COMMENTARY

Diabetes in the Delta: Helping Patients Meet Goals

Dace Trence, MD

Disclosures

March 30, 2015

Editor's Note: A two-part documentary, Rx: The Quiet Revolution, will air on PBS on April 2. The documentary's award-winning director, David Grubin, highlights a range of innovative practice models from Maine to Alaska. Medscape asked a number of our experts to preview the film and offer us their reactions and opinions about how well the documentary depicts medicine as they know it.

This was a more positive piece than I expected to see. The section on "Diabetes in the Delta" is very powerful, right from the opening scene of a woman declaring that she would not let diabetes get her down. I felt that this sent a message that patients are managers of their own health.

I particularly liked the setting of a church where this patient, Annie Ford, offered to reach out to others with diabetes; research has shown that community support between patients can have a tremendous impact on diabetes control, as patients share their stories, their challenges, and information about the disease with each other. Community "champions" can be incredibly instrumental in encouraging behavior changes, especially in ethnic communities where resources may be limited.

Limited access to traditional medical care is a significant issue for the Mississippi community that is featured. The closest endocrinologist is a 2-hour drive away. However, as part of a program partly funded by the state, patients at the local clinic are being taught to use electronic tablets to record their blood sugar levels, and the information is then sent to an office where all the data is monitored.

The tablet probably would not have been useful if it was given to a patient without educational support. However, patients participating in the study were taught how to use the tablets and were allowed to take them home.

The Mississippi statistics are very sobering: Many children are malnourished until about age 5 years, when they soon become overweight; the obesity prevalence of adolescents is about 40%. This clearly bodes poorly for the future health of these individuals, as they grow older with the increased risk for so many chronic illnesses associated with obesity.

Yet the simple means of the tablet as a communication tool, and then the capacity to call and discuss very abnormal blood sugars, is a step in the right direction. One of the telephone counselors explains that many of the enrolled patients have blood sugar levels around 300 mg/dL, that they "live there" and inevitably face serious consequences. However, the project impressively reports that they have been helping patients lower their blood glucose levels by about 100 points and that emergency department visits related to diabetes have decreased significantly.

The woman featured in this piece poignantly declares that "diabetes is tough," But what she added surprised me: Her biggest burden was not the frequent self-blood glucose monitoring or the need for medication, but rather the fear of what the disease could lead to in terms of complications.

She also said she felt that "nobody cared" before she enrolled in the program—that the doctor just gave her medication and told her to come back in 3 months. This illustrates the need to acknowledge diabetes as a chronic, daily challenge, and that patients need to have the ability to access a team member when they need help.

The medical literature supports this as an important key to success in diabetes management. Of course, the challenge is in being able to have the resources to provide this type of 24/7 accessibility—something that even major medical centers struggle with—because answering service teams are more limited than one might hope in addressing diabetes-related questions or issues.

I liked the physician's comment that the tablet was a very important team member. The film also shows how Skype® is used to connect a patient with the endocrinologist in Jackson. This is not an expensive technology—not a pump, nor a sensor—but a simple computer program that anyone with a computer or tablet could easily set up. The challenge is to have this recognized as an interaction that has value and requires time, and therefore should be reimbursed.

Barriers to clinical traditional care were briefly alluded to, and implications of these are seen everywhere, not just in Mississippi. Many individuals do not have jobs that allow them to take off time for a medical appointment; if they don't work, they are not paid, so a medical appointment costs much more than just the "charged fee." In addition, medication costs, glucose meters, and strips for glucose meters all are increasing in direct cost to the patient, adding to the challenge of diabetes self-management. How tempting it would be to take less medication, or skip days, owing to cost. This goes on even in academic medical centers, including those with robust charity care programs in place.

This piece ends on a very promising note about accountability. The medical system should accommodate patient needs, and the patient should be accountable as well. I think we tend to forget, with all the bureaucracy of today's medicine—meaningful use metrics; achievement requirements; patient volume numbers needing to be met; prior authorization; numerous forms and calls that need to be completed; and secondary medical care aspects, such as making sure that a Pneumovax® vaccine has been given—that it really is the individual patient with whom we need to engage, in a way that has meaning for the patient personally.

And this takes time. How wonderful to have help—a tablet, an educator, Skype—to assist both patient and physician!

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