Study Authors Recommend Adding Palliative Care to Diabetes Management
Almost half of adults with type 2 diabetes report acute and chronic pain, and close to one quarter report neuropathy, fatigue, depression, sleep disturbance and physical or emotional disability, according to a study of more than 13,000 adults conducted by researchers at the San Francisco VA Medical Center, the University of California, San Francisco and the Kaiser Permanente Division of Research in Oakland, Calif. The researchers also found significant rates of shortness of breath, nausea and constipation.
Patients in the study reported significant pain and non-pain symptoms across the entire course of the disease, among all age groups, with prevalence increasing as people neared the end of their lives.
The findings appear in the Journal of General Internal Medicine and were made available online last week at www.SpringerLink.com. According to the authors, it is the largest observational study to assess a full range of pain and non-pain symptoms among patients with type 2 diabetes, and the first to characterize the kinds of symptoms that patients experience.
"Adults living with type 2 diabetes are suffering from incredibly high rates of pain and non-pain symptoms, at levels similar to patients with living with cancer," said lead author Rebecca Sudore, a staff physician at SFVAMC and associate professor of medicine at UCSF.
She noted that tens of millions of Americans have type 2 diabetes.
"The field of diabetes has focused, and rightfully so, on decreasing patients' blood sugar, blood pressure and cholesterol levels in attempt to prevent complications such as cardiovascular disease, kidney failure, amputations and blindness," said Andrew J. Karter, PhD, a principal investigator of the DISTANCE and Diabetes & Aging Studies, and senior research scientist at Kaiser. "However, our observations provide an important wake up call for clinicians to not wait until the latest stages of diabetes to focus on these patient-reported outcomes, but rather to consider early palliative care as part of usual chronic disease management."
Palliative care is specialized medical care for people with serious illness that provides an added layer of support in addition to regular disease management, with the goal of relieving symptoms and improving quality of life, explained Sudore. She noted that other studies suggest that seriously ill patients who receive palliative care live longer with a better quality of life.
"Palliative care has already begun to be woven into the care provided to patients with cancer, heart failure and kidney failure," she said. "Our results highlight the need to expand diabetes management to also include the palliative care model."
The research team surveyed 13,171 adults with diabetes, aged 30 to 75 years, who were enrolled in Kaiser Permanente Northern California and participated in the NIH-funded Diabetes Study of Northern California (DISTANCE) and its ancillary Diabetes & Aging Study.
Adults over the age of 60 reported more physical symptoms such as pain, whereas adults younger than 60 reported more psychosocial symptoms such as fatigue and depression. Symptom burden remained high even after the researchers accounted for other medical illnesses and duration of diabetes. Results were based on self-reported symptoms and chart review.
In type 2 diabetes, the most common form of the disease, patients' blood sugars become chronically elevated, which in turn damages blood vessels and nerves leading to and from the heart, brain, kidneys, gastrointestinal tract, eyes, ears, legs and feet. This damage can lead to serious illness and death.
Dean Schillinger, MD, of the UCSF Center for Vulnerable Populations and UCSF Division of General Internal Medicine at San Francisco General Hospital, is senior co-author of the study. He also is director of the California Diabetes Program, a federally-funded program that is administered by UCSF for the California Department of Public Health. Elbert S. Huang, MD, of the University of Chicago, is the co-Principal Investigator for the Diabetes & Aging Study and co-Director for the Chicago Center for Diabetes Translation Research.
Co-authors include Andrew J. Karter, PhD; Howard H. Moffet, MPH; Jennifer Liu, MPH; Alyce Adams, PhD; and Rachael Whitmer, PhD from the Division of Research, Kaiser Permanente Northern California; Elbert S. Huang, MD, MPH; Neda Laiteerapong, MD; and Priya John, MPH from the University of Chicago, Chicago; Yael Schenker, MD from the University of Pittsburgh, and Yinghui Miao, MPH from the University of California, San Francisco.
Funds were provided by the National Institute of Diabetes, Digestive and Kidney Diseases, the National Institute of Child Health and Human Development and the National Center for Research Resources. Dr. Sudore is supported by funds from the Department of Veterans Affairs. Schillinger is supported by a grant from Agency for Healthcare Research and Quality and a NIH Clinical and Translational Science Award.
About the San Francisco VA Medical Center
SFVAMC has the largest medical research program in the national VA system, with more than 200 research scientists, all of whom are faculty members at UCSF.
UCSF is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care.
About the Kaiser Permanente Division of Research
The Kaiser Permanente Division of Research conducts, publishes, and disseminates epidemiologic and health services research to improve the health and medical care of Kaiser Permanente members and the society at large. It seeks to understand the determinants of illness and well-being and to improve the quality and cost-effectiveness of health care. Currently, DOR's 500-plus staff is working on more than 250 epidemiological and health services research projects.
About Kaiser Permanente
Kaiser Permanente is committed to helping shape the future of health care. We are recognized as one of America's leading health care providers and not-for-profit health plans. Founded in 1945, our mission is to provide high-quality, affordable health care services to improve the health of our members and the communities we serve. We currently serve 8.6 million members in nine states and the District of Columbia. Care for members and patients is focused on their total health and guided by their personal physicians, specialists and team of caregivers. Our expert and caring medical teams are empowered and supported by industry-leading technology advances and tools for health promotion, disease prevention, state-of-the art care delivery and world-class chronic disease management. Kaiser Permanente is dedicated to care innovations, clinical research, health education and the support of community health. For more information, go to: www.kp.org/newscenter.