BC: the land of substandard diabetes care?

I read with concern the Vancouver Sun article of 4 January 2007, in which Dr Penny Ballem states that she has good data that only 40% of patients in BC with diabetes mellitus are getting good care and that an estimated 60% of patients with diabetes are not getting the proper drugs. As well, she states that up to 80% of patients with heart disease are not on the proper drugs. I take exception to these statements. First, they are sensationalistic and all they do is create panic for patients. Second, she does not back them up with references or tell us how or where these statistics were obtained. Third, I think she does a great disservice to individuals with diabetes and heart disease and to the doctors who are caring for them.

Following publication of this article, I received a number of phone calls and visits to my office. What did the article mean? Are they not getting good care? Why aren’t they on the proper drugs? What are the right drugs? And so on.

Diabetes care (or care of any chronic disease) is difficult, but to say that this many patients are not on the proper drugs is an insult to physicians. Does she mean that patients are on inappropriate drugs? We have a number of drugs available now for lowering blood glucose and there are sound guidelines for when to start or adjust treatment. Unless someone experiences a side effect to a drug or a drug is ineffective, the management options are clear. These guidelines are just guidelines, of course, but they are derived from extensive review of the literature by experts in the field and are in the process of being revised to keep up with current data. So I’m not clear on the “proper” drugs. Are we using “improper” drugs? I admit that one of the concerns with diabetes control is that many physicians are hesitant to aggressively “treat to target,” so a patient may not be started on oral agents early enough or, if a patient is on maximal oral therapy, there is often a delay in starting insulin. However, this does not mean that the treating physician is providing substandard care. There are a number of programs that have been initiated in BC (by Dr Ballem, I believe), mainly at the GP level, to improve chronic disease management. The first of these targeted diabetes care and care of patients with congestive heart failure. From my perspective the diabetes program has been successful in raising awareness about the importance of good control. In my community I have seen a significant change in practice patterns and prescribing habits related to the care of patients with diabetes.

We still have far to go in achieving the targets for glycemic control, but diabetes management is a complex issue and isn’t just a question of blood glucose levels. Most people with diabetes have concomitant medical problems, typically hypertension and lipid disorders, as well as coronary artery disease and peripheral vascular disease. Treatment decisions must take into account all these factors. Despite being informed of the risks of not treating blood glucose aggressively, patients often choose not to take more pills or follow advice. This is not because physicians have been delinquent in discussing the risks and benefits of treatment.

As a well-respected specialist (hematologist) who worked in the trenches for many years, Dr Ballem should surely be aware of the difficulties we face daily as we try to do the best for our patients. 

Guidelines and targets for best practice are unlikely to result in better outcomes until patients decide to change their behavior. As an endocrinologist who deals with diabetes every day, I am frustrated by some of my outcomes, but it’s not for lack of trying. Oh yes, in the Sun article Dr Ballem said she is not critical of doctors, who she believes are conscientious and are generally doing a good job. Damned by faint praise!

—SEH