Source: Close Concerns from ADA 2019
The inimitable Dr. Anne Peters (USC Keck School of Medicine, Los Angeles, CA) delivered a powerful presentation on the barriers faced by patients living in under-resourced communities. “I don’t care if you’re rich or poor, I believe you need access to high quality diabetes care.” Drawing from her experiences treating patients at her diabetes clinic in East Los Angeles, she outlined two basic tenets for treating underserved patients: (i) technology alone fixes nothing; and (ii) technology combined with “unbelievably” persistent, actualizable, and incremental alterations in treatment can change everything. Dr. Peters rattled off a slew of challenges, including a medical system designed for a different demographic (“there’s a lot of energy around type 1 diabetes and technology that my patients don’t really touch” – pictures of caucasian Apple Watch users on CGM websites don’t necessarily resonate for obvious reasons); complex and stressful life situations (“diabetes may be way over here, while they’re running out of food and facing eviction”); and distrust of the traditional healthcare system. Her ask? Simple solutions with a high benefit that don’t disrupt patients’ already fragile system of existence. As she put it, “they need tools that work right now in the real world.” Sometimes, these solutions can have unintentional consequences. To this end, she shared unpublished data from the STEPP-UP study, an intervention funded by the Helmsley Charitable Trust to develop low-literacy educational tools for diabetes devices. While she was unable to provide the details, “the short story” showed a statistically significant increase in diabetes knowledge, decrease in diabetes distress and depression, and “an extreme increase” in fear of hypoglycemia. As Dr. Peters pointed out, sometimes this fear is yet another burden that patients may not want to experience. Still, despite this downside and a lack of change in patients’ glycemic control, Dr. Peters believes the study demonstrated the potential effectiveness of tailored educational tools. Ultimately, Dr. Peters called for a “DIY diabetes survival kit” to manage care for patients living in these communities. Among her proposed solutions were: (i) an accessible type 1 diabetes help line; (ii) simple, subsidized programs to provide devices to patients; (iii) unlimited monthly visits with diabetes educators or other health coaches from similar backgrounds; and (iv) diversity support by simplifying access and reducing language barriers.
- To illustrate the importance of having solutions come from patients rather than clinicians, Dr. Peters shared a particularly compelling story of one of her patients who works as a mechanic. He was performing fingersticks just once or twice a week. When Dr. Peters met with him, she realized that his hands were so brutally callused (from his day job) that it was extremely painful and difficult for him to take a fingerstick – the photograph was shocking. Her immediate instinct was to prescribe him a CGM; however, he shared that he has to “slither” on the ground between trucks during his job, which presented a sensor adhesion challenge. Walking between trucks instead was not an option, as the boss would fire him for taking too much time to get between the trucks. The ultimate solution came from the patient – he realized that he could wear the sensor under a lumbar support band that he already used at work, preventing the sensor from being ripped out. It was just one example demonstrating the level of troubleshooting that must occur to effectively integrate technology into patients’ lives.
- We were very distressed to hear some of the challenges associated with applying for diabetes devices. The system is simply not designed with underserved patients in mind – in just one example, Dr. Peters explained how order forms require an email address, which many of her patients do not have. She also explained that it can be incredibly burdensome to find device support and assistance in Spanish – one (not named) CGM company had a terrible Spanish help line experience, while another had a fantastic one. As she pointed out, Spanish is an extremely common language in the US – imagine what patients who speak less-common languages must undergo.