Endocrinologist focuses on the health benefits of preventing disease's complications
October 21, 2013 4:00 AM
Endocrinologist Swarna Varma is doing research, developing software and spending time with her patients in order to combat diabetes.
Carolyn Smead prepares a fresh lunch from the day's harvest from their backyard.
Herbert Smead harvests fresh vegetables from the backyard garden he and his wife, Carolyn, tend at their home in West Mifflin. Both are patients of Swarna S. Varma, whose practice emphasizes habits that prevent complications of disease.
By David Templeton Pittsburgh Post-Gazette
As a hospital nurse, Carolyn Smead witnessed how endocrinologist Swarna S. Varma spent extensive time with patients, sometimes at the craziest hours.
So when Ms. Smead, 67, of West Mifflin, developed thyroid problems, she went to Dr. Varma and eventually would be diagnosed with type 2 diabetes. She underwent Dr. Varma's rigorous "Preventive Care" model to manage her diabetes, which helped to wean her off all diabetes medications and leave her with normal blood-sugar levels.
"Usually the appointment with Dr. Varma takes about 35 to 45 minutes -- sometimes longer -- and she compares your results to previous ones and lets you know what's going up, what's going down and how to improve them," Ms. Smead said. "The patient, doctor and her staff have to be involved. And you have to take an active part in the treatment."
Welcome to the importance of prevention in diabetes care.
Based on a decade of patient data, Dr. Varma and her studies show how prevention of diabetes complications improves patient health while greatly reducing costs. With a main office in Collier, near Bridgeville, she continues her campaign to prevent diabetes complications in lieu of the traditional focus of treating them once they occur. She also sees patients in Uniontown, Somerset, Washington, the South Side and Robinson.
In presentations describing her methods, she says early diagnosis and chronic disease management could reduce the annual economic impact of chronic disease by $1.1 trillion by 2023, cut the number of people with chronic illness by 40 million and reduce cancer deaths by 50 percent.
The American Diabetes Association says nearly 26 million Americans have type 1 and 2 diabetes, including 7 million yet to be diagnosed. That represents 8.3 percent of the population, with 1.5 million new cases diagnosed annually in those 20 and older. By 2025, the rate of annual diabetes-associated deaths are expected to triple to 622,000, with 70,000 new cases of blindness, 119,000 cases of end-stage renal failure, and 239,000 amputations per year. The annual cost of diabetes-related health care will climb to $350 billion, with the University of Pittsburgh Diabetes Institute noting that diabetes-related illness accounts for 30 percent of the nation's health bill.
With her focus on diabetes, Dr. Varma said prevention of complications would reduce the risk of cardiovascular disease by up to 50 percent, ophthalmic disease by up to 60 percent and the risk of type 2 diabetes by 58 percent in those with prediabetes, among other improvements.
"If you believe the data we have for complications and mortality, the person with diabetes under control can almost behave like a nondiabetic individual," said Dr. Varma. "Nothing is 100 percent, but it provides the best possibility."
Irish doctor Denis Burkitt said modern medicine, with an emphasis on treatment rather than prevention, responds to people falling over a cliff by putting ambulances at cliff bottom instead of a fence along the top. He also said doctors are more skilled in cleaning up leaks than fixing pipes.
Dr. Varma has been using her own methods of building fences and fixing pipes for 10 years with results that far exceed the national rates of diabetes management, although the national numbers are steadily improving.
During appointments, Dr. Varma discusses her 23-point protocol for diabetes control that covers all aspects of lifestyle and good health. The protocol works to optimize calcium and vitamin D levels, with appropriate screening for bone density and various cancers, smoking cessation and maintaining a healthy diet with exercise.
For diabetes, the key goal is reducing complications through compliance with the American Diabetes Association's "ABC" guidelines:
"A" refers to A1C -- short for the blood-sugar test known as hemoglobin A1C -- that should be less than 7 percent, with a normal range of 4 to 6 percent.
"B" refers to a blood-pressure level below 130/80 mm/Hg.
"C" refers to an LDL cholesterol level below 100 mg/dL.
Meeting the guidelines even with a full battery of medications can require serious lifestyle changes, including exercise and diet, along with a steady focus on maintaining healthy blood-sugar levels.
"Diabetes is one condition that is very dependent on the individual doing a lot of work," Dr. Varma said. "It's not like prescribing an antibiotic for pneumonia and taking one pill a day. It is labor-intensive, detail-oriented and complicated. Even if you do the ABCs but do not focus on osteoporosis, resulting in a hip fracture, it can throw you backwards."
One feature that Dr. Varma emphasizes is her "Team of Four," including the patient, the doctor, the staff and the patient's family and friends. The goal is to help the patient to meet health goals, including ABC guidelines.
"If there are bad outcomes, all four members of the team have failed," Dr. Varma said. "It's like the team saying we lost because [Ben] Roethlisberger was sick. No, the whole team lost that day."
Those who fail to meet ABC guidelines face a significantly higher risk of renal failure, vision loss, loss of limbs, strokes and heart attacks, "which in my mind -- and the literature supports it -- are preventable," Dr. Varma said.
Patient data are organized in a 10-page Word document that Dr. Varma uses to optimize health outcomes and reduce medical costs for the patient.
"Our five-year and 10-year data show that we achieved ABC control, without weight gain, and there was no increased hypoglycemia [low blood-sugar] with better diabetes control," Dr. Varma said. Her database that shows significantly better patient outcomes than the national average is the basis of health studies and abstracts she's published, some by the ADA, on the success of her Team-of-Four approach and emphasis on prevention.
To date, she's financed her published studies and completed them on her own time, along with the cost of downloading patient data after every appointment. She's now working to develop software to better track and process patient results, with the goal of including them in patients' electronic medical records.
She's seeking a partner or investor to advance, test and market the software that's already in development.
Her investments of time and money, she said, were necessary to prove that preventive methods reduce diabetes complications and health care costs. One advance in the Affordable Care Act, she said, is reimbursements for preventive care.
"A greater investment of time and resources in providing quality diabetes care, prior to the onset of complications, may lead to decreased morbidity and mortality and increased quality of life for persons with diabetes," one of Dr. Varma's studies concludes.
Over the past 10 years, 23 percent of patients in her practice have achieved the ABC goals. The national rate climbed from single digits to the current level of 16 percent.
When a person chooses not to manage his or her diabetes properly, society pays with high costs for treating complications.
"We know what we're supposed to do and millions are spent to control diabetes and lipids, and the doctor is in the room for 10 minutes. How does the patient benefit from that?" Dr. Varma said. "Fifty percent of complications could be prevented. There has to be a way to reverse the trend. We should be proactive versus reactive. Everyone wants costs contained with perfect care and positive outcomes. Everyone is talking the talk."
Attention to prevention
Dr. Varma's efforts align with University of Pittsburgh Diabetes Institute pilot programs that advocate the availability of diabetes-education services in every primary-care office. The institute also advocates a team approach to include such community members as pharmacists. The institute has another program underway for endocrinologists to conduct telemedicine sessions with patients and their diabetes educators, in rural counties lacking an endocrinologist.
"I applaud her efforts because she is demonstrating the value of a team, which is wonderful. The most powerful interventions are with the team approach in improving [blood-sugar levels]," said Linda Siminerio, diabetes institute executive director. "We have to look at ways for better access for all kinds of support systems. Diabetes is a 24/7 disease, and people need support along the way."
Dr. Varma's care of Carolyn Smead convinced her husband, Herbert, to visit Dr. Varma due to his family history of diabetes. She diagnosed a thyroid disorder but eventually found him to have prediabetes -- slightly elevated blood-sugar levels that can lead to type 2 diabetes. He's now going through Dr. Varma's measures to prevent diabetes.
On occasion, he said, Dr. Varma calls them on a Sunday night with test results. Does the lady ever sleep?
"I'm always impressed with her," Mr. Smead said, "because I'd be sitting outside the hospital waiting for my wife to finish work and it would be midnight and snowing, and I'd see her pull into the emergency area and go inside to see a patient."