Washington state's decision to review the efficacy, safety, cost, and health impact of glucose monitoring in children with diabetes has sparked debate.
An editorial in today’s Wall Street Journal concerns a public meeting to be held today by Washington state’s Health Technology Assessment program that will discuss the program’s final evidence report on the “efficacy, safety, cost, and health impact of glucose monitoring on clinical outcomes among patients with diabetes (and/or subgroups)” under the age of 18.
The Health Technology Assessment program (HTA) is an arm of the Washington State Health Care Authority that focuses on comparative effectiveness research.
The Wall Street Journal contends that this “government board may decide that modern medicine is too expensive for kids with diabetes.” Far from being “controversial” as HTA calls it, blood glucose monitoring in children with diabetes under the age of 18 is “the established medical consensus for at least three decades” and “banning continuous monitors or limit[ing] finger sticks to a certain daily number…” smacks of “a government board looking to scrimp.”
The larger issue, according to the Journal, is related to “billions of dollars” devoted to comparative effectiveness research as part of health care reform and economic stimulus legislation. “As President Obama has so often put it, the idea is to pit Treatment X against Treatment Y and find out ‘what works and what doesn't.’ In theory, it sounds great. But the Health Technology Assessment is an example of how comparative effectiveness will work in the real world, as the political system tries to find ways to restrict or limit treatment to control entitlement spending.”
But is this stance misleading? Aaron E. Carroll, MD thinks so.
“Regardless of what the WSJ thinks, our care of children with diabetes is sub-optimal,” Carroll writes in a piece at The Incidental Economist. Blood glucose testing, he says, is not as simple as giving a child their monitor and sending them on their way.
“Part of the problem is that even a perfectly well controlled child with diabetes often has wildly fluctuating glucose values, likely due to hormonal changes during development and puberty. Testing also sucks. It’s painful, it’s intrusive, and it’s often stigmatizing. Moreover, children with diabetes naturally rebel against their parents as they try and establish independence. Control of diabetes — especially testing – becomes the means by which adolescents sometimes establish their independence. It’s a mess.”
Carroll would know. As an assistant professor of Pediatrics in the Children’s Health Services Research Program at the Indiana University School of Medicine, and the Director of the Center for Health Policy and Professionalism Research, he has led many studies on the topic.
Technology may not even be the answer, Carroll says. “When I began my work in the area, I assumed that better technology was the answer. But after lots of work talking to adolescents with diabetes and their parents, it turns out that better communication may be more important than technology. Or, technology that improves communication may be helpful. I’m not convinced that testing in and of itself is necessarily the answer.”
Carroll’s argument doesn’t stop at the literature, but what he believes to be the Journal’s selective use of it. When the Journal writes that “the best way to manage this chronic disease is with frequent self-monitoring and then calibrating the insulin dose to current blood-sugar levels,” they are citing studies in which the cohorts were adult populations.
“Children,” Carroll writes, “are not just ‘little adults.’ They act differently, they have to be approached differently, and their body chemistry works differently. What is great for adults is not often great for children. Sometimes we need to do research on children, too.”
This research, however, can’t be “met with cries of RATIONING and DEATH PANELS” or “things will never get better. “We won’t know that without research! We won’t know if we don’t check.”
Additional resources from HTA:
So what do you think?
Leave a comment below.