Global Challenges and Solutions for Our Diabetic Patients

I met Mr. W when he was first diagnosed with diabetes. He came in with diabetic ketoacidosis (DKA). He had a full work-up, he definitely had type 2 diabetes, and he was labeled as DKA-prone type 2. The diagnosis was tough on him. He didn’t fully understand what it meant to have diabetes, and the medications he was prescribed were confusing and potentially deadly when taken incorrectly. I got to know him well during my training because I saw him almost every time I was on call. He didn’t garner much sympathy from anyone. Attendings and residents across many specialties labeled Mr. W a “frequent flyer.” The hospital used all of the resources it had on him—from social work to case management. He seemingly had access to the tools that he needed to succeed—his medications, a primary care physician, and specialists. Yet, he was never out of the hospital long enough to make his follow-up appointments.

I began to question whether the tools that we thought were helpful were enough for him. We may think we are doing enough on our end to make patients' lives better, but we fail to realize that our patients’ lives are very complicated. Sometimes the tools we offer are just not enough.

An article recently published in Annals, “Excess Burden of Mental Illness and Hospitalization in Young-Onset Type 2 Diabetes: A Population-Based Cohort Study,” struck me because this study of patients in Hong Kong suggests that the challenges facing my patient in the United States exist globally. Regardless of the economy or wealth of a nation, having a chronic illness is difficult and dealing with the complexities of life while having a complex disease is exceedingly difficult. I wonder then: What is my role as a physician? What can I do to improve my patients’ outcomes?

The authors write:

In our large population- and registry-based study, the burden of hospitalization in patients with [young-onset type 2 diabetes] showed a striking evolution across the lifespan. We found a previously unknown burden of serious mental illness before age 40 years, and understanding its causes is imperative to improving mental health care in young adults... These associations were partially mediated by control of modifiable risk factors, demonstrating the importance of early intervention to reduce the adverse effects of cumulative exposure to cardiometabolic risk factors…. Hospitalization rates in patients with [young-onset type 2 diabetes] were reduced by one third with intensified management and by more than half if onset was delayed until age 40 years. (1)

When discussing Mr. W, I would often hear health care professionals say, "We're doing everything we can." But were we? Were we focusing on his needs, evaluating for possible mental illness, and looking at social determinants of his health? Were we able to fully understand the burden of a diabetes diagnosis? Was there anything we could do to make a difference for Mr. W?

The study reported in Annals shows that the challenges of diabetes are global. We should look for areas of idea exchange to improve outcomes. Lower hospitalization rates were associated with focused care. Perhaps more focused care could help keep Mr. W out of the hospital for longer. Making appointments, diabetic teaching in the hospital, even psychiatric management did nothing to prevent him from coming back in. For patients like Mr. W who can exist anywhere, we need more than these interventions.

Reference

1. Ke C, Lau E, Shah BR, Stukel TA, Ma RC, So WY, et al. Excess burden of mental illness and hospitalization in young-onset type 2 diabetes: A population-based cohort study. Ann Intern Med. 2019. [PMID: 30641547] doi:10.7326/M18-1900