ACE/AACE Diabetes Recommendations Implementation ConferenceRole of Self-Monitoring of Blood Glucose in Glycemic Control
Section snippets
INTRODUCTION
Several landmark studies have demonstrated that improved glycemic control reduces the risk of complications in type 1 diabetes—the Diabetes Control and Complications Trial (DCCT) (1) and the Stockholm Diabetes Intervention Study (2)—as well as type 2 diabetes—the United Kingdom Prospective Diabetes Study (3) and the Kumamoto Study (4). Despite this strong evidence supporting the importance of “tight” glycemic control, minimal improvement in overall glycemic control has been noted in patients
CONCEPTUAL FRAMEWORK
SMBG may lead to improved glycemic control through numerous pathways (Fig. 1). SMBG provides immediate feedback to patients regarding their levels of glycemia. This feedback can help patients achieve better glycemic control if the information is used to adjust the timing, type, or dose of therapy. Careful monitoring may reduce the risk of undetected, asymptomatic hypoglycemia and thereby enable a patient to intensify insulin therapy safely to achieve near-normoglycemia. Of note, in all the
SMBG SMBG UTILIZATION PATTERNS
In a survey-based study of SMBG utilization patterns in patients from the Kaiser Permanente Northern California Diabetes Registry, we (16) assessed adherence to the American Diabetes Association guidelines for SMBG practice (17). Although most patients reported some level of SMBG, 60% of those with type 1 diabetes and 67% of those with type 2 diabetes reported practicing SMBG less often than recommended (3 to 4 times daily for type 1 diabetes and daily for type 2 diabetes treated
BARRIERS TO SMBG
Because test strips are expensive, patients who lack insurance coverage for such strips usually bear the complete financial burden of purchasing the strips themselves. With appropriate utilization for a patient with type 1 diabetes, the annual, out-of-pocket costs for test strips alone can approach $1,000. This cost represents a financial barrier to utilization of SMBG, particularly for poorer patients lacking health insurance benefits that cover testing supplies. We (16) have previously
EMERGING EVIDENCE OF SMBG EFFECTIVENESS
Although SMBG is widely recommended as a component of diabetes management, substantial controversy exists about this costly practice, especially for patients not treated with insulin. It has been argued that existing evidence, particularly that pertaining to the ability of SMBG to improve glycemic control, is weak and does not support specific recommendations or reimbursement for test strips (for example, by private and governmental health plans) (23,24). Although most of the supporting
HEALTH-CARE COST CONSIDERATIONS AND POLICY CHANGES
Cost concerns are the primary reason that SMBG is controversial. The annual direct cost for SMBG test strips alone in the United States is currently estimated to exceed $3 billion. Test strips are the 4th largest pharmacy expenditure and represent 2% of the total pharmacy budget at Kaiser Permanente; they represent a substantial portion of the total pharmacy budget at the Veterans Affairs Hospitals as well (John Piette, personal communication). In 2002, the UK National Health Service, in a
PATIENT HEALTH EDUCATION
The weak past evidence for SMBG effectiveness is likely attributable, in part, to the lack of consistent actions, if any, taken by patients or health-care providers in response to SMBG readings. Thus, a reexamination of the current training available for patients and providers is needed. One recent study showed that among patients treated with orally administered agents or insulin, only 30% and 58%, respectively, were able to identify their low glycemic targets for home blood glucose monitoring
CONTINUING MEDICAL EDUCATION FOR HEALTH-CARE PROVIDERS
In light of the multitude of pharmaceutical options available, tailoring medication regimens as a function of glycemic patterns derived from SMBG data is a complex task. Decision trees could be based on algorithms that incorporate key SMBG summary statistics (for example, fasting, bedtime, and 2-hour postmeal SMBG readings) to make decisions about medication regimens. Continuing medical education that provides advanced training on how to utilize SMBG data optimally for fine-tuning of medication
NEW TECHNOLOGIES AND HEALTH-CARE SYSTEM FACTORS
Noninvasive (continuous) glucose monitoring may ultimately replace SMBG as it currently exists, providing a painless method of monitoring blood glucose automatically and frequently (54). This technologic advance, with provision of detailed information on glucose patterns and trends, could facilitate even better glycemic control and constitute an early warning system for hypoglycemic events. Patients are more likely to use a technology that causes no pain. Such new technologies, however, are
CONCLUSION
Because of the historically lackluster evidence of SMBG effectiveness and expense of test strips, managed care and governmental decision makers are struggling with decisions about whether, and to what extent, to support SMBG. Emerging evidence indicates that SMBG should have an important role in glycemic control efforts for both the patient and the health-care provider, but SMBG is only one facet in the complex intervention of diabetes care. Interventions aimed at a single facet of a complex
RECOMMENDATIONS
- 1.
Clinical Guidelines: Develop separate clinical recommendations for new SMBG users and ongoing SMBG users, and further stratify patients by type of diabetes therapy. Ideally, newly initiated SMBG practice would be integrated into a health education program for patients soon after the diagnosis of diabetes. Guidelines for the development of specific SMBG recommendations will need to merge expert opinion with a careful review of the scientific evidence through a consensus process. Such an effort
ACKNOWLEDGMENT
This work was funded in part by the National Institutes of Health (National Institute of Diabetes and Digestive and Kidney Diseases) Grant R01 DK61678-02.
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