Impact of self monitoring of blood glucose in the management of patients with non-insulin treated diabetes: open parallel group randomised trial

Cost effectiveness of self monitoring of blood glucose in patients with non-insulin treated type 2 diabetes: economic evaluation of data from the DiGEM trial

OBJECTIVE

To assess the cost effectiveness of self monitoring of blood glucose alone or with additional training in incorporating the results into self care, in addition to standardised usual care for patients with non-insulin treated type 2 diabetes.

DESIGN

Incremental cost utility analysis from a healthcare perspective. Data on resource use from the randomised controlled diabetes glycaemic education and monitoring (DiGEM) trial covered 12 months before baseline and 12 months of trial follow-up. Quality of life was measured at baseline and 12 months using the EuroQol EQ-5D questionnaire.

SETTING

Primary care in the United Kingdom.

PARTICIPANTS

453 patients with non-insulin treated type 2 diabetes.

INTERVENTIONS

Standardised usual care (control) compared with additional self monitoring of blood glucose alone (less intensive self monitoring) or with training in self interpretation of the results (more intensive self monitoring).

MAIN OUTCOME MEASURES

Quality adjusted life years and healthcare costs (sterling in 2005-6 prices).

RESULTS

The average costs of intervention were pound89 (euro113; $179) for standardised usual care, pound181 for less intensive self monitoring, and pound173 for more intensive self monitoring, showing an additional cost per patient of pound92 (95% confidence interval pound80 to pound103) in the less intensive group and pound84 ( pound73 to pound96) in the more intensive group. No other significant cost difference was detected between the groups. An initial negative impact of self monitoring on quality of life occurred, averaging -0.027 (95% confidence interval-0.069 to 0.015) for the less intensive self monitoring group and -0.075 (-0.119 to -0.031) for the more intensive group.

CONCLUSIONS

Self monitoring of blood glucose with or without additional training in incorporating the results into self care was associated with higher costs and lower quality of life in patients with non-insulin treated type 2 diabetes. In light of this, and no clinically significant differences in other outcomes, self monitoring of blood glucose is unlikely to be cost effective in addition to standardised usual care.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN47464659.

Efficacy of self monitoring of blood glucose in patients with newly diagnosed type 2 diabetes (ESMON study): randomised controlled trial

OBJECTIVES

To assess the effect of self monitoring of blood glucose concentrations on glycaemic control and psychological indices in patients with newly diagnosed type 2 diabetes mellitus.

DESIGN

Prospective randomised controlled trial of self monitoring versus no monitoring (control).

SETTING

Hospital diabetes clinics.

PARTICIPANTS

184 (111 men) people aged <70 with newly diagnosed type 2 diabetes referred to the participating diabetes clinics. Major exclusion criteria were secondary diabetes, insulin treatment, previous self monitoring of blood glucose.

INTERVENTIONS

Participants were randomised to self monitoring or no monitoring (control) groups for one year with follow-up at three monthly intervals. Both groups underwent an identical structured core education programme. The self monitoring group received additional education on monitoring.

MAIN OUTCOME MEASURES

Between group differences in HbA(1c), psychological indices, use of oral hypoglycaemic drugs, body mass index (BMI), and reported hypoglycaemia rates.

RESULTS

96 patients (55 men) were randomised to monitoring and 88 (56 men) to control. There were no baseline differences in mean (SD) age (57.7 (11.0) in monitoring group v 60.9 (11.5) in control group) or HbA(1c) (8.8 (2.1)% v 8.6 (2.3)%, respectively). Those in the monitoring group had a higher baseline BMI (34 (7) v 32 (6.2)). There were no significant differences between groups at any time point (12 months values given) in HbA(1c) (6.9 (0.8)% v 6.9 (1.2)%, P=0.69; 95% confidence interval for difference -0.25% to 0.38%), BMI (33.1 (6.4) v 31.8 (6.0); adjusted for baseline BMI, P=0.32), use of oral hypoglycaemic drugs, or reported incidence of hypoglycaemia. Monitoring was associated with a 6% higher score on the depression subscale of the well-being questionnaire (P=0.01).

CONCLUSIONS

In patients with newly diagnosed type 2 diabetes self monitoring of blood glucose concentration has no effect on glycaemic control but is associated with higher scores on a depression subscale.

TRIAL REGISTRATION

ISRCTN 49814766.

Guideline for management of postmeal glucose

An estimated 246 million people worldwide have diabetes. Diabetes is a leading cause of death in most developed countries, and is reaching epidemic proportions in many developing and newly industrialized nations. Poorly controlled diabetes is associated with the development of renal failure, vision loss, macrovascular diseases and amputations. Large controlled clinical trials have demonstrated that intensive treatment of diabetes can significantly decrease the development and/or progression of microvascular complications of diabetes. There appears to be no glycaemic threshold for reduction of diabetes complications; the lower the glycated haemoglobin (HbA1c), the lower the risk. The progressive relationship between plasma glucose levels and cardiovascular risk extends well below the diabetic threshold. Until recently, the predominant focus of therapy has been on lowering HbA1c levels, with a strong emphasis on fasting plasma glucose. Although control of fasting hyperglycaemia is necessary, it is usually insufficient to obtain optimal glycaemic control. A growing body of evidence suggests that reducing postmeal plasma glucose excursions is as important, or perhaps more important for achieving HbA1c goals. This guideline reviews the evidence on the harmful effects of elevated postmeal glucose and makes recommendations on its treatment, assessment and targets.

Self-monitoring of blood glucose in people with type 1 and type 2 diabetes living in France: the Entred study 2001

OBJECTIVE

To describe the practice of self-monitoring blood glucose (SMBG) testing and to determine factors linked to SMBG in people with diabetes living in France.

METHODS

The 2001 Entred study, a French national survey of people being treated for diabetes, is based on a representative sample of 10,000 adults who claimed reimbursement for oral hypoglycaemic agents and/or insulin in October to December 2001 and who were randomly extracted from the database of the major National Health Insurance System. A questionnaire was mailed to all these people and was returned by 36% of them, who were then classified into three groups: type 1 diabetes (T1D, N=235); type 2 diabetes treated with insulin (iT2D, N=635); and type 2 diabetes treated with oral hypoglycaemic agents (oT2D, N=2689). Factors associated with SMBG were analyzed using logistic regression models with a step-by-step forward approach.

RESULTS

HbA(1c) was greater than or equal to 8% in 42% of people with T1D, 48% of those with iT2D and 21% of those with oTD2. Almost all of those treated with insulin performed SMBG. The frequency of self-monitoring was higher in T1D than in iT2D. In T1D, 58% of people reported they took at least three tests a day, as recommended in guidelines, which was more frequent in those who knew what HbA(1c) meant and in women. In iT2D, 74% reported that they took at least two tests a day, as recommended, and it was more frequent in those who knew what HbA(1c) meant, who reported at least one severe hypoglycaemic episode in 2001 and who received dietary advice from their practitioner. In oT2D, 38% reported using SMBG (six tests a week on average), even though no official recommendation had been provided for these patients. SMBG was also more frequent in patients being treated with multiple oral hypoglycaemic agents, in those who benefited from a waiver of co-payment due to a chronic disease and in those, who had visited a diabetes specialist in 2001, reported they knew what HbA(1c) meant, received dietary advice and reported at least one severe hypoglycaemic episode in 2001 and/or a history of diabetes complications.

CONCLUSION

In France, as per the official recommendations, almost all people on insulin treatment use a SMBG device while, overall, their glucose control remains poor. More than one-third of those with oT2D regularly perform SMBG. In only 3% of people, the regular use of SMBG does not appear to be related to any special needs or events (such as insulin treatment, occurrence of severe hypoglycaemia or chronic complications).

Physician and patient management of type 2 diabetes and factors related to glycemic control in Spain

The objective of this study was to assess current treatment patterns, blood glucose test strip usage, and treatment compliance in patients with type 2 diabetes mellitus (T2DM) in primary care centers in Spain, and to assess factors related to glycemic control. We conducted a retrospective chart review of patients with T2DM and measured treatment compliance using the Morisky-Green questionnaire. 294 patients were included in the study from a population of patients attending 30 primary care centers throughout Spain. Results showed that the majority of patients were treated with oral monotherapy (36%) and oral combination therapy (35%). Less than half of the patients had good glycemic control (HbA(1c) </= 6.5%). Half of the patients treated pharmacologically reported good compliance with treatment. Logistic regression analyses performed to identify factors associated with glycemic control showed that high body mass index (BMI) and poor compliance were the strongest predictors of poor HbA(1c) control (OR: 2.198 and 1.789, respectively, p < 0.05). In conclusion, in the course of managing diabetes, physicians and patients should attempt to improve compliance and lower BMI, which could lead to better glycemic control.

Does patient blood glucose monitoring improve diabetes control? A systematic review of the literature

OBJECTIVE

The purpose of this systematic review was 2-fold: first, to perform a comprehensive review of relevant studies on the impact of self-monitoring of blood glucose (SMBG) on HbA1c levels for patients with type 2 diabetes mellitus and, second, to explore mediators and moderators within a self-regulation framework.

DATA SOURCES

Five databases-Medline, PsychInfo, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing & Allied Health Literature (CINAHL)-were searched.

STUDY SELECTION

Cross-sectional, longitudinal, and randomized control trials from 1990 to 2006, which included patients with type 2 diabetes not on insulin, were reviewed. In total, 6,769 studies were screened for inclusion, 89 were retrieved for detailed analysis, and 29 met criteria for inclusion in the review.

DATA EXTRACTION

Data on the impact of SMBG on HbA1c, potential mediators and moderators, study design and participants, and limitations of each study were retrieved.

DATA SYNTHESIS

Twenty-nine studies were included in this review: 9 cross-sectional studies, 9 longitudinal studies, and 11 randomized controlled trials. Evidence from the cross-sectional and longitudinal studies was inconclusive. Evidence from randomized controlled trials suggests that SMBG may lead to improvements in glucose control. Very few studies examined potential mediators or moderators of SMBG on HbA1c levels.

CONCLUSIONS

SMBG may be effective in controlling blood glucose for patients with type 2 diabetes. There is a need for studies that implement all the components of the process for self-regulation of SMBG to assess whether patient use of SMBG will improve HbA1c levels.

Self monitoring of blood glucose in type 2 diabetes: longitudinal qualitative study of patients' perspectives

OBJECTIVE

To explore views of patients with type 2 diabetes about self monitoring of blood glucose over time.

DESIGN

Longitudinal, qualitative study.

SETTING

Primary and secondary care settings across Lothian, Scotland.

PARTICIPANTS

18 patients with type 2 diabetes.

MAIN OUTCOME MEASURES

Results from repeat in-depth interviews with patients over four years after clinical diagnosis.

RESULTS

Analysis revealed three main themes-the role of health professionals, interpreting readings and managing high values, and the ongoing role of blood glucose self monitoring. Self monitoring decreased over time, and health professionals' behaviour seemed crucial in this: participants interpreted doctors' focus on levels of haemoglobin A(1c), and lack of perceived interest in meter readings, as indicating that self monitoring was not worth continuing. Some participants saw readings as a proxy measure of good and bad behaviour-with women especially, chastising themselves when readings were high. Some participants continued to find readings difficult to interpret, with uncertainty about how to respond to high readings. Reassurance and habit were key reasons for continuing. There was little indication that participants were using self monitoring to effect and maintain behaviour change.

CONCLUSIONS

Clinical uncertainty about the efficacy and role of blood glucose self monitoring in patients with type 2 diabetes is mirrored in patients' own accounts. Patients tended not to act on their self monitoring results, in part because of a lack of education about the appropriate response to readings. Health professionals should be explicit about whether and when such patients should self monitor and how they should interpret and act upon the results, especially high readings.

Self management of type 2 diabetes

More efforts are needed to capture the patients' perspective

Self monitoring of blood glucose in type 2 diabetes

Clinicians should stop patients doing this if it has no benefit