Diabetes in America: Research Proposal
Given the recognition and on-going research into the disease of diabetes, there has probably been thousands and perhaps millions of books and articles written on the subject. The most commonly recognized types are type 1 and types 2 diabetes, but others include gestational, monogeneic, and cystic-fibrosis related diabetes (NIDDK, 2017). It is impossible to determine how many people in the world have diabetes or how many will develop it. The estimates of the amount of money spent in patient care and research are only guesses, and the suffering by diabetes and their loved ones is incalculable. However, this paper will provide a brief overview of the available information and relate it to the application for current practice in the United States.
Current situation and practice application
The office manager of a primary care office consisting of three physicians is concerned regarding new managed care guidelines concerning diabetic patients. The guidelines state that 90 percent of the diabetic patients for each provider must now have documented quarterly visits with the hemoglobin A1c marker less than or equal to 7 twice a year. Although the office is independently billed, it is loosely associated with other offices in an attempt to create economy in reimbursement scale. In addition 90 percent of the diabetic patients must demonstrated blood pressure readings of 140/90 or less at each visit. Potential penalties of 10 percent reimbursement reductions would account for a $4 million annual loss in revenue. Currently, the office has a rate of no-shows for appointments at 7 percent, an average A1c value of 9.4, and average blood pressure of 145/97. It is vital to the financial success of the clinic to increase patient compliance with healthcare recommendations and keeping appointments for office visits.
The Disease of Diabetes
In a diabetic patient, a shortage of insulin produced causes high blood glucose levels (NIDDK, 2017). Symptoms of type 1 diabetes include blurred vision, delayed healing of sores, hand or feet tingling or numbness, unexplained weight loss, and increased thirst, urine production, and hunger. The same symptoms may develop less slowly in type 2 diabetics, if at all. Genetics, diseases such as Cushing’s syndrome, pancreatic damage, viruses, reactions to some types of medication, obesity, and ethnicity may contribute of the development of diabetes. As one of the leading causes of premature mortality and morbidity around the world, the epidemic of type 2 diabetic patients develop vascular complications; diabetic neuropathy leading to possible limb amputation affects as many as half of diabetic patients, diabetic retinopathy is the leading cause of blindness in adults ages 20 to 74 years, and diabetic nephropathy is the leading cause of chronic kidney disease and affects 40 percent of type 2 diabetic patients (Pratley, 2013).
As of 2014, there were 29.1 million diabetic patients in the United States and one-fourth of these people are unaware they have the disease (NIDDK, 2017). It is believed 86 million people in America over the age of 20 years are pre-diabetic. The economic impact on the country’s healthcare system is staggering. The American Diabetes Association estimated in 2013 that the cost of treating diagnosed diabetes rose from $174 billion in 2007 to $245 billion in 2012; this is a 41 percent increase over five years (Diabetes.org., 2017). The figures don’t include the pain, suffering, and loss of wages for family caregivers.
Diabetic Monitoring and Organizational Guidelines for Control
It is essential for type 1 diabetes to adhere religiously to an insulin regimen (CDC.gov., 2017; Diabetes.org., 2017; NHLBI.gov., 2017; NIDDK, 2017). Other oral medications, exercise, and healthy diets also assist in keeping blood glucose levels within acceptable ranges. A team of healthcare professionals assist in management of diabetes to promote the best possible treatment outcomes. Glucose monitoring is accomplished with finger sticks or urine strips, or continuous glucose monitoring systems may be put in place for a few days to a week and then replaced (NIDDK, 2017). The CDC recommends placing medications and glucose testing supplies in an emergency kit in the case patients are required to leave the home unexpectedly (CDC.gov., 2017).
Increasing Patient Compliance
A definition for compliance may be simply following the treatment regimen recommended by the healthcare provider (Chatterjee, 2006). Compliance is needed to keep control of costs, promote quality of care, and provide for reliable research conclusions. A diagnosis of diabetes is a life-long, chronic illness with many potential debilitating and life-threatening complications. While rates of non-compliance are inconsistent, it is felt that between 50 percent and 80 percent of diabetic patients do not adhere to treatment recommendations. An estimate of the national cost savings by increasing the number of compliant diabetic patients in the United States is almost $8.1 billion annually (Koçkaya & Wertheimer, 2011). Expenditures include medications, hospital visits, clinic checkups, and complications of the disease such as cardiovascular degeneration (Chatterjee, 2006). Lack of compliance also reduces the value of usefulness of research studies.
Patient adherence includes following the recommendations for a diabetic regimen of medications, urine and blood testing, office visits, foot care, blood pressure monitoring, diet, and exercise (Sokol, McGuigan, Verbrugge, & Epstein, 2005). However, the degrees of compliance are significantly influenced by factors such as age, gender, socioeconomic status, degree of education, type of diabetes, and if the patient is newly diagnosed. While diabetic medications may appear to be expensive, the amount saved in reduced disease-related costs is much larger for compliant patients.
The trend for payers is to change to reimbursement based on outcomes (Page, 2014). When doctors have high numbers of noncompliant patients, they will see a decrease in income. Noncompliant patients require more treatment and the payers want to take the additional expenses from the physicians. Post-fee-for-service places physicians in a place where they are under more pressure for patient compliance, which can be difficult to impossible. Some doctors are in favor of higher premiums or cash payment for noncompliant patients, or even removing them from their care.
There is no one intervention for promotion of patient compliance (Martin, Williams, Haskard, & DiMatteo, 2005). It is first necessary to determine the degree of adherence by the patient and in what areas. The concept of patient-centered treatment promotes strong communication between the patient and healthcare providers to provide a two-way interaction of what is important to everyone concerned and why. Teaching patients the importance of adherence to physician recommended diabetic programs in long-term benefits may also increase compliance. In order to address all the aspects of diabetic treatment and the importance of patient compliance, it is necessary for physicians and staff members to keep current on the issues (Diabetes.org). In addition to the doctor, nurse educators, and dieticians should have regular inservice training on specific patients and diabetes in general. In addition, diabetic patients may come into contact with diabetes educators, ophthalmologists, endocrinologists, social workers, psychologists or psychiatrists, podiatrists, pharmacologists, and other specialists.
References
Aggarwal, I. (2015). The Epidemiology, Pathogenesis, and Treatment of Type 1 Diabetes Mellitus. Inquiries Journal, 7(11), 1-2. Retrieved from http://www.inquiriesjournal.com/articles/1313/the-epidemiology-pathogenesis-and- treatment-of-type-1-diabetes-mellitus
CDC.gov. (2014). 2014 Statistics Report | Data & Statistics | Diabetes | CDC. Cdc.gov. Retrieved 26 January 2017, from https://www.cdc.gov/diabetes/data/statistics/2014StatisticsReport.html
Chatterjee, J. (2006). From compliance to concordance in diabetes. Journal of Medical Ethics, 32(9), 507-510. http://dx.doi.org/10.1136/jme.2005.012138
Diabetes.org. (2017). The Cost of Diabetes. American Diabetes Association. Retrieved 26 January 2017, from http://www.diabetes.org/advocacy/news-events/cost-of- diabetes.html?referrer=https://www.google.com/
Koçkaya, G. & Wertheimer, A. (2011). Can We Reduce the Cost of Illness with More Compliant Patients? An Estimation of the Effect of 100% Compliance with Hypertension Treatment. Journal of Pharmacy Practice, 24(3), 345-350. http://dx.doi.org/10.1177/0897190010389336
Martin, L., Williams, S., Haskard, K., & DiMatteo, M. (2005). The challenge of patient adherence. Therapeutic Clinical Risk Management, 1(2), 189–199. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1661624/#b35
NHLBI.gov. (2017). What Is Diabetic Heart Disease? - NHLBI, NIH. Nhlbi.nih.gov. Retrieved 26 January 2017, from https://www.nhlbi.nih.gov/health/health-topics/topics/dhd
Page, L. (2014). Why Should Your Noncompliance Harm My Income? Medscape.com. Retrieved 27 January 2017, from http://www.medscape.com/features/content/6006314
Pratley, R. (2013). The Early Treatment of Type 2 Diabetes. The American Journal of Medicine, 126(9), S2-S9. http://dx.doi.org/10.1016/j.amjmed.2013.06.007
Sokol, M., McGuigan, K., Verbrugge, R., & Epstein, R. (2005). Impact of Medication Adherence on Hospitalization Risk and Healthcare Cost. Medical Care, 43(6), 521-530. http://dx.doi.org/10.1097/01.mlr.0000163641.86870.af
