Key words: diabetes, barriers to care, adherence, depression
Diabetes is the most demanding chronic illness. It challenges every fiber of a patient’s body and spirit and demands a system of care that ministers to the biological, social, and psychological aspects of the illness. It takes a “village” to accomplish this task.
Type 2 diabetes mellitus may be the most challenging and frustrating disease faced by primary care clinicians. Excellent evidence exists that reaching goals for hemoglobin A1c (HbA1c), low-density lipoprotein (LDL) cholesterol, and blood pressure significantly reduces diabetic complications1,2 and costs.3 Fortunately, effective therapeutic options are available for reaching these goals. But unfortunately, even with our best efforts, only 48% of patients with diabetes reach goal for HbA1c and only 33% for LDL and blood pressure; only 7% achieve all 3 goals concurrently.4
Diabetes is also a significant challenge and frustration for patients. It requires a complete reorientation of a patient’s life. Multiple medications, needle sticks, food restrictions, increased exercise, and multiple visits to health care providers are a few of the changes needed to face diabetes. An additional challenge is the incorporation of these changes into a lifestyle that is strongly influenced by culture, belief system, values, socioeconomics, family, religion, and psychosocial wellbeing. Any or all of these may be a barrier to effective care.
Knowledge of the pathophysiology and pharmacology of diabetes forms the foundation of care. It facilitates writing scripts and monitoring chemical changes, but this knowledge alone is not sufficient. An understanding of the social and psychological aspects of diabetes care is also required. Care that does not include recognition and understanding of these aspects of the disease leads to frustration, anger, disappointment, fatigue, disorganization, and burnout for both the clinician and the patient. This leads to a sense of failure and the additional barrier of “inertia.” The clinician, patient, or both feel that nothing can be done and convey that sense through actions, words, and nonverbal behavior.
In this article, I explore the reasons behind the barriers to care, and I suggest measures that can help overcome them.
USING OFFICE SYSTEMS TO IDENTIFY AND ADDRESS BARRIERS
Overcoming barriers requires office systems that address the multiple issues discussed above. These systems include information technology such as a diabetes registry, effective use of office staff (medical assistants and nurses), and empowering patients to self-manage their disease.5,6 Appropriate delegation of some tasks to office staff increases the amount of time the clinician has to discover and address barriers. Staff members may also uncover barriers because patients may be more comfortable sharing information with them.
Emphasizing to patients and their family members that they are important members of the diabetes team and partners in their care empowers them to be better self-managers. Office systems can be used to inform patients and family of barriers, how to overcome them, and when and where to seek
DESCRIBING THE BARRIERS: “MEDICAL SPEAK” VS “PATIENT SPEAK”
The most common barriers listed in the medical literature are inability to pay for medication and supplies, depression, lack of transportation, literacy problems, and clinician inertia.7,8 But if we talk to patients, they may use a different set of words to describe their barriers. Their words reveal what they are feeling and provide the foundation for discovering the barriers. Listed in the Box are statements from telephone interviews with patients in our diabetes registry9 who had an average HbA1c value of 8% or higher.
Some readers may consider these patients “noncompliant.” But what is the value of this label? Noncompliant is a dysfunctional term.10 It places blame on the patient and does not facilitate consideration of other causes and solutions. It is a word that reflects the frustration that health care providers have when, despite all their efforts, the patient is not at goal.
Unfortunately, medical culture seeks to find blame. A shift in medical culture that considers systems of care as the cause rather than blaming produces a less defensive posture and facilitates finding solutions.11
Many of the patients’ statements in the Box may result from communication barriers. Were these patients literate? Did they understand what was being said to them? Did the caregivers understand all the patient’s circumstances? What are the patient’s goals? Is there a mismatch between the patient’s goals and the clinician’s goals? The following is a suggested way to enhance communication skills with patients.
1. UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas
or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes
(UKPDS 33) [published correction appears in Lancet. 1999;354:602]. Lancet. 1998;352:837-853.
2. UK Prospective Diabetes Study (UKPDS) Group. Effect of intensive blood-glucose control with metformin
on complications in overweight patients with type 2 diabetes (UKPDS 34) [published correction appears in Lancet. 1998;352:1558]. Lancet. 1998;352:854-865.
3. Bridges to Excellence Web site.http://www.bridgestoexcellence.org/Content/ContentDisplay.aspx?ContentID=21
4. Saydah SH, Fradkin J, Cowie CC. Poor control of risk factors for vascular disease among adults
with previously diagnosed diabetes. JAMA. 2004;291:335-342.
5. Shahady EJ. Targeted team approach improves patient outcomes and reduces costs. Drug Benefit
Trends. 2008;20(suppl D):5-10.
6. Shahady EJ. Diabetes management: an approach that improves outcomes and reduces costs. Consultant. 2008;48:331-339.
7. Shahady EJ. Barriers to care in chronic disease: how to bridge the treatment gap. Consultant. 2006;46:1149-1152.
8. Grant RW, Cagliero E, Dubey AK, et al. Clinical inertia in the management of Type 2 diabetes metabolic
risk factors. Diabet Med. 2004;21:150-155.
9. Shahady EJ. The Florida Diabetes Master Clinician Program: facilitating increased quality and
significant cost savings for diabetic patients. Clin Diabetes. 2008;26:29-33.
10. Anderson RM, Funnell MM. Compliance and adherence are dysfunctional concepts in diabetes
care. Diabetes Educ. 2000;26:597-604.
11. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century.
Washington, DC: National Academy Press; 2001.
12. Mezuk B, Eaton WW, Albrecht S, Golden SH. Depression and type 2 diabetes over the lifespan:
a meta-analysis. Diabetes Care. 2008;31:2383-2390.
13. Gonzalez J, Peyrot M, McCarl LA, et al. Depression and diabetes treatment nonadherence: a
meta-analysis. Diabetes Care. 2008;31:2393-2403.
14. Hamilton W, Round A, Sharp D. Patient, hospital, and general practitioner characteristics associated
with non-attendance: a cohort study. Br J Gen Pract. 2002;52:317-319.
15. Desai RA, Stefanovics EA, Rosenheck RA. The role of psychiatric diagnosis in satisfaction with primary
care: data from the department of veterans affairs. Med Care. 2005;43:1208-1216.
16. Gilbody S, Richards D, Brealey S, Hewitt C. Screening for depression in medical settings with
the Patient Health Questionnaire (PHQ): a diagnostic meta-analysis. J Gen Intern Med. 2007;22:1596-1602.
17. Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: validity of a two-item depression
screener. Med Care. 2003;41:1284-1292.