Co-production of diabetes care: Not doing me justice

Dr. Maren Batalden’s story:

In a diabetes group, a woman who was being seen by one my colleagues said to her doctor:  “Why are you so obsessed with this blood sugar number [Hemoglobin A1c]?!  In so many ways I’m so much healthier:  I’m eating better, exercising, losing weight.  I have a job, and I’m not drinking like I was six months ago.  I feel so good, and so empowered and supported by this group.  But my HgbA1C hasn’t moved yet.  I feel like these measures are not actually doing me justice.”  

Hemoglobin A1C is a blood test which measures average blood sugars over a three month period.  Doctors and patients use it to evaluate the degree to which a person’s diabetes has been “in control” in recent months. Ultimately the HbA1c should reflect the positive changes that the woman above is making, but sometimes it takes a while.  We have to be patient with that process.  Sometimes a person with diabetes needs to focus on some more foundational life changes that will eventually be reflected in the blood test, but may take several months to manifest.

Our efforts to measure and improve health outcomes in chronic diseases like diabetes have become “performance measures” for health professionals by which payers evaluate the “quality” of care being provided. In a subtle way, this has confused us about the nature of health professional work.  We’ve come to see numbers like the Hemoglobin A1c as if they are something that health professionals produce.  In fact, of course, numbers like these are co-produced by patients and health professionals working together.  In fact, blood sugar is largely controlled by people with diabetes – not their nurses and doctors and nutritionists. Blood sugar is determined by the everyday decisions of a person with diabetes -- what they eat and how they exercise.  The doctor is a bit player.  The doctor prescribes medication, helps to decide when it’s time to start insulin, or go up on a dose, and does a little teaching.  But most of the learning happens outside of the clinic, in the life of the person with diabetes in relationship with their families, by trial and error.

If they care about health outcomes for their patients, health professionals need to reframe their work.  Health professionals need to ask themselves not “How can I be successful in lowering my patient’s hemoglobin A1C” but rather “How can I be most useful, most helpful, most supportive to the person with diabetes who is already working in whatever way he or she can to be healthy?”

Thanks to Dr. Maren Batalden for her story.  Read Dr. Batalden's article on co-production, mentioned by the Institute for Healthcare Improvement today.