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Episode 56 continues from where we left off last time with type 2 diabetes. In this podcast, we bring out the numbers and put the risks of diabetes into context by discussing the absolute cardiovascular risks associated with different levels of HbA1c. In addition, we talk about other things to look at in the evaluation of type 2 diabetes and Jillian Popel again joins us for the ride. She is quite shocked by what she hears about how “absolutely low” the renal risks associated with type 2 diabetics really are. She is also quite shocked by most of what Mike and James have to say in general, but that’s a whole other issue for another time.
Show Notes
1) Diabetes is NOT a CHD risk equivalent
2) Calculating cardiovascular risk for type 2 diabetics
3) The risks associated with diabetes
{ 3 comments… read them below or add one }
In the USA Pay for Performance is becoming more and more prevalent for diabetics. So you get a bonus payment for diabetics if yearly they get: a foot exam, eye exam, microablumin assessment, smoking advice/cessation, and an A1c (usually less than 9). While some of these are reasonable, I don’t understand why we need to spend so much time arranging our new 45 year old diabetics to get over to the podiatrist. Literally, we’ve made whole systems to make sure people get to a podiatrist and a ophthalmologist every year. It seems like a lot of it is a big waste of time. Have you found any evidence that yearly foot exams save lives? or Feet?
Hi rocky3200. Thanks for your comment/question.
We don’t know of any studies and likely is based on extrapolated evidence.
In Canada, our foot assessment for diabetic neuropathy is done with a tuning fork or even better a monofilament.
The monofilament costs about $5 and is reusable.
It comes on a card showing where to press.
If it bends and they still can’t feel it, they then need an assessment – this happens 1% of the time in my (Mike’s) practice (when we do it!).
The following is a VERY ROUGH and likely full of holes economic analysis. If the podiatry assessment is $100. That means my yearly cost is $105 dollars (one referral, likely to neuro – not podiatry) and if we sent everyone it would cost $10,000 (assuming 100 DM pts in a small practice). Patients also don’t have to make the extra trip, etc.
If you find an answer to this foot testing business (saving feet or lives), let us know.
Our guidelines only give one sentence to justify it in Type 2 DM: “In those with type 2 diabetes, lower blood glucose levels are associated with reduced frequency of neuropathy” (NEJM 1995;333:89-94 & Lancet 1998;352:837-53 (UKPDS). Interestingly neither of these references provide solid evidence – the NEJM is not a treatment trial and even though the UKPDS was a treatment study all they showed was a biothesiometer test was “better” in the treatment group at 15 years but no other time frame. Amputations were no different but there were very few overall.
Thanks James,
We use a monofilament too… that’s another requirement. But we also have to send them to the opthomologist and the podiatrist.
See this timely article for more on all this foot testing: http://www.aafp.org/afp/20090901/editorials.html
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