CorrectCare

Pay Now or Pay Later: Why the Goal Is Control With Diabetes
By Rebecca B. Jones, RN, BSN, CDE

An epidemic is sweeping the United States. Diabetes affects over 20 million people, almost a third of whom do not know that they have the disease. People with this disease often find out only when an organ has already sustained damage.

The impact extends beyond health. From 1997 to 2002, the annual cost for this disease in medical expenditures and lost productivity rose 35% and the average per capita cost for treatment rose more than 30%.

At any given time, nearly 80,000 people with diabetes are incarcerated. Most of those have type 2 diabetes, which for years was erroneously thought to be a less serious form of the disease. Although any inmate health problem has associated costs for practitioner visits, medications and adjunct therapy, the price tag is even higher for unrecognized and uncontrolled diabetes.

Controlling Complications
Numerous studies, the most familiar being the Diabetes Control and Complications Trial, offer convincing evidence that good control of diabetes, as shown by a lower hemoglobin A1C level, can prevent or reduce the complications (and their related costs) of the disease.

What are those complications? It is well-documented that people with diabetes are two to four times more likely to have a heart attack or stroke. They are 10 times more likely to have an amputation; in fact, comprehensive foot care programs can reduce amputation rates by as much as 85%, according to the American Diabetes Association. Diabetes also is the leading cause of new cases of blindness and of kidney failure in the United States.

The ADA Position Statement on Diabetes Management in Correctional Institutions reflects these findings and provides a framework of preventive and therapeutic interventions that can save health care dollars and achieve better inmate health. The statement addresses such issues as initial and ongoing screening for diabetes, frequency of testing for complications, diabetes management plans, and preventive and educational measures.

ADA clinical practice recommendations also form the basis of the National Commission on Correctional Health Care’s clinical guidelines on diabetes, which are tailored to care in correctional settings.

Although the details of these position statements and guidelines may seem formidable at first glance, good diabetes care primarily requires two things: good understanding of diabetes and knowledge about current therapies, and an organized, methodical approach to management of the inmate’s diabetes care.

One of the most challenging aspects of care is simply staying on top of who gets what test when! For me, an invaluable tool is a spreadsheet of all inmates with diabetes. It notes the required testing and the last results, making it easy to see at a glance who has elevated A1C levels or other out-of-range test results. Another plus of organizing the data this way is that it prevents unnecessary repeats of costly lab work as well as the dreaded FTC (fell through the cracks) syndrome.

Easy as A-B-C
Especially in a correctional facility, the goal is control. All inmates with diabetes should have a management plan that monitors and optimizes their glycemic control. The management plan should focus on three key components, labeled as the ABCs of diabetes management:

A — The A1C test, which measures the average blood glucose level over the past 60 to 90 days, is the gold standard for how well a person’s diabetes is managed overall. Although the goal should be individualized, the management plan should strive for the near-normal A1C goal of less than 7%.
   Good glycemic control is achieved through therapies of diet, exercise and medication (if needed). Regular finger-stick blood glucose tests are necessary because they measure the daily effects of the therapies and give practitioners the information needed to make adjustments. Daily blood glucose tests tell us how to fine-tune the therapy; A1C tests tell us the overall success of those adjustments.

B — Blood pressure control is essential in diabetes management. People with diabetes are at especially high risk of coronary artery disease and kidney disease. Blood pressure should be controlled to less than 130/80 mmHg.

C — Cholesterol and triglyceride control are especially important for people with diabetes because of the increased incidence of coronary artery and other blood vessel disease. Often, lipid control follows normalization of blood glucose levels.

I also focus on two other components:

D — Diet, more correctly referred to as medical nutrition therapy, focuses on a healthy way of eating. MNT, by the way, could benefit all inmates in reducing their risk for chronic diseases.
   There is no such thing as the “diabetic diet,” at least not any more. Instead, diabetes MNT considers the timing and amounts of carbohydrate intake and choosing “good” fats. It also seeks to add fruit and vegetables to meals and increase fiber intake. This can be very challenging in correctional institutions, but it can be done. Often, there is an almost complete lack of understanding by inmates of making better food choices and portion control.

Which leads to the last, and surely the most important, element of any diabetes management plan:

E — Education. For 25 years I have taught thousands of patients and professionals about diabetes management, and I have learned a valuable lesson: The more you know about diabetes and its management, the better the outcomes.
   Knowledgeable health professionals provide better care for patients. And knowledgeable patients make better choices, communicate more effectively with the providers and self-manage their disease better. Diabetes self-management training (DMST) is a standard of care in the free world, and it can improve the care and cooperation of inmates.
   Staff education for both the health care staff and correctional officers should be ongoing to ensure that they have the information and skills to effectively manage inmates with diabetes. 

Better glycemic control reduces the complications of diabetes. Fewer complications reduce the health care dollars spent. In the words of Dr. Robert A. Rizza, in an address at the 2006 annual scientific sessions of the ADA, “It costs less to properly treat diabetes than it does to treat the complications that you get if you don’t properly treat diabetes. It’s a wise investment no matter how you look at it.”

[This article first appeared in the Fall 2006 issue of CorrectCare.]