Diabetes-Related Complications: A Focus on Diabetic Macular Edema - Episode 6
Peter Salgo, MD: We were all talking about Medicare. Let me pick up on one Medicare issue.
Steven Peskin, MD, MBA, FACP: Sure.
Peter Salgo, MD: Medicare will not pay for continuous glucose monitoring, except in very limited cases. Is this good medicine? And is this position, on the part of Medicare, cost-effective?
Rishi P. Singh, MD: Well, I can only speak on behalf of ophthalmologists. We have found that, at least, A1c value is reason enough to follow the patient from a blood sugar perspective. We don’t need the daily blood sugars. It’s helpful when the patient has blurred vision and we’re trying to determine the blurred vision cause, or we’re not giving glasses when their blood sugar is 400 to 500. Otherwise, we don’t use the typical day-to-day blood sugar. We use the A1c value.
Peter Salgo, MD: What you’re implying is that you’re looking to see, in terms of etiology, whether this is something in the retina or whether this is something in the lens.
Rishi P. Singh, MD: In the lens of the eye, yup.
Peter Salgo, MD: Or simply that the osmolality of the blood and the vitreous is all wacked.
Rishi P. Singh, MD: That’s right. And I can’t speak for the primary care people, but I’d love to hear the opinions of the table as far as that goes.
John W. Kitchens, MD: You know, I’ll tell you, it’s the old axiom from medical school of, “Don’t order a test unless you’re going to do something about it.” If you’re not taking insulin, then why are you doing continuous blood glucose monitoring?
So, only if you’re going to do something dynamically to change that measurement do you really need it. Now, in those patients that are taking insulin and are dosing based on their sugars, it’s invaluable.
Peter Salgo, MD: I actually heard you say that if you’re not taking insulin, and you’re just taking oral hypoglycemics, why bother checking glucose at all.
John W. Kitchens, MD: Sure, continuous glucose monitoring.
Peter Salgo, MD: Continuous glucose monitoring.
Steven Peskin, MD, MBA, FACP: And I’d go further than that. An individual who is doing well, on say metformin and maybe a dipeptidyl peptidase-4, there’s not a reason to routinely check blood sugar. Again, if you’re having a certain symptom of hypo or hyperglycemia? Absolutely. But absent that, the A1c will give you the information that you need because that shows glucose over time as opposed to any, “Oh, it was 172.” Again, if I’m on oral agents, what am I going to do with that?
Peter Salgo, MD: When I was in medical school, if you professed this, you got kicked out. “We want more data.” “We want more labs.” “We want to know more about our patients.” What’s wrong with that position?
Steven Peskin, MD, MBA, FACP: Well, remember telling patients to check their urine sugar? And then we threw that out and said, “Oh, that’s really worthless.”
Peter Salgo, MD: Glutamic acid decarboxylase autoantibodies, we used to check all the time, right?
Rishi P. Singh, MD: Or prostate-specific antigen samples.
John W. Kitchens, MD: I love our patients, but we’ll have some that come in with this list of all their blood sugars for the last 30 days checked three or four times a day, and they’ll want you to look at it. And you say, “Just tell me your A1c.” And the one thing that that shows is that they care. But aside from that, I’m not going to do anything with that 384 on March 10th at 2 PM in the afternoon.
Peter Salgo, MD: It sounds to me, if they’re doing that many blood checks, you’d do better to check their hematocrit, frankly, than their blood sugar.