Caring for Diabetes in China
How clinical care in China differs from the U.S.
An opportunity to work in eastern China for a few months came my way recently. I was asked to manage a two-year-old diabetes center in Hangzhou and to open a new diabetes center in a large city hospital in Ningbo. I asked many questions of my predecessor before I left the United States, but nothing could have truly prepared me to see firsthand what China is facing with the diabetes epidemic.
First, to put things in perspective, there are many people in China living in a very small space. Slightly larger than the United States but with four times as many people, China boasts the world’s largest population: close to 1.4 billion people. It also leads the world in diabetes numbers. A 2013 Journal of the American Medical Association study estimates that there are 113.9 million Chinese people with diabetes. This is just the tip of the iceberg: There are 493 million people there with prediabetes. Just 35 years ago, diabetes affected only 1 percent of the population compared with 11.6 percent today.
China has become burdened with obesity and type 2 diabetes. Environmentally speaking, the country is following in America’s footsteps—rapid growth, urbanization, affluence, sedentary factory jobs replacing farm labor, and an abundance of fast food and sugary drinks. Like the United States, China also has an aging population. One noticeable difference in the Asian population is that they can develop type 2 diabetes at a lower body mass index (a ratio of weight to height) than is considered “overweight” in America.
Endocrinologists in the hospital setting, not a primary care doctor’s office, manage most diabetes care in China. A typical endocrinology visit in the outpatient clinic lasts less than five minutes. The waiting room is jam-packed with patients waiting to get their prescriptions refilled (often required every month). An endocrinologist may see up to 95 patients in a single morning. It’s not uncommon for the next patient in line to barge into the exam room and hover over the patient being seen by the doctor. There is no patient privacy in China, just controlled chaos.
The most commonly used drugs in China to treat type 2 diabetes are metformin, sulfonylureas, acarbose, and older premixed insulins. I haven’t seen acarbose (an alpha-glucosidase inhibitor) used in the United States for years, probably because patients don’t tolerate the gastrointestinal side effects. The medication works reasonably well for an Asian population consuming a relatively high-carbohydrate diet. Newer classes of drugs, such as DPP-4 inhibitors, GLP-1 agonists, and even some of the insulin analogs, are not reimbursed by China’s universal health system.
Newer drugs are typically reserved for those who can afford to pay the high out-of-pocket costs. Many large hospitals in China have “VIP clinics” for wealthy patients who are willing to pay for longer consultations with a doctor and more expensive treatments and medications.
Injections are a big hurdle for the Chinese (and Americans, too, for that matter) to overcome. This makes it very challenging to convince patients that they need to take insulin. Many people simply say it’s not convenient and ask to take a pill. My sense is that more education is needed with both doctors and patients. There seems to be an attitude of allowing patients to make uninformed choices rather than educating them about blood glucose control to avoid the complications of diabetes.
In the Hospital
Diabetes complications are extensive in hospitalized patients. I have observed two camps of patients: those who come in for a yearly physical exam and to take a little “rest” and time off from the stresses of daily life, and those who are quite burdened with diabetes complications. Despite the universal health coverage in China, screening and outpatient services for diabetes are not a covered medical benefit in many parts of the country. Typically patients do not seek care until they have serious complications that are impossible to ignore. It is very common to see A1Cs in the 11 to 14 percent range (under 7 percent is the target for most U.S. adults).
Probably because hospital stays are more affordable, patients will often remain under care for seven to 14 days, which, due to cost, is almost unheard of in the United States. I have questioned many doctors and nurses about the length of stay. One reason hospital stays may last so long is that lab tests or examinations are ordered, but not always done in a timely manner. There may be a waiting list for a particular exam.
Diabetes control also comes into play. Patients will not be discharged until their blood glucose has been stable for at least 48 hours. It is easy to argue that one slightly elevated blood glucose reading is a good reason to stay for an extra day or two. Some patients simply don’t want to go home and they refuse to leave.
One of the reasons for longer stays caught me by surprise: There have been several incidences of patients resorting to violence toward their doctors because of dissatisfaction with the health care system. Much of this has to do with health care reform in China and patients’ unmet needs. Even though these may be unusual and isolated incidences, I get the sense that doctors want to keep patients happy and not “rock the boat.” If patients want to stay longer, they usually will be accommodated.
I have learned that type 1 is not as common in China as in America, though I certainly have seen my share of people with type 1.
With ever-changing health care reform in China, it’s hard to know which services or products are covered, but from what I have gathered, pumps, continuous glucose monitors (CGMs), and supplies are not covered for the type 1 patient. In fact, pumps and CGMs are mostly reserved for hospital use to quickly get blood glucose in control. Pumps and CGMs are out-of-pocket expenses for those who can afford them. I have seen several pump patients; each was using infusion sets for about seven days (changing the set and site every two to three days is recommended) as a cost-saving strategy, but they had site issues.
These type 1 patients had not been taught to count carbohydrates and were using fixed doses for mealtime insulin boluses. Essentially, they had not received adequate education. I have been told that type 1 is poorly understood here, and sometimes patients face discrimination.
Things have improved since the advent of the Internet, which allows people with diabetes in China to communicate with and learn from each other, but there is still a gaping hole when it comes to diabetes education. Training nurses to be diabetes educators is still in its infancy in China. Professional development and teaching nurses to be diabetes educators are two of the many things I am working on to improve the situation here.
These observations are just a drop in the bucket when it comes to what I have learned: the common use of traditional Chinese medicine along with pharmaceuticals, the lack of hand-washing and gloves in the hospital setting, the lack of basic nutrition concepts and carbohydrate counting, the way patients come and go as they please while hospitalized, and the Chinese government’s attempt to reform health care. How will China organize its medical establishment and provide diabetes education and care for the enormous number of people who need help? It will cost a lot of yuan and take a village of dedicated people to meet the challenge.