You may have seen the recent series of articles about the growing type 2 diabetes crisis in New York City that was published in the New York Times. Buried among the facts about the skyrocketing rates of Type II in certain neighborhoods, were civil libertarian objections as to how the information had been gathered in the first place. This is the part of the article that is of interest to me, as a parent of a kid with type 1 and as your faithful blogger.
Apparently New York is now the first city in the country to ask the labs that service the primary care providers to please send a copy of each patient’s A1C test not only to the doctor, but to the municipal government as well. (The A1C test is the blood test that both type 1 and type 2 patients get at every check-up, to determine their three-month average blood sugar. It’s a long-range picture of whether blood sugar numbers are under control, rather than the snapshot that a glucometer reading gives of that moment’s blood sugar.)
This is causing outrage among certain segments of New Yorkers.
Here is the main argument from the opponents: So you have bad blood sugar numbers and suddenly you get a phone call or a knock on the door from some government bureaucrat giving you even more of a hard time about it. Plus – what’s next? Your cholesterol is bad too, and so’s that bunion and another thing, who’s that loser guy you’re hanging out with? To them, it’s one more example of Big Brother, and this time he’s harassing sick people.
The proponents of the reporting feel that it’s a valuable tool in two ways: 1. They’ve already found that certain neighborhoods are worse than others in terms of the incidence of diabetes; this will help them better place resources – like community diabetes clinics, more diabetes supplies in neighborhood drugstores, even exercise facilities -- in the places where they are needed most. This may help with prevention as well. 2. At the micro level, this will allow them to contact patients whose A1C levels are particularly high to see if they have access to a doctor, need help with transportation to get to clinics and appointments, or need help with diabetes education.
I think both sides have valid concerns. But here’s what neither one is saying: Collecting A1C numbers of patients would be very valuable information to parents of kids with type 1 because if it were done on a national level we could learn where the best doctors and hospitals are for our children. An A1C level is a good barometer of the quality of care a doctor is giving -- the better you are at prescribing the proper amount of insulin, emphasizing the importance of exercise and diet, and giving them the very best tools to cope with the disease, the better your patients’ A1C numbers will be. (I don’t know if it would be a good idea to mix the A1C numbers of type 1 and type 2 patients into one category or not; the diseases are so different it might be warranted. That question may have to wait for another blog.)
One caveat: It wouldn’t be fair to just measure successful care based on mortality rates, because there are plenty of people with diabetes who die from things other than diabetes (like car accidents and the like). It seems to me that the A1C would be the best way to statistically measure quality of care. Of course there are issues with the numbers being distorted by demographics, the size of the doctor’s practice, and the like. But it’s better than what we’ve got right now, which is nothing.
I’ve read that there’s a similar measurement used by the Cystic Fibrosis Foundation, a national organization that, among other things, collects statistics on lung capacity from doctors and hospitals that treat CF patients. Every CF patient gets his or her lung capacity measured at every appointment, and it is also a good barometer of having the disease under control. The more the disease progresses, the less lung capacity you have. The better you are at taking your meds and doing your breathing exercises, the higher your lung capacity is. So the foundation set up a national reporting system and publishes the names of the best hospitals in the country for lung capacity numbers. They don’t publish the bad ones – they don’t want to embarrass specific doctors or hospitals, and the information could be used against them in malpractice lawsuits. So they just put the word out about the good ones.
If we were to do the same thing – if we convinced the ADA or the JDRF to follow the New York model and ask for A1C numbers (we don’t even need the patients’ names) from doctors and hospitals – patients would be able to make informed decisions about getting the best care. Other factors come into play – location of the practice, one’s relationship with the doctor, for example – that may cause individual patients to disregard the A1C stats and stay with their doctors. That’s fine. We’d still see what’s working and what’s not, by studying the best practices of the top physicians. Maybe the ones at the bottom of the rankings would see what’s working too, and learn from the best. How can that be such a bad thing?
Published On: February 07, 2006