May 19, 2005

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On the cover: Dr. Alan Glaseroff test his blood sugar. Photo by Bob Doran.
Measuring up: How a local diabetes project may help change the face of medicine

by HANK SIMS

November 2002 was not a good month for Cindy Dobereiner. [photo below right]

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 says.

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 numbers around.

The new medicine?

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."

Measuring health care

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 questionnaire
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 one.

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."

Lagging behind

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 community.

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.

More understanding

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 to retrain."

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 health.

"You asked him how he feels, and the answer would always be, 'I feel great!'" Glaseroff said.

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 down.

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 case.

The patient had died the day before.

(Freelance reporter Karol Wilcox contributed to this report.)

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