Questioning Diabetes Standards of Care

Hey, All — if you’ve got questions about life with diabetes, then you’ve come to the right location! That would be our weekly diabetes advice column, Ask D’Mine, hosted by veteran type 1, diabetes author and clinical specialist Wil Dubois.

This week, Wil responds to a question about all those “standards” set by healthcare professionals concerning how we ought to be tackling our diabetes therapy. No real surprise that Wil has any pointed remarks on that!

Dan, type 1 in Washington, writes: Every time I visit the doctor they always state to me that the insurance provider gets on them whenever they do not put a type 1 diabetic on a statin and a blood pressure pill. However, as a patient, I don’t take pills for prevention of illness till I could find proof, beyond a reasonable doubt, that the pill is effective rather than dangerous. That is, I do not have kidney disease and I do not have cardiovascular disease. I do not have high blood pressure. I have type 1 diabetes (35 years) and that’s it. By the way, my A1C is obviously around 5.5.   My cholesterol is 200 and LDL is 125 and HDL 60.

Once I review the research, there is only marginal improvement in choosing a statin (that is, it requires 100 individuals to be treated to prevent 1 heart attack), if you believe the studies all done and paid for by the drug companies that make this material. In addition, the Framingham Heart Study revealed over half those who had a cardiac event had NORMAL cholesterol levels.

Why are we type 1 diabetics told that no matter what, you need to take this? I am tired of these doctors acting like I have a disorder I do not have and telling me concerning insurance companies and how they get in trouble. And I am rational: I had an advanced cholesterol evaluation done that even shmade my LDL is the massive fluffy kind (pattern A) rather than the small dense LDL (pattern B). Nevertheless, I get plagued every time I see my general practitioner along with my endocrinologist.   Is all this really going on (insurance firms pressuring doctors to carpet bomb all type 1 diabetics using statins and blood pressure pills in the lack of clear cut research, replicated a few times, demonstrating benefit)?   I am tired of being treated for a disease I don’t have by tablets with marginal proof they actually prevent anything.   

Wil@Ask D’Mine replies: Confession: I’m a heretic.

Obviously, I was not always a heretic. I used to be a True Believer. A believer in the criteria of care. I believed that wiser people than me, with scientific evidence, had closely created diabetes therapy algorithms that could assure long life, happiness and health. All I had to do was follow the rules.

I’m not sure when I began losing my diabetes care religion. It came in baby steps. But I believe the very first thing was baby aspirin. Once I was diagnosed, I had been set on a statin, an ACE, and a baby aspirin. All standards of care. When I began working in diabetes therapy, one of my jobs was to ensure those damned noncompliant diabetics shot their statins, ACEs, and aspirins.

Like any fantastic zealot, I strongly urged for the trio. I put a fantastic example by taking them myself, even though I didn’t desire them , and urged, cajoled, and begged my patients to do exactly the same. I even created a adorable visual aid by means of a toy medieval armor place where sword had been diabetes meds, so the statin was the breastplate, the ACE was the protector, and the baby aspirin was the helmet.

And one day the high priests said, “Uh… never mind about that whole aspirin thing we have been pushing on you for a long time. Turns out it doesn’t help. Our bad. But keep taking all the other stuff we told you to take.”

And the real Believer entertained his very first uncertainty.

Time, wind, and rain erode mountains. The more I worked in the field, the more fallible I understood the priesthood was. The standards of care weren’t carved in rock. They were made of Playdough. Each year they shifted. Part of this was the fact that understanding changes, but what I came to understand was that there was more politics than science involved with setting criteria.  

Speaking of science, I think I completely lost my religion when I was involved in a university “scientific” research that allow me see up close and personal how badly conducted these analyses could be. The lead investigator ran out of time, but needed a certain on-going volume of published works for job safety in the dog-eat-dog academic world. Exhausted and dreading occupational effects, this individual simply fudged the missing data.

I was horrified. Appalled. Knowledge was not the goal. Successful publication was.

Heresy EverywhereBut I still half-heartily peddled the standard drugs on the job. It had been in my job description, even though it wasn’t any more in my heart. Ironically, I even continued taking them myself , more out of habit than anything else. Then, worn down and worn myself out, 1 day I had a hissy fit and stopped taking all my drugs — even vitamins — except for my insulin along with my thyroid tablet.

Within days I felt 100 percent better. Ten years younger.

Officially, I’m still supposed to advocate for the criteria. I mention what the criteria are, and how they’re created, but I do not expend much energy.

And the play armor is no more in my office.

Do the insurance companies trouble us for our lackluster application of standards of care? This depends on how you define “hassle.” Historically we get quarterly letters listing their members who do not seem to be toeing the line when it comes to criteria, but that is about it.

However, the times they are a’changin’. These schizophrenic insurance companies that won’t pay for test strips are beginning to put their money where the criteria are. More importantly, docs have been bribed to ensure that their diabetes patients fulfill the criteria. If their diabetes patients behave, docs qualify for incentives. As in additional cold, hard cash incentives.

Later on, things seem grimmer.

We’re in a significant state of turmoil in health care, and a version for the long run that gets kicked around a lot is pay for performance. Whether this model is widely adopted, docs wouldn’t be paid for what that they do, but instead they would be paid for what you do. They will be penalized if you do not toe the line.

I can see a world in which non-compliant diabetics like you and me will probably be discharged from care because doctors won’t be able to be compensated for taking care of us. No matter how healthy we are.

Then what? Well, there may come a day after, so as to keep your health policy, you may have to fill the prescriptions to the criteria and create the copay. But in the solitude of your bathroom, nobody will know whether you take the pill flush it down the toilet.

Obviously, I never said that, also will deny stating it if requested. This column will probably self-destruct in five seconds.

Meanwhile, calmly and logically explain to your team how you feel, and request that they stop hassling you. When they don’t, for the time being, you have the choice of shopping around. Healthcare remains a consumer marketplace. You’re the customer.

Locate someone who’s still selling the kind of health care you want.

This is not a medical advice column. We are PWDs publicly and publicly sharing the wisdom of our collected experiences — our been-there-done-that understanding in the trenches. But we are not MDs, RNs, NPs, PAs, CDEs, or partridges in pear trees. Bottom line: we are just a small portion of your whole prescription. You still require the expert guidance, therapy, and care of a licensed medical practitioner.


Disclaimer: Content created by the Diabetes Mine team. For more details click here.


This content is created for Diabetes Mine, a customer health blog focused on the diabetes community. The content is not medically reviewed and doesn’t stick to Healthline’s editorial instructions. For more information about Healthline’s venture with Diabetes Mine, please click here.

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