In It for the Long Haul

KentuckyOne Health Endocrinology and Diabetes Associates has embraced a chronic care model for the long–term treatment of their patients

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LOUISVILLE As the Rolling Stones famously sang, “You can’t always get what you want.” In medical care, everyone wants the issue to be fixed, healed, and cured. But there aren’t cures for every condition. Sometimes, long-term treatment is the only option.

“The care model for managing acute conditions and chronic conditions is radically different,” says Fred Williams, MD, FACP, FACE. “Medicine in the past was built almost solely on an acute care model – healthcare reacted to whatever was wrong with the patient. Now, you have all of these chronic diseases and people are living much longer, which is great, but the old models don’t work.”

Williams practices at KentuckyOne Health Endocrinology and Diabetes Associates in Louisville. There, they treat chronic conditions such as diabetes, pre-diabetes, obesity, thyroid disorders, pituitary disorders, and osteoporosis. Endocrinology and Diabetes Associates was established in 1993 and became part of KentuckyOne Health in 2015. At that time, Williams and his partners – Lara Fakunle, MD, FACE, and Mary Self, MD, CDE, all board certified in internal medicine and endocrinology and metabolism – had approximately 8,000 active patients, and the practice is completely outpatient.

Williams, who attended the University of Louisville School of Medicine and completed his residency and fellowship at the University of Virginia School of Medicine, estimates that they treat 30 to 60 percent of their patients for diabetes and closely related problems. Thyroid-related issues make up the practice’s second-largest patient population. Virtually everything they treat is a chronic condition requiring long-term care. They see patients ages 18 and older.

“Chronic health disease is no respecter of wealth, educational background, socioeconomic status or any other limiting factors,” says Fakunle. After attending Obafemi Awolowo University in Nigeria, Fakunle completed her residency program in internal medicine and a fellowship in endocrinology and metabolism at the University of South Carolina.

While chronic illness can impact anyone, it can add additional stresses for those without the means to fully combat it.

“Individuals frequently have deductible insurance plans that make needed outpatient testing out of reach for many,” Self says. “Often, insurers don’t cover programs that help with lifestyle change. Medication and durable medical goods are expensive and frequently limit true choice of therapy. It is difficult for employed individuals to take time off work for appointments. The stress of all of these challenges can make it difficult for the most well intentioned patients to reach their goals.”

Treatment Challenges and Triumphs – Diabetes, Obesity, and Osteoporosis

An example of this exists with diabetic patients. Williams points to the tremendous advancements in the medications to treat the disease and the increasingly high costs that accompany them.

“We have the drugs and the know-how, but you have these insurance middle people that create problems with access to the medications,” he says. “Nevertheless, there are options out there, and our ability to achieve treatment goals is tremendously better than even five years ago.”

Another major development in the treatment of diabetes is the ability to identify patients with pre-diabetes. Patients with a fasting blood sugar between 101 and 126 and a hemoglobin A1C of 5.8 to 6.5 are considered to be pre-diabetic and, in most cases, will become diabetic without changes in diet and exercise. YMCAs and public health departments have become active participants in creating programs designed to help pre-diabetic patients make these lifestyle changes.

Lifestyle changes have long been the primary treatment for another chronic condition – obesity. But when obesity was officially labeled a disease by the American Medical Association in 2013, it sparked some changes in treatment.

“It forced the issue in terms of insurance companies and healthcare systems recognizing that not everybody who is obese just eats too much, that there is a whole complex physiology that’s involved that’s a lot broader than just people eating too many calories,” Williams says. “We do have medications that are FDA approved that are theoretically available for obese patients. The drugs are out there, and they work, but you can’t get people on them because the insurance companies won’t cover any obesity-related medication.”

But insurance generally does cover bone density measurements every other year, which is great news for patients with osteoporosis. Referrals for osteoporosis have declined as many patients are treated by their primary physician or gynecologist, but KentuckyOne Health Endocrinology and Diabetes Associates has seen a dramatic increase in the number of referrals for patients with thyroid conditions.

Thyroid issues include overactive or underactive thyroids, patients with goiters, and patients with nodules, which can be benign or malignant.

“We are seeing a whole lot more of the patients with nodules, one, because doctors and nurse practitioners and PAs are looking for them, and two, because we now have ultrasound devices that are very sensitive in being able to pick them up,” Williams says. “The number of referrals we get for evaluation of thyroid nodules or tumors has skyrocketed. The incidence of thyroid cancer has increased, but no one knows if that’s a true increase or if we’re just more aware of patients having nodules.”

Making an Accurate Diagnosis – Thyroid Disorders and PCOS

On the bright side, technology is making diagnosis of thyroid conditions easier and more definitive than ever before.

“If I compare the pictures I have now to the ones I was looking at 15 years ago, it’s like an old black-and-white TV from the 1950s and a high definition TV now,” Williams says.

While thyroid problems can be hereditary, Williams points to several recent studies that suggest environmental factors might be contributing to the surge in diagnoses. Some substances in plastics used for food packaging, for instance, have been shown to influence the function of various hormones.

“There’s a lot of smoke,” Williams says, referring to the number of studies and theories suggesting the impact of environmental factors. “The whole issue of plastics and what is in them is going to be really big going forward. I believe there are some environmental factors involved, and it’s kind of scary.”

Another issue with thyroid conditions is that they can sometimes mask other issues, Self says. There are so many symptoms affiliated with thyroid disease that can also be attributed to other conditions. “We frequently see individuals who are so focused on their thyroid being responsible for their symptoms, that many important medical conditions are overlooked,” Self says. Self, a board-certified endocrinologist, joined the practice in 1997. She attended the University of Louisville School of Medicine and completed her residency and fellowship there as well. “Many symptoms are listed under thyroid disease that are common with many medical conditions, including normal aging.”

Another chronic condition frequently seen at KentuckyOne Health Endocrinology and Diabetes Associates is Polycystic Ovary Syndrome (PCOS). It too brings with it a host of affiliated health issues that are sometimes misdiagnosed.

“PCOS is a metabolic and reproductive disorder,” Fakunle says, noting that she sees two-to-four PCOS cases per day. “Apart from the reproductive issues, attention should be paid to the other potential health issues such as heart disease, impaired glucose tolerance, diabetes mellitus, gestational diabetes mellitus, sleep apnea, hyperlipidemia, and obesity. There is also concern for under diagnosis. The long-term effects – including psychological effects – are probably under addressed.”

Finding ways to identify and address the many needs of patients with chronic conditions is one of the challenges of the chronic care model. Physicians need to anticipate the patient’s upcoming needs, rather than simply reacting to their acute conditions.

“Today, a good medical office has a prepared proactive team and an informed, activated patient,” Williams says. He cites an article identifying the “5 C’s” of a chronic care model: contact, continuity, comprehensive care, coordination of care, and compassion.

Notice that “cure” isn’t one of those “C’s.” It’s true you can’t always get what you want. But as practices like KentuckyOne Health Endocrinology and Diabetes Associates continue to implement and develop a chronic care model, you can get the expertise, treatment, and support needed to manage chronic illness.

Medicine in the past was built almost solely on an acute care model – healthcare reacted to whatever was wrong with the patient. Now, you have all of these chronic diseases and people are living much longer, which is great, but the old models don’t work.— Dr. Fred Williams