new member would be next year. As such, I feel that we need to ask the old members first and go with what they feel. I said I would do the program, but that A.J or Barry could possibly be better received.

Tim said he would talk with Allen and send out emails. Then when he had heard back, he would talk to A.J and Barry to see whether they would want to present the program as he know they could use some of my blogs for ideas and slides. I said that would work for me. With that, Tim said he would talk to me when he heard back from them.

Allen called and thanked me for having added to his thoughts and said he hopes everyone will answer promptly. Allen got his wish, as Saturday morning, Tim called and said everyone was in favor and that A.J and Barry wanted to do it together and I would be hearing from Barry about slides. When my wife and I returned home late Saturday afternoon, I had a message from Barry asking me to call him the next afternoon.

When I called Barry on Sunday, he thanked me for not doing the program as he had talked to Allen and felt it would be good for someone else to be presenting the program. He said he was working on an outline with A.J and would send it to me when they were about done. I said okay and I would start the slides when I had the outline.

On Wednesday, December 17, Barry sent me the outline and I started the slides and when completed sent them to Barry. Then that evening, he called and thanked me and asked that I add more slides from the instructions he had obtained from Jack who was using the same meter and test strips as Albert was using. I said that was great and I would use the instructions and meter information that all of us with the VA were using. Barry said that he would be by shortly to pick the instructions and scan them into his computer as his program allowed him to size them for easier use for slides.

When he arrived, I already had the instructions from Barry on the Medicare supplied meter and test strips and commented this might get Albert's attention, but from talking to Tim, I was not high in the hope department. Barry said that Allen was not hopeful either, but we had to try. Barry said that all of us getting our testing supplies from the VA were currently using the same meter and test strips which was good and this should help both those receiving testing supplies from Medicare and the VA. Barry said he normally read the instructions he received and if no changes were evident, he and Ben normally discarded them.

Barry took time to read the meter instructions and said they were very similar to the meter instructions for the Medicare meters and the test strip instructions were almost identical. Barry commented that we should attempt to keep up to date with as many meters as the group was using and keep the instructions on slides that could be printed out for any changes made. Barry said that Jack had tried to obtain the test solution for the Medicare test strips, but had not been able to obtain it, but was informed that it would be available sometime in 2015.

Barry concluded that Jack was researching information for us and anyone else that received testing supplies from Medicare. Barry said that members not on Medicare and the VA would be receiving an email from Tim asking for copies of meter instructions and test strip instructions for meters they may be using. First, he was asking for the brand of meters to find out the different brands being used by the members. Then we will use copies of the different brands and get slides made to have them available. I said we should include our type 1 member is this and said I would send an email to Tim and Barry said Allen had already done this and she was using the same meter as those used by the VA members.

December 17, 2014

Time to Transform Rural Health Care

I need to start this with a statement that I think my definition of rural healthcare differs from the definition used in this article. The article uses 19.3 percent as the number living in a rural area, and says only about 10 percent of physicians practice in rural areas. The article also declares that 65 percent of all Health Professional Shortage Areas are in rural areas. It is small wonder that many must travel long distances to see a specialist after months waiting for an appointment.

Even in areas where rural primary care providers (PCPs) remain committed and engaged in the community, often having been raised and educated there, these providers often lack close connections to specialists who tend to be based in larger, urban academic medical centers (AMC). The result is a worsening gap in specialty care access, in turn leading to a deteriorative effect on rural provider morale and retention.

Much of this is because many local hospitals are being bought out by regional hospital groups and becoming larger and more incapable to serving rural primary care providers (PCPs). We are seeing this in our community and now the local hospital sends many patients out to other hospitals. What is disturbing is that most patients are transported by medical helicopters at added costs rather that by ambulance which still are expensive, but about a tenth of the cost of a helicopter.

Most of the efforts to improve rural care have focused on enhancing the patchwork of federally regulated safety net programs, with the goal of increasing quality of care by increasing access to primary, routine, and emergency care. Innovative communications technologies, decision support tools, and initiatives to enhance “broadband” access in rural areas are enabling some frontline rural health care professionals, and even patients and family members themselves, to implement new approaches to delivering high-quality care even with limited availability of physicians, and particularly expert physicians.

I do not understand why authors of many articles dance around the issues. Telemedicine and its use are not new technologies – just underused technologies that many third party payors (medical insurance companies and Medicare) do not want to pay for and constantly put obstacles up to stop its use.

Some states are attempting to install high-speed internet lines, but the political issue is being lobbied heavily against from many businesses and internet providers. In addition to improving quality and capacity of care within rural communities, these approaches also have the potential to generate cost savings. Receiving more specialized treatment from a PCP may reduce complications and emergency department visits, as well as the volume of costly and unnecessary referrals to tertiary centers. Provider education and electronic consultation approaches may also provide cheaper ‘junior’ specialty care as this dissemination of knowledge enables PCPs to provide more care themselves.

Yes, telemedicine can do this and more. Yet, despite this potential for improved care and cost savings, the United States health care system is not set up to recognize and reward these approaches. Because they represent a traditional health care facilities and in-person consultations and services, they are often not supported under traditional fee-for-service payment systems like Medicare.

Changes are supposed to happen under the Affordable Care Act, but many of the provisions are being postponed by the President or his Health and Human Services department. However, until our Congress decides that rural healthcare is important, very little will be accomplished. Funding of telemedicine to obtain the cost savings many know has potential will not happen until Congress does something positive to force the insurance industry to support telemedicine.

December 16, 2014

Patient Engagement Is Backwards

This was a surprise when I read this about patient engagement! Finally, someone that felt similar to what I thought about patient engagement and a doctor to boot. This is worth quoting - “This drive for patient engagement often fails to recognize one important truth: Our healthcare system inadvertently, yet potently, discourages engagement. It ignores the fact that the patient is already the most engaged person in healthcare. The patient bears the disease, the pain, the scar – and, ultimately, the bill. In our search for greater engagement, we must realize what the comic strip Pogo said years ago – “we have met the enemy, and he is us.””

Yes, our healthcare system discourages patient engagement by discouraging honest, straightforward communication. Many doctors also patronize us and feel they are the only source of information we, as patients need. They talk at us instead of with us and many belittle us because they don't receive the information from us that is already in their records and they are too lazy to look up, or are not accessible because one electronic record will not communicate with another electronic record. HIPAA is often blamed, when it is the proprietary electronic systems that are to blame.

Physicians expect patients to bring test results to an appointment – because patient information is often not shared throughout the complex and fragmented systems. Patients are expected to remember their entire health history, and repeat it ad nauseum, because the unconnected systems fail to share. Patients are expected to recount the complex names of the all the drugs they are taking, and at what doses. And it’s not uncommon for these questions to be asked many times in a single hospitalization, during outpatient visits, and again each time a patient encounters a new caregiver.

The Office of the National Coordinator for Health Information Technology reports that one in three patients experience gaps in information exchange, which we rely on the patient to solve. This number may be a significant underestimate because physicians are so used to this level of fragmentation and repetition, that they no longer see it for the system failure it is.

In reality, patients have no choice but to be engaged. They are provided these details in an inefficient way that causes a lot of frustration, worry and fear on top of already stressful medical concerns. Physicians need to think less about the patient being more engaged, and focus on how they can simplify, encourage, and automate engagement tools on behalf of the patient. People are accustomed to integrated, automated, 24-hour customer service in almost every other industry.

Yet, when it comes to the patient's most important asset – health – the consumer experience is dependent on fax machines, scribbled notes, hand-carried printouts, and the memories of those most in need of care. If our healthcare system were to implement the automation, connection and coordination that other industries have used to change the face of consumer engagement, boosting patient engagement wouldn’t be an issue. Physicians would instead be easing the burdens on the very patients they are trying to help.

I can honestly say that as a patient with diabetes the physicians in this area cannot access my records unless they are in the same practice and this is very discouraging and I have to keep banging my head against the errors in the different medical records – and believe me – each electronic medical record has errors and try as I have, none of them have been corrected. What is scary is that some of the offices have refused to correct the errors that even they know are in error.

The article used an example of how concerned parents figured out how to hack into their diabetic children’s glucose monitors so they could remotely track their blood sugar levels. I know other heart patients that have tried to obtain information from heart monitors, but could not because the data was only supposed to be accessible to doctors with the right equipment. Hacking turned out to be the only solution. Should something so essential to managing a loved ones’ health or one's own health require it to be hacked to make that data accessible? I think you know my answer.

We, as patients, need to improve how the healthcare system engages with patients by demanding the various technologies used to take care of us talking to each other. Additionally, we need to demand transparent pricing information or we won’t succeed in receiving better individual care, or lowering costs.

December 15, 2014

Diabetes Training Programs Are Underused

Study leader Rui Li, who is a researcher with the National Center for Chronic Disease Prevention and Health Promotion of the Centers for Disease Control and Prevention in Atlanta told Reuters Health in an email that diabetes training programs are underused.  For me it is easy to understand why they are underused. To begin, there are too few qualified people to teach diabetes self-management education and training (DSME/T) and some of those that could do this are more enamored with using mandates and mantras than actually teaching.

The other problem with the general delivery of the article, because no distinction is made between type 1 and type 2 diabetes. Some reference is made about those on insulin taking the classes, but here again, we are left guessing. A comment is made that those in the North Central region of the U.S. and in metropolitan areas generally have a higher participation rate in DSME/T. This is understandable as there are more certified diabetes educators in metropolitan areas and less in rural areas and often none in many rural areas.

The curriculum of DSMT often includes information about diabetes disease process and treatment options; healthy lifestyle; blood glucose monitoring; preventing, detecting and treating diabetes complications; and developing personalized strategies for decision making

When DSME/T is done correctly, it helps patients improve glycemic management which in turn reduces the risk for diabetes complications, hospitalizations, and health care costs. The study looked at claims data for almost 100,000 adults with private insurance that were diagnosed with diabetes in 2009 to 2012. They found that less than seven percent participated in diabetes self-management education training. Although many people with diabetes know about the classes, a major issue was that individuals with diabetes may not be attending DSME/T once they are referred.

Researchers said better marketing efforts, focusing on education of doctors, patients, and support persons, are needed to publicize the DSME/T programs. Promotion of the message that DSME/T is the foundation of diabetes care might be helpful in promoting the programs. In my own opinion, certified diabetes educators need to improve their method of delivery, actually do education, and stop with the mandates and mantras and then more people might attend the education classes.

The researchers stated that everyone in the study had private insurance, but Medicare and Medicaid programs cover the cost of DSME/T. They said that 40 states mandated private insurance cover DSME/T, but there are private plans that still do not cover it and others that require a co-payment. A person not involved in the study, Kate Lorig, director of the Stanford Patient Education Research Center at Stanford School of Medicine in California, stated that the system for becoming a recognized diabetes program eligible for Medicare reimbursement is difficult and restrictive, plus it is expensive for a program to apply for and receive recognition.

Lorig thinks the way to boost the use of diabetes training programs is to lower the barriers to reimbursement faced by the health care providers who do the training.
Right now reimbursement is usually based on first having a billing code and then have the right content in the education and the right person giving it, she said.

December 14, 2014

Tramadol Causes Low Blood Glucose

As painkillers go, this was a surprise! Admittedly, I have not used this painkiller, but none that I have used caused me any problems and I have taken some powerful painkillers, but not tramadol. Tramadol is a narcotic painkiller whose use has increased worldwide steadily. The new research demonstrates that the drug creates about a threefold increased risk of being hospitalized for low blood glucose.

Even though some of these low blood glucose episodes proved fatal, the association seen in the study does not prove a cause and effect relationship, and instead of issuing a cautionary warning, the researchers just call for more research. Something this problematic should be further researched and at the same time should cause a warning pending additional research. Granted the research was done in Canada, but when WebMD and then Endocrinology Advisor have articles on it, then there has to be some importance attached.

Even though the researchers emphasize that the study found serious low blood glucose even occurred in fewer than one person for every 1,000 people taking tramadol every year. The big surprise is that this is among all types of people and not just those with diabetes. The researchers said an analysis of people who have taken tramadol suggests that 40 percent of tramadol induced hypoglycemia cases did not have known risk factors.

Tramadol is considered a week narcotic drug used for mild to moderate pain and has grown in popularity because it has been said to be less addictive. Tramadol acts differently than other narcotic drugs, as it disrupts the functioning of two chemicals in the body: serotonin and norepinephrine. This is the aspect of the drug that appears to be related to lowering blood sugar

Anyone who takes tramadol is at risk for low blood sugar, not only people with diabetes, who may already be at risk of low blood sugar due to their diabetes treatment. Prior to use, physicians and patients should consider the balance of all of the possible concerns about tramadol along with its relatively mild beneficial effect at relieving pain.

Tramadol may have a limited role in some patients, but like other narcotics, it carries risks that often outweigh the benefits. Patients should be told about the potential for all adverse effects, including hypoglycemia. Tramadol isn't the only option for pain relief, as there are other weak narcotic drugs that can be used instead of tramadol.

December 13, 2014

Assisting a New Member with Testing

On Tuesday, Allen called and asked if I had time to help the newest member to join, Albert, as he had an A1c that was much higher than he had anticipated. Allen asked me to stop by his place and we would go to Albert's apartment. When we arrived, we parked behind his car and as we passed Albert's car, we could see a meter and test strip container lying on the passenger seat. I commented that I could already see problems. Allen then looked and said he hoped not that.

When we were greeted at the apartment door, Albert invited us in and after we were in the kitchen, I could see other potential problems. A meter was lying on the counter and another meter was lying on a kitchen stool. I asked how many meters he had. He said seven that he uses and a few others he has lost. He said they were all the same meter brand and he didn't need to worry about test strips that way. None of the meters was in a case and the test strip containers were setting around the kitchen.

Allen suggested we talk about his meters and where he was storing them. After Allen explained that he had some serious concerns about the accuracy of the equipment, Albert asked why. I explained that the kitchen was not the best place to keep the containers of test strips and that applied to the bathroom as well. Albert then showed us the bathroom where there was another meter and two containers of test strips setting on the counter next to the sink.

I asked Albert to select the bathroom meter and one container of test strips and then when we were back in the kitchen, to select another set. Then we adjourned to the living room and we asked Albert to test with each meter and a test strip. Allen and I both had our meter and test strip and we took them out. We used an alcohol pad to clean the lancing device and put new lancets in the device. When Albert was ready, we asked him to test using each meter.

Before he tested, Allen and I asked when he had last eaten and he said about three hours earlier. Allen said he would use his meter and test him first. After Allen had tested him, the reading was 184 mg/dl. I then used my meter and the result was 182 mg/dl. Albert then set his up and tested with the bathroom meter and the reading was 116 mg/dl and the reading from the kitchen meter was 102 mg/dl. Albert asked to look at our meters and when he saw that they were the same, he asked why our meters were so much higher than his were.

Allen nodded at me and I said because our meters are kept in the case when not in use and not laying around catching dust and lint. Allen then said we also keep our test strip container in the case along with the lancet and lancing device. This minimizes the dust and lint from getting in the meter and keeps our test strip container protected.  I continued that with the test strip containers setting around and in high moisture areas, which was probably why he was not getting near accurate blood glucose readings. I said that I keep all of my test strip containers in a zip-lock bag in a room that is fairly dry and not receiving direct sunlight. Plus this, I cover the bag with a dark washcloth to protect them.

Allen asked where he had obtained the meters and test strips and Albert said from the supply outlet that Medicare had told him to use. I had never heard of the meter brand and Allen had not either. We told Albert to attempt to obtain a test solution to be able to check his test strips, but added that he may have no luck in obtaining the test strip solution.

Allen then stated that the test strips were probably all unreliable and his meters not being properly protected could also be adding to the problem of his blood glucose readings being low and his A1c much higher. I asked Albert if he used the meter and test strips we saw in the car. He answered yes when he feels low. I stated that both the meter and test strips had temperature ranges for storage and use and keeping them in the car during the summer and winter and in direct sunlight would make both unreliable and basically unusable.

Next, I asked if he had read the instructions that came with his meter and the instructions that were in the box with his test strip container. He said he had never read them. We asked if he had any of the instructions around and he said he always takes the test strip container out of the box and throws any papers away as soon as he receives them in the mail.

Allen and I just looked at each other and shook our heads. We knew we had some educating to perform and soon. We asked when he would receive this next order and he said after the first of the year on the day following New Year's or on Saturday. Allen emphasized to him that he should not open all the test strip boxes immediately and if he needed to open one, to keep the instructions and read it. I asked if he would be receiving a new meter then and he said no, but he would in the July order of next year.

We said we would talk after he received his new supply and cover the proper use of the meter and test strips. Allen told him that he had an extra case for the meter and test strips and he would give him one if he would use it and not leave everything lying around and exposed to the elements. Since he was on metformin, we did not understand why he would feel a low since metformin did not cause them. He may have a false low when his blood glucose dropped quickly, but with his meter and test strips being stored where they could freeze, they would not be reliable. He said if he would carry the case next to his body when outside, he would supply him with a case he could use if he would promise to use it. Allen said he would see him the next day and we left.