May 19, 2005
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On the cover: Dr. Alan Glaseroff
test his blood sugar. Photo by Bob Doran.
up: How a local diabetes project may help change the face of
November 2002 was not a good
month for Cindy Dobereiner. [photo
Her husband had been laid off
from Pacific Lumber Co. for about a year. He was collecting unemployment
while he took courses in computers, an attempt to find a career
that paid at least as well as his old job. She was on disability.
The family was living in Scotia, but the Dobereiners would soon
have to move from their company-owned home.
So the stress had already been building when, in
mid-November, Dobereiner was diagnosed with diabetes. A few days
later, her mother died. Her grief and her fears about her family's
future together pushed her newly discovered illness to the bottom
of her list of problems. She didn't so much ignore her diabetes
as deny that it existed.
"For the first few months,
I said to myself, 'This is B.S. I don't have this,'" she
As she now knows, she was headed
down a dangerous path. She says that what saved her -- apart
from God and her nurse practitioner -- was the example set by
her son's friend's mother a few months later. While resting in
her easy chair one afternoon, the woman dropped dead from a diabetes-related
heart attack. She was 43 years old.
"I went straight to my
doctor," Dobereiner says. "I thought to myself, `I
want to see my grandkids' kids.' I said, `O.K., I'm ready.'"
Since that day, diabetes has
been both Dobereiner's burden and her calling. Now 50 years old
and living in Rio Dell, she keeps her own diabetes on a very
tight leash, checking her blood sugar levels several times a
day and keeping all her medical appointments. And she travels
around the county meeting with other diabetics, offering her
support to others afflicted by the chronic illness, which can
quickly turn deadly if not managed properly.
There is only so much she can
do. In recent months, she says, three people she knew died of
complications stemming from their diabetes -- complications that
were likely preventable if they had been as fastidious as Dobereiner
in taking care of themselves. One was a man in his early 30s;
the other two were women in their 40s.
Lately, though, there has been
some good news -- actually, some extraordinary news -- for the
estimated 9,000 diagnosed diabetics in Humboldt and Del Norte
counties. (If national figures hold true here, another 3,600
local people have the disease without knowing it.) The local
medical community has recently finished the first phase of a
project designed to improve diabetes care, and its initial results
have been remarkably encouraging. The county once lagged behind
the national average in several key indicators of diabetic health;
in just a year, through the efforts of local physicians, nurses
and peer counselors like Dobereiner, the county has turned those
Perhaps even more impressive
than these immediate results is the contribution that the program
-- called the Humboldt Diabetes Project -- is making in a current
debate over reform of medical care in the United States. At its
core, the Humboldt Diabetes Project is based on the idea that
doctors must engage in sometimes painful self-criticism. The
project never would have been launched if area doctors had not
been willing to admit that they were not doing as well they could
with their diabetic patients -- that they might not be managing
their patients' files well; that they might not be completely
up-to-date on best medical practices; and that they might not
really know how to do something as simple as talk to their patients.
This dose of humility is key
to a movement in medicine known as "quality improvement,"
and the Humboldt Diabetes Project has become a widely known piece
of evidence supporting its precepts. Its implications extend
far beyond diabetes care, and far beyond the confines of the
Redwood Curtain. Dr. Wells Shoemaker, medical director of Santa
Cruz County's Physicians Medical Group, is working to institute
a similar program in his part of the state.
"I'm on conference calls
once or twice a week with people all over the country,"
Shoemaker says. "I'm talking to people regularly -- all
the time -- and people everywhere know about what's happening
in Humboldt County."
Last Wednesday, Dr. Alan Glaseroff,
[photo at left] chief medical officer of the Humboldt-Del Norte
Independent Practice Association, was still catching up on his
work after a weekend trip to St. Louis, where he was invited
to present the first results from the Humboldt Diabetes Project
at a conference sponsored by the National Quality Forum, an institution
associated with the quality improvement movement.
Glaseroff, 53, is a balding,
lanky man with a quick smile. In his off-hours, he and his wife
Dr. Ann Lindsay -- the county's public health officer and his
partner in medical practice -- play in a blues band, the Back
Seat Drivers. In conversation, he looks straight into your eyes
and leans forward, nodding slightly as he speaks and checking
constantly to gauge if you have understood.
He is himself diabetic.
"What's happening nationally
is that there's a trend toward measuring health care," he
said. "And we're not doing very well."
Diabetes is a national tragedy.
If not strictly watched and cared for, it can lead to nerve damage,
blindness, heart failure, kidney failure, stroke, depression
and a multitude of other serious consequences. It was the sixth-leading
cause of death in the United States in the year 2000. There are
various types of diabetes, but by far the most common is "Type
2," which is in most cases preventable with a healthy diet
and a decent exercise regimen. Once it develops, the condition
never goes away.
But even if a person does get
diabetes, there are proven practices that, if strictly followed,
greatly diminish his chances of developing life-threatening or
debilitating illnesses. Patients should have their eyes examined
regularly, to check for the onset of diabetes-related blindness.
They should have regular foot exams, as foot problems -- sometimes
leading to amputation -- are a common side effect of diabetes.
They should be vaccinated regularly for influenza and pneumococcus,
a bacteria that causes types of pneumonia and meningitis.
But there were indications that
many local doctors -- like their colleagues across the nation
-- were not keeping up with the recommended treatment and testing
regime. Getting them to do so became the first target of the
Humboldt Diabetes Project.
After designing the program
in consultation with the medical community and diabetes counselors,
the IPA created a centralized system for managing the county's
diabetic patients. The IPA itself took over management of patients'
case files, in collaboration with a "site champion"
at each of the 26 medical practices participating. Between September
2003 and September 2004, the IPA sent reminders to each practice
whenever a patient became due for an exam or a regular office
visit. Patients in the system were mailed reminders.
When an exam was done, the results
would be sent back and entered in the IPA's central computerized
register of patients. The doctors could, at any time, get their
patients' past results directly through the IPA's computer system.
At the same time, they could download standardized forms designed
to streamline patient referrals to specialists or to counseling
services. By and large, the IPA took responsibility for making
sure that all the recommended practices got done.
By any measure, the project
was a success. Most the 802 patients who agreed to participate
in the study answered a survey before and after the project.
In addition, 338 of them had their progress charted by blood
test known as an A1c, a measure of the body's average glucose
levels over the previous three months.
The results were striking. All
the patients at greatest risk -- those with an A1c level of seven
or above at the start of the project -- experienced a great improvement
in their glucose levels, with the most dire patients making the
biggest gains. Survey results echoed the finding. Participants
were given a standardized questionnaire known as the SP-12, which
quizzes patients on their overall health.
The Humboldt Diabetes
Project measured patients with the SP-12 survey, a standardized
designed to gauge overall health. The results were measured against
the national average for diabetics.
Before the program began, Humboldt
County patients ranked below the national average for diabetics
in each aspect of health measured by the test. After the program,
patients ended above the national average in every measure but
More to the point, the survey
showed that the project accomplished what it set out to do. Patients
reported a great increase in the frequency of the examinations
that doctors should be routinely doing on their diabetic patients.
Before the project, only 32 percent of the patients reported
that they had received an eye exam within the past year. Afterwards,
68 percent of the patients reported that they had been examined.
Only 32 percent of patients had had their feet examined in the
year before the test began. Afterwards, 72 percent had been checked.
At the end of the project, all
26 medical practices were recognized for excellence in diabetes
care by the National Committee for Quality Assurance, a nonprofit
group dedicated to improving health care standards. This made
Humboldt the first county in the nation to be fully accredited
under the program. The American Diabetes Association certified
the local Health Education Alliance, a program set up by the
IPA, as an official diabetes educator, allowing it to directly
bill insurance companies for services provided.
Chris Cody [photo
at right] , a pediatrician with
Eureka Pediatrics, is a board member of the IPA. Though the project
did not directly involve children, Cody adopted many of the procedures
advocated by the IPA within his own office. Cody said
that the results were a testament to the hard work of the medical
community, and to local professionals' dedication to seeing the
quality of their care improve.
"The fact that this was
just with one year, with a pilot program, was phenomenal,"
Cody says. "The fact that we got all the doctors in the
community involved -- which has never been done in a rural community
before, as far as anyone knows -- to get them all on board and
educated was an extremely difficult task."
It would probably come as a
surprise to many that doctors are often far behind the times
when it comes to treating their patients with chronic illnesses.
But the science often moves faster than individual doctors can
keep up with, and the doctors themselves sometimes become set
in their ways as they age. A recent national study by the RAND
Corp. showed that medical tests recommended in treating a variety
of conditions were only performed 55 percent of the time.
One person who is not surprised
is Karen Moulton, a nurse practitioner with the Open Door Clinic
in McKinleyville. Moulton specializes in diabetes care, and was
one of the people who helped design the Humboldt Diabetes Project.
"I think if you look at
the average of how long it takes research to get into practice,
it's like 10 to 20 years," she said. "Unless you have
people working as a whole group and really on the ball about
it, it's hard to keep up with."
The quality improvement movement
is dedicated to changing this fact. Spearheaded by Dr. Don Berwick,
an immensely influential medical policy thinker at Harvard, quality
improvement is aimed at reversing the results of the RAND study
by getting doctors to follow step-by-step procedures in medical
care, rather than trusting their own instincts.
Berwick also recommends that
medical providers "open their books" -- to put their
success and failure rates on the table for all to see. When doctors
begin to realize that some of their colleagues have better treatment
rates than they do, they will want to learn from and emulate
the best practices, he says.
Jan Eldred, a senior program officer
for the California Health Care Foundation, the nonprofit group
that provided much of the initial funding for the Humboldt Diabetes
Project, said last week that quality improvement requires fundamental
changes in the way doctors see their roles. In a way, they have
to accept that they are not quite the experts they customarily
imagine themselves to be.
"It's really telling doctors
how to practice medicine," she said. "And a lot of
doctors are really resistant to that, especially in small practices
and in rural areas."
That's one of the reasons that
the Humboldt Diabetes Project has been so remarkable, she said.
It was a classic quality improvement program, but spread out
across an entire, sprawling, rural area. She credits the "wild
success" of the program to the dedication of the local medical
One large impediment to quality
improvement is beginning to undergo reform. By and large, doctors
only get paid when their patients got sick. A person goes to
the doctor's office when she is experiencing a crisis; the doctor
makes a diagnosis, prescribes a treatment and bills an insurance
company or Medicare. If a doctor teaches a patient to manage
her own health effectively, she isn't coming into the office
as much. Perversely, the doctor stands to lose.
But insurance providers are
beginning to recognize the deficiencies of this system, which
ends up costing them more in the long run. In California, an
organization called the Integrated Healthcare Association has
instituted a program called "Pay for Performance,"
under which insurance companies agree to give annual bonuses
to physicians' groups that provide superior preventive care.
Last year, six of the largest insurance companies in the state
paid out $40 million under Pay for Performance. This year, for
the first time, Humboldt County is slated to receive a large
bonus from Blue Cross -- up to $500,000 -- under the program.
According to Glaseroff, a good deal of that money is the direct
result of the success of the diabetes project.
Cindy Dobereiner tests her blood
sugar levels with a glucose meter.
These days, the Humboldt Independent
Practice Association is seeking to build on the success of the
diabetes project's first phase. Together with the Humboldt Community
Breast Health Project, the organization has received another
grant from the California Health Care Foundation to bring some
of the same methods to improving the treatment of breast disease.
At the same time, the IPA is
partnering with Community Health Alliance on a second phase of
the diabetes project, one that focuses more on getting patients
to take charge of their own care. For the medical community,
that means, in part, getting doctors and other medical providers
to accept a smaller role than the one they are accustomed to.
"We traditionally call
patients `patients' and are being told to call them `consumers,'"
Glaseroff wrote in a recent e-mail. "We give nurses `orders'
and `prescribe medications and treatments' for patients rather
than develop mutually agreeable treatment plans. Our plan is
The question this second phase
of the diabetes study seeks to answer, according to Glaseroff,
is "Why wouldn't a person with diabetes do everything in
their power to live longer and feel well?" The answer often
lies with the illness itself, which can be a cause of depression.
But many feel that through a change in habits, doctors themselves
could prepare themselves better to understand what a patient
is going through, increasing the doctor's chances of putting
a patient back on track.
On April 30 -- a Saturday --
about 170 health care professionals, some of them from other
parts of the state, attended a workshop at Arcata's North Coast
Inn designed to officially kick off the new phase of the diabetes
project. Guest speakers, renowned experts in diabetes care, were
invited to address workshop participants and run role-playing
exercises in which typical patient-doctor interactions were held
up to scrutiny.
In his introduction, Glaseroff
told the story of one of his diabetic patients, someone he had
been seeing for 20 years. He said that the patient was a nice
guy with a positive attitude. He was always upbeat about his
"You asked him how he feels,
and the answer would always be, 'I feel great!'" Glaseroff
But as the years went on, he
realized that there was more to the story. He said that the patient
began to disappear for four or five months at a time, traveling
to visit family in Nevada, and when he came back for an office
visit his condition had often taken a turn for the worse. Glaseroff
said that he became increasingly frustrated with the patient's
disregard for the seriousness of his disease. He issued stern
warnings to the patient; he even threatened to "fire"
him, thinking that perhaps another doctor would be able to do
better. The patient wouldn't have it.
"He said, `Doc, I'm not
trying to let you down. You're a great doctor, I've really connected
with you,'" Glaseroff said.
When the patient came back to
town about three weeks ago, he was in terrible condition and
had to be hospitalized. It was then, Glaseroff told the workshop
participants, that he realized what had gone wrong. An unhealthy
relationship had sprung up between them. The patient had become
too embarrassed to tell his doctor when he had slipped -- when
he stopped taking his medicine, or when he indulged in food that
he knew he shouldn't have eaten. He didn't want to let his doctor
It was a type of misunderstanding
common to many relationships between fellow, fallible human beings.
Few people would hold it against him; fewer would have any idea
what he could have done differently. For Glaseroff, that was
no excuse. Choking back tears, he admitted his part in the failed
The patient had died the day
(Freelance reporter Karol
Wilcox contributed to this report.)
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