Treating the Diabetic Client
Pop quiz: What home medical supplies are needed to treat a diabetic client? If your list includes the tried and true glucose monitors, test strips and lancets, you've remembered the vital tools for managing the condition. If your list leaves off scooters, ambulatory aids, seat cushions, support surfaces, blood pressure monitors, footwear and wound care supplies, you might be missing some valuable HME opportunities with products that target co-morbidities associated with diabetes.
The fact is that the 20.8 million people in the United States living with some type of diabetes may also have related conditions that require home medical equipment. For example, heart disease and stroke account for about 65 percent of deaths in people with diabetes, according to the American Diabetes Association and Centers for Disease Control and Prevention. About 73 percent have high blood pressure. On top of that, complications of diabetes can lead to amputation and other mobility impairments, such as diabetic foot drop, not to mention lack of sensation that may require special seat cushions and support surfaces to prevent skin breakdown.
"Obesity runs hand in hand with diabetes, heart disease, and then as you get toward end of life issues, you have neuropathy which of course results in loss of fingers and toes," says Ray Krauss, CEO, GlucoLight, Bethlehem, Pa. "It's a miserable end of life and the interesting part about it is if you aggressively manage glucose, you can live a normal life as a diabetic."
Obesity has in fact contributed to the rise in prevalence of Type 2 diabetes. "I think you have to give the majority of the credit to the fattening of the world," says Krauss. "The propensity for fast food, for sugary soft drinks, and the fact that we've exported those habits all over the world, is a big part of the problem. (For) some people it's hereditary, but for the most part, obesity and diabetes are pretty strongly linked."
To truly treat the diabetic client, the provider must also address these other co-morbidities. For that reason, providers must take a look at each client and determine what his or her unique needs are.
"Every patient has different needs," says Frank Suess, president, Pharma Supply, West Palm Beach, Fla. "Find out if the patient is overweight, has vision problems, foot problems, impotence, dietary requirements, etc. What is the patient's financial situation? Is the patient insured and what is the insurance paying for? You have to know all this and more to treat the patient as a whole."
Are you maximizing the sale potential of your diabetic clientele? Check out the following areas of HME that you should be tapping to treat the myriad of conditions associated with diabetes.
How Well Do You Know the Diabetic Client?
Diabetic Supplies
Step one to controlling diabetes is managing glucose levels, especially for Type 2 diabetes, also known as adult-onset diabetes, which accounts for about 90-95 percent of all diagnosed cases. Type 2 diabetes usually begins as insulin resistance, in which the cells do not use insulin properly. Slowly, the pancreas begins to lose the ability to produce insulin.
"If you're a Type 1 and your pancreas is producing no insulin, you have to test or you will die. It's just a fact of life," says Krauss. "But most diabetics are Type 2 —their pancreas is working partially." He says the key for these patients is to keep blood sugar below 200.
Monitoring glucose levels, and keeping blood sugar below 200, reduces the likelihood of co-morbidities, such as amputations. On the flip side, if blood sugar drops too low, diabetics could slip into a coma.
Technology has yielded a wide variety of glucose monitors that track data and reduce the pain associated with testing with small blood samples and alternate site testing.
"All glucose monitors now store a certain amount of test results and most can average the results over a period of time, i.e. seven days, 14 days, etc.," says Suess. "This shows the patient if his condition is improving. Most glucose monitors now use very little blood. This allows the patient to use thinner lancets and syringes which means less pain. With less pain, the patient is inclined to be more compliant."
Reimbursement for diabetic supplies is still going strong and hasn't changed much in the past few years. "In order to make a profit, you have to steer the patient away from brand names to secondary manufacturers," advises Suess. "You are increasing your profit and, as long as the quality is equal, you are not hurting the patient. Medicare doesn't pay for insulin or syringes. These items, together with alcohol pads, cold packs, ID bracelets, diabetic socks, wound creams, etc. offer a potential for cash sales."
TIP: Patient education can go a long way in boosting referrals and increasing sales. In fact, partnering with diabetes educators or developing a Web site devoted to patient information may be just what the doctor ordered for sluggish diabetes sales. "The diabetic patient is definitely more educated about the disease then he was five years ago," says Pharma Supply's Frank Suess. "Not only the young and middle-aged patients, but also senior citizens are looking for more knowledge about the disease. And with the help of the Internet, patients can easily gather information about their condition. The American Diabetes Association and other organizations distribute a host of printed material. Patients don't just depend on doctors or nurses anymore, but have access to diabetes educators."
The Future of Diabetes Testing
Blood Pressure Monitors
Cardiovascular disease and stroke, a serious co-morbidity associated with diabetes, accounts for about 65 percent of deaths in people with diabetes. A heart attack or stroke can occur because diabetes makes blood more likely to clot, according to Medline's Compass Diabetes Resource.
But what puts diabetes at a greater risk for cardiovascular disease is the prevalence of high blood pressure associated with the condition. According to the American Diabetes Association, approximately 73 percent of adults with diabetes have blood pressure greater than or equal to 130/80 mmHg or use prescription medications for hypertension. Diabetes can have a negative effect on arteries, predisposing them to hardening or atherosclerosis, a cause of high blood pressure.
The hardening of the arteries causes the heart to work harder, which is why keeping a handle on blood pressure is essential for managing cardiovascular disease. Atherosclerosis can lead to stroke, heart failure or heart attack.
While medication and lifestyle changes target high blood pressure, the treatment plan often entails home monitoring of blood pressure to stay on track. Offering a choice of blood pressure equipment or a glucose monitor that also takes blood pressure readings can help diabetic clients manage their conditions.
Medline Offers Resource for Managing Diabetes
Footwear
People with diabetes experience a wide range of foot problems involving nerve damage, or neuropathy, and poor blood flow. As a result, even normal foot problems can lead to serious complications.
Common skin changes, like dry, cracked skin or calluses, in fact may lead to severe infections, such as foot ulcers, that result in amputation. Poor circulation and high glucose levels further complicate matters, making it harder to fight infection and heal problem areas. For that reason, it is important that diabetics take good care of their feet.
According to a study by the Seattle Veterans Affairs Medical Center, 86 percent of amputations were attributed to minor trauma causing tissue injury. The study also showed that shoe-related repetitive pressure led to cutaneous ulceration in 36 percent of all cases.
Because of neuropathy, which often presents as numbness, many diabetics may not feel ulcerations on their feet.
Manufacturers have developed a wide range of diabetic footwear that targets sensitive areas, reducing pressure with non-binding materials for a more comfortable fit. Well-fitting, properly constructed shoes and inserts can greatly reduce repetitive stresses for people with loss of sensation.
The American Diabetes Association asserts that foot care programs can reduce amputation rates by 45-85 percent.
TIP: The American Podiatric Medical Association (APMA) lists the following warning signs of foot complications:
- Changes in skin color
- Elevation in skin temperature
- Swelling of the foot or ankle
- Pain in the legs
- Open sores on the feet that are slow to heal
- Ingrown and fungal toenails
- Bleeding corns or calluses
- Dry cracks in the skin, especially around the heel
Wound Care, Cushions & Support Surfaces
Neuropathy, or loss of sensation, and predisposition to diabetic ulcers makes skin care an important part of managing diabetes, especially because diabetes makes wound healing difficult.
"Diabetes …slows down the healing process, which causes diabetic ulcers," says Suess.
Wound care starts with preventative products like cushions and support surfaces to redistribute pressure. As neuropathy progresses to the feet, limiting mobility, these products become more important, especially when using mobility devices.
"The focus of care for a person with diabetes and a wound must be a total systems approach," says Margaret Falconio-West, BSN, RN, APN/CNS, ET, CWOCN, DAPWCA, vice president, Clinical Education, Medline Industries, Mundlelein, Ill. "Controlling blood sugars is necessary, especially when the potential for blood sugar fluctuation is increased (as with infection). Good foot care including appropriate foot wear is essential for anyone with diabetes. Aggressive wound debridement as well as the use of topical antimicrobial agents can be the key to decreasing the incidence of infection and even preventing amputation."
Mobility
Nerve damage, also known as neuropathy, can impact a diabetic's mobility. Neuropathy is often associated with loss of feeling and pain, and can affect other body systems. According to Medline's Compass Diabetes Resource, three types of peripheral neuropathy exist: motor, which mainly affects the muscles and general muscular movement; sensory, which affects the ability to feel or sense stimuli, such as hot or cold; and autonomic, which affects involuntary movements and causes abnormal sweating.
"Neuropathy weakens the foot and ankle which can result in foot drop," says Suess. For those diabetics who cannot feel their feet or ankles, a scooter may be ideal for keeping them mobile.
For minor numbness canes, walkers or rollators can be helpful.
In addition, neuropathy also can lead to amputation of the foot or leg. Nerve damage, which reduces sensation, and poor blood flow create a perfect environment for infections that lead to amputation. According to the American Diabetes Association, in 2002, 82,000 nontraumatic lower-limb amputations were performed in people with diabetes.
Scooters and wheelchairs are essential to keeping clients with amputations mobile and independent.
While Kansas City, Kan-based PaceSaver/Leisure-Lift does not actively market mobility products to diabetic clients, says CEO DuWayne Kramer, scooters do offer benefits. "We deal with the mobility consequences of obesity, diabetics who can't walk and amputation," he explains. Kramer says providers should be marketing products for diabetic clients with limited mobility.
Sleep Apnea & Diabetes: Is There A Link?
Sleep Apnea & Diabetes: Is There A Link?
Recent studies have revealed an interesting trend: obstructive sleep apnea (OSA) shows a strong connection with diabetes. Though clinical studies are currently under way to further explore the relationship, research indicates that as many as 30 to 40 percent of diabetic patients also have OSA, says James Herdegen, MD, medical director, Center for Sleep and Ventilatory Disorders Section of Pulmonary, Critical Care and Sleep Medicine, the University of Illinois Medical Center, Chicago.
"There are a number of studies now that suggest that sleep apnea increases the risk of insulin resistance, which is a prediabetic condition," says Herdegen. "There's been several studies that have shown that the more severe someone's sleep apnea is, the greater the risk of having insulin resistance."
Perhaps the strongest proof of the correlation is the improvement in the control of glucose levels after treating sleep apnea with CPAP. Studies have shown that diabetes biomarkers, including glucose values and Hemoglobin A1C, improve with the successful treatment of sleep apnea.
And what does weight have to do with the coexisting conditions? "A couple of studies have tried to separate out the issue of being overweight and having sleep apnea and have shown that regardless of whether you're overweight or not, if you have sleep apnea and you're overweight, your risk of having diabetes or insulin resistance is higher than if you're just overweight," says Herdegen.
The Future of Diabetes Testing
Pain management has long been the crux of diabetes monitoring. Ray Krauss, CEO of GlucoLight, calls the manufacturer's quest to alleviate pain from testing the "holy grail of diabetes monitoring." The company is inching ever closer to that end with its new product set to launch in hospitals in 2008.
"We set out four years ago to see if we could develop a continuous noninvasive way to measure blood sugar to reduce the need for finger sticks and to provide diabetic patients with a lot more data more often," says Krauss.
The result is the GlucoLight, which uses near infrared light to scan the skin from top to bottom. The proprietary design picks up physiology in the skin that correlates to the presence or absence of glucose. The device locks onto the target and continuously scans the skin to provide real-time glucose monitoring.
"We're not measuring blood directly; we're measuring near the blood," explains Krauss.
The device requires only one drop of blood to calibrate glucose and scanning can occur anywhere were the skin is reasonably normal, or not calloused, including the arm, leg, upper chest or earlobes, says Krauss.
After the company collects sufficient data from medical professionals in the hospital setting, it intends to shrink the device down for consumer use. Though the consumer product is still four or five years away, the vision is a wearable device that continually tracks glucose levels for better diabetes management.
"You can imagine if you're a diabetic consumer, instead of pricking your finger a couple of times a day if you're a Type 2 or maybe eight to 10 times a day if you're a Type 1, now you could potentially be wearing a device that as you're eating a meal …you can actually watch your glucose rising minute by minute and take appropriate action," says Krauss.
How Well Do You Know the Diabetic Client?
The following statistics are available at the American Diabetes Association Web site, www.diabetes.org:
- Diabetes is the fifth deadliest disease in the United States.
- An estimated 20.8 million children and adults in the United States, or 7 percent of the population, have diabetes. While an estimated 14.6 million have been diagnosed, 6.2 million people are not aware that they have the disease.
- Each day, approximately 4,110 people are diagnosed with diabetes.
- One out of every 10 health care dollars spent in the United States is spent on diabetes and its complications.
- Heart disease and stroke account for about 65 percent of deaths in people with diabetes.
- About 73 percent of adults with diabetes have blood pressure greater than or equal to 130/80 mm Hg or use prescription medications for hypertension.
- Blood pressure control reduces the risk of cardiovascular disease (heart disease or stroke) among persons with diabetes by 33-50 percent.
- Diabetic retinopathy causes 12,000 to 24,000 new cases of blindness each year making diabetes the leading cause of new cases of blindness in adults 20-74 years of age.
- Diabetes is the leading cause of kidney failure, accounting for 44 percent of new cases in 2002.
- About 60-70 percent of people with diabetes have mild to severe forms of nervous system damage. The results of such damage include impaired sensation or pain in the feet or hands, slowed digestion of food in the stomach, carpal tunnel syndrome and other nerve problems.
- Almost 30 percent of people with diabetes age 40 years or older have impaired sensation in the feet (i.e., at least one area that lacks feeling).
- More than 60 percent of non-traumatic lower-limb amputations occur in people with diabetes.
Medline Offers Resource for Managing Diabetes
Medline Industries' comprehensive education program, Compass Diabetes Resource, addresses diabetes in long-term care, including complications of diabetes such as heart disease, stroke, high blood pressure, blindness, kidney disease, dental disease, nervous system disease and amputation.
The resource offers everything needed to educate staff and family members. The guide includes:
- Director of Nursing (DON) Instruction Manual, a teacher's guide to the Compass Diabetes Resource, which includes four CE training hours
- Three Glucose Monitoring Training Resource Books
- Five Family Education Books
- Educational Compact Discs, two discs to educate staff on using the Optium? Glucose Monitoring System.
For more information on the Compass Diabetes Resource box, contact Medline at (800) MEDLINE.
This article originally appeared in the April 2007 issue of HME Business.