Structured self-monitoring of blood glucose significantly reduces A1C levels in poorly controlled, noninsulin-treated type 2 diabetes: results from the Structured Testing Program study

Self-monitoring of blood glucose in noninsulin-using type 2 diabetic patients: right answer, but wrong question: self-monitoring of blood glucose can be clinically valuable for noninsulin users

Given the importance of glycemic control in the development of diabetes complications, the plethora of tools now available to monitor the day-to-day trends in glycemia is remarkable. In this regard, self-monitoring of blood glucose (SMBG) has been considered a key component of patient management. Arguably, there remains almost universal agreement that SMBG should be available to all diabetic patients regardless of current treatment strategy. However, recently there have been reports that have challenged the current paradigm that all patients should use SMBG and concluded that SMBG for type 2 diabetic patients not on insulin may not be beneficial on glycemic control and must be weighed against the expense and inconvenience. In the counterpoint narrative following the contribution by Malanda et al., Drs. Polonsky and Fisher provide a compelling argument suggesting that while it is evident that implementing SMBG in unstructured ways without training patients and clinicians is likely to be a waste of resources, there are effective and powerful ways to use structured SMBG in insulin-naïve type 2 diabetic patients. -William T. Cefalu, MD Editor in Chief, Diabetes Care.

Self-monitoring of blood glucose (SMBG) improves glycaemic control in oral hypoglycaemic agent (OHA)-treated type 2 diabetes (SMBG-OHA study)

BACKGROUND

We conducted a clinical research study to determine the effect of self-monitoring of blood glucose (SMBG) on glycaemic control and the value of a putatively less painful blood sampling technique on SMBG in oral hypoglycaemic agent-treated type 2 diabetes patients; SMBG has not been broadly applied in non-insulin-treated patients in Japan.

METHODS

One hundred thirty-seven subjects were recruited for the 24-week, prospective, comparison study and randomized into three groups: 46, no SMBG group; 46, fingertip group; and 45, palm group. The primary endpoint was change in HbA(1c). The secondary endpoints were SMBG compliance, dropout rate, treatment changes, and patient's and physician's satisfaction.

RESULTS

Six subjects in the fingertip group (13.2%) and one subject in the palm group (2.2%) were dropped because of pain. A(1C) level of all subjects at 24-week was decreased more in the fingertip (-0.23%) and palm (-0.16%) groups than that in the no SMBG group (+0.31%) (p < 0.05). SMBG compliance was higher in the fingertip group (2.17 times/day) than that in the palm group (1.65 times/day) (p < 0.05). A(1C) level of treatment-unchanged subjects was decreased more in the fingertip (-0.25%) and palm (-0.21%) groups than that in the no SMBG group (+0.30%) (p < 0.05). SMBG compliance was higher in the fingertip group (2.24 times/day) than that in the palm group (1.65 times/day) (p < 0.05). Patient's questionnaire showed that 84.1% of the fingertip group and 90.2% of the palm group were satisfied with SMBG. Physician's satisfaction was higher in the palm group (94.0%) than that in the fingertip group (80.0%) (p < 0.05).

CONCLUSION

SMBG is beneficial for glycaemic control, and palm blood sampling is a useful procedure for oral hypoglycaemic agent-treated type 2 diabetes.

Performance variability of seven commonly used self-monitoring of blood glucose systems: clinical considerations for patients and providers

BACKGROUND

Blood glucose data are frequently used in clinical decision making, thus it is critical that self-monitoring of blood glucose (SMBG) systems consistently provide accurate results. Concerns about SMBG accuracy have prompted the development of newly proposed International Organization for Standardization (ISO) standards: ≥ 95% of individual glucose results shall fall within ± 15 mg/dl of the results of the manufacturer's reference procedure at glucose concentrations <100 mg/dl and within ± 15% for values ≥ 100 mg/dl. We evaluated seven marketed systems against the current and proposed ISO criteria (criterion A).

METHOD

Capillary blood samples were collected from 100 subjects and tested on seven systems: Accu-Chek Aviva Plus, Advocate Redi-Code, Element, Embrace, Prodigy Voice, TRUEbalance, and WaveSense Presto. Results were compared with manufacturer's documented reference system, YSI or perchloric acid hexokinase; three different strip lots from each system were tested on each subject, in duplicate.

RESULTS

Compared against current ISO criteria (≥ 95% within ± 15 mg/dl for values <75 mg/dl and ± 20% for values ≥ 75 mg/dl) the Accu-Chek Aviva Plus, Element, and WaveSense Presto systems met accuracy criteria. However, only the Accu-Chek Aviva Plus met the proposed ISO criteria (criterion A) in all three lots. The other six systems failed to meet the criteria in at least two of the three lots, showing lot-to-lot variability, high/low bias, and variations due to hematocrit.

CONCLUSIONS

Inaccurate SMBG readings can potentially adversely impact clinical decision making and outcomes. Clinicians can reduce controllable variables by prescribing accurate SMBG systems. Adherence to the proposed ISO criteria should enhance patient safety by improving the accuracy of SMBG systems.

[Importance of nutritional counseling and dietary fiber content on glycemic control in type 2 diabetic patients under intensive educational intervention]

OBJECTIVE

To evaluate the importance of nutritional counseling within a set of multidisciplinary interventions.

SUBJECTS AND METHODS

Forty-seven patients with type 2 diabetes and hyperglycemia (A1C ≥ 8%), treated conventionally (n = 19, GC) or intensively in six weekly visits (n = 28, GI) were analyzed. We evaluated mean weekly blood glucose (MWG) at baseline and after 6 weeks in both groups.

RESULTS

GI reduced caloric (p = 0.001), carbohydrate (p = 0.004), and fat (p = 0.001) intake, and increased fiber consumption, while GC reduced fiber intake (p = 0.018). Glycemic control (MWG ≤ 150 mg/dL) occurred in 75% of GI patients and in 31.6% of CG patients (p = 0.003), with negative correlation between changes in fiber intake and MWG values (r =-0.309; P = 0.035). Results were maintained after 12 weeks.

CONCLUSION

Educational short-term intensive intervention was more effective than conventional treatment to achieve glycemic control. Our results also indicate that a more appropriate fiber content in the diet contributes for better blood glucose control in these patients.

Diabetes as a case study of chronic disease management with a personalized approach: the role of a structured feedback loop

As non-communicable or chronic diseases are a growing threat to human health and economic growth, political stakeholders are aiming to identify options for improved response to the challenges of prevention and management of non-communicable diseases. This paper is intended to contribute ideas on personalized chronic disease management which are based on experience with one major chronic disease, namely diabetes mellitus. Diabetes provides a pertinent case of chronic disease management with a particular focus on patient self-management. Despite advances in diabetes therapy, many people with diabetes still fail to achieve treatment targets thus remaining at risk of complications. Personalizing the management of diabetes according to the patient's individual profile can help in improving therapy adherence and treatment outcomes. This paper suggests using a six-step cycle for personalized diabetes (self-)management and collaborative use of structured blood glucose data. E-health solutions can be used to improve process efficiencies and allow remote access. Decision support tools and algorithms can help doctors in making therapeutic decisions based on individual patient profiles. Available evidence about the effectiveness of the cycle's constituting elements justifies expectations that the diabetes management cycle as a whole can generate medical and economic benefit.

The role of blood glucose monitoring in non-insulin treated type 2 diabetes: what is the evidence?

Over the past few decades, self-monitoring of blood glucose (SMBG) has been recognized as a core component of effective diabetes self-management among insulin-treated type 2 diabetes (T2DM) patients. Given the costly nature of current T2DM care, especially as the worldwide prevalence of T2DM continues to increase rapidly, it is critical to determine whether resources devoted to SMBG in non-insulin treated T2DM patients are also justified and being applied effectively. We review the conflicting evidence on the use of SMBG in insulin-naïve T2DM patients.

Structured self monitoring of blood glucose in Iranian people with type 2 diabetes; A cost consequence analysis

Background

Self-Monitoring of Blood Glucose (SMBG) is considered as a key factor in management of people with diabetes which is a growing and cost demanding health problem. The purpose of this study was to investigate the effect of comprehensive patient management using structured SMBG on metabolic control as well as its cost consequence analysis.

Methods

Sixty subjects were recruited in an observational study for a period of 6 months. They were provided with the ACCU-CHEK 360° View tool to fill in the values of the 7-point blood glucose profiles in three consecutive days during the study on a monthly basis. Changes in metabolic control were assessed by HbA1c and lipid profile measurement at the beginning and at the end of the study. In addition, cost consequence analysis was done considering different level of health care professionals with or without insurance coverage. The Average Cost Effectiveness Ratio (ACER) as well as Cost saving analysis were calculated and compared.

Results

The analysis showed significant reduction in HbA1c during the 6-month period in all subjects (P = 0.000). Furthermore, a positive effect was observed on lipid profile. The cost of endocrinologist’s visit in private sector was estimated to be 265.76 USD while this figure was149.15 USD for general practitioner in public sector with insurance coverage. Total complications and mortality cost saving was 154.8 USD. The lowest ACER was calculated for intervention with general practitioner in public sector with insurance coverage.

Conclusion

Structured SMBG results in significant improvement of glycemic status. Moreover, it is more cost saving in public sector with insurance coverage. It seems that general practitioner visits with insurance coverage is the most affordable option for people with type 2 diabetes.

The association of self-monitoring of blood glucose use with medication adherence and glycemic control in patients with type 2 diabetes initiating non-insulin treatment

BACKGROUND

The value of self-monitoring of blood glucose (SMBG) for persons with type 2 diabetes who do not use insulin remains controversial. This observational study compares the likelihood of medication adherence and change in glycated hemoglobin (A1C) for non-insulin-using patients using SMBG versus those not using SMBG. The study also assessed the association between diabetes medication adherence and SMBG use.

PATIENTS AND METHODS

Data were extracted on 5,172 patients who began non-insulin diabetes medication between October 1, 2006, and March 31, 2009. The study assessed change in A1C associated with SMBG use and testing frequency at different categorical levels of baseline A1C. The likelihood of medication adherence for SMBG users was compared with that for non-SMBG users at different categorical levels of baseline A1C. The study further explored the interactions between SMBG use and medication adherence on change in A1C.

RESULTS

SMBG users had greater reductions in A1C compared with nonusers when the baseline A1C was ≥ 7%. Increasing SMBG frequency was associated with greater reductions in A1C. The study also examined the associations among SMBG use, medication adherence, and change in A1C. SMBG users had greater decreases in A1C for both medication-adherent and -nonadherent patients. As expected, medication adherence was associated with greater reductions in A1C for both SMBG nonusers and users. It is interesting that medication-nonadherent SMBG users had similar reductions in A1C compared with medication-adherent non-SMBG users.

CONCLUSIONS

Both SMBG use and medication adherence were associated with similar degrees of A1C reduction after controlling for baseline A1C, suggesting that both factors may be important for attaining glycemic control.

System accuracy evaluation of 43 blood glucose monitoring systems for self-monitoring of blood glucose according to DIN EN ISO 15197

BACKGROUND

The accuracy of systems for self-monitoring of blood glucose is important, as reliable measurement results are a prerequisite for therapeutic decisions.

METHODS

This system accuracy evaluation study was performed according to DIN EN ISO 15197:2003 for 43 Conformité Européenne (CE)-labeled blood glucose (BG) monitoring systems. Measurement results of each system were compared with results of the designated comparison method (manufacturer's measurement procedure): glucose oxidase method (YSI 2300 glucose analyzer) or hexokinase method (Hitachi 917/ cobas 501).

RESULTS

Complete assessment according to the International Organization for Standardization (ISO) standard was performed for 34 out of 43 systems, and 27 (79.4%) meet the requirements of the standard, i.e., ≥95% of their results showed at least the minimum acceptable accuracy. For 9 of the 43 systems, complete accuracy assessment was not performed due to an oxygen sensitivity (manufacturer's labeling). The bias (according to Bland and Altman) of all 43 evaluated systems ranged from -14.1% to +12.4%.

CONCLUSIONS

From the 34 systems completely assessed, 7 systems did not fulfill the minimal accuracy requirements of the ISO standard. The CE mark apparently does not guarantee that all BG systems provide accuracy according to the standard. Because inaccurate systems bear the risk of false therapeutic decisions, regular and standardized evaluation of BG meters and test strips should be requested in order to ensure adherence to quality standards.

Lot-to-lot variability of test strips and accuracy assessment of systems for self-monitoring of blood glucose according to ISO 15197

BACKGROUND

Accurate and reliable blood glucose (BG) measurements require that different test strip lots of the same BG monitoring system provide comparable measurement results. Only a small number of studies addressing this question have been published.

METHODS

In this study, four test strip lots for each of five different BG systems [Accu-Chek® Aviva (system A), FreeStyle Lite® (system B), GlucoCheck XL (system C), Pura™/mylife™ Pura (system D), and OneTouch® Verio™ Pro (system E)] were evaluated with procedures according to DIN EN ISO 15197:2003. The BG system measurement results were compared with the manufacturer's measurement procedure (glucose oxidase or hexokinase method). Relative bias according to Bland and Altman and system accuracy according to ISO 15197 were analyzed. A BG system consists of the BG meter itself and the test strips.

RESULTS

The maximum lot-to-lot difference between any two of the four evaluated test strip lots per BG system was 1.0% for system E, 2.1% for system A, 3.1% for system C, 6.9% for system B, and 13.0% for system D. Only two systems (systems A and B) fulfill the criteria of DIN EN ISO 15197:2003 with each test strip lot.

CONCLUSIONS

Considerable lot-to-lot variability between test strip lots of the same BG system was found. These variations add to other sources of inaccuracy with the specific BG system. Manufacturers should regularly and effectively check the accuracy of their BG meters and test strips even between different test strip lots to minimize risk of false treatment decisions.

Blood glucose monitoring: an overview

Glucose monitoring is done to obtain information on blood glucose levels to ensure a therapeutic regimen; the aim is to maintain consistent glucose levels and avoid hypoglycaemia and hyperglycaemia. Self-management is central to diabetes control. Diabetes is individual, so self-monitoring of blood glucose (SMBG) targets and frequency of testing must be decided to meet each patient's needs. Nurses have key roles in education and advocacy. They can educate patients on what affects glucose levels, why they need to carry out SMBG, and how to interpret and act on the results. Nurses also match glucose monitoring meters to patients' needs by considering ease of use, technical features and lifestyle. Access to testing supplies is sometimes restricted through blanket policies and nurses have an advocacy role here in challenging inappropriate restrictions.

A comprehensive evaluation of the performance of the test strip technology for OneTouch Verio glucose meter systems

BACKGROUND

OneTouch® Verio™ test strips (LifeScan Inc., Milpitas, CA) are designed to minimize error when used in blood glucose monitoring systems. These strips have a specialized architecture and incorporate a sophisticated waveform and proprietary algorithm.

MATERIALS AND METHODS

Performance of OneTouch Verio test strips was assessed in the laboratory in the presence of a wide range of patient, environmental, and pharmacologic factors. A clinical evaluation was conducted in which 296 patients and healthcare professionals (HCPs) performed glucose testing using OneTouch Verio test strips and OneTouch VerioIQ meters.

RESULTS

In the laboratory study, OneTouch Verio test strip results achieved a high level of performance over a wide range of hematocrit (19-61%), temperature (5-45(°)C), humidity (10-90% relative humidity), and altitude (0-3,048 m) conditions. Performance was not affected by 22 of 23 chemical compounds. In the clinical study, 100% (31/31) of lay-user test results were within ±10 mg/dL of reference values for blood glucose <75 mg/dL. At blood glucose ≥75 mg/dL, 99.2% (243/245) were within ±15% of reference values. A feature of the VerioIQ meter, PatternAlert(™) Technology, was correctly used and positively evaluated by >98% of lay users.

CONCLUSIONS

OneTouch Verio test strips are accurate and precise over a wide range of patient, environmental, and pharmacologic conditions. In addition, lay-users were able to successfully use the OneTouch VerioIQ PatternAlert Technology without HCP training.

Self-monitoring of blood glucose: one STeP forward?

INTRODUCTION

In times of short health care budgets, reimbursement for self-monitoring of blood glucose (SMBG) in diabetes patients without insulin treatment is subject to debate. The Structured Testing Program (STeP) trial found a positive correlation of test frequency and improved hemoglobin A1c (HbA1c) levels in poorly controlled type 2 diabetes patients not treated with insulin.

METHODS

A structured literature search for other clinical studies reporting on SMBG frequency was performed.

RESULTS

There is scarce evidence: three trials, including STeP, noted a significant and relevant correlation between testing frequency and improved HbA1c levels (FA effect), whereas two studies did not. The comparability between the identified studies is problematic.

CONCLUSION

Future research should consider correlations between testing frequency and level of glycemic control. More emphasis should be placed on a structured approach to use SMBG and to address adherence to testing and therapy.

Results that matter: structured vs. unstructured self-monitoring of blood glucose in type 2 diabetes

Self-monitoring of blood glucose (SMBG) is one component of diabetes management. SMBG presents information about current glycemic status and provides the ability to obtain immediate feedback regarding the impact of behavioral and pharmacological interventions on glucose levels. However, SMBG is useful only when the glucose information is understood correctly, data are accurately interpreted, and results prompt appropriate therapeutic actions. The International Diabetes Federation (IDF) recently published guidelines for SMBG use in non-insulin treated people with diabetes, recommending that SMBG should be used only when patients and/or their clinicians possess the ability and willingness to incorporate SMBG monitoring and therapy adjustment into their diabetes care plan. If SMBG is used, the IDF also recommends that structured SMBG be performed utilizing defined regimens to meet individual needs. Structured SMBG can be performed as daily glucose profiles that are representative of daily glucose excursions. Measuring preprandial/postprandial blood glucose (bG) levels on consecutive or alternating days ("testing in pairs") also provides impactful glucose information for daily diabetes management. This article reviews recent studies that appropriately utilized structured SMBG as an integral component of comprehensive diabetes management and discusses how their findings support the IDF recommendations. Our goal is to help clinicians make more informed decisions about the value and utility of SMBG in diabetes management.

Efficacy of a computerized simulation in promoting walking in individuals with diabetes

BACKGROUND

Regular walking is a recommended but underused self-management strategy for individuals with type 2 diabetes mellitus (T2DM).

OBJECTIVE

To test the impact of a simulation-based intervention on the beliefs, intentions, knowledge, and walking behavior of individuals with T2DM. We compared two versions of a brief narrated simulation. The experimental manipulation included two components: the presentation of the expected effect of walking on the glucose curve; and the completion of an action plan for walking over the next week. Primary hypotheses were (1) intervention participants' walking (minutes/week) would increase more than control participants' walking, and (2) change in outcome expectancies (beliefs) would be a function of the discrepancy between prior beliefs and those presented in the simulation. Secondary hypotheses were that, overall, behavioral intentions to walk in the coming week and diabetes-related knowledge would increase in both groups.

METHODS

Individuals were randomly assigned to condition. Preintervention measures included self-reported physical activity (International Physical Activity Questionnaire [IPAQ] 7-day), theory of planned behavior-related beliefs, and knowledge (Diabetes Knowledge Test). During the narrated simulation we measured individuals' outcome expectancies regarding the effect of exercise on glucose with a novel drawing task. Postsimulation measures included theory of planned behavior beliefs, knowledge, and qualitative impressions of the narrated simulation. The IPAQ 7-day was readministered by phone 1 week later. We used a linear model that accounted for baseline walking to test the main hypothesis regarding walking. Discrepancy scores were calculated between the presented outcome and individuals' prior expectations (measured by the drawing task). A linear model with an interaction between intervention status and the discrepancy score was used to test the hypothesis regarding change in outcome expectancy. Pre-post changes in intention and knowledge were tested using paired t tests.

RESULTS

Of 65 participants, 33 were in the intervention group and 32 in the control group. We excluded 2 participants from analysis due to being extreme outliers in baseline walking. After adjustment for baseline difference in age and intentions between groups, intervention participants increased walking by 61.0 minutes/week (SE 30.5, t(58 = 1.9, )P = .05) more than controls. The proposed interaction between the presented outcome and the individual's prior beliefs was supported: after adjustment for baseline differences in age and intentions between groups, the coefficient for the interaction was -.25, (SE 0.07, t(57 = -3.2, )P < .01). On average participants in both groups improved significantly from baseline in intentions (mean difference 0.66, t(62 = 4.5, )P < .001) and knowledge (mean difference 0.38, t(62 = 2.4, )P = .02).

CONCLUSIONS

This study suggests that a brief, Internet-ready, simulation-based intervention can improve knowledge, beliefs, intentions, and short-term behavior in individuals with T2DM.

The role of self-monitoring of blood glucose in glucagon-like peptide-1-based treatment approaches: a European expert recommendation

The role of glucagon-like peptide (GLP)-1-based treatment approaches for type 2 diabetes mellitus (T2DM) is increasing. Although self-monitoring of blood glucose (SMBG) has been performed in numerous studies on GLP-1 analogs and dipeptidyl peptidase-4 inhibitors, the potential role of SMBG in GLP-1-based treatment strategies has not been elaborated. The expert recommendation suggests individualized SMBG strategies in GLP-1-based treatment approaches and suggests simple and clinically applicable SMBG schemes. Potential benefits of SMBG in GLP-1-based treatment approaches are early assessment of treatment success or failure, timely modification of treatment, detection of hypoglycemic episodes, assessment of glucose excursions, and support of diabetes management and diabetes education. Its length and frequency should depend on the clinical setting and the quality of metabolic control. It is considered to play an important role for the optimization of diabetes management in T2DM patients treated with GLP-1-based approaches.

Association between sitagliptin adherence and self-monitoring of blood glucose

BACKGROUND

We evaluated the association between self-monitoring of blood glucose (SMBG) use and sitagliptin or sitagliptin/metformin (SSMT) adherence. SSMT was chosen as these medications have little risk of hypoglycemia and are believed to not require SMBG data for titration.

METHODS

This was an observational study using data extracted from a large United States insurance claims database (i3 InVision™ Data Mart, Ingenix, Inc.). Data were extracted on noninsulin-using patients initiating SSMT for each 12-month period pre- and post-SSMT initiation. Logistic regression was used to assess the relationship between SMBG use and the likelihood of being medication adherent (defined as a medication possession ratio of ≥75%) while controlling for covariates.

RESULTS

This analysis included 7,306 patients (57.6% male; mean age 54.2 years). Mean pre-SSMT hemoglobin A1c (HbA1c) was 8.0%. In the post-SSMT initiation period, 58% of patients were adherent with SSMT. Older age, male gender, prior use of oral diabetes medication, and lower HbA1c were associated with improved SSMT adherence. SMBG use was associated with improved adherence [odds ratio (OR) ranged from 1.198 to 1.338; p < .05] compared with patients with no SMBG use pre- or post-SSMT initiation. For patients who began SMBG after starting SSMT, greater SMBG use was associated with better adherence (OR 1.449 for higher vs 1.246 for lower strip use; p < .05).

CONCLUSIONS

This study demonstrated that SMBG is associated with improved SSMT adherence. This relationship is strengthened with greater SMBG use.

The impact of structured blood glucose testing on attitudes toward self-management among poorly controlled, insulin-naïve patients with type 2 diabetes

INTRODUCTION

Patients with T2DM often view self-monitoring of blood glucose (SMBG) as burdensome and pointless, which may affect their broader attitudes toward diabetes management. We examined how a structured SMBG protocol influenced diabetes self-efficacy and autonomous motivation over time, and linked these to changes in glycemic control.

MATERIALS AND METHODS

The Structured Testing Program (STeP) is a 12-month, two-arm, cluster-randomized trial that assessed the efficacy of structured SMBG in 483 insulin-naïve T2DM patients. Measures included: Confidence in Diabetes Self-Care for Type 2 patients (CIDS-T2), Diabetes-related Autonomous Motivation (DRAM), self-management behaviors and HbA1c.

RESULTS

Intent-to-treat (ITT) and per-protocol (PP) analyses showed significant increases in CIDS-T2 scores over time (main effects p<0.0001). PP analysis showed significant between-group differences (p<0.05), with adherent STG patients displaying greater CIDS-T2 improvement than ACG patients. PP analyses showed main and between-group effects in DRAM with similar findings. Changes in CIDS-T2 were related to HbA1c changes over time; no self-management variable mediated this relationship. CIDS-T2 and HbA1c displayed a significant time-concordant relationship.

DISCUSSION

Structured SMBG leads to significant increases in self-confidence and autonomous motivation associated with diabetes self-management. Changes in self-confidence are linked to changes in glycemic control and share a time-concordant relationship.

Personalizing treatment in type 2 diabetes: a self-monitoring of blood glucose inclusive innovative approach

A strong correlation exists between improved blood glucose control, obtained from the earliest stages of diabetes, and the prevention of complications. However, tight glycometabolic control does not always translate into an advantage for every patient. Because the characteristics of individual patients play an important role in diabetes care, there is a need to develop personalized action plans. This article suggests tailored therapeutic algorithms for some of the commonest type 2 diabetes phenotypes, taking into consideration age, body mass index, presence of micro- and macrovascular complications, hypoglycemia risk, and the co-existence of chronic renal failure. Particular emphasis is placed on exploiting information supplied through the rational use of self-monitoring of blood glucose as a tool for optimizing diabetes management, according to the prevalence of fasting/preprandial or postprandial hyperglycemia.

Value and utility of structured self-monitoring of blood glucose in real world clinical practice: findings from a multinational observational study

BACKGROUND

The Structured Testing Program (STeP) study, a cluster-randomized, controlled trial, showed that a structured self-monitoring of blood glucose (SMBG)-based intervention improves clinical outcomes. It is important to determine whether this intervention can be adapted for use in general medical practice. This study examined the feasibility and effects of a modified version of the STeP intervention on clinical and attitudinal outcomes in real world clinical settings.

METHODS

In this 3-month, observational, multinational study, 375 type 1 and type 2 diabetes patients in 11 countries were asked to generate a blood glucose (bG) profile once per month for 3 consecutive months, using a paper-based bG analysis tool (Accu-Chek® 360° View® bG analysis system, Roche Diagnostics, Mannheim, Germany). Measurements were to be performed before and 2 h after main meals and before bedtime on 3 consecutive days. End points included change from baseline in glycated hemoglobin (HbA1c) and other parameters of diabetes complications. Patient and physician attitudes toward use of the structured testing form were also assessed.

RESULTS

Reductions in mean (SD) HbA1c from baseline were significant, from 9.2% (1.6%) to 8.0% (1.4%) (Δ -1.2% [1.6%], P<0.001). Reductions in mean (SD) average bG from baseline were significant, from 189.5 mg/dL (55.5 mg/dL) to 153 mg/dL (39.6 mg/dL) (Δ-36.4 mg/dL [52.5 mg/dL], P<0.001). Significant (P<0.001) improvements in body mass index, lipids, and blood pressure were also observed. Patients and physicians were generally positive about the utility of the structured testing form.

CONCLUSIONS

Use of the structured SMBG intervention is practical in real world clinical settings and is associated with improved diabetes management.

Use of an automated decision support tool optimizes clinicians' ability to interpret and appropriately respond to structured self-monitoring of blood glucose data

OBJECTIVE

We evaluated the impact of an automated decision support tool (DST) on clinicians' ability to identify glycemic abnormalities in structured self-monitoring of blood glucose (SMBG) data and then make appropriate therapeutic changes based on the glycemic patterns observed.

RESEARCH DESIGN AND METHODS

In this prospective, randomized, controlled, multicenter study, 288 clinicians (39.6% family practice physicians, 37.9% general internal medicine physicians, and 22.6% nurse practitioners) were randomized to structured SMBG alone (STG; n = 72); structured SMBG with DST (DST; n = 72); structured SMBG with an educational DVD (DVD; n = 72); and structured SMBG with DST and the educational DVD (DST+DVD; n = 72). Clinicians analyzed 30 patient cases (type 2 diabetes), identified the primary abnormality, and selected the most appropriate therapy.

RESULTS

A total of 222 clinicians completed all 30 patient cases with no major protocol deviations. Significantly more DST, DVD, and DST+DVD clinicians correctly identified the glycemic abnormality and selected the most appropriate therapeutic option compared with STG clinicians: 49, 51, and 55%, respectively, vs. 33% (all P < 0.0001) with no significant differences among DST, DVD, and DST+DVD clinicians.

CONCLUSIONS

Use of structured SMBG, combined with the DST, the educational DVD, or both, enhances clinicians' ability to correctly identify significant glycemic patterns and make appropriate therapeutic decisions to address those patterns. Structured testing interventions using either the educational DVD or the DST are equally effective in improving data interpretation and utilization. The DST provides a viable alternative when comprehensive education is not feasible, and it may be integrated into medical practices with minimal training.

Does self monitoring of blood glucose as opposed to urinalysis provide additional benefit in patients newly diagnosed with type 2 diabetes receiving structured education? The DESMOND SMBG randomised controlled trial protocol

BACKGROUND

The benefit of self-monitoring of blood glucose (SMBG) in people with type 2 diabetes on diet or oral agents other than sulphonylureas remains uncertain. Trials of interventions incorporating education about self-monitoring of blood glucose have reported mixed results. A recent systematic review concluded that SMBG was not cost-effective. However, what was unclear was whether a cheaper method of self-monitoring (such as urine glucose monitoring) could produce comparable benefit and patient acceptability for less cost.

METHODS/DESIGN

The DESMOND SMBG trial is comparing two monitoring strategies (blood glucose monitoring and urine testing) over 18 months when incorporated into a comprehensive self-management structured education programme. It is a multi-site cluster randomised controlled trial, conducted across 8 sites (7 primary care trusts) in England, UK involving individuals with newly diagnosed Type 2 diabetes.The trial has 80% power to demonstrate equivalence in mean HbA1c (the primary end-point) at 18 months of within ± 0.5% assuming 20% drop out and 20% non-consent. Secondary end-points include blood pressure, lipids, body weight and psychosocial measures as well as a qualitative sub-study.Practices were randomised to one of two arms: participants attend a DESMOND programme incorporating a module on self-monitoring of either urine or blood glucose. The programme is delivered by accredited educators who received specific training about equipoise. Biomedical data are collected and psychosocial scales completed at baseline, and 6, 12, and 18 months post programme. Qualitative research with participants and educators will explore views and experiences of the trial and preferences for methods of monitoring.

DISCUSSION

The DESMOND SMBG trial is designed to provide evidence to inform the debate about the value of self-monitoring of blood glucose in people with newly diagnosed type 2 diabetes. Strengths include a setting in primary care, a cluster design, a health economic analysis, a comparison of different methods of monitoring while controlling for other components of training within the context of a quality assured structured education programme and a qualitative sub-study.

TRIAL REGISTRATION

ISRCTN: ISRCTN95696668.

Insulin therapy and hypoglycemia

Hypoglycemia is the most important and common side effect of insulin therapy. It is also the rate limiting factor in safely achieving excellent glycemic control. A three-fold increased risk of severe hypoglycemia occurs in both type 1 and type 2 diabetes with tight glucose control. This dictates a need to individualize therapy and glycemia goals to minimize this risk. Several ways to reduce hypoglycemia risk are recognized and discussed. They include frequent monitoring of blood sugars with home blood glucose tests and sometimes continuous glucose monitoring (CGM) in order to identify hypoglycemia particularly in hypoglycemia unawareness. Considerations include prompt measured hypoglycemia treatment, attempts to reduce glycemic variability, balancing basal and meal insulin therapy, a pattern therapy approach and use of a physiological mimicry with insulin analogues in a flexible manner. Methods to achieve adequate control while focusing on minimizing the risk of hypoglycemia are delineated in this article.

Perceptions of Caribbean type 2 diabetes patients on self-monitoring of blood glucose

CONTEXT

The views of type 2 diabetes (T2DM) patients have not been considered in the debate on the role of self-monitoring of blood glucose (SMBG) in the management of T2DM.

OBJECTIVE

To assess the views of T2DM patients on SMBG.

METHODS

Two previously trained research assistants used a structured pre-tested questionnaire to interview 416 T2DM patients practising SMBG in out-patient clinics in the privacy of the patients after they have consented to be interviewed.

RESULTS

79% of patients were unemployed with mean duration of diabetes of 11.8 ± 0.5 year. 94% of patients did not have health insurance policies while 86% did not belong to any diabetes support group. Although 70% of the patients identified SMBG as expensive, 94% believed it assists glycaemic control, while 89% thought it was worth the expense.

CONCLUSION

Caribbean T2DM patients believe SMBG was beneficial for the management of their diabetes and empowering them may reduce diabetes complications.

Self-monitoring of blood glucose in patients with type 2 diabetes mellitus who are not using insulin

BACKGROUND

Self-monitoring of blood glucose (SMBG) has been found to be effective for patients with type 1 diabetes and for patients with type 2 diabetes using insulin. There is much debate on the effectiveness of SMBG as a tool in the self-management for patients with type 2 diabetes who are not using insulin.

OBJECTIVES

To assess the effects of SMBG in patients with type 2 diabetes mellitus who are not using insulin.

SEARCH METHODS

Multiple electronic bibliographic and ongoing trial databases were searched supplemented with handsearches of references of retrieved articles (date of last search: 07 July 2011).

SELECTION CRITERIA

Randomised controlled trials investigating the effects of SMBG compared with usual care, self-monitoring of urine glucose (SMUG) or both in patients with type 2 diabetes who where not using insulin. Studies that used glycosylated haemoglobin A(1c) (HbA(1c)) as primary outcome were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data from included studies and evaluated the studies' risk of bias. Data from the studies were compared to decide whether they were sufficiently homogeneous to pool in a meta-analysis. Primary outcomes were HbA(1c), health-related quality of life, well-being and patient satisfaction. Secondary outcomes were fasting plasma glucose level, hypoglycaemic episodes, morbidity, adverse effects and costs.

MAIN RESULTS

Twelve randomised controlled trials were included and evaluated outcomes in 3259 randomised patients. Intervention duration ranged from 6 months (26 weeks) to 12 months (52 weeks). Nine trials compared SMBG with usual care without monitoring, one study compared SMBG with SMUG, one study was a three-armed trial comparing SMBG and SMUG with usual care and one study was a three-armed trial comparing less intensive SMBG and more intensive SMBG with a control group. Seven out of 11 studies had a low risk of bias for most indicators. Meta-analysis of studies including patients with a diabetes duration of one year or more showed a statistically significant SMBG induced decrease in HbA(1c) at up to six months follow-up (-0.3; 95% confidence interval (CI) -0.4 to -0.1; 2324 participants, nine trials), yet an overall statistically non-significant SMBG induced decrease was seen at 12 month follow-up (-0.1; 95% CI -0.3 to 0.04; 493 participants, two trials). Qualitative analysis of the effect of SMBG on well-being and quality of life showed no effect on patient satisfaction, general well-being or general health-related quality of life. Two trials reported costs of self-monitoring: One trial compared the costs of self-monitoring of blood glucose with self-monitoring of urine glucose based on nine measurements per week and with the prices in US dollars for self-monitoring in 1990. Authors concluded that total costs in the first year of self-monitoring of blood glucose, with the purchase of a reflectance meter were 12 times more expensive than self-monitoring of urine glucose ($481 or 361 EURO [11/2011 conversion] versus $40 or 30 EURO [11/2011 conversion]). Another trial reported a full economical evaluation of the costs and effects of self-monitoring. At the end of the trial, costs for the intervention were £89 (104 EURO [11/2011 conversion]) for standardized usual care (control group), £181 (212 EURO [11/2011 conversion]) for the less intensive self-monitoring group and £173 (203 EURO [11/2011 conversion]) for the more intensive self-monitoring group. Higher losses to follow-up in the more intensive self-monitoring group were responsible for the difference in costs, compared to the less intensive self-monitoring group.There were few data on the effects on other outcomes and these effects were not statistically significant. None of the studies reported data on morbidity.

AUTHORS' CONCLUSIONS

From this review, we conclude that when diabetes duration is over one year, the overall effect of self-monitoring of blood glucose on glycaemic control in patients with type 2 diabetes who are not using insulin is small up to six months after initiation and subsides after 12 months. Furthermore, based on a best-evidence synthesis, there is no evidence that SMBG affects patient satisfaction, general well-being or general health-related quality of life. More research is needed to explore the psychological impact of SMBG and its impact on diabetes specific quality of life and well-being, as well as the impact of SMBG on hypoglycaemia and diabetic complications.

What do we need beyond hemoglobin A1c to get the complete picture of glycemia in people with diabetes?

Hemoglobin A1c (HbA1c) is currently the most commonly used marker for the determination of the glycemic status in people with diabetes and it is frequently used to guide therapy and especially medical treatment of people with diabetes. The measurement of HbA1c has reached a high level of analytical quality and, therefore, this biomarker is currently also suggested to be used for the diagnosis of diabetes. Nevertheless, it is crucial for people with diabetes and their treating physicians to be aware of possible interferences during its measurement as well as physiological or pathological factors that contribute to the HbA1c concentration without being related to glycemia, which are discussed in this review. We performed a comprehensive review of the literature based on PubMed searches on HbA1c in the treatment and diagnosis of diabetes including its most relevant limitations, glycemic variability and self-monitoring of blood glucose (SMBG). Although the high analytical quality of the HbA1c test is widely acknowledged, the clinical relevance of this marker regarding risk reduction of cardiovascular morbidity and mortality is still under debate. In this respect, we argue that glycemic variability as a further risk factor should deserve more attention in the treatment of diabetes.

Short- and long-term effects of real-time continuous glucose monitoring in patients with type 2 diabetes

OBJECTIVE

To determine whether short-time, real-time continuous glucose monitoring (RT-CGM) has long-term salutary glycemic effects in patients with type 2 diabetes who are not on prandial insulin.

RESEARCH DESIGN AND METHODS

This was a randomized controlled trial of 100 adults with type 2 diabetes who were not on prandial insulin. This study compared the effects of 12 weeks of intermittent RT-CGM with self-monitoring of blood glucose (SMBG) on glycemic control over a 40-week follow-up period. Subjects received diabetes care from their regular provider without therapeutic intervention from the study team.

RESULTS

There was a significant difference in A1C at the end of the 3-month active intervention that was sustained during the follow-up period. The mean, unadjusted A1C decreased by 1.0, 1.2, 0.8, and 0.8% in the RT-CGM group vs. 0.5, 0.5, 0.5, and 0.2% in the SMBG group at 12, 24, 38, and 52 weeks, respectively (P = 0.04). There was a significantly greater decline in A1C over the course of the study for the RT-CGM group than for the SMBG group, after adjusting for covariates (P < 0.0001). The subjects who used RT-CGM per protocol (≥48 days) improved the most (P < 0.0001). The improvement in the RT-CGM group occurred without a greater intensification of medication compared with those in the SMBG group.

CONCLUSIONS

Subjects with type 2 diabetes not on prandial insulin who used RT-CGM intermittently for 12 weeks significantly improved glycemic control at 12 weeks and sustained the improvement without RT-CGM during the 40-week follow-up period, compared with those who used only SMBG.

A survey of blood glucose monitoring in patients with type 2 diabetes: are recommendations from health care professionals being followed?

OBJECTIVE

To survey the self-reported use of self-monitoring of blood glucose (SMBG) among patients with type 2 diabetes (T2DM), both insulin users (IUs) and non-insulin users (NIUs), in the United States and to examine: how often patients test; what SMBG instructions patients report receiving from their health care providers (HCPs); how the frequency of testing conforms with reported HCP recommendations for testing; and what is done with the results of testing. Differences between IUs and NIUs were also investigated.

METHODS

A convenience sample of 886 T2DM participants at a series of one-day conferences across the United States completed a survey on current and recommended SMBG frequency, how SMBG results were used, and how HCPs reportedly talked about SMBG issues with the patient. IUs (65% of the sample) and NIUs (35%) were examined separately.

RESULTS

IUs and NIUs reported testing significantly less frequently than was recommended (in both cases, p < 0.001), with wide variations within both groups. Many IUs (42%) and NIUs (50%) did not bring SMBG data regularly to medical visits, and 54% of IUs and 56% of NIUs did not respond regularly to out-of-range SMBG readings. HCPs were generally supportive and responsive to SMBG data. More frequent SMBG was associated with more regular HCP attention to SMBG records, for IUs (p = 0.02) and NIUs (p = 0.004).

CONCLUSIONS

Self-reported SMBG use is common in T2DM, though frequency is lower than HCP recommendations. Wide variations in actual and recommended SMBG were observed. HCP support for SMBG is reportedly common, and is associated with greater SMBG frequency. While SMBG data can be valuable, recommendations are often not followed and data often goes unused by both HCPs and patients.

Cost effectiveness of self-monitoring of blood glucose (SMBG) for patients with type 2 diabetes and not on insulin: impact of modelling assumptions on recent Canadian findings

BACKGROUND

Canadian patients, healthcare providers and payers share interest in assessing the value of self-monitoring of blood glucose (SMBG) for individuals with type 2 diabetes but not on insulin. Using the UKPDS (UK Prospective Diabetes Study) model, the Canadian Optimal Prescribing and Utilization Service (COMPUS) conducted an SMBG cost-effectiveness analysis. Based on the results, COMPUS does not recommend routine strip use for most adults with type 2 diabetes who are not on insulin. Cost-effectiveness studies require many assumptions regarding cohort, clinical effect, complication costs, etc. The COMPUS evaluation included several conservative assumptions that negatively impacted SMBG cost effectiveness.

OBJECTIVES

Current objectives were to (i) review key, impactful COMPUS assumptions; (ii) illustrate how alternative inputs can lead to more favourable results for SMBG cost effectiveness; and (iii) provide recommendations for assessing its long-term value.

METHODS

A summary of COMPUS methods and results was followed by a review of assumptions (for trial-based glycosylated haemoglobin [HbA(1c)] effect, patient characteristics, costs, simulation pathway) and their potential impact. The UKPDS model was used for a 40-year cost-effectiveness analysis of SMBG (1.29 strips per day) versus no SMBG in the Canadian payer setting. COMPUS assumptions for patient characteristics (e.g. HbA(1c) 8.4%), SMBG HbA(1c) advantage (-0.25%) and costs were retained. As with the COMPUS analysis, UKPDS HbA(1c) decay curves were incorporated into SMBG and no-SMBG pathways. An important difference was that SMBG HbA(1c) benefits in the current study could extend beyond the initial simulation period. Sensitivity analyses examined SMBG HbA(1c) advantage, adherence, complication history and cost inputs. Outcomes (discounted at 5%) included QALYs, complication rates, total costs (year 2008 values) and incremental cost-effectiveness ratios (ICERs).

RESULTS

The base-case ICER was $Can63 664 per QALY gained; approximately 56% of the COMPUS base-case ICER. SMBG was associated with modest risk reductions (0.10-0.70%) for six of seven complications. Assuming an SMBG advantage of -0.30% decreased the current base-case ICER by over $Can10 000 per QALY gained. With adherence of 66% and 87%, ICERs were (respectively) $Can39 231 and $Can54 349 per QALY gained. Incorporating a more representative complication history and 15% complication cost increase resulted in an ICER of $Can49 743 per QALY gained.

CONCLUSIONS

These results underscore the importance of modelling assumptions regarding the duration of HbA(1c) effect. The current study shares several COMPUS limitations relating to the UKPDS model being designed for newly diagnosed patients, and to randomized controlled trial monitoring rates. Neither study explicitly examined the impact of varying the duration of initial HbA(1c) effects, or of medication or other treatment changes. Because the COMPUS research will potentially influence clinical practice and reimbursement policy in Canada, understanding the impact of assumptions on cost-effectiveness results seems especially important. Demonstrating that COMPUS ICERs were greatly reduced through variations in a small number of inputs may encourage additional clinical research designed to measure SMBG effects within the context of optimal disease management. It may also encourage additional economic evaluations that incorporate lessons learned and best practices for assessing the overall value of SMBG for type 2 diabetes in insulin-naive patients.

The impact of blood glucose monitoring on depression and distress in insulin-naïve patients with type 2 diabetes

OBJECTIVE

To test whether a structured self-monitoring of blood glucose (SMBG) protocol reduces depressive symptoms and diabetes distress.

RESEARCH DESIGN AND METHODS

A 12-month, cluster-randomised, clinical trial compared patients who received a collaborative, structured SMBG, physician/patient intervention with an active control. Studied were 483 insulin naïve type 2 diabetes patients (experimental = 256, control = 227) (≥ 7.5% HbA1c) from 34 primary care practices (experimental = 21, control = 13). Experimental patients used a paper tool to record a 7-point SMBG profile on each of three consecutive days prior to their quarterly physician visit. Patients and physicians interpreted SMBG results to make medication and lifestyle changes.

CLINICAL TRIAL REGISTRATION

NIH Trial Registry Number: NCT00674986.

MAIN OUTCOME MEASURES

Depressive symptoms (Patient Health Questionnaire: PHQ-8), diabetes-related distress (Diabetes Distress Scale: DDS). HbA1c and SMBG frequency were assessed quarterly; data were analysed using Linear Mixed Models (LMM) for intent-to-treat (ITT) and per protocol (PP) analyses.

RESULTS

ITT analyses showed significant improvement in depression and disease-related distress among experimental and control patients from baseline to 12 months (p < 0.01 in both cases) with no between-group differences. Experimental patients displayed significantly greater reductions in distress related to regimen adherence than controls. Also, experimental patients with elevated diabetes distress or depressive symptoms at baseline showed significantly greater reductions in distress and depressive symptoms than control patients at 12 months. The greater improvement in mood in the experimental than control group was independent of improvements in glycaemic control and changes in SMBG frequency.

CONCLUSIONS

Using well standardised measures, collaborative, structured SMBG leads to reductions, not increases, in depressive symptoms and diabetes distress over time, for the large number of moderately depressed or distressed type 2 patients in poor glycaemic control. Changes in affective status are independent of improvements in glycaemic control and changes in SMBG frequency for these patients.

Consensus report: the current role of self-monitoring of blood glucose in non-insulin-treated type 2 diabetes

The Coalition for Clinical Research--Self-Monitoring of Blood Glucose Scientific Board convened a meeting in San Francisco, CA, July 20-21, 2011, to discuss the current practice of self-monitoring of blood glucose (SMBG) in non-insulin-treated (NIT) type 2 diabetes mellitus (T2DM). Twelve physician panel members from academia, practice, and government attended this meeting. These experts came from the United States, Brazil, Canada, France, Germany, Italy, and the United Kingdom. In addition, three consultants from Australia, Germany, and the United States contributed to the group's final report. This coalition was organized by Diabetes Technology Society. Self-monitoring of blood glucose was studied from eight perspectives related to patients with NIT T2DM: (1) epidemiological studies; (2) randomized controlled trials (RCT)s and meta-analyses; (3) targets, timing, and frequency of SMBG use; (4) incidence and role of SMBG in preventing hypoglycemia with single-drug regimens and combination regimens consisting of antihyperglycemic agents other than secretagogues and insulin; (5) comparison of SMBG with continuous glucose monitoring; (6) technological capabilities and limitations of SMBG; (7) barriers to appropriate use of SMBG; and (8) methods and end points for appropriate future clinical trials. The panel emphasized recent studies, which reflect the current approach for applying this intervention. Among the participants there was consensus that: SMBG is an established practice for patients with NIT T2DM, and to be most effective, it should be performed in a structured format where information obtained from this measurement is used to guide treatment; New, high-quality efficacy data from RCTs have demonstrated efficacy of SMBG in NIT T2DM in trials reported since 2008; Both patients and health care professionals require education on how to respond to the data for SMBG to be effective; and Additional well-defined studies are needed to assess the benefits and costs of SMBG with end points not limited to hemoglobin A1c.

Actionable self-monitoring of blood glucose: redefining the role for patients using multiple daily injection therapy

Self-monitoring of blood glucose (SMBG) values is an accepted requirement for patients with diabetes using multiple daily injections of insulin. Nevertheless, for many patients, the full value of SMBG has yet to be realized due to a number of factors that contribute to patients not taking appropriate action based on the achieved result. The reasons for this are complex but are related to the burden imposed by performing the tests, the need for complex numerical calculations, and the demand for undertaking this activity multiple times each day. In the near future, SMBG devices are likely to include technological innovations that are aimed at overcoming these barriers, offering "actionable" SMBG for patients using insulin. These innovations should include technologies that will allow customization and individualization based upon specific therapy regimens.

Rapid improvement of glycemic control in type 2 diabetes using weekly intensive multifactorial interventions: structured glucose monitoring, patient education, and adjustment of therapy-a randomized controlled trial

BACKGROUND

We evaluated intensive intervention in poorly controlled patients with type 2 diabetes mellitus involving weekly clinic visits and adjustment of therapy with analysis of three seven-point glucose profiles and intervention from an interdisciplinary staff.

METHODS

Sixty-three patients were randomized to an intensive treatment group that obtained self-monitoring of blood glucose (SMBG) profiles (six or seven values per day, 3 days/week) and were seen in the clinic at Weeks 1-6 and 12. SMBG results were downloaded, analyzed using Accu-Chek(®) 360° software (Roche Diagnostics, Indianapolis, IN), and used to adjust therapy. Control group subjects obtained glucose profiles and had clinic visits only at Weeks 0, 6, and 12.

RESULTS

There were highly statistically significant improvements in the intensive treatment group compared with the control group between Weeks 0 and 6 with greater reductions in weekly mean glycemia (WMG) (-76.7±8.9 mg/dL vs. -20.5±8.1 mg/dL), glycemic variability (SD) (-16.3±3.1 mg/dL vs. -5.0±3.1 mg/dL), and glycated hemoglobin (-1.82±0.16% vs. -0.66±0.22%) without significant changes in frequency of hypoglycemia or weight. Improvements were sustained in the intensive treatment group through Week 12. A minimal but statistically significant degree of improvement was seen in the control group at Week 12.

CONCLUSIONS

This short-term pilot study of an intensive monitoring, educational, and pharmacological interventions program resulted in dramatic improvement of glycemic control within 6 weeks, and these effects are sustained through Week 12. SMBG glucose profiles, calculation of WMG and SD, and graphical displays of glucose data can improve the effectiveness of adjustment of therapy at weekly clinic visits when combined with intensive support from a multidisciplinary team.

Features of mobile diabetes applications: review of the literature and analysis of current applications compared against evidence-based guidelines

BACKGROUND

Interest in mobile health (mHealth) applications for self-management of diabetes is growing. In July 2009, we found 60 diabetes applications on iTunes for iPhone; by February 2011 the number had increased by more than 400% to 260. Other mobile platforms reflect a similar trend. Despite the growth, research on both the design and the use of diabetes mHealth applications is scarce. Furthermore, the potential influence of social media on diabetes mHealth applications is largely unexplored.

OBJECTIVE

Our objective was to study the salient features of mobile applications for diabetes care, in contrast to clinical guideline recommendations for diabetes self-management. These clinical guidelines are published by health authorities or associations such as the National Institute for Health and Clinical Excellence in the United Kingdom and the American Diabetes Association.

METHODS

We searched online vendor markets (online stores for Apple iPhone, Google Android, BlackBerry, and Nokia Symbian), journal databases, and gray literature related to diabetes mobile applications. We included applications that featured a component for self-monitoring of blood glucose and excluded applications without English-language user interfaces, as well as those intended exclusively for health care professionals. We surveyed the following features: (1) self-monitoring: (1.1) blood glucose, (1.2) weight, (1.3) physical activity, (1.4) diet, (1.5) insulin and medication, and (1.6) blood pressure, (2) education, (3) disease-related alerts and reminders, (4) integration of social media functions, (5) disease-related data export and communication, and (6) synchronization with personal health record (PHR) systems or patient portals. We then contrasted the prevalence of these features with guideline recommendations.

RESULTS

The search resulted in 973 matches, of which 137 met the selection criteria. The four most prevalent features of the applications available on the online markets (n = 101) were (1) insulin and medication recording, 63 (62%), (2) data export and communication, 61 (60%), (3) diet recording, 47 (47%), and (4) weight management, 43 (43%). From the literature search (n = 26), the most prevalent features were (1) PHR or Web server synchronization, 18 (69%), (2) insulin and medication recording, 17 (65%), (3) diet recording, 17 (65%), and (4) data export and communication, 16 (62%). Interestingly, although clinical guidelines widely refer to the importance of education, this is missing from the top functionalities in both cases.

CONCLUSIONS

While a wide selection of mobile applications seems to be available for people with diabetes, this study shows there are obvious gaps between the evidence-based recommendations and the functionality used in study interventions or found in online markets. Current results confirm personalized education as an underrepresented feature in diabetes mobile applications. We found no studies evaluating social media concepts in diabetes self-management on mobile devices, and its potential remains largely unexplored.

Addressing schemes of self-monitoring of blood glucose in type 2 diabetes: a European perspective and expert recommendation

Self-monitoring of blood glucose (SMBG) in type 2 diabetes has increasingly been shown to display beneficial effects on glycemic control. SMBG is not only associated with a reduction of hemoglobin A1c but has also been demonstrated to increase patients' awareness of the disease. SMBG has also the potential to visualize and predict hypoglycemic episodes. International guidelines by the International Diabetes Federation, the European Society of Cardiology, and the European Association for the Study of Diabetes and also the International Society for Pediatric and Adolescent Diabetes emphasize that SMBG is an integral part of self-management. More recently, two European consensus documents have been published to give recommendations for frequency and timing of SMBG also for various clinical scenarios. Recently, a European expert panel was held to further facilitate and enhance standardized approaches to SMBG. The aim was to present simple, clinically meaningful, and standardized SMBG strategies for type 2 diabetes. The panel recommended a less intensive and an intensive scheme for SMBG across the type 2 diabetes continuum. The length and frequency of SMBG performance depend on the clinical circumstances and the quality of glycemic control. The expert panel also recommended further evaluation of various schemes for SMBG in type 2 diabetes in clinical studies.

A structured self-monitoring of blood glucose approach in type 2 diabetes encourages more frequent, intensive, and effective physician interventions: results from the STeP study

BACKGROUND

We evaluated how a structured patient/physician self-monitoring of blood glucose (SMBG) intervention influenced the timing, frequency, and effectiveness of primary care physicians' treatment changes with type 2 diabetes mellitus (T2DM) patients over 12 months.

METHODS

The Structured Testing Program (STeP) study was a cluster-randomized, multicenter trial with 483 poorly controlled, insulin-naive T2DM subjects. Primary care practices were randomized to the Active Control Group (ACG) or the Structured Testing Group (STG), the latter of which included quarterly review of structured SMBG results. STG patients used a paper tool that graphs seven-point glucose profiles over 3 consecutive days; physicians received a treatment algorithm based on SMBG patterns. Impact of structured SMBG on physician treatment modification recommendations (TMRs) and glycemic outcomes was examined.

RESULTS

More STG than ACG patients received a TMR at each study visit (P < 0.0001). Of patients who received at least one TMR, STG patients demonstrated a greater reduction in glycated hemoglobin A1c (HbA1c) than ACG patients (-1.2% vs. -0.8%, P < 0.03). Patients with a baseline HbA1c ≥8.5% who received a TMR at the Month 1 visit experienced greater reductions in HbA1c (P = 0.002) than patients without an initial TMR. More STG than ACG patients were started on incretins (P < 0.01) and on thiazolidinediones (P = 0.004). The number of visits with a TMR was unrelated to HbA1c change over time.

CONCLUSIONS

Patient-provided SMBG data contribute to glycemic improvement when blood glucose patterns are easy to detect, and well-trained physicians take timely action. Collaborative use of structured SMBG data leads to earlier, more frequent, and more effective TMRs for poorly controlled, non-insulin-treated T2DM subjects.

The effect of real-time continuous glucose monitoring on glycemic control in patients with type 2 diabetes mellitus

BACKGROUND

Real-time continuous glucose monitoring (RT-CGM) improves hemoglobin A1c (A1C) and hypoglycemia in people with type 1 diabetes mellitus and those with type 2 diabetes mellitus (T2DM) on prandial insulin; however, it has not been tested in people with T2DM not taking prandial insulin. We evaluated the utility of RT-CGM in people with T2DM on a variety of treatment modalities except prandial insulin.

METHODS

We conducted a prospective, 52-week, two-arm, randomized trial comparing RT-CGM (n = 50) versus self-monitoring of blood glucose (SMBG) (n = 50) in people with T2DM not taking prandial insulin. Real-time continuous glucose monitoring was used for four 2-week cycles (2 weeks on/1 week off). All patients were managed by their usual provider. This article reports on changes in A1C 0-12 weeks.

RESULTS

Mean (± standard deviation) decline in A1C at 12 weeks was 1.0% (± 1.1%) in the RT-CGM group and 0.5% (± 0.8%) in the SMBG group (p = .006). There were no group differences in the net change in number or dosage of hypoglycemic medications. Those who used the RT-CGM for ≥ 48 days (per protocol) reduced their A1C by 1.2% (± 1.1%) versus 0.6% (± 1.1%) in those who used it <48 days (p = .003). Multiple regression analyses statistically adjusting for baseline A1C, an indicator for usage, and known confounders confirmed the observed differences between treatment groups were robust (p = .009). There was no improvement in weight or blood pressure.

CONCLUSIONS

Real-time continuous glucose monitoring significantly improves A1C compared with SMBG in patients with T2DM not taking prandial insulin. This technology might benefit a wider population of people with diabetes than previously thought.