I first started using the GlucoPALS term to describe a certain protocol of using our system to connect peers inside of patient-centric teams back in 2005 while working closely with a teen who was then using the second generation GlucoMON. It seems that this model of self-care is taking hold with large care delivery systems both here in Texas and another one primarily located in California.

Now 4 years seems like a very long time but I read an article a few months ago that said it takes about 17 years for anything new to catch on in the practice of medicine. Only 13 years to go.

Link to the story to see a video of a day in Daisy's and her family's lives

Unless We Make Some Changes…

Read this story from the BBC for yourself. We’ve seen this dramatic increase in type 1 already starting about a year ago in the diabetes centers that we work with in the USA. Basically, the new cases of kids with type 1 diabetes have doubled!

Historically, the statistics on type 1 in kids is roughly 1 in 400 or 1 in 600 depending on the source. So let’s say 1 in 500. With doubling, that number will soon begin to approach 1 in 250 over time. In the USA, there are approximately 200,000 school age kids with type 1. Another source I read in the past states that there are approximately 30,000 new cases of type 1 each year in the USA and that approximately half of those are school aged kids. Based on this story and recent discussion, it’s safe to say that there are 30,000 new onset cases of type 1 in school aged kids. It used to be that a typical age for new onset (the mode) was around 8 to 11 years. Based on discussions with endocrinologists and educators along with the information in the story, the age of new onset is clearly moving to younger and younger kids. That means more diabetes supplies over more years and more risk of trips to the Emergency Department not to mention more time at risk for complications like cardiovascular disease in the teen years.

My experience has shown me that each endocrinologist working with diabetic patients handles approximately 200 to 400 patients. There are only 200 pediatric endocrinologists in the US and very few docs coming out of med school are attracted to the relatively low pay (vs other specialist alternatives), unbilled hours for telephone consults and logbook review, and lack of control (behavior change is the required skillset vs. diagnosing to prescribe pills/dose change to fix the condition).

While there are something like 14,000 diabetes educators in the US, most of them are trained and experienced on how to work with adults with type 2 diabetes - a very different scenario than working with a kid with type 1 who may also come from a broken home or other family issues.

If each patient requires 6 hours per year (30 minutes per office visit 4 times per year plus 20 minutes per month on average for another hour over the course of a year) and there are 700 trained providers, then there are a total of 1,380,000 hours of skilled care required at a minimum since this assumes no complications. If each provider is available for 30 hours per week of patient facing time, then the current skilled pediatric labor pool is able to provide 1,050,000 hours of patient directed care. Not enough providers to deliver standard care especially when you factor in the doubling effect of new onset. The numbers I use here are only rough assumptions to illustrate the gap in the current health care delivery model for type 1 diabetes. At some point there is a scary reality and a breaking point that nobody is aware of.

Sadly, until the economics are changed to incent providers to work with type 1 kids, I don’t believe we’ll get sufficient trained people to help us with this avalanche of new patients. That leaves us with having to develop new models of care that increase the efficiency, effectiveness and reach of the trained providers we already have as well as making patients better at self-care in the absence of their diabetes coaches. A little technology will go a long way if done right and adopted (embraced) by providers. I’m reminded of a slogan we adopted a year or two ago which is now posted at the top of Diabetech’s home page on the Web, “We’re dragging Diabetes Technology ‘kicking and screaming’ into the 21st Century”. With recent successes made on the payer front, we’re soon going to need to swap out the word ‘Technology’ for ‘Providers’.

My reason for making this post is to raise the awareness that the perfect storm is upon us. Who is doing the study to prove that we need to make changes now - based on irrefutable proof that maintaining the status quo is like using a syringe to bail out a sinking ship?

The trial data I’m sharing below came out of a study presented at the 2007 Diabetes Technology Meeting by one of the investigator endocrinologists from Texas Children’s Hospital; the largest pediatric type 1 regional diabetes center in the country. Not only were the outcomes impressive - this trial was abandoned after a few months the first time it was attempted due to the difficulties experienced by the research team in getting timely access to quality outpatient blood sugar data. Then we added the GlucoMON® (an embedded long-range wireless telemetry device) to the protocol and voila - timely accurate data. Let the research party continue! So you see it’s sometimes as simple as Possible vs Not Possible and when you see the results you’ll appreciate that it is essential that we drive advancements in remote healthcare (via M2M for you tech geeks) because it’s possible - not to mention proven better.

In a randomized, controlled pilot study from 2005, 34 children completed a 3-month, open-labeled study using Diabetech’s automated monitoring and tethered-wireless transmission of blood glucose data. Subjects were children with an average age of 14 who had had type 1 diabetes for an average of 6 years with an average HbA1c of 11.0 ± 1.5 %.

The control group used standard SMBG, while the intervention group used the automated diabetes management system (aka - GlucoMON-ADMS). At the beginning of the trial, HbA1c was comparable in the control and the intervention group (11.2 ± 1.3 % Vs 10.8 ± 1.6 %, p = 0.56). After 3 months the HbA1c in the control group was unchanged (11.2 ± 1.3 % vs. 11.5 ± 1.7 %, p = 0.40), while HbA1c in the wireless-enabled intervention group went from 10.8 ± 1.6 % to 9.2 ± 1.1% (p < 0.0001) over 3 months.

Conclusions from this pilot study indicate that wireless-enabled SMBG in combination with direct supervision significantly improves HbA1c levels in children with poorly controlled T1DM. A previous attempt to conduct this study was abandoned due to the inability of the research team to reliably collect SMBG data from the treatment group demonstrating how GlucoMON-ADMS is a proven technology for overcoming human behavior and a general unwillingness of patients and caregivers to perform manual logging and sharing.

In other words, simply asking people to log and fax their numbers, use a website, text their data or any other method that requires extra work by the patient or patient caregiver is a non-starter when compared to the Automated Diabetes Management System. Maybe we should be calling this Health3.0?