May 29, 2015

Are You Using Your CPAP?

I wish the people who title some of these articles could use the correct terms. I had to cringe when I read this - "Are You Wearing Your CPAP?" To begin with, it is impossible to wear a CPAP machine and that is the reason for my title. Yes, if you have obstructive sleep apnea, you should use a type of CPAP, but you will only wear the mask.

The article in Diabetes in Control is a good reminder of what can happen when people do not use the CPAP equipment. In addition to elevated blood glucose levels, the person's hypertension was also worse and he was gaining weight. The patient was complaining about exhaustion, but eating right and taking his medications.

The office did not make any medication changes, but encouraged the patient to resume using his CPAP at night, and monitor. They established remote patient monitoring, and in the following week saw the blood pressure and glucose levels return to his targets. In addition, the weight started to drop. When contacted at the end of the week, the patient declared that after using the CPAP for one night, his energy was better and he thanked the office.

What lessons can be learned from this? For the patient:
  • Assess your sleep habits.
  • Respect sleep apnea as an underlying cause of increased blood pressure, glucose, weight, and more.
  • Have yourself screened for sleep apnea, and referred to sleep labs/sleep specialists if you suspect a sleep issue.
For the patient's provider:
  • If you know your patient has sleep apnea, ask the simple question, "Are you using your CPAP machine?"
  • If your patient is not using his/her CPAP, ask why. Sometimes the answer is simple, and a simple solution can turn things around. Sometimes it is because it is uncomfortable. If uncomfortable, encourage your patient to contact their sleep medicine team to help recommend a device that is more comfortable.
  • Follow up with your patients to make sure they use the recommended treatment. If they aren't using the recommended treatment, find out why, and help problem solve.
I can say from experience that using my CPAP machine makes my diabetes and blood pressure (hypertension) easier to manage. While my weight loss is not as rapid as I would like, using my CPAP is helping me avoid weight gain.

May 28, 2015

Who Will Take Care of Us As We Age?

Yes, the baby boomer generation is here and the American Geriatrics Society (AGS) is starting to take notice. Where will we find the workforce to care for the aging population? Most doctors are not prepared, and this will leave a large portion of the care to retired doctors that don't want to work. I presently know two doctors that have reentered the medical community to help care for their elderly friends and others of the elderly.

Have they had the training? No! Like one of them says, but neither does the rest of the medical community in this area. He continued that many in today's medical profession do not want the elderly patients. He said that he found this out shortly after he retired and could not find a doctor to treat him. In the past, young doctors took good care of the older doctors, retired or not. Today, the young doctors are not interested and only want younger patients.

The author of this blog says, “Most residency education in the US is funded through Medicare. Given Medicare’s charge is primarily to care for adults over 65, you would think that Medicare would emphasize training physicians to meet the needs of an aging population. Yet the statement that sticks with me from AGS is this: “10,000 new beneficiaries enroll in Medicare every day, yet we lose 5 geriatricians every week.””

The author, Paul Tatum, goes on to say, “Moreover, the additional trends in geriatric education actually point to less support for training physicians to care for older adults. The Reynolds Foundation, which has been a tremendous supporter, is a foundation designed to spend down its assets and will soon no longer be a source for innovative grants to improve delivery of care to older adults. Likewise, the main grant for training geriatrics clinician educators, the Geriatric Academic Career Award, will not be funded by the Health Research Services Administration this year. How will we create the clinicians that we need for our future without support for the educators who will teach them?

The National GPS Corps (National Geriatrics and Palliative Service Corps) should consist of three elements:
  1. To promote geriatric or palliative care training, all residents who complete a geriatric or palliative care fellowship shall have half of their student loan burden relieved through federal debt forgiveness or payment to private lenders. Crushing student debt is a key factor driving trainees to higher paid specialties and this will make geriatric and palliative care training more feasible. 
  2. To promote excellent geriatric and palliative care academicians, those who opt for a second year of additional academic or research training will have all subsequent student loans forgiven or paid.
  3. To promote clinicians practicing in geriatrics and palliative care rather than further specialty training and to allow for appropriate geographic distribution across the country, those who only complete one year of fellowship will be eligible for further debt forgiveness after completion of a three or five year clinical commitment in a designated geriatrics/palliative care service area.
I agree that teachers must be created to train the workforce needed to care for the elderly. Congress needs to act now to meet this need.

May 27, 2015

My Thoughts Over the Last Few Weeks

The last few weeks have been worrisome for me and most of the members of our diabetes support group. We have had meetings almost every day and often using the phone, or computers using Skype. We have had disruption after disruption to our daily activities and we don't know when it will end. After last Friday, 23 of our members are very upset and angry at the person causing the disruptions. Not a pleasant way to spend Memorial weekend.

I may vent some, so you will have to leave this page or follow with me. I need to write about several of the articles I have read about research in the last few months. Granted many of the studies are using 18 to 24 participants and the length of the studies is less than three months (most only one month) and contain many premises without factual data. Even two of the studies that I received the full copy of are not reliable in my estimation.

The blog from yesterday (go back and read it if necessary) is important for many reasons and shows that not everyone follows the big two from this blog written on July 12, 2013. These two big Pharma supporters are recommending harm to those of us with diabetes. In addition to advocating the stacking of oral medication on top of oral medication, they don't wish us to learn self-monitoring of blood glucose or even to learn how to test.

It seems that many doctors follow the ADA and AACE advice and don't realize the harm they are doing to patients. To be able to manage diabetes and avoid the complications of diabetes, we cannot follow the orders of these doctors. I don't care whether you are managing your diabetes without medications or using insulin. You need to know how the different foods and food combinations affect your blood glucose levels. This will give you information about which carbohydrates to limit or remove from your food plan.

Granted, once you have determined how the different carbohydrates affect your blood glucose levels, often you may be able to reduce the number of times you need to test. It is still wise to test before and after several meals to check when trends are moving upward. Yes, it is easy to become lax and miscount the carbohydrates you are consuming. Been there, done that, and it is a rude awakening when it happens. This makes a person feel very small and look for a place to hide while also wanting to have
a big punching bag available.

Back to the first paragraph. This has caused several of our members to have some blood glucose problems and we are working with each other to limit the excursions into hyperglycemia. Our resources are doing everything possible to stop further disruptions to our lives, but still we don't know when this will end. The person is now after each of us as individuals and this is what has everyone upset.

More on this when we are allowed to say anything in a public way.

May 26, 2015

Access to Test Strips Linked to Mortality Rates

This is a shock, but makes common sense. The title used is, “Access to Glucose Monitoring Supplies Linked to Mortality Rates.” Yes, those that can obtain sufficient test strips live longer. This is another reason for taking every advantage possible even if the Centers for Medicare and Medicaid Services (CMS) and the Veterans Administration (VA) don't like it as shown in my blog here.

Even the American Diabetes Association and the American Association of Clinical Endocrinologists (AACE) don't think people with type 2 diabetes need to test and want us to rely on the A1C two or four times a year. That is why this was such a shock to have this come out during the AACE meeting in Nashville, TN during the 24th Annual Scientific & Clinical Congress.

The researchers conducted an analysis of the importance of Medicare patients with diabetes having the proper supply of blood glucose monitoring tools (test strips). They found higher death rates among patients who received fewer supplies than the prior year. Then found lower death rates among patients who received more supplies than the year prior.

Study author Jaime Davidson, MD, who is the President of Endocrine and Diabetes Associates of Texas and is also a clinical professor of medicine at the University of Texas Southwestern Medical School in Dallas stated that safeguards must be put in place to monitor changes in the acquisition and to ensure patient lives are not being put at risk.

Davidson and his colleagues investigated the potential disruption of patent access to blood glucose monitoring supplies and its impact on health outcome after the recent implementation of the CMS competitive bidding program. Then the researchers assessed to impact of full acquisition of blood glucose testing supplies compared with partial acquisition on death among insulin-treated Medicare patients. The researchers defined full self-monitoring blood glucose (SMBG) acquisition as greater than 80 test strips covered, based on three test strips used per day.

The researchers found that 71.1% of the beneficiaries were treated with rapid-acting insulin, including analog pre-mix, and 20.4% with rapid-acting and long-acting insulin, including analog, recombinant human pre-mix. They reported that 4-year survival was negatively associated with partial or no SMBG acquisition in both groups.

The mortality rates were higher among beneficiaries with full SMBG acquisition in
2010 who migrated to partial SMBG acquisition or no SMBG record the next year compared with maintaining full SMBG acquisition.

However, the mortality rates were lower among beneficiaries with partial SMBG acquisition or no SMBG record in 2010 but migrated to full SMBG acquisition the next year, according to the researchers.

Davidson stated, “As a physician, I'm concerned that CMS did not report any changes in acquisition of SMBG supplies in their initial report of the competitive bidding program. We're continuing to look at the data to understand more about the full impact, but at this stage, given that acquisition of blood glucose monitoring supplies is indicative of actual blood glucose monitoring, anything that disrupts acquisition has a very strong potential to impact patient safety.”

May 25, 2015

Medical Care of Older Diabetes Patients

I am glad that someone else is writing about this. And she is right, older patients with diabetes are not receiving adequate medical care. Doctors are so busy spending more time looking at the computer, checking off “something” and not really listening to what the patients are saying. Older patients repeatedly expressed frustration at the lack of time they spend with their doctor and feel they are not being heard.

Now not all doctors are doing this, I know, as some of my doctors are using recording devices and either having someone enter the information later or are doing this themselves later.

Recent standards for treatment of older patients with diabetes include more flexibility in setting goals for this population, including current health status (comorbid conditions) and expected lifespan. Due to the many pathways to help monitor and control diabetes, along with the variable and ever changing goals, more individualized time is required to assess and set a disease management course during the patient’s visit to their health care provider. This one on one time, in reality, is shrinking.

I am fortunate to have doctors and nurse practitioners that are helping me along the way. I have left the Diabetes Clinic that served me well until I reached 70 years of age and then they kept telling me to let my A1c rise to 7.0% to 7.5%. Then in a fortunate move, the local Veterans Clinic added a Clinical Pharmacist specializing in diabetes that encourages me to manage my diabetes to the best of my abilities.

I can say that I do not agree with the author when she writes, “We as diabetes educators have such an important job. We can have a huge impact on the lives of the older person with diabetes and help to achieve the 2020 healthy goals for Americans which includes: “Reduce the disease and economic burden of diabetes mellitus (DM) and improve the quality of life for all persons who have, or are at risk for, DM””. This could true if most certified diabetes educators did not teach to a one-size-fits-all mantra. Plus most CDEs do not and will not work with type 2 diabetes people, especially the elderly.

Then with the lack of clinical evidence from trials that confirm treatment therapies for the elderly, those of us over the age of 65 have nothing to compare to for determining whether we are even being treated properly.

The last AACE conference heard of a trial promoting oral medications over insulin in a very small study of only 18 individuals under the age of 60 when oral medications were effective in lowering A1Cs effectively for people starting at 9.0% or higher. Many had stacked oral medications and lost weight as a result. The presenter emphasized that this was better than insulin which often caused weight gain. This only happens when endocrinologists do not advise patients to reduce the quantity of carbohydrates consumed and to find an exercise regimen they can follow.

Since the study did not include people over 65, we don't know if people with other conditions such as kidney problems and heart disease will be able to tolerate this therapy. Yet many doctors will force this therapy on the elderly because it worked for younger patients. This is just another case of elderly discrimination.

May 22, 2015

Are Large Breakfasts Better?

I know that many people with diabetes pass on breakfast. Even some of my friends just have a snack. Now these two articles don't give me hope. The first article is from Medscape and says a large breakfast and small dinner are tied to better diabetes control. The second article appeared in ScienceDaily (reported from the Missouri Education research press release) and says prevent type 2 diabetes blood-sugar spikes by eating more protein for breakfast. Both studies appear to be junk science at best.

It is sad that the first study is so small, only 18 people, eight men and ten women, ages 30 to 70. The 18 people were being treated with either metformin and dietary advice or diet advice alone. This also begs the question if some might not have diabetes. The study period was also only six days and then two weeks later another six days on a different diet. At least the study leader wants longer studies to see if the benefits would continue over time. This means that the study has little value.

The second study says even less. It does not discuss the length of the study or give the number of people involved in the study. This leaves only one thing in common, the promotion of protein for breakfast and the statement that this helps blood glucose management later in the day.

The only reason I am writing about this is because I eat a high protein breakfast and have since I was a child. My mother saw to that. She always prepared two or three eggs of various preparations and homemade sausage or other pork product. Add to that hash browns, or fried potatoes (American). There were never a large quantity of potatoes except when I was a teenager and doing lots of chores on the farm before going to school.

Yet, this does not affect my blood glucose level after evening meal. The fewer carbs I eat for the evening meal is the only factor that I can say helps my blood glucose level. Granted, I use insulin and this may be why I have not had the results claimed in either of these two studies.

This is why each person must find their own food plan and make it their own. Studies like this should be considered, but they should never become an end-all. Your blood glucose meter should be your guide and eating to your meter to maintain your blood glucose levels is my suggestion.

May 21, 2015

Hospitals Are At It Again

If hospitals could get worse, I don't know how they would do it. When I read this blog, I had to laugh at what they do in the name of progress. I also thank the doctor that wrote the blog and is standing up for nurses. Too often, the reverse is true.

I must admit that the Nurses Week of May 6 to May 12 seems strange and but the dates are picked to honor certain nurses and that is their choice. But that is not the reason for this blog. Hospitals are pulling out the wallet to pay for some rather absurd customer relations. Hospitals are hiring "customer relations" experts to train hospital staff, and nurses in particular, in how to become more Disney. They think this will solve their problems.

A recent article in Atlantic, titled “The Problem with Satisfied Patients," describes the economic incentives hospitals face to improve patient satisfaction scores. Granted, hospitals have a financial stake in this, and the Centers for Medicare and Medicaid Services (CMS) controls some of the money they feel they are entitled to receive. The amount of this money is linked to patient satisfaction scores. The majority of the 32-question survey, known as HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) addresses nursing care. For example, in a section about nurses, the survey asks, “During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?”

This sounds reasonable on the surface, but then look deeper to see what sorts of issues patients were concerned about when they rated nursing care poorly on this section. Again, from the Atlantic:
  • “My roommate was dying all night and his breathing was very noisy”
  • “The hospital doesn’t have Splenda.” A nurse at the New Jersey hospital lacking Splenda said, “This somehow became the fault of the nurse and ended up being placed in her personnel file.”
  • An Oregon critical-care nurse had to argue with a patient who believed he was being mistreated because he didn’t get enough pastrami on his sandwich (he had recently had quadruple-bypass surgery).

Now hospitals are using misguided attempts to improve healthcare and this has led some hospitals to focus on making people happy, rather than making them well. When healthcare is at its best, hospitals are four-star hotels, and nurses, personal butlers at the ready, at least, that’s how many hospitals seem to interpret a government mandate.

When Department of Health and Human Services (HHS) administrators decided to base 30 percent of hospitals’ Medicare reimbursement on patient satisfaction survey scores, they likely figured that transparency and accountability would improve healthcare. The CMS officials wrote, rather reasonably, “Delivery of high-quality, patient-centered care requires us to carefully consider the patient’s experience in the hospital inpatient setting.” They probably had no idea that their methods could end up indirectly harming patients.

The doctor then wrote, “Now think of the terrific nurses in your lives. Are they terrific because they act like Disney concierge services to patients? Now certainly that wouldn't exclude them from being terrific, but those are not the qualities that come to my mind when I think of terrific nurses. Think of: strong, compassionate, "real," able to confront challenging patients in a way that I could never do as a physician, resourceful, creative, and watchful for errors or early signs of distress. Note that "finds Splenda and extra pastrami" do not appear on this list.”

This patient satisfaction thing has gotten out of control. It's a tremendous amount of money being spent on the wrong thing. Of course, treating patients with respect and dignity is important. That's not the same thing as satisfaction, though. The patient satisfaction thing places the emphasis on making patients happy, not healthy, feeling pampered, not prepared for the worst.

An example that really makes the point is this:
A hospital that switched its meal service to microwaved meals, food-service administrators openly attributed low patient scores to nurses’ failure to present and describe the food adequately. It is both noteworthy and unsurprising that the hospital’s response was to tell the nurses to “make the food sound better” rather than actually to make the food better.
This is the wrong way to enhance patient satisfaction. This may come back to haunt the hospitals. I feel the effort is misplaced and will result if less patient satisfaction.

May 20, 2015

Testing for Diabetes Diagnosis

Why are doctors misdiagnosing the type of diabetes? I find it shameful the number of people I have met in the last year that have been given the incorrect diagnosis. Granted most have been diagnosed with type 2 diabetes when, in fact they had LADA. I have also seen one that was considered type 2 and upon testing by an endocrinologist was found to have MODY #3.

It seems that many doctors still use age as the determinate for the type of diabetes. What makes me feel this way? I was contacted on Saturday by the parents of a teenager that had been diagnosed as type 1 and the parents were asking me if the doctor could be wrong. I did say possibly and asked why they thought this. The mother said he is about 30 pounds overweight and since he had not lost weight, they were wondering if their son might be a type 2. I advised them to have an endocrinologist retest him and then they would know for sure. They were able to get into the endocrinologist on Tuesday, May 12, and after the tests; they did find out that their son had type 2 diabetes.

When they called Tuesday evening, May 19, the mother thanked me for suggesting the endocrinologist. She said the endo did suggest that he stay on insulin for a few years and then see how the diabetes was affecting him. She added that the guidelines were insulin as the first line of treatment until he reached an older age. I said this is something that is still in study, but this should make it easier for their son to manage his diabetes. I did ask their son's age and she answered that he had just turned 13. I answered that then things were being done correctly and she and her husband should work with it and be thankful they had the correct diagnosis.

The mother then asked about pumps and a continuous glucose monitor. I said that would need to be talked about with the endocrinologist. I said I am not aware of any insurance that covers this for type 2 people, but I could not say for sure or how the endocrinologist would answer. I suggested to the mother that until she had her questions about equipment answered by an endocrinologist that she continue with the current treatment. She said that his glucose level was still too high and she did not know what to do about it.

I said she needed to call the endocrinologist and have the readings available for them and ask her questions. Then I asked if their son was rebelling and not testing as often as he should. She said that was possible and she would carefully watch when he was at home. I asked if he was eating more than he should eat and had food stashed for between meals or other times. She was uncertain, but would investigate. I suggested that she do this carefully and not to confront her son. She said the endocrinologist had cautioned her about doing this as well. I concluded by suggesting she ask the endocrinologist how often she should call with questions and if she could write the questions down to prevent calling every time they had questions. She said she had started this and was leaving room for answers. I assured that I would answer non-medical questions and give suggestions between doctor visits and possible calls. With that, she thanked me as they were learning and the URLs I had supplied were helping also.