Barriers to Effective Diabetes Care: How to Recognize and Overcome

Key words: diabetes, barriers to care, adherence, depression

Diabetes is the most demanding chronic illness. It challenges every fiber of a patient’s body and spirit and demands a system of care that ministers to the biological, social, and psychological aspects of the illness. It takes a “village” to accomplish this task.

Type 2 diabetes mellitus may be the most challenging and frustrating disease faced by primary care clinicians. Excellent evidence exists that reaching goals for hemoglobin A_1c (HbA_1c), low-density lipoprotein (LDL) cholesterol, and blood pressure significantly reduces diabetic complications^1,2 and costs.³ Fortunately, effective therapeutic options are available for reaching these goals. But unfortunately, even with our best efforts, only 48% of patients with diabetes reach goal for HbA_1c and only 33% for LDL and blood pressure; only 7% achieve all 3 goals concurrently.⁴

Diabetes is also a significant challenge and frustration for patients. It requires a complete reorientation of a patient’s life. Multiple medications, needle sticks, food restrictions, increased exercise, and multiple visits to health care providers are a few of the changes needed to face diabetes. An additional challenge is the incorporation of these changes into a lifestyle that is strongly influenced by culture, belief system, values, socioeconomics, family, religion, and psychosocial wellbeing. Any or all of these may be a barrier to effective care.

Knowledge of the pathophysiology and pharmacology of diabetes forms the foundation of care. It facilitates writing scripts and monitoring chemical changes, but this knowledge alone is not sufficient. An understanding of the social and psychological aspects of diabetes care is also required. Care that does not include recognition and understanding of these aspects of the disease leads to frustration, anger, disappointment, fatigue, disorganization, and burnout for both the clinician and the patient. This leads to a sense of failure and the additional barrier of “inertia.” The clinician, patient, or both feel that nothing can be done and convey that sense through actions, words, and nonverbal behavior.

In this article, I explore the reasons behind the barriers to care, and I suggest measures that can help overcome them.

USING OFFICE SYSTEMS TO IDENTIFY AND ADDRESS BARRIERS
Overcoming barriers requires office systems that address the multiple issues discussed above. These systems include information technology such as a diabetes registry, effective use of office staff (medical assistants and nurses), and empowering patients to self-manage their disease.^5,6 Appropriate delegation of some tasks to office staff increases the amount of time the clinician has to discover and address barriers. Staff members may also uncover barriers because patients may be more comfortable sharing information with them.

Emphasizing to patients and their family members that they are important members of the diabetes team and partners in their care empowers them to be better self-managers. Office systems can be used to inform patients and family of barriers, how to overcome them, and when and where to seek

help.

DESCRIBING THE BARRIERS: “MEDICAL SPEAK” VS “PATIENT SPEAK”

The most common barriers listed in the medical literature are inability to pay for medication and supplies, depression, lack of transportation, literacy problems, and clinician inertia.

^7,8

But if we talk to patients, they may use a different set of words to describe their barriers. Their words reveal what they are feeling and provide the foundation for discovering the barriers. Listed in the

Box

are statements from telephone interviews with patients in our diabetes registry

⁹

who had an average HbA

_1c

value of 8% or higher.

Some readers may consider these patients “noncompliant.” But what is the value of this label? Noncompliant is a dysfunctional term.¹⁰ It places blame on the patient and does not facilitate consideration of other causes and solutions. It is a word that reflects the frustration that health care providers have when, despite all their efforts, the patient is not at goal.

Unfortunately, medical culture seeks to find blame. A shift in medical culture that considers systems of care as the cause rather than blaming produces a less defensive posture and facilitates finding solutions.¹¹

COMMUNICATION BARRIERS
Many of the patients’ statements in the Box may result from communication barriers. Were these patients literate? Did they understand what was being said to them? Did the caregivers understand all the patient’s circumstances? What are the patient’s goals? Is there a mismatch between the patient’s goals and the clinician’s goals? The following is a suggested way to enhance communication skills with patients.

Mrs K is a 55-year-old woman with type 2 diabetes of 10 years’ duration. She takes 2 oral medications. Her HbA_1c level is 8.1%, and her body mass index is 33.

Dr J: Hello, Mrs K. Since this is your diabetes visit, can you tell me what concerns you most about your diabetes?

Mrs K: Well, Doctor, it’s the food and exercise.

Dr J: Okay, can you choose one of those for us to work on today?

Mrs K: I guess it would probably be exercise.

Dr J: Good! Can you tell me why it is important for people with diabetes to exercise?

Mrs K: I am not sure, but I think it helps blood sugar come down.

Dr J: Excellent! It also helps with blood pressure, lipids, and weight. Tell me, Mrs K, have you tried to exercise before?

Mrs K: Yes, I joined the Y because that is what my last doctor told me to do. He said I needed to do it to bring my weight down.

Dr J: How did that work out?

Mrs K: I went a few times, but I am too fat and did not look good in exercise clothes and the class I took made my knees hurt. In fact, I gained weight because I was so frustrated.

Dr J: Do you have any ideas about what type of exercise you would like to do?

Mrs K: I like to walk, but I can’t go very far because it hurts my knees.

Dr J: Let’s change words here and use the word activity. Is there some type of fun activity you might do that does not cause your knees to hurt?

Mrs K: Well, I like to dance, and my husband and I sometimes go to dances. If we do one or two then sit down, my knees feel pretty good. He is a good dancer and wishes I would go more often.

Dr J: Would you be willing to dance some with your husband every day? Maybe you could devote two 15-minute periods each day to dancing in your house and then go out for dancing once a week. What do you think about that?

Mrs K: I am not sure about 2 times a day, but I think once a day would be possible with my husband’s schedule. But maybe I could dance by myself, or even better I bet that my friend Sue next door would come over and dance with me. I can’t wait to tell everyone that my doctor wants me to dance to help my diabetes.

Dr J: That’s great, Mrs K. I would like for you to come back in 1 month to discuss how you are doing with your dancing and see how it influences your blood sugar. What do you think about that plan?

Mrs K: Thank you, Doctor. I think this might work. I will check my blood sugars and be back in a month.

What were the barriers in this dialogue? Was it the knee pain, the patient’s lack of control in the choice of exercise, her lack of understanding of her disease, or the previous physician’s style of telling rather than asking?

What led to the solution? Was it initially giving the patient the choice of addressing her concerns rather than the physician’s concerns? Was it asking her what exercise does for diabetes? Was it changing the word exercise to activity? Was it asking her what fun activity she likes that does not hurt her knees? Was it asking her for agreement about how many times a day she would dance?

The answer is probably all or most of the above. Using these communication techniques may help uncover and deal with the many barriers faced by clinicians and patients.

This patient has other issues that are affecting her health, and it is tempting to want to address all of them at this visit. She has had diabetes for 10 years. Traditional care has probably been addressing all the issues but does not seem to be working.

Why overwhelm her? She will have 1 month to gain confidence with a solution she created. When she returns, the clinician can build on the effectiveness of this visit and address other issues in a similar manner. Solutions that fit the patient’s values and culture are the most sustainable.

DEPRESSION: ONE OF THE MOST DIFFICULT BARRIERS
The relationship between depression and diabetes is bi-directional. Over time patients who are depressed are at increased risk for diabetes, and patients with diabetes are at heightened risk for depression.¹² Over 60% of persons with diabetes have some form of depression, and it is often unrecognized. If a patient has difficulty in achieving glycemic control, depression should be considered.

In the statements listed in the Box, 3 patients mention depression that is not being addressed by their primary care clinician. The patient who made the statement “It doesn’t do any good to worry about my diabetes because I can’t do anything about it,” as well as others, may be depressed.

Effect of depression on adherence and outcomes. There is a significant association between depression and treatment nonadherence in patients with diabetes. A number of studies have shown that depression is associated with worse diabetes outcomes, such as poor quality of life, increased complications, functional impairment, and mortality. A recent meta-analysis indicated that depression had the greatest impact on missed medical appointments and self-care.¹³

Depressed patients depress their health care providers. Missed medical appointments increase provider frustration, decrease empathy, and are associated with less continuity of care.¹⁴ Depressed patients also report more dissatisfaction with their providers.¹⁵

If depression is not addressed, the vicious circle of dissatisfaction continues as the complications of diabetes continue to grow. Increased recognition and treatment of depression in the primary care setting is critical to effective diabetes care.¹³ Depression may be the most treatable of all barriers to care.

Screening for depression. Effective screening tools are available to aid in the recognition of depression in the primary care setting.

Two of the best-validated ones are the Patient Health Questionnaire–9 (PHQ-9) and its 2-item version, the PHQ-2.^16,17 The PHQ-9 is 81% sensitive and 92% specific for major depressive disorder, and the PHQ- 2 is 87% sensitive and 78% specific for major depressive disorder.

The PHQ-2 contains the following questions:

• During the past month, have you often been bothered by feeling down, depressed, or hopeless?

• During the past month, have you often been bothered by little interest or pleasure in doing things?

If answers to these 2 questions are positive, the patient is most likely depressed. Additional questionnaires, such the PHQ-9, are needed to assess severity and impact on daily activity.

For increased efficiency, a staff member could ask the 2 questions of all patients with diabetes when they are brought to the examination room. Those who respond positively could be given the PHQ-9 to complete for the clinician’s review.

References:

REFERENCES:1. UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33) [published correction appears in Lancet. 1999;354:602]. Lancet. 1998;352:837-853.

2. UK Prospective Diabetes Study (UKPDS) Group. Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34) [published correction appears in Lancet. 1998;352:1558]. Lancet. 1998;352:854-865.

3. Bridges to Excellence Web site.http://www.bridgestoexcellence.org/Content/ContentDisplay.aspx?ContentID=21

4. Saydah SH, Fradkin J, Cowie CC. Poor control of risk factors for vascular disease among adults with previously diagnosed diabetes. JAMA. 2004;291:335-342.

5. Shahady EJ. Targeted team approach improves patient outcomes and reduces costs. Drug Benefit Trends. 2008;20(suppl D):5-10.

6. Shahady EJ. Diabetes management: an approach that improves outcomes and reduces costs. Consultant. 2008;48:331-339.

7. Shahady EJ. Barriers to care in chronic disease: how to bridge the treatment gap. Consultant. 2006;46:1149-1152.

8. Grant RW, Cagliero E, Dubey AK, et al. Clinical inertia in the management of Type 2 diabetes metabolic risk factors. Diabet Med. 2004;21:150-155.

9. Shahady EJ. The Florida Diabetes Master Clinician Program: facilitating increased quality and significant cost savings for diabetic patients. Clin Diabetes. 2008;26:29-33.

10. Anderson RM, Funnell MM. Compliance and adherence are dysfunctional concepts in diabetes care. Diabetes Educ. 2000;26:597-604.

11. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.

12. Mezuk B, Eaton WW, Albrecht S, Golden SH. Depression and type 2 diabetes over the lifespan: a meta-analysis. Diabetes Care. 2008;31:2383-2390.

13. Gonzalez J, Peyrot M, McCarl LA, et al. Depression and diabetes treatment nonadherence: a meta-analysis. Diabetes Care. 2008;31:2393-2403.

14. Hamilton W, Round A, Sharp D. Patient, hospital, and general practitioner characteristics associated with non-attendance: a cohort study. Br J Gen Pract. 2002;52:317-319.

15. Desai RA, Stefanovics EA, Rosenheck RA. The role of psychiatric diagnosis in satisfaction with primary care: data from the department of veterans affairs. Med Care. 2005;43:1208-1216.

16. Gilbody S, Richards D, Brealey S, Hewitt C. Screening for depression in medical settings with the Patient Health Questionnaire (PHQ): a diagnostic meta-analysis. J Gen Intern Med. 2007;22:1596-1602.

17. Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: validity of a two-item depression screener. Med Care. 2003;41:1284-1292.