Poor Control-Whose Fault?

by Ronald Chusid, D.O.

It is common for physicians to blame their patients for not keeping their sugars under control. Speaking with diabetics about their care often provides a different story, as many complain that their doctor doesn't take their elevated sugars seriously. Several studies have been performed on the effectiveness of the medical profession in dealing with chronic diseases such as diabetes, and have demonstrated that the lack of control is frequently the fault of the medical community rather than the patients. Besides reviewing articles on care of diabetics, I have extended this to include hypertension and hyperlipidemia. They were included because:

A study performed at the University of Michigan between 1988 and 1994 (published in the Annals of Internal Medicine in early 1996) found that "most community-based patients with NIDDM are not aggressively managed because of attitudinal, educational, and systemic factors that act as barriers to optimal health care delivery." They found that diabetics often receive too few physician visits and insufficient education. In discussing this problem, they concluded that:

The asymptomatic character and long latent period between onset of hyperglycemia and overt diabetic complications have apparently resulted in perceiving NIDDM as a mild illness, largely attributable to lifestyle factors that many physicians believe patients will be unwilling to modify substantially. Patients are told that they have a "touch of sugar" and that they should "watch their diet" and "lose some weight." The confused patient alternates between taking comfort in the physician's description of the mild character of the condition and feelings of guilt that they are not taking care of themselves properly. The sustained, conscientious effort required, both by physician and patient, to treat NIDDM intensively is not motivated in this setting.

The authors proceed to chastise physicians for not understanding the genetic basis for obesity resulting in blaming the patient for conditions which may be beyond their control.

Reports on hypertension are similar. The Cardiovascular Institute of the South published The First National Hypertension Report Card, compiled by a panel representing eight medical groups in 1996. They found that "only 35 percent of those suffering hypertension are aware that they have it; only 49 percent of those diagnosed with high blood pressure are being treated for it; and only 21 percent of the nation's hypertension victims are controlling the condition."

The results on treatment of hyperlipidemia are no better. A study published earlier in 1997 in the Journal of the American College of Cardiology found that "despite national campaigns on the importance of periodically screening adults for high cholesterol, many doctors are not performing routine checks . . . In addition, many physicians are not appropriately treating people with high cholesterol."

The Journal of the American Medical Association published an article soon afterwards which confirms previous findings showing that women, as well as men, need to receive better treatment for high cholesterol. "Not only are physicians not prescribing these medications frequently enough, they are also dropping the ball by not treating to goal." The lack of proper treatment for hyperlipidemia is disappointing in light of studies such as those cited by the American Diabetes Association in April showing that use of cholesterol-lowering drugs reduces heart attacks in diabetics by 55 percent.

With this failure of conventional medicine to provide proper treatment for these "silent killers," many have hoped that Managed Care might make a difference. This was studied in the same issue of the Annals of Internal Medicine quoted at the beginning of this article. They concluded "that although managed care organizations have the potential to provide excellent care for diabetic persons, little evidence exists that they have improved either the quality or the cost-effectiveness of diabetes care."

Another recent study, Health Outcomes for Chronically Ill Seniors Treated in HMO and Fee-for-Service Systems: Results from the Medical Outcomes Study, examined outcomes of two thousand chronically ill patients. The study compared patients treated by HMO's and traditional fee-for-service (FFS) plans over a four-year period (1986 through 1990). Seniors under Medicare had worse outcomes in HMO's than in fee-for-service plans. They were twice as likely to show deterioration in their health in HMO's than in fee-for-service plans. For seniors who also were poor, the difference in outcomes was even larger (68% worsened in HMO's compared to 27% in a traditional FFS plan). Poor patients in ill health also were better off in traditional fee-for-service plans, with 57% showing improvement in FFS plans versus 22% in HMO's. The study also revealed that physical health was much less stable over time for elderly patients in HMO's compared to those in FFS.

The American Association of Clinical Endocrinologists (AACE) reported in June that most of the 16 million Americans with diabetes are not receiving sufficient preventive care. Showing concern with limitations in care imposed by HMO's, they announced a national effort to persuade managed care companies to provide greater access to medical services. "Managed care must commit to preventive care," said Dr. Stanley Feld, a former AACE president."Ironically, too many people with diabetes are needlessly suffering expensive complications from their disease even though managed care is supposed to emphasize prevention," said Dr. Feld.

With medical systems failing to provide adequate medical care for chronic conditions such as diabetes, hypertension, and hyperlipidemia, it is necessary for people with these problems to vigilantly monitor the course of their diseases, and the treatment they are receiving. Tips for such monitoring will be discussed in upcoming articles on this site.

Dr. Chusid has practiced Internal Medicine in Muskegon since 1985, and has held positions including Chairman of the Department of Medicine and Chairman of the Critical Care Committee at Muskegon General Hospital. He is also an Assistant Clinical Professor of Medicine at Michigan State University, Medical Director of IHS Home Care, and a member of the Council on Complications of the American Diabetes Association. His office is located at 1762 E. Oak Avenue, Muskegon, Michigan. Phone (616) 773-3258.

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