Clinical Leadership

Clinical Leadership

Technology Provides Options in Diabetes Care

Before 1922, death from diabetes often came within a few months of diagnosis. The discovery of insulin that year gave patients hope for treatment and survival. In 2003, advances in technology and knowledge give patients with more options for care. The potential for reducing the complications of diabetes is great.

In fall 2002, the Diabetes Care Center at University of Washington Medicine Center initiated the Purple and Gold Awards for patients who had been living with diabetes through decades of insulin treatment. One hundred thirty-five patients received Purple Awards for 25 years of successful insulin treatment. Gold Awards were presented to 31 individuals who had been treated with insulin for 50 years or more.


	Dr. Irl Hirsch (in background) and a patient demonstrate new technology for monitoring diabetes.

Despite these and thousands of similar success stories, treatment of diabetes nationally has been a disappointing failure, according to Dr. Irl Hirsch, medical director of the Diabetes Care Center and professor of medicine in the Division of Metabolism, Endocrinology and Nutrition. He explained that this failure is not the fault of patients.

"Advances in this field are coming so fast and furious that treatment of patients is 10 years behind the research," Hirsch said. "We in academic medicine need to do a better job of educating doctors, including endocrinologists and primary care physicians, who see these patients."

The keys to improved treatment, according to Hirsch, are making technological advances available to patients and using these tools to get them more involved in their own monitoring and care.

The problem is that even the most conscientious patients monitor their blood glucose levels no more than a few times a day. These relatively infrequent measurements give an incomplete picture of their condition.

New tools are available to track glucose levels and to analyze this data alongside contributing factors such as food intake, medication, exercise and stress. The UW Diabetes Care Center is evaluating approaches aimed at individualizing treatment using these tools.

For example, a new subcutaneous sensor tracks the body's glucose levels every five minutes over a 72-hour period. Information downloaded from the device's monitor, analyzed in combination with the patient's detailed log of diet, medication, physical activities and stress levels, is used to design a highly tailored treatment program.

"We can see every Reese's peanut butter cup," said Hirsch.

Individual blood glucose monitors, specialized software, home computers, and the Internet could someday enable patients to monitor their own care and email their data to the specialists in charge of their treatment at the Diabetes Care Center. Care providers would then use the results to recommend and adjust treatment more precisely. This approach would make such highly individualized care available to any patient with a computer and Internet access.

Trials to determine if this type of treatment can be effective are in progress. About 100 patients with Type 2 diabetes are enrolled. For one year, half of the volunteer patients will receive routine treatment, and half will have the new technology incorporated into their care. This early trial has been initiated at the General Internal Medicine Clinic at UW Medical Center - Roosevelt.

Long-distance treatment is important at a time when endocrinologists and diabetes experts are scarce, and family doctors are overworked and often insufficiently trained in diabetes care. UW Medicine has the only medical school in a five-state area that includes Washington, Wyoming, Montana, Alaska and Idaho, a region encompassing 27 percent of the landmass of the United States. Because of its faculty expertise in diabetes care, UW Medicine has become a regional care center. Within the region, parents of children with Type 1 diabetes often must travel 500 miles or more to see the nearest pediatric endocrinologist.

Hirsch is quick to point out that high-tech, long-distance, patient-physician interactions will not replace office appointments where a doctor examines eyes, feet, and other indicators of the patient's condition. However, the patient's primary care physician and an endocrinologist might work together as a team. The endocrinologist receives detailed information about the patient over the Internet and sees the patient periodically. The primary-care physician assumes responsibility for ongoing check-ups.

This approach could reduce a patient's commute time. It also might mean that patients and parents with diabetic children won't have their lives disrupted by a move to a city where specialized treatment can be obtained.

Economic considerations reduce patient access to diabetes care. Endocrinologists are in short supply, primarily because the income lost during the many years of training required to undertake this type of specialization often are unrecoverable over the course of a medical career. This is especially true as other economic factors, such as the soaring cost of medical liability insurance, push up the cost of maintaining almost any type of medical practice. In addition, insurance companies and Medicare traditionally have been unwilling to pay for care outside of a medical office. Without a fundamental change in reimbursement regulations, diabetes treatment incorporating tools such as the Internet may not be financially feasible, even if the telemedicine approach proves effective.

Development Note

The Diabetes Training and Teaching Professorship was established at UW Medicine this year. Dr. Irl B. Hirsch, the UW Diabetes Care Center medical director, is the first holder of the professorship. Among other goals, Hirsch intends to broaden UW Medicine's reach in the community by educating doctors on diabetes treatment. With the help of Aventis Pharmaceuticals and others who have donated to diabetes treatment and research at the UW, Hirsch's efforts will have far-reaching effects on the quality of care available to people with diabetes.