Tuesday, November 13, 2007

This is my stats card, with only the stats for 2007 (I had a higher high score in 2006, and some higher A1cs)

A short while back, Richard Kahn of the ADA gave the keynote speech at the Diabetes Technology Conference. By now, if you read much in the diabetes blogosphere, you might know what he said, and you've certainly read some reactions.

Richard Kahn said that we're too quick to adopt new technologies when they work, rather than when they work better than what we've already got. And he is right.
He also made an analogy to a study where 70% of hypertension patients were not taking their meds correctly, and said that if doctors focused on getting diabetics to use current stuff correctly, we'd be better of. And that was more than a little bit off base.

But the reaction of a goodly chunk of the blogosphere was to get mad and say that technology, and specifically pumps, were something really important that insurance should pay for.

I don't agree. I've read study after study on pumping, and I think that for the majority of type 1s, pumping is a luxury. Pumping is a very very useful tool for dealing with diabetes in cases where: there's a predictable meal spike. Exercise really can't be managed otherwise. Or the person needs incrememnts of insulin too small for a syringe to handle.

Studies showing improvement in people moving from MDI to Pumping have a few major flaws. First, they fail to control for what regimen the person is coming from. If the person is just starting to carb count, if the person had been on two shots a day before, or if the person was on NPH and it didn't really suit them, then of course it's gonna help to move to pumping. Many people might switch because what they were doing didn't work for them.
Second, switching regimens is in and of itself something that tends to get people more involved in their diabetic care, and that helps. The classes and paperwork required to start pumping pretty much guarantee that the diabetic is going to put some effort into making the pump work for him.
And third, if we compare people on CSII to the rest of the diabetic population, I think you'll find that the ones on CSII are on average more affluent and more educated, because they were able to get on the pump, and those two factors are also a big part of diabetes control.

I think that for the majority of T1s, MDI can be made to work just as well as pumping. Since it's obvious that most T1s don't actually do as well MDI, I'm not sure if insurances should pay for pumps just on that evidence. But I sure as hell do not plan to ask mine to pay for a pump when I don't think it would make a difference in my overall diabetes control. No fucking way. The money could be better spent on multitudes of other things.
People tell me that pumps are really great, but the average pumper has worse control than I do. People tell me that pumping is as good as what you put into it, but I think that they fail to apply that same thing to MDI, and I think that MDI is also as good as you make it. I think that you need to pick and adjust from MDI regimens to one that suits you, that carb counting is a great idea no matter what, and that accuracy in dosing is MDI's greatest flaw.

I've been thinking a lot lately about the plight of diabetics in South America, parts of Asia, and Africa, who do not have the technology to deal with diabetes. Places where there's no electricity to keep insulin cool. Places where insulin costs more than the average adult earns and places where test strips are too expensive, places where diabetes is a fairly quick death sentence.
And I've been thinking about the approaches to getting diabetes care into these regions, and I think they go about it wrong, and this ties into what Kahn said. First, I think that trying to provide blood glucose test strips is inefficient. If we are only providing these for a limitted time, say until the diabetic turns 18, and then the diabetic can't afford them anymore, it might be useful to teach diabetics how to make due. If tests for glycosuria are much cheaper, then lets use our blood test strips to figure out the diabetic's urine glucose thresshold so that he'll have an idea of how it correlates, because if he can't afford blood test strips, then let him make the best possible use of what he'll have.
I know Novolog keeps outside the fridge in a way that Lantus and NPH do not. So let's make the best use of Novolog, teach people how to use expired Lantus, and maybe if there is a basal insulin that's as hardy as Novolog (is there?) then let's make sure to use that. Sometimes I wonder if it might also be cheaper to start production of animal insulins in some of these countries rather than trying to export our analog insulins. If it might be more affordable. If the Saxls did it, maybe it can be done.

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