Confounding Factors Impacting Diabetes Care

FEBRUARY 12, 2018


Troy Trygstad, PharmD, MBA, PhD; Dhiren Patel, PharmD; Steven Peskin, MD, MBA; Richard Wynn, MD; and Tripp Logan, PharmD, discuss the various comorbidities affecting diabetes care and the impact that financial concerns can have on patient decision making.

Troy Trygstad, PharmD, MBA, PhD: Now, I want to get into this discussion on the challenges, or barriers, of taking care of patients with diabetes. Everybody on the panel practices. Give me your best example of a patient where the chief complaint was diabetes management and you ended up finding yourself in a circumstance where it was absolutely essential for you to treat the comorbid condition in order for the diabetes to be treated. Dhiren?

Dhiren Patel, PharmD: Sure. I think I’m going to piggyback off of what you were just saying. I think the biggest one that I see, at my institution, is depression. We have done our own projects and pilots where we’ve looked at, if the depression is poorly controlled—just because of the patient population that I work with—the level of PTSD is really high. The same thing goes for depression. And so, we work closely with those colleagues. It doesn’t matter. I could prescribe the best drug out there that has low hypoglycemia rates, no weight gain, and cardiovascular data, and this data, but at the end of the day if I don’t solve that underlying problem that they might be housing—and it might be something else, like financial resources—it’s not going to be effective. In our patient population that has the underlying depression, we probably try to take care of that first, before we even try to pitch any type of care plan or any advice that we might have.

Troy Trygstad, PharmD, MBA, PhD: So, it’s almost like a rule-out scenario for you? You say, “I need to rule this out, because I know this is going to influence the diabetes. I know that if I end up having to rule it in, now I’ve got a scenario where I’ve got to approach this scenario differently.”

Dhiren Patel, PharmD: Very much so.

Troy Trygstad, PharmD, MBA, PhD: And practice experience.

Steven Peskin, MD, MBA: Yes, sort of. This one is a tough one. The resident came in and said, “Dr. Peskin, we’re doing fine with this person. The hemoglobin A1C is 7.2%. It is below 8%. The blood pressure is 128/73.” The person was known to have high blood pressure. I go into the room. There’s a man there with a below-the-knee amputation. He has a cane because he’s essentially blind. He is about to need to go on dialysis. After we left the room, because I didn’t want to embarrass the resident, I said, “We have failed this person. This person is now not our patient. This is Carlos’ patient.” Carlos retired. He was the head of social services. So, it just left an impression on me—the profound negative consequences of diabetes and its comorbidities. Social services were all that we had to meaningfully offer that patient. All of our interventions to control the disease had been inadequate.

Troy Trygstad, PharmD, MBA, PhD: So, another example is, if the focus is strictly on the pathology, and nothing in or around the pathology, it’s very difficult to change the health trajectory because of the pathology itself.

Dhiren Patel, PharmD: That’s what I always tell residents: “Treat the patient, not the numbers.”

Troy Trygstad, PharmD, MBA, PhD: Practice experience.

Richard Wynn, MD: There are a number of them, but the biggest side effect of a lot of the medications we use now is poverty. It’s people not being able to afford medication. They’re embarrassed to say it, so patients go without. There are patients who get their medications, but they’re depending on food pantries for half of the month. They only get rice. I’ve worked with a lot of immigrant families. I did a talk for a refugee clinic on diabetes, and I realized that I could tell how long each of the people had been here for. They looked like typical people from Southeast Asia when they got here. The longer that they’d been here, they gradually got a big belly and skinny legs; they were eating so much rice. The cheap food is what they could afford. They feel happy to have it. They don’t complain about their diet. They don’t complain about access to food because they’re full of rice. The good and bad is different than what we would expect. But having them understand choices in food and making opportunities to do that is important. I have patients who work marginally at home. They’re not homeless, exactly, but they aren’t secure in their housing. Insulin is not really an option for those people. So, we’ve had to use more oral medications, even for the type 1 diabetics, to manage hyperglycemia because of their circumstances. Just knowing the patient is key.

Troy Trygstad, PharmD, MBA, PhD: There’s a circumstance, perhaps, where the proportion of patients that are affected by inability or financial stressors from access to medications grows, and grows, and grows. You have middle-class middle-income households that struggle.

Tripp Logan, PharmD: Right. We see it in the summer. Here folks are doing really well. Then everything is starting to spike. What’s going on? Well, they hit the donut hole in the Medicare Part D coverage. They were on a fixed income and they were used to predictable payment for that prescription. Then all of a sudden, it goes up. So, that’s the deal.

I’m going to piggyback on this, because we have hosted free diabetes support groups. As a community, we started teaching clinical diabetes classes. We realized that’s not what we needed to be doing. There’s plenty of that out there. A lot of it is, people go home to this environment that is not very diabetes friendly, with respect to holiday meals and all of these things. And so, it helped so much to have people in a room sharing ideas and talking about what dishes they’ve taken to holiday events so that they would have something to eat. And so, I think with the panels of patients that we talk to in these support groups, there really is a benefit. None of this is clinical. It’s just sharing ideas and learning how to live in their household, in their community, and in their family with diabetes.

Richard Wynn, MD: What he said was very important. The pharmacist’s role and the donut hole issue, they need to say, “This patient is approaching ‘this.’ Can we do this?” This would spare them the cost and kill the donut hole. “This product has a plan that will pay for their medications during the donut hole.” We need that kind of feedback, where we realize the patient is getting into trouble or is about to get into a problem.

Troy Trygstad, PharmD, MBA, PhD: To me, that’s a great example of an ongoing living, breathing, dynamic care plan process.

Richard Wynn, MD: Yes.

Troy Trygstad, PharmD, MBA, PhD: That’s what you’re describing. The care plan is much more than just, “You have diabetes of this type. Here’s what the prescribed treatment is.” It’s all of those out in the world, sort of environmental considerations that go with it. It’s not a fixed thing, in time. You’re talking about a moment in time where things might change. Part of the care plan might be, “Hey, we need to check in, mid-summer, with this patient, to see if there’s some affordability issues going on.”

Steven Peskin, MD, MBA: Tripp mentioned holiday meals. Richard mentioned food and security or a diet that’s low cost. So, I will kind of take those together and say that nutrition is an area where we’re not doing a great job. There is ample information to show that we can significantly change the trajectory of diabetes with good nutritional support. Again, it is complicated and nuanced, when you’re talking about people being unable to afford fresh food. Or there are these so-called food deserts. That said, an area where we have a very profound potential impact is nutrition.


 


Troy Trygstad, PharmD, MBA, PhD; Dhiren Patel, PharmD; Steven Peskin, MD, MBA; Richard Wynn, MD; and Tripp Logan, PharmD, discuss the various comorbidities affecting diabetes care and the impact that financial concerns can have on patient decision making.

Troy Trygstad, PharmD, MBA, PhD: Now, I want to get into this discussion on the challenges, or barriers, of taking care of patients with diabetes. Everybody on the panel practices. Give me your best example of a patient where the chief complaint was diabetes management and you ended up finding yourself in a circumstance where it was absolutely essential for you to treat the comorbid condition in order for the diabetes to be treated. Dhiren?

Dhiren Patel, PharmD: Sure. I think I’m going to piggyback off of what you were just saying. I think the biggest one that I see, at my institution, is depression. We have done our own projects and pilots where we’ve looked at, if the depression is poorly controlled—just because of the patient population that I work with—the level of PTSD is really high. The same thing goes for depression. And so, we work closely with those colleagues. It doesn’t matter. I could prescribe the best drug out there that has low hypoglycemia rates, no weight gain, and cardiovascular data, and this data, but at the end of the day if I don’t solve that underlying problem that they might be housing—and it might be something else, like financial resources—it’s not going to be effective. In our patient population that has the underlying depression, we probably try to take care of that first, before we even try to pitch any type of care plan or any advice that we might have.

Troy Trygstad, PharmD, MBA, PhD: So, it’s almost like a rule-out scenario for you? You say, “I need to rule this out, because I know this is going to influence the diabetes. I know that if I end up having to rule it in, now I’ve got a scenario where I’ve got to approach this scenario differently.”

Dhiren Patel, PharmD: Very much so.

Troy Trygstad, PharmD, MBA, PhD: And practice experience.

Steven Peskin, MD, MBA: Yes, sort of. This one is a tough one. The resident came in and said, “Dr. Peskin, we’re doing fine with this person. The hemoglobin A1C is 7.2%. It is below 8%. The blood pressure is 128/73.” The person was known to have high blood pressure. I go into the room. There’s a man there with a below-the-knee amputation. He has a cane because he’s essentially blind. He is about to need to go on dialysis. After we left the room, because I didn’t want to embarrass the resident, I said, “We have failed this person. This person is now not our patient. This is Carlos’ patient.” Carlos retired. He was the head of social services. So, it just left an impression on me—the profound negative consequences of diabetes and its comorbidities. Social services were all that we had to meaningfully offer that patient. All of our interventions to control the disease had been inadequate.

Troy Trygstad, PharmD, MBA, PhD: So, another example is, if the focus is strictly on the pathology, and nothing in or around the pathology, it’s very difficult to change the health trajectory because of the pathology itself.

Dhiren Patel, PharmD: That’s what I always tell residents: “Treat the patient, not the numbers.”

Troy Trygstad, PharmD, MBA, PhD: Practice experience.

Richard Wynn, MD: There are a number of them, but the biggest side effect of a lot of the medications we use now is poverty. It’s people not being able to afford medication. They’re embarrassed to say it, so patients go without. There are patients who get their medications, but they’re depending on food pantries for half of the month. They only get rice. I’ve worked with a lot of immigrant families. I did a talk for a refugee clinic on diabetes, and I realized that I could tell how long each of the people had been here for. They looked like typical people from Southeast Asia when they got here. The longer that they’d been here, they gradually got a big belly and skinny legs; they were eating so much rice. The cheap food is what they could afford. They feel happy to have it. They don’t complain about their diet. They don’t complain about access to food because they’re full of rice. The good and bad is different than what we would expect. But having them understand choices in food and making opportunities to do that is important. I have patients who work marginally at home. They’re not homeless, exactly, but they aren’t secure in their housing. Insulin is not really an option for those people. So, we’ve had to use more oral medications, even for the type 1 diabetics, to manage hyperglycemia because of their circumstances. Just knowing the patient is key.

Troy Trygstad, PharmD, MBA, PhD: There’s a circumstance, perhaps, where the proportion of patients that are affected by inability or financial stressors from access to medications grows, and grows, and grows. You have middle-class middle-income households that struggle.

Tripp Logan, PharmD: Right. We see it in the summer. Here folks are doing really well. Then everything is starting to spike. What’s going on? Well, they hit the donut hole in the Medicare Part D coverage. They were on a fixed income and they were used to predictable payment for that prescription. Then all of a sudden, it goes up. So, that’s the deal.

I’m going to piggyback on this, because we have hosted free diabetes support groups. As a community, we started teaching clinical diabetes classes. We realized that’s not what we needed to be doing. There’s plenty of that out there. A lot of it is, people go home to this environment that is not very diabetes friendly, with respect to holiday meals and all of these things. And so, it helped so much to have people in a room sharing ideas and talking about what dishes they’ve taken to holiday events so that they would have something to eat. And so, I think with the panels of patients that we talk to in these support groups, there really is a benefit. None of this is clinical. It’s just sharing ideas and learning how to live in their household, in their community, and in their family with diabetes.

Richard Wynn, MD: What he said was very important. The pharmacist’s role and the donut hole issue, they need to say, “This patient is approaching ‘this.’ Can we do this?” This would spare them the cost and kill the donut hole. “This product has a plan that will pay for their medications during the donut hole.” We need that kind of feedback, where we realize the patient is getting into trouble or is about to get into a problem.

Troy Trygstad, PharmD, MBA, PhD: To me, that’s a great example of an ongoing living, breathing, dynamic care plan process.

Richard Wynn, MD: Yes.

Troy Trygstad, PharmD, MBA, PhD: That’s what you’re describing. The care plan is much more than just, “You have diabetes of this type. Here’s what the prescribed treatment is.” It’s all of those out in the world, sort of environmental considerations that go with it. It’s not a fixed thing, in time. You’re talking about a moment in time where things might change. Part of the care plan might be, “Hey, we need to check in, mid-summer, with this patient, to see if there’s some affordability issues going on.”

Steven Peskin, MD, MBA: Tripp mentioned holiday meals. Richard mentioned food and security or a diet that’s low cost. So, I will kind of take those together and say that nutrition is an area where we’re not doing a great job. There is ample information to show that we can significantly change the trajectory of diabetes with good nutritional support. Again, it is complicated and nuanced, when you’re talking about people being unable to afford fresh food. Or there are these so-called food deserts. That said, an area where we have a very profound potential impact is nutrition.


 
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