- © 2004 Canadian Medical Association or its licensors
In a study published last year in Canadian Family Physician, Harris and associates1 found evidence that many Canadians with diabetes are not being monitored appropriately: 16% had not had their glycosylated hemoglobin (A1C) level tested in the preceding year, 85% had not been assessed for diabetes-related foot conditions, and more than half had not had their lipids tested. Clearly we are doing something wrong.
The Canadian Diabetes Association (CDA) published state-of-the-art clinical practice guidelines2 in the same year as the Harris study appeared. These guidelines are a tremendous resource, but I am concerned that they will not improve the delivery of diabetes health care unless we abandon the traditional top-down approach and replace it with a bottom-up strategy.
What would such a bottom-up strategy entail? We should ensure that diabetic patients become intimately familiar not only with the traditional tenets of diabetes education (e.g., proper nutrition and exercise therapy, blood glucose testing) but also with traditionally physician-centric issues such as target levels for A1C, lipids, microalbumin and certain clinical parameters including blood pressure and 10-g monofilament testing. There is no reason that patients cannot be knowledgeable enough to ask their physicians if they should be taking acetylsalicylic acid or an angiotensin-converting enzyme inhibitor or a statin or to ask about — and be engaged in discussions regarding — the implications of abnormal clinical parameters (such as impaired 10-g monofilament sensory awareness).
That the guidelines are available on-line3 is helpful, but because they are written for a professional audience, many people with diabetes are unlikely to use them. So how about an online lay version of the guidelines? Why not encourage pharmacists to distribute CDA-designed information sheets instead of noncontextual (and at times alarmist) lists of potential adverse drug effects? Why not duplicate the American-based Lower Extremity Amputation Prevention (LEAP) program,4 which distributes free monofilaments for patient (and professional) use? Or even enclose a monofilament and instruction sheet with every new prescription for an oral hypoglycemic agent?
I believe that Canada could be at the forefront of a change to bottom-up diabetes management in the same way that we have been (and continue to be) at the forefront of diabetes research. And I believe that such a change will create a better informed, more engaged and, ultimately, healthier diabetes patient population.
Ian Blumer Internist Ajax, Ont.
Footnotes
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Competing interests: Dr. Blumer is a coauthor of Diabetes for Canadians for Dummies (Wiley & Sons, 2004).