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Thursday, Mar 28, 2024

The Diabetes Puzzle

Hospitals in the Valley region have combined technology, education and outreach to combat the rising diabetes epidemic. Whether it’s hyperbaric chambers, data mining, tailored management programs or a mixture of these strategies, health care providers are finding improved ways to help patients manage the chronic condition of diabetes. According to UCLA Center for Health Policy, more than 45 percent of adults in California are living with pre-diabetic conditions or undiagnosed diabetes. If unmanaged, those with pre-diabetic conditions can develop full-blown diabetes over time. With such a large number, how can hospitals slow the surge? “It’s a complex question,” said Dr. Tony Kuo, director for the Division of Chronic Disease and Injury Prevention at the Los Angeles County Department of Public Health. “It really comes down to how you distribute the resources. For most hospitals, they need a coordinated plan on how to tackle diabetes.” Diabetes is caused by the body’s inability to produce or use insulin. Insulin is an essential hormone which regulates metabolism of carbohydrates, fats and protein. There are two types of diabetes. Type 1 symptoms mostly start in childhood, and cannot be prevented. Type 2, which accounts for about 90 percent of those with diabetes, is usually discovered in adulthood, with about 25 percent occurring among seniors, 65 and older. The upside is that Type 2 diabetes can be prevented or delayed significantly with a healthy lifestyle. The rise of type 2 diabetes has been directly linked to a rise in obesity. Despite the fact that it can be averted, once developed, diabetes is a chronic disease that can spur into multiple serious complications like heart disease, stroke or nerve damage. According to Kuo, this can lead to personal finance issues beyond direct medical costs. “When people have a chronic disease they need to take care of, there’s loss in productivity,” said Kuo. “The burden of chronic disease has intangible costs too. Diabetes doesn’t affect just that person but affects a whole family.” In fact, those diagnosed with diabetes had 2.3 times higher medical expenditure than adults without the disease, according to the American Diabetes Association,. However, proper management of diabetes can decrease the prevalence of complications. To provide the most comprehensive solution, hospitals emphasize both professional medical care and educational programs. Hyperbaric solution At the heart of Henry Mayo Newhall Hospital’s new wound care center are two hyperbaric chambers that will be used for treating chronic wounds, meaning the type of wounds that take more than two weeks to heal. According to Dr. Brian Downs, up to 85 percent of the patients who come in for wound treatment are diabetics. This is because chronic diabetes can lead to neuropathy, or deadening of nerves in patients’ extremities. This lack of feeling can prevent patients from noticing small cuts, which then can become large ulcers if left untreated. Once a patient enters the chamber, the pressure inside is gradually increased and the oxygen content of the air is concentrated. After about an hour of being “in-depth” the pressure is gradually decreased to normal levels. Downs said most patients sleep inside the chamber, or watch TV through the thick outer plexiglass. The patients who receive such treatments due to diabetic ulcers are usually part of another program that helps diabetes management. “It helps bud new vessels at the wound base,” said Downs, referring to the chamber. “Our goal is to preserve the wound and not to cut it off. It’s not a cure-all but it’s something we can add that can have better outcomes and quicker healing rates.” But he cautioned that at the same time, the care regimen must address underlying issues. They include diet, medication, exercise and self-monitoring of blood sugar. Dee Rickett, program manager at Henry Mayo, oversees the diabetes program led by registered nurses and dietitians who are certified in diabetes education. “They are highly specialized in all things related to diabetes,” said Rickett. “They will meet with the patient and understand what their unique needs are.” The programs are offered at both in-patient and out-patient sites. They can include nutritional counseling, weight loss regiment or an emotional support class on how to survive the holidays. Overall, the program focuses on self-care and tries to help patients make the right decisions as they try to manage their illness. “Patients themselves can have a lot of control, or complete lack of control,” said Rickett. “They have to make lot of decisions and deal with them every day.” Technology for prevention According to Kuo at L.A. County Department of Public Health, it may be worthwhile for hospitals to invest resources in preventative measures. “Ideally one feeds into the other,” said Kuo. “If you can prevent complications, hospitals can reduce their cost.” The doctors at Providence Holy Cross Medical Center at Mission Hills have combined technology with preventative care. The hospital has adopted a risk-trigger monitoring program, which uses a data mining technology. A computer program scans hundreds of patients’ electronic medical records, collecting data that includes basic vitals, lab results and even notes that nurses leave on patients’ files. Then, the program analyzes the numbers and identifies patients who are at risk for adverse health conditions like hypoglycemia, or low blood sugar. Dr. Robert Raggi, the chief medical officer at Mission Hills, said the monitoring program revealed that hypoglycemia was prevalent among the patients in the hospital. “When a patient comes into a hospital, they tend to eat less and get less nutrition than at home,” said Raggi. “This tool gives us a warning that something bad might happen. It’s like an early warning system.” In response, the hospital formed a hypoglycemia task force to re-educate the nursing staff on how to prevent as well as recover patients after a hypoglycemic episode. This risk-trigger monitor is also used to detect early signs of other acute complications like kidney failures. Talking with doctors Other hospitals, like Dignity Health Northridge, have created community outreach programs to prevent serious complications in diabetic patients. Joni Novosel, the director for Center for Healthier Communities at Northridge, said diabetes ranked as a top priority for people who were interviewed in the community health needs assessment. The center currently offers 10 six-week classes on diabetes education, focusing on management techniques like guided grocery shopping, meditation for stress management and, appropriate use of medication. According to Novosel, another important factor in prevention is teaching patients how to communicate with their doctors. Diabetes tends to be prevalent in immigrant communities that are unfamiliar with the medical system. When expressing ailments, or asking questions, things can get lost in translation, Novosel said. As with most prevention programs, there are challenges in the lack of measurable metrics and sustained engagement by patients. “You have to be creative and incentivize people to choose to spend a couple of hours with you,” said Novosel. “Keeping people engaged is the biggest challenge.” Especially when servicing working-class patients, child care and transportation can be significant barriers to keeping people in the program. For those who are fully engaged, the program offers baseline measurements with continual follow up so that the patients can track their progress. “It’s really difficult to see what the long-term success will be,” said Novosel. “But even if we can reach 20 percent of patients to the point where they can continuously manage their disease and not develop complications, we will consider ourselves successful.” Cost impact When a chronic disease like diabetes increases, does it become a cost problem or a profit opportunity for hospitals? Greg Facktor at health care consulting firm Greg Facktor & Associates in Los Angeles said it’s a mix of both for health care providers. That’s because diabetes is both a chronic illness and a source of multiple acute conditions. “It’s an opportunity because they will receive new patients,” said Facktor. “But as the disease is managed by out-patient groups, it will become less beneficial to hospitals.” Not all admitted patients are an income opportunity for hospitals. According to Facktor, as patient stays increase, hospitals are paid a declining rate from insurance companies. This gives hospitals a financial incentive to get the patient healthy and out of the hospital, Faktor said. Also, with the passage of the Affordable Care Act, hospitals who treat Medicare patients are given monetary incentives to keep their patients healthy. For example, LA Care Health Plan provides insurance to MediCal recipients and requires providers to report on patients’ health metrics. The idea is that if patients come in and report better metrics than before receiving care, the provider will receive an incentive payment. According to Facktor, 15 to 20 percent of a physician’s income can come from this type of incentives. Facktor said while the health care system still needs a lot of improvements like the timely exchange of health records, there are somethings that are getting better. “They are really understanding now that everyone has a similar goal and what’s good for the health plan is good for the hospital,” said Facktor. “When the goals are aligned, everybody wins.”

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