05/30/2007

Bridging the diabetes divide

Gap in care between haves and have-nots

BY SUSAN BRINK
The Los Angeles Times

LOS ANGELES — Jack Perkins, 28, has lifestyle choices middle-class people take for granted. From his home in Valencia, it's a quick walk to the grocery or health foods store.

He exercises daily, lifting weights in his condo's workout room or jogging through safe, quiet, meandering streets.

"It's almost like it's designed for runners and walkers,'' he says.

By contrast, Maria Sahagun's home has bars on the windows and doors, and the 61-year-old doesn't venture far on foot. And her neighborhood has a hefty supply of mom-and-pop food markets where the variety of chips and sodas vastly exceeds that of fruits and vegetables.

Perkins, who has health insurance, and Sahagun, who does not, both have diabetes. He has Type 1, and since childhood his pancreas has not been able to make insulin; she has Type 2, and her body can no longer make enough insulin nor properly respond to it. For each, the disease means using insulin, medications, diet and exercise to do the work the pancreas cannot do.

Diabetes is afflicting more people, at younger and younger ages, sending doctors, insurers and public health officials into a tizzy as the epidemic threatens to overwhelm the health-care system. The annual cost of health care for an adult with diabetes is more than $13,000, and rates of Type 2 have risen sharply in the wake of the upsurge in obesity in the United States.

A bold experiment is unfolding in Los Angeles County that may serve as a lesson for the nation as it battles the epidemic.

Experts know that the cost of care could be much lower if patients could take simple measures to control their disease and avoid complications such as nerve damage, amputations, heart disease and blindness. But surveys show that many, even those with adequate health insurance, do not get that care, which is costly and labor intensive, demanding daily attention from patients and timely responsiveness from doctors.

Poverty creates additional obstacles, such as finding fresh vegetables and a safe place to exercise. Study after study shows that low-income people have less access to health care and a greater risk of getting sick and dying prematurely.

But in an odd twist to the usual health-care disparity, more than 1,000 residents in low-income areas, most of them uninsured or on California's version of Medicaid, are getting the gold standard of aggressive diabetes management — better, even, than many with insurance who live in ritzy ZIP codes.

A team of doctors is participating in the experiment, training nurse practitioners, pharmacists, social workers and community educators to intervene in a way that doctors cannot. They're offering frequent patient checkups to monitor the disease and teaching patients to track blood sugar, get out and take a walk, cut out the doughnuts — all the things they need to do if they hope to keep complications at bay.

There are signs that it's working. Studies so far show that patients in the program have improved blood sugar and have had fewer emergency room visits and hospitalizations.

Uncontrolled, diabetes results in a buildup of sugar in the blood and, over time, damage to the eyes, kidneys, nerves and heart. According to a study released in April, 3 in 5 diabetic patients suffer from at least one significant complication.

Those numbers could worsen, because diabetes is striking more people at younger ages. Type 2 diabetes used to be unheard of in children. Now more than 200,000 children and teens younger than 20 have the disease, according to the Centers for Disease Control and Prevention.

There are an estimated 20 million diabetics today, 18 million with Type 2, and the Centers for Disease Control and Prevention now projects that 1 in 3 children born in 2000 will develop diabetes in their lifetime. When Type 2 diabetes hits a middle-aged person, the consequences of uncontrolled disease show up 20 to 30 years later as heart attacks, strokes, blindness, kidney failure, amputations and death.

When the disease strikes younger adults and children, it's anybody's dismal guess what will happen. The number of children hospitalized, already suffering from complications from Type 2 diabetes, increased by 200 percent between 1997 and 2003, according to data presented earlier this month at a pediatrics meeting.

"I have colleagues who tell me that they have actually lost patients in their 20s to heart attacks,'' says Dr. Larry Deeb, pediatric endocrinologist and president of the American Diabetes Association.

Reducing complications is key to protecting patients and controlling costs. The preventive measures are relatively straightforward: lose weight; watch your diet; exercise; monitor blood sugar, blood pressure and cholesterol; take your medications; have regular eye and foot exams.

But often, these things aren't done. When the federal Agency for Healthcare Research and Quality looked at national rates of recommended diabetes interventions between 2000 and 2002, they found that about half of patients received the blood glucose test and foot and eye exams called for in treatment guidelines. Only 40 percent had their blood glucose levels under good control; half had cholesterol levels controlled; and 70 percent had their blood pressure controlled.

Even fully insured patients rarely get the hands-on medical attention it takes to control diabetes properly. All but about 5 percent of diabetics are seen by primary care doctors, who are rushed and have varying degrees of expertise in the disease.

Some insurers have adopted an intensive team approach to diabetes management, but such programs are uncommon.

"It's not happening much in the real world out there,'' says Mayer B. Davidson, endocrinology professor at Charles Drew Medical Center and UCLA.

The reason, he says, is the convoluted bottom line of America's fragmented health-care system, which pays more to amputate a foot than to prevent amputations, or to treat heart attacks than to prevent them.