Health

Team diabetes (American College of Physicians annual session)

Physicians wrestle with ways to prevent, control and treat this increasingly occurring disease.

By Victoria Stagg Elliott — Posted May 16, 2005

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When it comes to diabetes care, primary care physicians no longer are being asked to shoulder the burden alone.

In recognition of both the fact that the disease's incidence continues to increase and its management is becoming more complicated, the American College of Physicians launched a $10 million, three-year diabetes project. The initiative aims to improve care by advancing a team-approach model and providing educational tools for physicians, allied health care practitioners and patients.

"To tackle diabetes, we are looking beyond our 116,000 member internists to the health care team as a whole: the medical subspecialists, physician assistants, nurse educators and patients themselves," said ACP President Charles K. Francis, MD.

The project was launched last month at the organization's annual meeting in San Francisco, which also featured 16 educational sessions about various aspects of diabetes care. Practices that participate and demonstrate improvements will receive official ACP recognition. "That will be something they can hang in their practice or use as a measure in pay for performance," said Vincenza Snow, MD, ACP's clinical director for the initiative.

The project is the largest of its kind ever launched by the college and is funded by Novo Nordisk, a manufacturer of diabetes treatments. At the three-year point, ACP hopes to have data showing that the effort improved overall outcomes and generated new ideas for managing the condition.

Getting to the goal

Physicians praised this diabetes focus as offering help in an area that continues to perplex them in patient care.

"We've all been frustrated by the patient who doesn't get to the goal we've learned can make a difference," said Cheryl E. Weinstein, MD, general internist from Cleveland.

The educational sessions explored several relatively new strategies that, although well-supported by data, are making care for this patient group increasingly complex. For example, experts called for more emphasis on cardiovascular risk factors while keeping prevention of complications in mind.

"Our patients suffer from microvascular complications but they die of macrovascular complications. Treat aggressively. Try to get the hemoglobin A1c to less than seven within six months, but don't be gluco-centric. We really need to have a global approach to our patients and treat all the cardiovascular risk factors," said Edward S. Horton, MD, director of clinical research at the Joslin Diabetes Center in Boston during his presentation about outpatient management of diabetes.

Dr. Horton favors getting cholesterol low, keeping blood pressure under control and pushing patients to quit smoking. As for controlling blood sugar, he urges attention to the declining function of beta cells rather than the issue of insulin resistance.

"At the time we diagnose people with diabetes, they've already lost about 50% of beta cell function, and it only gets worse over time," he said.

Using combinations of drugs geared toward different aspects of the disease rather than higher doses of a single drug was another of his suggestions. Patients also should be put on insulin replacement more quickly.

"It's often a challenge to convince patients that they should start insulin. I think a lot of physicians don't like to take that step either because it means a lot more patient education, and there's a lot of concern about hypoglycemia," he said. "But the majority of patients will ultimately be on combination therapy with oral agency and/or insulin treatment."

Control issues

Other sessions concentrated on controlling postprandial as well as preprandial blood sugars because of a growing body of evidence suggesting that high post-meal blood sugars could be contributing to some of the disease's morbidity.

"If a normal person never gets [blood sugar] above 140 mg/dL, why should it be OK for diabetics to be 200 or 300 after every meal?" asked Steven Edelman, MD, professor of medicine in the division of endocrinology, metabolism and diabetes at the University of California, San Diego. He spoke on diabetic management dilemmas. "If you want to get the A1c to normal, you're going to have to attack postprandial glucose."

Sessions also addressed debates regarding unanswered questions about where improvements in care can be made. Many doctors quizzed speakers on what to do with patients with impaired glucose tolerance or pre-diabetes, a relatively new category of diabetes with no recommended pharmacology. Experts suggested starting with lifestyle changes, and audience members agreed that medication should be used with caution.

"It's all the more incentive for using lifestyle changes, which is my primary focus," said Timothy W. Allari, MD, general internist from Santa Cruz, Calif.

The only issue not a matter of debate was the fact that diabetes is becoming more common and more complicated to manage. The subject pervaded every session.

Physicians said that otherwise clear treatment situations can become murky when diabetes is in the picture. Almost regardless of the patient's complaint, whether a common cold or achy joints, most experts tend to be more aggressive with diabetics who had poor control of their disease but tended to treat their well-controlled diabetics much like any other patient. Should this be the case?

"We don't have good studies to really give us good answers," said Ralph Gonzales, MD, MSPH, associate professor of medicine, epidemiology and biostatistics at the University of California, San Francisco, during his session, "Conundrums in the Management of Upper Respiratory Tract Infections in the Era of Antibiotic Resistance."

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ADDITIONAL INFORMATION

Diabetes therapy trends

Compared with five years earlier, the percentage of diabetic patients in 2002 who were on insulin only fell, while the percentage of those on oral medication alone or insulin and oral medication increased.

Diabetes therapy19972002
Oral medication only42.1%49.7%
Insulin only26.0%18.4%
Insulin and oral medication9.1%11.6%

Source: Centers for Disease Control and Prevention's Diabetes Surveillance System

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Prevention may require more nutritional guidance

In addition to an extensive focus on treating diabetes, several sessions at last month's American College of Physicians meeting in San Francisco explored what physicians can do to prevent the disease from ever developing -- especially in terms of weight management.

Experts recommended that these efforts go beyond the usual diet and physical activity advice and that primary care physicians be prepared to discuss commercial weight-loss programs and over-the-counter meal replacement products.

"We have to find a way to provide patients with more structure and teach people how to fill their plate," said Caroline M. Apovian, MD, director of the Nutrition and Weight Management Center at Boston Medical Center during the panel discussion, "Obesity Medicine: Emergence of a New Discipline."

Physicians also should increase familiarity with weight-loss medications. Discussing these drugs with patients could lead them to reconsider diet and exercise options, particularly in light of the modest efficacy of currently available drugs, according to the panelists.

"People who come in to see us have fundamentally failed at self-management," said Daniel H. Bessesen, MD, chief of endocrinology at the Denver Health Medical Center. "We've got to build self-efficacy in these people. The fact that they are in your office means they can't do it themselves."

Audience members responded that the additional options to facilitate weight loss were welcome but also advocated for access to mental health services to determine the underlying causes for overeating.

"It isn't all calories in, calories out," said Melinda J. Johnson, MD, assistant professor at the University of Iowa College of Medicine. "We need to address the underlying issue of why these patients eat."

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Adult ADHD care encouraged

The 30-year-old woman had an uphill battle in school and always thought herself lazy and stupid. It was not until her daughter was diagnosed with attention-deficit/hyperactivity disorder that she approached her own doctor with the possibility that she might have the condition, too.

When this suspicion was confirmed, she cried from the relief of learning that she could have had more potential than anyone, including herself, had given her credit for.

"This patient spent all those years struggling, in some ways needlessly," said Howard H. Schubiner, MD, clinical professor in the departments of internal medicine, pediatrics, and psychiatry and behavioral neurosciences at Wayne State University in Southfield, Mich.

Patients like this are why Dr. Schubiner told a packed house at a session during the American College of Physicians meeting last month that internists and other primary care physicians must become more involved in the treatment and management of adult cases of ADHD.

"This is a disorder of the whole fabric of daily life," Dr. Schubiner said. "It's easy to treat, and my patients are so thankful."

An additional impetus for primary care involvement, Dr. Schubiner added, is the fact that drugs used to treat it have cardiac contraindications that are more likely to be dealt with in this setting than in a mental health setting. For example, it's crucial to get hypertension under control before prescribing stimulants.

"For the most part, psychiatrists don't take blood pressures on their patients," he said. "There's no question that this should be treated by primary care."

Dr. Schubiner also recommended screening for ADHD among adults who have children with the condition, have substance abuse disorders themselves, appear to be underachievers or have more frequent car crashes than average. Those with depression or anxiety disorders also should be considered as possibly having ADHD, although more complicated cases, such as those that might involve bipolar disorder, should be referred.

"If it's not clear, get help. It's too important to be casual about this," he said.

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External links

American College of Physicians 2005 Annual Session meeting details, with more information about lectures, presentations and other developments. (link)

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