Monthly Archives: August 2007

Good News For People With Unwanted Wrinkles

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Two articles in the New York Times yesterday (August 29, 2007) should give us pause about the sorry state of health care in the U.S.

Botox

First, there was an article entitled “Botox Appointments faster than For Moles, Study Finds,” written by Natasha Singer. In summary, the article written by Jack Resneck, Jr, and colleagues reviewed a study published online August 28, 2007 in the Journal of the American Academy of Dermatology in which wait-times for Botox treatment for unwanted wrinkles and evaluations for suspicious (i.e., is it cancer?) moles were compared. The authors found that wait times for appointments for Botox treatments averaged 13 days vs. 68 days for mole evaluations. The authors concluded that dermatologists should better monitor how their patients are scheduled. No duh!

This report is not at all surprising. Who can blame dermatologists and other physicians who treat people for skin “disorders,” including those that are considered cosmetic. Treatment with Botox is lucrative while evaluation of moles is “nickle and dime” stuff. The data are just symptomatic of how bizarre the U.S. health-care system is at present. It would be easy to blame the skin docs for this situation but should we hold them to a higher standard than anyone else in business? Maybe, but I think the blame should go to our higly dysfunction health-care system.

Health Insurance Woes

The second article is actually an editorial entitled “Bleak Findings on Health Insurance.” The editorial discusses the recent Census Bureau’s report on the state of American health insurance. I haven’t read the Census Bureau’s report but according to the editorial the number of uninsured Americans has been “rising inexorably over the past six years.” Last year the number of uninsured Americans increased by more than 2 million to almost 50 million. The leading reason for the steady increase in people without insurance is the steady decline in employment-based coverage (in 2006, 22 million full-time workers have no health insurance). The number of uninsured children increased by more than half a million to almost 9 million. The editorial urges reauthorization of the expiring State Children’s Health Insurance Program (called S-CHIP) but does not give recommendations regarding the overall scary health coverage situation in the U.S.

Of course, the health insurance coverage mess does not have any impact on Botox treatment for unwanted wrinkles since the procedure is not covered by insurance. All it takes is a large supply of cash ($400-500/treatment). What to do about noncosmetic medical care? This is a very complex problem which will require a comprehensive approach if we are to achieve our potential for the best medical care in the world for all people in the U.S. As I discussed in an earlier posting, I have concerns about S-CHIP as it is currently designed given the problems with access to medical care even with S-CHIP coverage in many places in the U.S. (including in my State, Missouri).

Bariatric Surgery And Mortality: Long-term Follow-up Data

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Two interesting studies on bariatric surgery and an accompanying editorial were published in the New England Journal of Medicine yesterday (Volume 357, August 23, 2007). The first study was entitled “Effects of Bariatric Surgery on Mortality in Swedish Obese Subjects,” and written by Lars Sjostrom and colleagues from a group of academic institutions in Sweden. The second study was entitled “Long-term Mortality after Gastric Bypass Surgery,” written by Ted Adams and colleagues at the University of Utah School of Medicine. The editorial was entitled “The Mising Link-Lose Weight, Live Longer,” and written by George Bray at Louisiana State University in Baton Rouge.

In Summary

Taken together the two studies show quite convincingly that bariatric surgery (from an earlier posting you may remember that the term “bariatric” comes from the Greek word “baros” which means weight) has a statistically significant effect on mortality from cardiovascular diseases, diabetes, and cancer. The Swedish study had a rather impressive duration of follow-up with a mean of almost 11 years. The data support earlier cross-sectional studies showing clear-cut benefits from bariatric surgery in people with obesity (BMIs over 40 or over 35 with obesity complications).

Any pitfalls?

I was a bit surprised to find that the Swedish study which was a non-randomized longitudinal design showed so many deaths in the surgery group (101 vs. 129 in the controls) and many more deaths from non-typical obesity-related conditions (e.g., accidents, suicide) than the control group. I have no idea what this means. My main concern with the data is that the only way to really tell how much the surgery works and what the non-obesity-related deaths are all about is to have a randomized trial. This would be a study design where potential study volunteers agree to be in a study about bariatric surgery and would agree to be in either the surgery or control group, as determined by a “flip of the coin.” The problem with both the Swedish and Utah studies was that controls were not selected on a randomized basis. Regardless of their limitations, these data are important and support the use of bariatric surgery in selected patients.

We still have much to learn about this subject. I fear that there will be a steady increase in surgery for patients with lower and lower BMIs, where the long-term benefits are unknown. To all you bariatric surgeons out there- temper your enthusiasm with a dose of good judgment in selecting cases.

What Should People With Diabetes Know?

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Background

In my last post, I ranted and raved about an article in the New York Times that tried to document how little information people with diabetes (and maybe their doctors?) have about their condition. In all the excitement, I neglected to outline what I think people with diabetes should know about their diabetes.

Summary of diabetes complications

We can divide diabetes complications into 2 major categories, short-term, and long-term. The short-term problems include hypoglycemia (low blood sugar levels) and keto-acidosis, a condition that mostly affects people with type 1 diabetes and is the result of severe insulin deficiency. This most often occurs in newly-diagnosed cases and in established cases with acute illnesses or other stresses that increase insulin requirements or with poor adherence to the care plan (e.g., missed insulin doses).

The second category, and the one I want to emphasize here includes chronic complications that are specific to diabetes- eye, kidney, and nerve diseases, and those that can also occur in people without diabetes but are more frequent in people with diabetes. These include heart disease, stroke, and peripheral vascular diseases.

Preventing diabetes chronic complications

As I have discussed in an earlier posting, we now understand quite a bit about diabetes complications including how to prevent them. That’s the good news. The bad news is that diabetes chronic complications still occur frequently. Why is that? In my opinion the answer is not a simple one but includes societal barriers to optimal health care (e.g., no insurance, poor insurance, insufficient skilled health-care providers) and poor education of our health-care providers and patients with diabetes. In addition, doing well with diabetes is hard work and even with all the knowledge necessary to do well, it still takes quite an effort to be successful.

A check-list of basic diabetes care requirements

If all people with diabetes had just the most basic of care in monitoring for diabetes complications, we could achieve dramatic improvements in outcomes. This would be nice for the person with diabetes and their loved ones, and for the society which would save big bucks. Experts could disagree with my choices but I can handle the criticism.

1. 2X/year- Medical check-up by a physician or other health-care provider who is up-to-date on managing diabetes. The check-up should include examination of the weight, blood pressure, eyes, and feet. Cardiovascular assessment should include detailed history and examination of the heart and peripheral pulses. Laboratory testing should include hemoglobin A1c testing (a way of assessing blood sugar levels during the previous 2-3 months)

2. 1X/yr- dilated eye examination

3. 1X/yr- kidney protein test (called microalbumin). If + protein, measure serum creatinine

4. 1X/2yr- fasting lipid profile (triglycerides, LDL- and HDL-cholesterol and total cholesterol (more frequently if being treated with lipid-lowering agents)

5. ECG and/or other cardiac testing- frequency depends on clinical situation and risk factors (e.g., hypertension, pooly-controlled blood sugars long-term, hyperlipidemia, previous heart attack, angina, stroke)

That’s the list. It’s not very complicated but obviously many people with diabetes do not get these very basic assessments as needed. Of course, just doing the tests is not enough. People with diabetes and their health-care providers need to understand what the test results mean and what to do about the infomation. Once a person is diagnosed as having diabetes, it should be virtually automatic that we teach the patient what they need to know and set up the monitoring plan. Remember, we really do know how to prevent diabetes conmplications.

Alota Gina Kolata: Should Ms. Kolata Do Her Homework Better In Reporting Diabetes News?

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Background

Today there were several articles in the New York Times (Monday, August 20, 2007) that had to do with treatment of diabetes in the U.S. Gina Kolata authored 3 of the articles, including one on the front page of the newspaper entitled “Looking Past Blood Sugar To Survive With Diabetes.” The gist of the articles was to emphasize in fairly dramatic fashion that patients with diabetes need to be concerned about complication risk factors beyond blood sugar levels. Ms. Kolata profiled Dave Smith, a 43-year-old pastor from Minnesota who was diagnosed with type 2 diabetes about 9 years ago. Apparently, Pastor Smith had a heart attack last October and was surprised to learn that diabetes is a well-known risk factor for heart disease. The article went on to document how poorly people, and presumably their health-care providers, understand diabetes complications risk factors.

What’s my gripe?

Ms. Kolata did interview a number of very smart diabetes specialists all of whom addressed the issue of diabetes complications risk factors beyond blood sugar levels (mostly blood lipid levels and blood pressure levels). So what’s my problem? Answer: scientists have known about these risk factors for quite some time and the fact that so many people apparently are clueless about them is disturbing. Is it patients with diabetes who have been taught about these risks but have ignored or forgotten them? Is it physicians who have never been taught about these risks or who have ignored or forgotten them? Is it a health-care system that creates barriers to optimal diabetes care?

What can we learn from Kaiser-Permanente?

Kaiser-Permanente is a large HMO which years ago learned that comprehensive care of people with chronic diseases was good for business and good for patients. They have devoted considerable resources to managing certain chronic diseases including cancer, heart disease, and diabetes. I do not know all the details but their outcomes data for diabetes are dramatically better than the national average. I can assure you that the Kaiser care-givers are well-aware that diabetes complications are strongly related to blood sugars, lipids (e.g., cholesterol levels), and blood pressure and do their best to decrease risks. So what’s wrong with the rest of us? Is it our lousy health-care delivery system? I don’t know the answer but I would have liked Ms. Kolata to have focused on the failures of our health-care delivery system. We do how to prevent diabetes complications, including heart disease. There is no new medical news here. Clearly, we need to do better. I am skeptical that we can achieve meaningful gains unless we invest in major changes to our health-care delivery system. Certainly the people at Kaiser have taught us that.

Last but not least

In ending this little critique I want to be certain that readers of the New York Times pieces today are not misled in thinking that blood sugar levels are not all that important risk predictors for diabetes complications. Nothing is further from the truth. It is true that the Diabetes Control and Complications Trial (DCCT) follow-up data did not show for many years (2006) that blood sugar levels were important risk factors for cardiovascular disease; links between blood sugar levels and eye, kidney, and nerve disease were shown in 1993. The fact that it took a long time for the data to achieve statistical significance was to a great extent related to the fact that patients at onset of the study in 1983 were relatively young (13-39 years of age), had diabetes of short duration, and were free from heart disease and hypertension. As noted in one of Ms. Kolata’s articles, the links between hypertension and lipid abnormalities and heart disease in patients with type 2 diabetes were established in 1998 with publication of the United Kingdom Prospective Diabetes Study (UKPDS).

So, it is now well-established that blood sugar control, lipids, and blood pressure are the key risk factors for complications in patients with either type 1 or type 2 diabetes. The good news is that these risk factors can all be treated, thereby greatly diminishing risks for development of these serious complications. As I recall it is 2007, and in my opinion, any physician who does not know this information should not be caring for people with diabetes.

I’m feeling a little guilty.  Maybe I should not have been so critical of Ms. Kolata’s articles.  After all she did document nicely our rather astonishingly poor approach to managing diabetes in the U.S.  I only wish she would have put much more emphasis on what we already know about managing diabetes and raising questions about why we are doing such a poor job in caring for people with diabetes.l