Even with insurance, many patients with diabetes turn to GoFundMe to offset high cost of care

Abstract: https://www.acpjournals.org/doi/10.7326/M23-0540
URL goes live when the embargo lifts
An analysis of medical crowdfunding campaigns reveals the types of expenses that patients with diabetes may struggle to afford. The data showed that even insured patients with diabetes used GoFundMe to offset the excess costs of treatment beyond insulin, such as uncovered co-pays, indirect care, and alert dogs. The findings are published in Annals of Internal Medicine.

More than 40% of patients with diabetes in the United States have trouble paying their medical bills. Among patients with health-related financial hardship, 56% have delayed or foregone care. Crowdfunding, such as GoFundMe, is increasingly being used by these patients to cover medical costs. Studying crowdfunding campaigns can shed light on the expenses that contribute to their financial distress.

Researchers from Duke University School of Medicine, the University of Washington School of Medicine, and Stanford University School of Medicine studied a random sample of 313 active U.S. medical crowdfunding campaigns requesting support for a single patient with diabetes posted on GoFundMe from 2010 to 2020. The real-world testimonies detailing patient situations were reviewed to characterize the types of expenses patients were looking to cover. The researchers found that the median fundraising goal was $10,000, with 14% of campaigns reaching their fundraising goal. The data showed that many aspects of diabetes care beyond insulin were deemed cost-prohibitive, including life-saving care, such as hospitalizations and food. Even people with insurance used crowdfunding due to lack of coverage for certain expenses or unaffordable copayments. The researchers also found that 35% of patients with type 1 diabetes started fundraising campaigns for diabetic alert dogs, which cost about $15 000 and are not covered by insurance because of high variability in effectiveness. The researchers say that clinicians who learn of a patient’s intent to purchase a dog could redirect them toward proven management strategies, such as continuous glucose monitors. Policymakers should consider these patient needs and expenses when developing policies to help diabetes care become more affordable.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author, Caroline Sloan, MD, please email aroline.sloan@duke.edu.
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2. Starting CFTR modulator therapy in mother with cystic fibrosis associated with less severe complications in the fetus
Abstract: https://www.acpjournals.org/doi/10.7326/L23-0112
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A woman with cystic fibrosis was treated with elexacaftor-tezacaftor-ivacaftor (ETI), a cystic fibrosis transmembrane conductance regulator (CFTR) modulator, during pregnancy and gave birth to a healthy baby after experiencing complications in two previous pregnancies. The case report is published in edr34

CF is a life-shortening, autosomal recessive disease affecting approximately 150,000 people worldwide. Most cases in populations of Northern European ancestry are due to a biallelic pathogenic variant (F508del) in the CFTR gene. As such, professional societies recommend screening for CF either in the preconception period or in early pregnancy.

Researchers from Stanford University School of Medicine report the use of ETI in a pregnant carrier of CF to prevent adverse in utero effects of CF in the fetus. The mother’s other two children are affected by CF, have the F508del mutation, and both had meconium ileus in utero and required intestinal surgery after birth. Amniocentesis showed the current fetus was positive for the F508del mutation. The mother was treated with ETI and 7 weeks after starting therapy, ultrasound showed resolution of both meconium ileus and distal microcolon. At 39 weeks’ gestation, the patient delivered a healthy female infant with normal stools while tolerating breast milk. Unlike her siblings, she did not require bowel surgery. The researchers were encouraged that starting CFTR modulation therapy in the mother was associated with fewer and less severe complications in the fetus. Their findings suggest that additional studies of this therapy in larger patient cohorts are warranted.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author, Yair J. Blumenfeld, MD, please contact Erin Digitale at digitale@stanford.edu.
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3. Does this patient need an antibiotic? Imaging? Physicians discuss diagnosis and treatment strategy for patient with diverticulitis
‘Beyond the Guidelines’ features are based on the Department of Medicine Grand Rounds at Beth Israel Deaconess Medical Center
Abstract: https://www.acpjournals.org/doi/10.7326/M23-0669
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In a new Annals ‘Beyond the Guidelines’ feature, two gastroenterologists with expertise in acute diverticulitis debate CT scanning for diagnosis, antibiotics for treatment, colonoscopy to screen for underlying malignancy, and elective surgery to prevent recurrent disease in a patient with diverticulitis. All ‘Beyond the Guidelines’ features are based on the Department of Medicine Grand Rounds at Beth Israel Deaconess Medical Center (BIDMC) in Boston and include print, video, and educational components published in Annals of Internal Medicine.

Acute diverticulitis is a common medical condition that may occur repeatedly in some patients and generally presents with left-sided abdominal pain that may be accompanied by low-grade fever and other gastrointestinal symptoms. Complications may include abscess, fistula formation, perforation, and bowel obstruction, which is why proper diagnosis and treatment are important.

In recently published clinical practice guidelines, the American College of Physicians (ACP) recommended the use of abdominal CT scanning in cases where there was diagnostic uncertainty; initial management of uncomplicated cases in the outpatient setting without antibiotics; referral for colonoscopy after an initial episode if not performed recently; and discussion of elective surgery to prevent recurrent disease in patients with complicated diverticulitis or frequent episodes of uncomplicated disease. However, not every patient falls neatly within guideline parameters.

BIDMC Grand Grounds discussants, Judy W. Nee, MD, Assistant Professor of Medicine at Harvard Medical School, Division of Gastroenterology and Anthony J. Lembo, MD, Director of Research for the Digestive Disease and Surgery Institute at Cleveland Clinic reviewed the case of a 62-year-old woman with recurrent uncomplicated episodes of diverticulitis initially diagnosed by CT scan. In their assessment, both Drs. Nee and Lembo agree with ACP guidelines in that they do not recommend antibiotics for patients diagnosed with mild uncomplicated diverticulitis or advise repeat colonoscopy for patients with uncomplicated diverticulitis who are up to date with routine colorectal cancer screening. Dr. Nee says that a CT scan was important for the initial diagnosis of acute diverticulitis in the patient to rule out alternative causes of abdominal pain and may be warranted now because the patient has recurrent symptoms. However, antibiotics and colonoscopy do not seem necessary because the patient’s diverticulitis is uncomplicated and she is up to date on colonoscopy. Dr. Lembo agrees that colonoscopy is unnecessary, but antibiotics could be warranted unless symptoms are mild. Dr. Nee thinks that the patient should be referred for a discussion about elective surgical resection given her frequent recurrences, as the benefits of this procedure may outweigh the risks. Dr. Lembo would not recommend elective surgery at this time but would advise further discussion with a colorectal surgeon given that the patient expressed a desire for surgery.

A complete list of ‘Beyond the Guidelines’ topics is available at www.annals.org/grandrounds.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. For an interview with the discussants, please contact Kendra McKinnon at Kmckinn1@bidmc.harvard.edu.