Annals of Internal Medicine tip sheet for July 10, 2012, online issue

Economists warn that health care spending in the United States is rising at an unsustainable rate. To slow the rate of increase, while preserving high quality care, thought leaders in academic medicine suggest that clinicians focus on using medical interventions that provide good value. This means that clinicians should weigh potential benefits against potential harms and costs before initiating an intervention. As part of an ongoing initiative to promote high-value, cost-conscious care, the American College of Physicians (ACP) and the Alliance for Academic Internal Medicine (AAIM) developed a free curriculum to help train internal medicine residents about how to avoid overuse and misuse of tests and treatments that do not improve outcomes and may cause harms. The high-value, cost-conscious care curriculum is designed to engage internal medicine residents and faculty in small group activities organized around actual patient cases that require careful analysis of the benefits, harms, costs, and use of evidence-based, shared decision making. According to the study authors, the curriculum is important because physicians receive little specific training about identifying and eliminating wasteful treatment options. Since habits that are learned during residency training have been shown to stick with physicians throughout their professional careers, it is an optimal time to prepare physicians to become good stewards of health care resources. ACP-AAIM members and staff, program directors, associate program directors, a department chair, residency faculty, and internal medicine residents collaborated to develop the curriculum. It can be accessed for free at www.highvaluecarecurriculum.org,

Advances in intensive insulin therapy and glucose monitoring are designed to improve glycemic control and quality of life while limiting adverse effects such as hypoglycemia and weight gain. Currently, there are several therapies being heavily marketed to patients, but there is little objective evidence available to guide decision making about which therapy is best for the individual patient. Researchers reviewed published studies to evaluate how intensive insulin therapy (multiple daily injections versus insulin pump) or mode of blood glucose monitoring (self-monitoring versus real-time monitoring) affects outcomes in children and adults with type 1 or 2 diabetes. The researchers found that insulin pump and multiple-daily injections have similar effects on glycemic control and the incidence of severe hypoglycemia in children and adolescents with type 1 diabetes and in adults with type 2 diabetes. However, insulin pump yielded better satisfaction with diabetes treatment in children with type 1 diabetes, and better diabetes-specific quality-of-life in adults with type 1 diabetes. As for blood-glucose monitoring, real-time monitoring achieved a lower blood glucose level compared to self-monitoring. The researchers also found that real-time glucose monitoring was associated with a lower blood glucose level compared with multiple daily injection in individuals 18 years of age or younger, but the rate of severe hypoglycemia, weight gain, and quality of life did not seem to differ between intervention groups. Patients that used a sensor-augmented pump experienced greater reduction in blood glucose compared to multiple daily injection/self-monitoring use in individuals with type 1 diabetes. The researchers conclude that based on the evidence, physicians can use patient preference to guide treatment decisions for type 1 and type 2 diabetes.