Editorials - November 1, 1999 - American Academy of Family Physicians

Editorials

The Costs of Helping Patients with Type 1 Diabetes Achieve Tight Control

JIM NUOVO, M.D.
University of California, Davis, School of Medicine
Davis, California
JENNIFER NUOVO, M.D.
MedClinic
Sacramento, California

See article in this issue.

The management of patients with type 1 diabetes mellitus (formerly known as juvenile-onset or insulin-dependent diabetes mellitus) poses a number of challenges to the practicing physician. These challenges include helping patients maintain optimal blood glucose control, implementing a monitoring schedule to screen for micro- and macrovascular complications, providing primary and secondary interventions to prevent or ameliorate these complications, and screening for and managing comorbid conditions (e.g., hypertension and hyperlipidemia). Reasonable targets for tight control have been defined as a mean blood glucose level of 155 mg per dL (8.6 mmol per L) and a glycosylated hemoglobin (HbA_1c) level of approximately 7 percent.¹An important question is whether the efforts necessary to achieve tight control are worthwhile.

The Diabetes Control and Complications Trial (DCCT)² was a landmark multicenter trial designed to assess the impact of tight blood glucose control on patients with type 1 diabetes. The study included two groups of patients: the first group was treated conventionally (typically a two-injections-daily regimen of short- and intermediate-acting insulin). The second group was treated with an intensive multi-injection or pump regimen that used a multidisciplinary health care team to help the patient achieve tighter control.

The significant finding of the DCCT² was that, while normalization of glucose values (HbA_1c level less than 6 percent) was not achieved in the intensively treated cohort over the seven-year study period, a 60 percent reduction was achieved in the development of diabetic retinopathy, nephropathy and neuropathy. This benefit was achieved most dramatically in patients who could achieve and maintain a HbA_1c level of approximately 7 percent, which, while not normal, was adequate for the reduction of complications.^2,3

In this issue of American Family Physician, Havas⁴ presents a summary of patient-centered educational guidelines to help patients achieve tight control. These guidelines are based on the author's unique experience as an internist, a subspecialist in preventive medicine, and a patient with diabetes who has practiced tight control for more than 40 years. We agree with the author that the special relationship between the family physician and the patient is integral to achieving optimal control. However, to meet the challenge of providing services that patients need to achieve such control, the physician is likely to require assistance from outside providers. We endorse the statement from the American Diabetes Association¹ that "people with diabetes should receive their treatment and care from a physician-coordinated team. Such teams include, but are not limited to, physicians, nurses, dietitians, and mental health professionals with expertise and a special interest in diabetes."

The time commitment and the expertise needed to help a patient achieve tight control can be considerable. For example, in the DCCT study,² the patient population was young, relatively healthy and highly motivated. The professional personnel conducting the study included endocrinologists, diabetes educators, dietitians and social workers. The intensive-treatment group received far more attention and medical services than are routinely available in clinical practice. In our opinion, a successful intensive regimen will require a highly motivated patient using the resources available from a family physician, diabetes educator, dietitian, social worker and, occasionally, a psychologist. The "diabetes team" ideally includes an endocrinologist serving as consultant to the family physician and providing ongoing education to other members of the team.

Tight glucose control has an associated high monetary cost. Appointments with a nurse educator and nutritionist are typically poorly reimbursed by traditional fee-for-service insurance. The costs of nonphysician personnel under capitation are closely watched and often considered unnecessary. This, along with the added supply costs (e.g., additional glucose strips that cost 75 cents each and are used multiple times a day), may result in an expense to the patient that is burdensome.

We feel that the genuine risks of tight control are understated. Tight control of blood glucose can be inconvenient and occasionally dangerous.³ The major danger is hypoglycemia. Serious hypoglycemia may result in altered consciousness, coma or convulsions resulting in injury to the patient or others. Hypoglycemia contributing to a motor vehicle collision typically results in forfeiture of the patient's driver's license. Older patients with macrovascular disease may be vulnerable to an ischemic event (myocardial infarction or stroke) as the result of the hypoglycemic event. Tight control should not be attempted by patients who are unable or unwilling to participate actively in their glucose management.³

As described by Havas,⁴ the risk of hypoglycemia is clearly reduced by frequent monitoring of blood glucose levels, adjustments in insulin dosing, alterations in timing and content of meals, and change in activity patterns. Even with these behavior modifications, episodes of severe hypoglycemia may occur. In a study by Clarke and colleagues⁵ involving 93 adults with type 1 diabetes, patients with a history of episodes of severe hypoglycemia did not show objective evidence of managing their diabetes differently from those without a history of hypoglycemic episodes. Specifically, when low blood glucose levels occurred, the preceding management behaviors were not different. Again, it is our opinion that an understanding of these issues will require comprehensive "team" management.

In summary, we share the goals of providing family physicians with practical information needed to help patients achieve optimal control. Improvement in control sustained over many years has been associated with striking reductions in rates of complications associated with diabetes. It is important that family physicians stay actively involved with their patients with type 1 diabetes and maintain an optimistic outlook that these patients can achieve better control. It is also important that the patient share this belief. However, the treatment plan must include all of the financial and time costs to the patient and the physician that are associated with this endeavor, as well as considering the resources necessary to reach the objective and the potential risks of tight control.

Dr. Jim Nuovo is an associate professor in the Department of Family and Community Medicine at the University of California, Davis, Medical Center. He is an assistant editor of American Family Physician. Dr. Jennifer Nuovo is an endocrinologist and director of the Diabetes Care Team for the MedClinic of Sacramento.

Address correspondence to Jim Nuovo, M.D., Department of Family and Community Medicine, Davis, Medical Center, 4869 Y St., Sacramento, CA 95817.

REFERENCES

Standards of medical care for patients with diabetes mellitus. From American Diabetes Association: clinical practice recommendations 1999. Diab Care 1999;22:S32-41.

The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993;329:977-86.

Implications of the diabetes control and complications trial. From American Diabetes Association: clinical practice recommendations 1999. Diab Care 1999;22:S24-6.

Havas S. Educational guidelines for achieving tight control and minimizing complications of type 1 diabetes. Am Fam Physician 1999;60:1985-98.

Clarke WL, Cox DJ, Gonder-Frederick L, Julian D, Kovatchesv B, Young-Hyman D. Biopsychobehavioral model of risk of severe hypoglycemia. Self-management behaviors. Diab Care 1999;22: 580-4.

Influenza Vaccine for Adults 50 to 64 Years of Age

RICHARD CLOVER, M.D.
University of Louisville School of Medicine
Louisville, Kentucky

See article in this issue.

Influenza continues to be a major cause of morbidity and mortality in the United States. Each year, approximately 20,000 deaths and 110,000 hospitalizations occur because of influenza.¹Rates of infection are highest in children, but rates of serious morbidity and mortality are highest in persons 65 years of age or older and in persons who have medical conditions that place them at high risk for serious complications from influenza.

Rates of influenza-associated hospitalization are lowest in young adults, but rates of influenza-associated hospitalizations begin increasing in adults who are about 45 years of age with high-risk conditions. Among those persons with high-risk conditions, the rate of hospitalization associated with influenza is approximately 40 to 60 per 100,000 population in those who are 15 to 44 years of age, compared with a rate of approximately 80 to 400 per 100,000 population in those who are 45 to 64 years of age. In all persons 65 years of age or older, influenza-associated hospitalization rates have ranged from approximately 200 to more than 1,000 per 100,000 population.¹

The proportion of persons 65 years of age or older who have received the influenza vaccine increased from 33 percent in 1989 to 65.5 percent in 1997.^1,2Among persons less than 65 years of age who are at high risk for influenza-related complications, vaccination rates are less than 30 percent.³ Increasing vaccination coverage among these high-risk groups is the highest priority for expanding influenza vaccine use.

As indicated in Zimmerman's article⁴ in this issue of American Family Physician, the American Academy of Family Physicians (AAFP) has made an aggressive move by lowering the age of universal influenza vaccination to 50 years. Zimmerman refers to the 1995 National Health Interview Survey data that indicate the rate of vaccination is only 38 percent in persons 50 to 65 years of age who are at risk for complications of influenza.³ He argues that this low rate is in part caused by the difficulty in identifying persons who are at risk for complications of influenza, either because the persons are unaware they have a high-risk condition or because the clinician has difficulty in implementing an adequate manual or computerized reminder system based on high-risk conditions. He further acknowledges the limited success of other vaccination strategies for other high-risk groups.⁴

The assumptions that Zimmerman⁴ has made about the factors that contribute to the low vaccination rate in adults 50 to 64 years of age should be addressed. Because many medical organizations are recommending that all adults be evaluated at age 50 for a variety of diseases and preventive interventions, why are patients not being made aware of high-risk conditions that they have? If those patients are simply not seeking health care, is it logical to assume that they will just have an influenza immunization?

The implementation of a reminder system based on risk conditions has its difficulties. The cost of personnel for risk assessment and the cost of telephone or mail reminder systems may not be recovered from charges associated with vaccination. Electronic reminder systems can be readily programmed, but they also have costs associated with them. How to underwrite these costs becomes an issue. However, in an era of managed care, should insurance companies partner with physicians in developing programs that would identify persons with high-risk conditions, because the literature clearly shows a cost savings with influenza vaccination?

When a shift in strategy occurs from vaccinating primarily those who are at greatest risk from complications of influenza to include otherwise healthy adults, then the cost-benefit of this strategy also needs to be closely examined. Although Nichol and colleagues⁵ have shown cost savings from vaccinating working adults against influenza, the magnitude of this benefit relies on a close antigenic match between the circulating influenza strain and the influenza vaccine strain and a relative high attack rate of influenza infection.⁶ Furthermore, most of the cost savings associated with vaccination was in avoiding lost wages and not in direct cost savings.⁵

Despite these questions and comments, Zimmerman⁴ and the AAFP make a solid argument for vaccinating all adults 50 to 64 years of age. However, physicians should not forget there are persons in all age groups with indications to receive the influenza vaccine, either because they have a medical condition that places them at high risk of complication from influenza or because they are at risk of transmitting influenza to those who are at high risk. Physicians, therefore, still must develop a mechanism to identify these persons so that they may benefit from the vaccine.

Dr. Richard Clover is a professor and chair of the Department of Family and Community Medicine and Associate Vice President for Health Affairs/ Health Informatics at the Univversity of Louisville School of Medicine.

Address correspondence to Richard Clover, M.D., Department of Family and Community Medicine, University of Louisville School of Medicine, Louisville, KY 40292.

REFERENCES

Centers for Disease Control and Prevention. Prevention and Control of Influenza. MMWR Morb Mortal Wkly Rep 1999;48:(RR4).

Centers for Disease Control and Prevention. Influenza and pneumococcal vaccination levels among adults aged >65 years. MMWR Morb Mortal Wkly Rep 1998;47:797-802.

Walker FJ, Singleton JA, Greby SM, Strikas RA. Influenza and pneumococcal vaccination of adults aged 18-64 years, United States, 1995 [abstract]. In: Abstracts of the 33rd National Immunization Conference. Atlanta, GA: Centers for Disease Control and Prevention, 1999 (in press).

Zimmerman RK. Lowering the age for routine influenza vaccination to age 50 Years. Am Fam Physician 1999;60:2061-70.

Nichol KL, Lind A, Margolis KL, Murdoch M, McFadden R, Hauge M, et al. The effectiveness of vaccination against influenza in healthy, working adults. N Engl J Med 1995;333:889-93.

Patriarca PA, Strikas RA. Influenza vaccine for healthy adults? [Editorial]. N Engl J Med 1995;333: 933-4

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