Introduction
The American diabetes association and European association for the study of diabetes
(ADA-EASD) position statement[1] chooses the definition of the Institute of Medicine, which describes patient-centered
care (PCC) as “providing care that is respectful of and responsive to individual patient
preferences, needs, and values and ensuring that patient values guide all clinical
decisions.”[2]
The following words should be noted: Respect, responsive (ness), preferences, needs,
values, guide (ance). These characteristics can be used to determine the “patient-centeredness”
of the guidelines.
This debate discusses whether the ADA-EASD position statement lives up to its claim
of being a patient centered guideline.
Discussion
Initial sections
The guidelines begin with a definition of PCC, and the rationale for applying PCC
to type 2 diabetes cares. They touch the concepts of patient involvement, decision
aids, shared decision making, and adherence. In this section, the authors seem to
follow PCC in letter and sprit.
The guidelines then discuss epidemiology and impact of type 2 diabetes the relationship
of glycemic control to outcomes, and the pathogenesis of diabetes.
While the medical impact is mentioned, including “serious psychiatric illness,” no
effort is made to describe the psychological and psychosocial effects of diabetes.
No mention is made of the potential impact of on psychiatric conditions such as depression.[3]
The guidelines present an exhaustive “biomedical” view of the pathogenesis of diabetes,
but omit the autonomic nervous system and “stress” from discussion.[4] The background also neglects patient-centric factors which contribute to the diabetes
pandemic, viz, diet, physical inactivity and life-style.
The section does, however, end by stating “type 2 diabetes - is heterogeneous - a
point to be considered when determining the optimal therapeutic strategy for individual
patients.”
The guidelines use ADA′s recommendations of HbA1c as a benchmark.[5] Patient desires and values, and availability of resources and support systems are
highlighted as factors to help in deciding individual targets. The scale proposed
by Ismail-Beigi[6] is utilized to facilitate PCC.
Therapeutic options
Life-style is unique for each patient. While guidelines recommend “standardized general
diabetes education,” they promote “personalized” diet, and highlight encouraging consumption
of foods consistent with an individual′s preference and culture. They emphasize: “Health-care
team should remain non-judgmental.” They give a choice to start lifestyle change alone,
or life-style modification along with metformin, and practice PCC by suggesting physical
activity based on mobility and age.
The guidelines strongly suggest that “agent- and patient-specific properties, such
as dosing frequency, side-effect profiles, cost and other benefits” be used to guide
selection.
The guidelines write that “an insulin treatment program should be designed specifically
for an individual patient,” and ask for a “balance with the convenience of the regime.”
Thus far, the guidelines remain patient-centered.
While discussing the choice of anti-diabetic drugs, they mention “specific patient
preferences should play a major role in drug selection.” However, it appears to be
a strong bias which makes them conclude that alpha-glucosidase inhibitors are “less
attractive candidates?” In Asia, these drugs are commonly used as well as “attractive.”
The efficacy and good side effect of both acarbose and voglibose is well documented
in diverse ethnic populations.[7]
While discussing intensification to dual combination therapy, the guidelines reiterate
“advantages and disadvantages of specific drugs for each patient should be considered.”
However, there is no mention of fixed dose combinations (FDCs). At this stage, the
guidelines begin to display a concern for resource-limited settings, encouraging less
expensive agents, while cautioning about cost implications of mandatory monitoring
and side effects.
While intensifying to triple combination, physicians are reminded that “rationale,
benefits, and side-effects of each new medication should be discussed with the patient.”
It is while discussing transition to, and titration of insulin, however, that a major
deviation from the principles of PCC is made. The guidelines describe pre-mixed insulin
as being “perhaps more convenient but less adaptable,” while in practice, its titration
is more patient-friendly than that of basal insulin. Titrating the dose of basal insulin
to achieve normal HbA1c is difficult, as it is difficult to manage prandial glycemia
with this insulin.[8]
The guidelines mention a twice daily regime for premixed insulin, while it can actually
be given once or thrice daily as well.[9]
[10] The authors feel that premixed insulin is “somewhat inflexible,” while in reality
it is a flexible method of managing basal and postprandial glycemia with minimal injections.
They also go on to say that premixed insulin is “appropriate for certain patients
who eat regularly.” A majority of diabetic patients do eat regularly.
In a back handed compliment of sorts for Asia - perhaps Asians eat regularly, hence
the most commonly prescribed insulin is premixed insulin in Asia!
In this section, the authors seem to lose respect for, and responsiveness to, patients.
They also fail to convey a globally acceptable or culturally competent attitude toward
diabetes therapy.
The guidelines mention impact of age, life expectancy, weight and comortid conditions
on drug choice. The use of racial, ethnic and genetic features in deciding optimal
therapy is described as “being in its infancy.” While this may partly be true, the
authors have chosen not to look at data which suggest greater postprandial hyperglycemia,
and better outcomes with premixed insulin[9]
[11] in Asian subjects. Such ethnopharmaceutic research must be encouraged as part of
patient- or community-oriented care.
The guidelines encourage research related to costs, patient related outcomes, pharmacogenetics,
and patient-based drug choice. They conclude with a comforting remark “Informed judgment
and the expertise of experienced clinicians will therefore, always be necessary.”
Conclusion
The current guidelines for management of type 2 diabetes are a strong statement in
favor of patient-centered approach. The guidelines remind us of our enhanced responsibility
in choosing the “right” therapy for each patient, in a patient-centered manner, without
relying on “dictatorial” algorithms.
At the same time, this approach increases the burden on authors to think, write, and
act in a patient-friendly manner, while framing guidelines. A revised version should
have more emphasis on psychosocial and psychiatric comorbidity of diabetes, on emerging
data related to ethnopharmacy, and on patient-friendly insulin regimes and oral FDCs.
A more culturally competent guideline, framed in a globally acceptable manner, will
live up to the objectives of PCC.
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Source of Support: Nil.
