Self-monitoring of blood glucose in type-2 diabetes: what is the evidence?

Comparing the benefits of applying a vacuum assisted lancing device in reducing lancing pain, improving self-monitoring frequency and reducing HbA1c in people with diabetes

BACKGROUND AND AIMS

For most people with diabetes (PwD), lancing fingertips for obtaining a blood sample is unavoidable during blood glucose monitoring (BGM). This study investigated the potential benefits of applying a vacuum over the penetration site immediately, before, during, and after lancing to determine if a vacuum would allow a less painful lancing process from fingertips and alternate sites, while still drawing sufficient blood, thereby allowing PwD to have a painless lancing experience and improving self-monitoring frequency. The cohort was encouraged to use a commercially available vacuum assisted lancing device. Change in pain perception, testing frequency, HbA1c, and future probability of VALD use were determined.

METHODS

In a 24-week randomized open-label, interventional, cross-over trial, 110 PwD were recruited who used VALD and non-vacuum conventional lancing devices, for 12 weeks each. Percentage reduction in HbA1c, percentage BGM adherence, scores of pain perception, and probability of selecting VALD in the future were measured and compared.

RESULTS

There was reduction in overall HbA1c values (mean ± SD), (from 9.01 ± 1.68% at baseline to 8.28 ± 1.66%) and individually in T1D (from 8.94 ± 1.77% to 8.25 ± 1.67%) and T2D (from 8.31 ± 1.17% to 8.59 ± 1.30) after using VALD for 12 weeks. Lower pain perception and high probability of using VALD over conventional devices were observed.

CONCLUSION

The study highlights the benefits of applying a vacuum to the lance site which enhances the effectiveness in reducing and eliminating pain, improving self-monitoring frequency, and lowering HbA1c over non-vacuum conventional devices.

Systematic review of economic evaluation studies and budget impact on ambulatory monitoring of capillary glucose in type 2 diabetics

OBJECTIVE

Realise a review of studies of economic evaluation about the ambulatory monitoring of capillary glucose (AMGC) in diabetic type II persons.

METHODOLOGY

A review of the literature was conducted, in MedLine, various websites, referenced paper and provided by expert's persons.

RESULTS

Five studies concluded that the AMGC was a cost-effective strategic, of this papers use Kaiser Permanente data base, its make that these studies could be considered a solely one study. The rest of the papers did not find difference in the AMGC use.

CONCLUSIONS

The use of AMGC has an uncertainty efficiency. More studies are needed.

Self-monitoring of blood glucose in Black Caribbean and South Asian Canadians with non-insulin treated Type 2 diabetes mellitus: a qualitative study of patients' perspectives

BACKGROUND

To examine the views and current practice of SMBG among Black Caribbean and South Asian individuals with non-insulin treated Type 2 diabetes mellitus.

METHODS

Twelve participants completed semi-structured interviews that were guided by the Health Belief Model and analyzed using thematic network analysis.

RESULTS

The frequency of monitoring among participants varied from several times a day to once per week. Most participants expressed similar experiences regarding their views and practices of SMBG. Minor differences across gender and culture were observed. All participants understood the benefits, but not all viewed SMBG as beneficial to their personal diabetes management. SMBG can facilitate a better understanding and maintenance of self-care behaviours. However, it can trigger both positive and negative emotional responses, such as a sense of disappointment when high readings are not anticipated, resulting in emotional distress. Health care professionals play a key role in the way SMBG is perceived and used by patients.

CONCLUSION

While the majority of participants value SMBG as a self-management tool, barriers exist that impede its practice, particularly its cost. How individuals cope with these barriers is integral to understanding why some patients adopt SMBG more than others.

The use of a CoolSense device to lower pain sensation during finger pricking while measuring blood glucose in diabetes patients--a randomized placebo

BACKGROUND

Patients with type 1 diabetes and a significant portion of patients with type 2 diabetes must use subcutaneous insulin injections, in order to maintain normoglycemia and to prevent immediate and long-term complications. For these patients, testing blood glucose levels more frequently is necessary to safely achieve glycated hemoglobin targets. In the current study, the effects of a CoolSense™ device (CoolSense Medical Ltd., Tel Aviv, Israel) were examined in relieving pain caused by needle-pricking for glucose measurements in adult patients with diabetes.

SUBJECTS AND METHODS

One hundred seventy-seven patients assessed the severity of pain they experienced during needle-pricking. The patients were randomly divided into an experimental group or a control group that used either a cooled CoolSense instrument or a non-cooled device, respectively. Participants were asked to rank the severity of their pain by a questionnaire developed for this study. Blood glucose levels were monitored as a control.

RESULTS

The majority of participants (58.3-71.7%; P<0.001) reported significant ache during measurements, the desire for an instrument that relieves pain, and its negative influence on their quality of life. Significant differences were indicated in pain perception between the experimental group and the control group that served as placebo, with no differences in blood glucose measurements in the groups.

CONCLUSIONS

The CoolSense instrument significantly reduces subjective pain felt by patients and can therefore serve as an additional tool for clinicians to help ease the needle-pricking pain. Future study is needed in order to provide information regarding the practical use of the instrument and its effect on hyper- and hypoglycemia.

Self-monitoring of blood glucose experiences of adults with type 2 diabetes

PURPOSE

The purpose of this study was to analyze the experiences of self-monitoring of blood glucose (SMBG) usage of adults with type 2 diabetes mellitus (T2DM) who are not using insulin.

DATA SOURCES

Nineteen adults were asked to describe their experiences with self-monitoring. Data were analyzed using the grounded theory method.

CONCLUSIONS

The theory of "SMBG as a Cue in T2DM Self-Care" emerged from the data and is composed of four categories: (a) Engaging, (b) Checking, (c) Responding, and (d) Establishing a Pattern. Engaging marks the beginning. Frequent monitoring characterizes this stage. Checking involves evaluating and validating the blood glucose level. The most common item evaluated or validated was the effect of foods. Responding involves taking action or experiencing emotion. Actions taken centered on dietary changes. Emotions felt were dependent on the level and ranged from blame to happiness. Participants established a pattern and used SMBG regularly or sporadically. Frequency was based on obtaining "normal" patterns, the absence of symptoms, provider disinterest, and fingertip pain.

IMPLICATIONS FOR PRACTICE

Participants described many benefits and struggles when incorporating SMBG into their self-care. Information from this study could be used to develop effective guidelines for the use of SMBG in T2DM.

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.

Using multiple measures of glycemia to support individualized diabetes management: recommendations for clinicians, patients, and payers

By the year 2030, the diabetes pandemic will likely affect more than 10% of the world's population. The personal, public health, and economic crises implicit in this trend call for decisive action. Yet, escalating dilemmas thwart full realization of current therapies. First, controversial studies, such as the Action to Control Cardiovascular Risk in Diabetes (ACCORD) Trial, have amplified calls to individualize glycated hemoglobin (A1C) targets in the absence of adequate infrastructures for supporting personalized care. Second, costlier medications and technologies addressing more nuanced aspects of metabolic dysfunction are expanding options for diabetes management amidst growing disparities between "affordable" and "best" care. Third, common clinical quandaries, such as discrepancies between A1C and self-monitoring of blood glucose data, as well as misconceptions about long-term glycemic assessment, compound entrenched cycles of inadequate self-care, delayed intervention, and suboptimal glycemic outcomes. Because individual, clinical, and public policy responses to these conflicting forces are based largely on methodologies for glucose measurement, a panel of clinical experts from Europe and North America was convened to reexamine our glucose measuring tools and determine ways in which they can be better applied toward more purposeful processes of glycemic management. Among the main issues addressed were the need for caution in interpreting A1C for individual patients, the role of alternative biomarkers in identifying aspects of glycemic dysregulation not captured by A1C, and the value of using patients' own glucose data to consolidate therapeutic, educational, and behavior-change objectives.

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.

Self-monitoring of blood glucose in patients with diabetes who do not use insulin--are guidelines evidence-based?

AIMS

To evaluate if clinical practice guideline recommendations regarding self-monitoring of blood glucose in patients with diabetes not using insulin follow the principles of evidence-based medicine.

METHODS

After a search from 1999 to 2011, 18 clinical practice guidelines were included. Recommendations regarding self-monitoring of blood glucose were graded on a scale from one (strongly against self-monitoring) to four (strongly in favour of self-monitoring) and compared with the similarly graded conclusions of systematic reviews that were cited by the clinical practice guidelines. We also investigated how clinical practice guideline characteristics, for example funding sources, and quality of references cited could be related to the guideline recommendations.

RESULTS

The clinical practice guidelines cited in total 15 systematic reviews, 14 randomized controlled trials, 33 non-randomized controlled trials papers and 18 clinical practice guidelines or position statements. The clinical practice guideline recommendations had an average grade of 3.4 (range 2.0-4.0). Higher grades were seen for clinical practice guidelines that acknowledged industry funding (mean value 4.0) or were issued by organizations depending on private funding (mean value 3.6 vs. 3.0 for governmental funding). The conclusions of the 15 systematic reviews had a mean grade of 2.2 (range 1.0-3.8). Systematic reviews with low grades were less cited. In total, 21 randomized controlled trials were included in the systematic reviews. Approximately half of these evaluated an educational intervention where the effect of self-monitoring of blood glucose could not be clearly isolated.

CONCLUSIONS

Clinical practice guidelines were more in favour of self-monitoring use than the systematic reviews that were cited. The citation practice was non-systematic and industry funding seemingly led to a more positive attitude towards use of self-monitoring of blood glucose.

Biophysiologic outcomes of the Enhancing Adherence in Type 2 Diabetes (ENHANCE) trial

BACKGROUND

Behavioral research to improve lifestyle in broadly defined populations of patients with type 2 diabetes is limited.

OBJECTIVE

We evaluated a behavioral intervention featuring technology-based self-monitoring on biophysiologic outcomes of glycemic control and markers of cardiovascular risk.

DESIGN

In this single-site, randomized clinical trial, participants were stratified by good and poor glycemic control (glycated hemoglobin <8% or ≥8%) and absence or presence of kidney disease, (estimated glomerular filtration rate ≥60 or <60 mL/min) and randomized within strata. Measurements were obtained at 0, 3, and 6 months.

PARTICIPANTS/SETTING

Self-referred, community-dwelling adults with type 2 diabetes mellitus.

INTERVENTION

The intervention group received Social Cognitive Theory-based counseling paired with technology-based self-monitoring, and results were compared with an attention control group.

MAIN OUTCOME MEASURES

Glycated hemoglobin, fasting serum glucose, lipid levels, blood pressure, weight, body mass index, and waist circumference were evaluated.

STATISTICAL ANALYSES PERFORMED

Mean differences within and between randomization groups were compared over time. Intervention effects over time were estimated using random intercept models.

RESULTS

Two hundred ninety-six subjects were randomized, 256 (86.5%) completed 3-month and 246 (83.1%) completed 6-month assessments. Glycated hemoglobin was reduced in the intervention group by 0.5% at 3 months and 0.6% at 6 months (P<0.001 for each), and the control group by 0.3% (P<0.001) at 3 months and 0.2% (P<0.05) at 6 months; but between-group differences were not significant. In those with baseline glycated hemoglobin ≥8% and estimated glomerular filtration rate ≥60 mL/min, glycated hemoglobin was reduced in the intervention group by 1.5% at 3 months and 1.8% at 6 months (P<0.001 for each), and the control group by 0.9% (P<0.001) at 3 months and 0.8% (P<0.05) at 6 months; but between-group differences were not significant. In random intercept models, the estimated reduction in glycated hemoglobin of 0.29% was not significant.

CONCLUSIONS

Two behavioral approaches to improving general lifestyle management in individuals with type 2 diabetes mellitus were effective in improving glycemic control, but no significant between-group differences were observed.

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.

Benefits of self-monitoring blood glucose in the management of new-onset Type 2 diabetes mellitus: the St Carlos Study, a prospective randomized clinic-based interventional study with parallel groups

BACKGROUND

Intensive treatment of patients with Type 2 diabetes mellitus (T2DM) from the moment of diagnosis facilitates β-cell recovery. Self-monitoring of blood glucose (SMBG)-based educational and pharmacological intervention may be better than conventional HbA1c algorithms in the treatment of newly diagnosed T2DM.

METHODS

Newly diagnosed T2DM patients were randomized to either an SMBG-based intervention or an HbA1c-based control group (n = 99 and 62, respectively) and were followed for 1 year.

RESULTS

Higher rates of diabetes regression (HbA1c < 6% on metformin alone) and remission (HbA1c between 6.0% and 6.4%) were achieved in the intervention compared with the control group (39% vs 5% (P < 0.001) and 37% vs 30% (P < 0.01), respectively). Furthermore, significantly greater reductions in median HbA1c (6.6% to 6.1%; P < 0.05) and body mass index (29.6-27.9 kg/m(2) ; P < 0.001) were seen in the intervention over the 1 year of therapy. The percentage of patients achieving a lifestyle score >12 was significantly greater in the SMBG compared with the control group (38.4% vs 9.7% respectively; P < 0.001). An inverse correlation was observed between SMBG and HbA1c levels (P < 0.04).

CONCLUSIONS

The results indicate that SMBG-based structured educational and pharmacological programs empower patients to achieve nutritional and physical activity goals, and encourage physicians and patients to use SMBG to optimize therapy. We believe that the concept of intensive treatment of T2DM patients should be modified; instead of referring to the type of treatment (insulin use), the term should reflect the intensity with which we work to reach glucose objectives.

Efficacy of self-monitoring of blood glucose in patients with type 2 diabetes mellitus managed without insulin: a systematic review and meta-analysis

BACKGROUND

Self-monitoring of blood glucose levels is commonly performed by patients with diabetes mellitus. However, there is debate surrounding the clinical utility and cost-effectiveness of this practice among patients with type 2 diabetes managed without insulin. We conducted a systematic review and meta-analysis to determine the effect of self-monitoring versus no self-monitoring, and the optimal frequency of self-monitoring, in this population.

METHODS

MEDLINE, EMBASE, BIOSIS Previews, CINAHL and PsycINFO were searched for randomized controlled trials (RCTs) and observational studies published in English from January 1990 to March 2009. Additional citations were obtained through searches of the Internet and conference proceedings, and from stakeholder feedback. Two reviewers independently selected studies, extracted data and performed an assessment of the methodologic quality of the studies. Key outcomes of interest were hemoglobin A1c (HbA(₁c)) concentration, hypoglycemia, quality of life, long-term complications of diabetes and death. Where appropriate, we pooled data using random-effects meta-analysis.

RESULTS

We identified 1624 citations through the literature search and selected 25 articles for inclusion. We observed a statistically significant improvement in the HbA(₁c) concentration across RCTs that compared self-monitoring of blood glucose levels with no self-monitoring among patients taking oral antidiabetes drug therapy (weighted mean difference --0.25%, 95% confidence interval -0.36% to -0.15%). Subgroup analysis indicated that results from RCTs that provided patients with education on how to interpret and apply self-monitoring test results were similar to those from RCTs that did not. On the basis of limited evidence, self-monitoring of blood glucose levels did not demonstrate consistent benefits in terms of quality of life, patient satisfaction, prevention of hypoglycemia or long-term complications of diabetes, or reduction of mortality. There was insufficient evidence pertaining to the optimal frequency of self-monitoring.

INTERPRETATION

Self-monitoring of blood glucose levels was associated with a modest, statistically significant reduction in hemoglobin A1c concentrations, regardless of whether patients were provided with education on how to interpret and use the test results. Further studies are required to determine whether self-monitoring reduces the risk of long-term complications of diabetes and to identify patients most likely to benefit from self-monitoring.

System accuracy evaluation of 27 blood glucose monitoring systems according to DIN EN ISO 15197

BACKGROUND

Blood glucose (BG) monitoring systems enable diabetes patients to effectively control and adjust their therapy. BG monitoring systems with a Conformité Européenne (CE) label should meet the standard DIN EN ISO 15197:2003: > or =95% of the BG results shall fall within +/-15 mg/dL of the reference method at BG concentrations <75 mg/dL and within +/-20% at BG concentrations > or =75 mg/dL. We intended to verify if BG monitoring systems with a CE label fulfill these minimum accuracy requirements.

METHODS

We evaluated 27 BG monitoring systems from 18 manufacturers for system accuracy according to DIN EN ISO 15197:2003. Twenty-four systems were compared with the glucose oxidase reaction (YSI 2300 glucose analyzer [YSI Life Sciences, Yellow Springs, OH]) and three systems with the hexokinase reaction (Hitachi 917 [Roche Diagnostics GmbH, Mannheim, Germany]). Duplicate measurements of 100 blood samples with a defined distribution of BG concentrations from 20 mg/dL to 600 mg/dL from > or =100 subjects were included in the evaluation.

RESULTS

Sixteen of the 27 BG monitoring systems fulfilled the minimum accuracy requirements of the standard, i.e., > or =95% of their results showed the minimum acceptable accuracy. Overall, the mean percentage of results showing the minimum acceptable accuracy was 95.2 +/- 5.2%, ranging from 80.0% to 100.0%.

CONCLUSIONS

More than 40% of the evaluated BG monitoring systems did not fulfill the minimum accuracy requirements of DIN EN ISO 15197:2003. As inaccurate BG monitoring systems bear the risk of false treatment decisions by the diabetes patient and subsequent possible severe health injury, manufacturers should regularly and effectively check the quality of BG meters and BG test strips.

On what evidence-base do we recommend self-monitoring of blood glucose?

Self-monitoring of blood glucose (SMBG) has been considered one major breakthrough in diabetes therapy because, for the first time, patients were able to determine their blood glucose levels during daily life. It seems obvious that this must be of advantage to disease management and clinical outcome, but it has become a nightmare for those trying to provide evidence. Randomised controlled trials have yielded inconsistent results on a benefit of SMBG-based treatment strategies not only in type 2 but - surprisingly - also in type 1 and gestational diabetes. Despite this, SMBG is being considered indispensible in intensive insulin treatment, but is being debated for other clinical settings. When considering the non-RCT based reasons for recommending SMBG in type 1 and gestational diabetes it becomes apparent that the same reasons also apply to type 2 diabetes.

Evaluation of a simple policy for pre- and post-prandial blood glucose self-monitoring in people with type 2 diabetes not on insulin

BACKGROUND AND AIMS

Since there is no agreement on regimens of self-monitoring of blood glucose (SMBG) in type 2 diabetes not on insulin, we evaluated the effects of a simple SMBG policy taking into account compliance.

METHODS AND RESULTS

273 type 2 diabetic patients not on insulin with HbA1c >7% attending our Diabetes Clinic and already using SMBG were randomized as follows: Group A, one BG profile/month with fasting and post-prandial values; Group B, one BG profile every 2 weeks with pre- and post-prandial values. Patients were followed-up by the same team every 3 months with the same education and treatment policies. At 3 and 6 months, SMBG profiles were evaluated and HbA1c measured. SMBG was carried out as recommended by 73% of Group A and 44% of Group B patients. In compliant patients, HbA1c and BG were unchanged in Group A whereas in Group B fasting, pre-prandial and two out of three post-prandial BG values were reduced and HbA1c decreased from 8.09+/-0.84% to 7.60+/-0.73% (p<0.001). The influence on BG control was similar for the two policies when compliance was not considered.

CONCLUSIONS

The more intensive SMBG policy considered is associated with improvements in glycaemic control in compliant subjects.

Impact of self-measurement of blood glucose on complications of type 2 diabetes: economic analysis from a Czech perspective

OBJECTIVE

A growing body of evidence indicates that self-measurement of blood glucose (SMBG) also has beneficial effects in people with type 2 diabetes, irrespective of the type of therapy. The objective of this analysis was to determine the economic impact of SMBG by comparing the cost share of self-monitoring and the direct costs of diabetes-related complications in users and non-users.

RESEARCH DESIGN AND METHODS

A matched-pair analysis based on the cohorts of a large retrospective study of patients with type 2 diabetes (ROSSO) was conducted. The average annual direct costs of diabetes monitoring, treatment-related services, complications and follow-up costs of the disease for SMBG users versus non-users were calculated from the perspective of the Czech statutory health insurance system. Univariate sensitivity analysis was performed to determine the main cost drivers. Limitations of this study are: (1) differences in medical facilities/practice between Germany and the Czech Republic, (2) causal relationship between SMBG and health outcomes is missing, (3) ROSSO underestimated the number of test strips used, (4) Czech cost data are scarce.

RESULTS

In patients treated with oral antidiabetic drugs (OAD) only, total annual costs in Czech koruna (CZK) were CZK 16 476 for SMBG users and CZK 19 440 for non-users. In patients treated with OAD + insulin, total annual costs were CZK 32 590 and CZK 48 600, respectively. The main cost drivers were stroke and myocardial infarction in patients treated with OAD only, and stroke, dialysis and myocardial infarction in patients treated with OAD + insulin.

CONCLUSION

Cost analysis indicated that SMBG provides a rapid return on initial investment. By increasing the number of patients using SMBG, the statutory health insurance system in the Czech Republic may save several million CZK annually.

Comparison of lancing devices for self-monitoring of blood glucose regarding lancing pain

BACKGROUND

Self-monitoring of blood glucose empowers diabetes patients to effectively control their blood glucose (BG) levels. A potential barrier to frequent BG controls is lancing pain, intrinsically linked to pricking the finger several times a day. In this study, we compared different state-of-the-art lancing devices from leading manufacturers regarding lancing pain, and we intended to identify lancing devices that are less painful.

METHODS

First, 165 subjects compared 6 different BG monitoring systems-consisting of a lancing device and a BG meter-at home for 36 days and at least 3 BG tests per day. Second, the subjects directly compared 6 different lancing devices-independent from a BG meter-in a laboratory setting. The test results were collected in questionnaires, and lancing pain was rated on a numerical rating scale.

RESULTS

One hundred fifty-seven subjects were included in the analysis. Accu-Chek BG monitoring systems were significantly (p < or = .006) preferred to competitor BG monitoring systems and were rated by >50% of the subjects as "less painful" than competitor BG monitoring systems. Accu-Chek lancing devices were significantly (p < .001) preferred to competitor lancing devices and were rated by >60% of the subjects as "less painful" than competitor lancing devices.

CONCLUSIONS

We found significant differences in lancing pain between lancing devices. Diabetes patients clearly preferred lancing devices that cause less lancing pain. In order to improve patient compliance with respect to an adequate glycemic control, the medical staff should preferentially prescribe lancing devices that cause less lancing pain.

Cost impact of self-measurement of blood glucose on complications of type 2 diabetes: the Spanish perspective

BACKGROUND

Despite the increasing prevalence of type 2 diabetes, its financial burden on the Spanish healthcare system remains unclear. This study was conducted to determine the cost share of self-measurement of blood glucose (SMBG) by comparing the direct costs of reduced complications of diabetes in SMBG users versus nonusers in the Spanish statutory health insurance system.

METHODS

Matched-pair analysis was done of the average annual total direct cost of diabetes monitoring, treatment-related services, complications, and follow-up in the RetrOlective Study Self-Monitoring of Blood Glucose and Outcome in Patients with Type 2 Diabetes (ROSSO) study cohort, updated to 2008 from the year of occurrence or diagnosis of diabetes.

RESULTS

In patients treated with oral antidiabetes drugs (OADs) only, total annual costs were euro1,934 in SMBG users and euro1,982 in nonusers. In those treated with OADs plus insulin, total annual costs were euro3,451 and euro4,167, respectively. By increasing the number of patients using SMBG, the Spanish statutory health insurance system might save several million Euros annually.

CONCLUSIONS

The analysis showed that the promotion of SMBG in patients with type 2 diabetes is associated with considerable cost savings for the Spanish healthcare system.

Comparison of blood glucose meters in a New Zealand diabetes centre

Background

To assess the accuracy and precision of the Roche Performa and Medisense Optium Xceed (5 and 10 s reading) blood glucose meters.

Methods

Capillary blood samples were taken from 100 patients attending a diabetes centre and blood glucose measured on Roche Performa ( n = 4) and Medisense Optium Xceed 5 s ( n = 2) and 10 s reading ( n = 2) meters. Venous plasma glucose from samples taken simultaneously was measured by the laboratory hexokinase method as reference standard. Imprecision was determined on the meters by replicate analysis ( n = 20) of control solutions provided by the manufacturers and also patient venous whole-blood samples. Accuracy was assessed relative to the reference method by Bland–Altman plots, Passing and Bablok regression analysis, and both Clarke and consensus error grid analysis. Coefficients of variation (CVs) were calculated to determine imprecision.

Results

Bland–Altman and Passing–Bablok analysis confirmed significant systematic bias for all meters, with relative under-reading of higher glucose concentrations. Error grid analysis showed that <5% readings exceeded ±20% (or ±0.83 mmol/L for readings <4 mmol/L) deviation from the reference method (1%, 2% and 4% for the Roche, Optium 5 and 10 s meters, respectively). CVs were all <4% for the control solutions and <6% for patient samples.

Conclusions

Both Roche Performa and Medisense Optium glucose meters (5 and 10 s readings) perform satisfactorily and are acceptable for operational use.

Prevention of diabetic ketoacidosis and self-monitoring of ketone bodies: an overview

OBJECTIVE

Diabetic ketoacidosis (DKA) is associated with significant morbidity and mortality. Self-monitoring of ketone bodies by diabetes patients can be done using blood or urine. We compared the two self-monitoring methods and summarized recent developments in the epidemiology and management of DKA.

METHODS

MEDLINE and EMBASE were searched for relevant publications addressing the epidemiology, management and prevention of DKA up to 2009. The current, relevant publications, along with the authors' clinical and professional experience, were used to synthesize this narrative review.

FINDINGS

Despite considerable advances in diabetes therapy, key epidemiological figures related to DKA remained nearly unchanged during the last decades at a global level. Prevention of DKA - especially in sick day management - relies on intensive self-monitoring of blood glucose and subsequent, appropriate therapy adjustments. Self-monitoring of ketone bodies during hyperglycemia can provide important, complementary information on the metabolic state. Both methods for self-monitoring of ketone bodies at home are clinically reliable and there is no published evidence favoring one method with respect to DKA prevention.

CONCLUSIONS

DKA is still a severe complication potentially arising during prolonged hyperglycemic episodes with possibly fatal consequences. Education of patients and their social environment to promote frequent testing - especially during sick days - and to lower their glucose levels, as well as to recognize the early symptoms of hyperglycemia and DKA is of paramount importance in preventing the development of severe DKA. Both methods for self-monitoring of ketone bodies are safe and clinically reliable.

Individual patient data meta-analysis of trials of self-monitoring of blood glucose in non-insulin treated type 2 diabetes: protocol for a systematic review

BACKGROUND AND AIM OF THE STUDY

Recent trials have provided differing estimates of the benefits of self-monitoring of blood glucose (SMBG) for non-insulin treated patients with type 2 diabetes. Designing and conducting randomised trials to demonstrate the efficacy of complex interventions is challenging. Variations in the components of the intervention delivered, target population selected, and reporting methods used have limited the conclusions drawn in recent systematic reviews. We will systematically examine these factors within the trials of SMBG to enable further investigation of the data through an individual patient data analysis (IPD).

METHODS/DESIGN

The IPD analysis will include data from randomised trials comparing blood glucose self-monitoring and decisions about self-management versus a control group with standardised or routine care. The data requested for each trial will include outcomes (HbA1c, blood glucose and quality of life), potential moderators of effect (e.g. demographic variables, clinical data and psychosocial factors) and intervention descriptors. The primary outcome of interest will be HbA1c. Secondary outcomes include alternative measures of glycaemia, cardiovascular risk factors, persistence with monitoring, and measures of health status, quality of life and psychosocial factors. Analysis of patient sub-groups defined by age at randomisation, gender, prior use of monitoring and health status will be carried out. An intention to treat analysis will be performed and assessed for clinical and statistical heterogeneity.

DISCUSSION

With current uncertainty about the extent of benefit from SMBG for non-insulin treated patients with type 2 diabetes, this study will provide the best estimates to date of overall effectiveness, effectiveness within potential target populations, and optimal components of the intervention.

The value of self-monitoring of blood glucose: a review of recent evidence

AIMS

To review the recent literature relating to the role of self-monitoring of blood glucose (SMBG) and glycemic control.

METHODS

Medline and EMBASE databases were searched between 1996 and June 2008 using terms that included diabetes mellitus, self-care, and blood glucose self monitoring. Both experimental and nonexperimental studies with HbA(1c) as an outcome measure were included. A meta-analysis was performed on randomized controlled trials (RCTs) in type 2 diabetes which met the inclusion criteria.

RESULTS

From 1102 relevant papers, 34 original containing 38 separate studies were identified as being published between 2000 and June 2008. There were 23 studies of type 2 diabetes and, of these, 13 were nonexperimental and 10 experimental, including six RCTs. The results of five of these RCTs in non-insulin-treated type 2 diabetic patients were combined in a meta-analysis with two earlier RCTs which yielded a significant pooled SMBG-related decrease in HbA(1c) of -0.22 (95% CI -0.34% to -0.11%).

CONCLUSIONS

The present meta-analysis showed an SMBG-related HbA(1c) reduction in non-insulin-treated type 2 diabetes patients that was similar to that in previous systematic reviews but in a substantially larger patient sample. This finding is consistent with most observational studies of similarly treated patients.

Standardized evaluation of nine instruments for self-monitoring of blood glucose

BACKGROUND

Instruments for self-monitoring of blood glucose (SMBG) should undergo a standardized evaluation including a user-test before being marketed. In this study the results from standardized evaluations of nine different SMBG instruments are presented, and the standardized evaluation is discussed.

METHODS

Approximately 80 diabetes patients using three lots of test strips participated in each evaluation. Half of the patients were educated in how to use the meter, and the evaluations were carried out by both medical laboratory technologists (MLTs) and patients. Questionnaires were used to assess the user manual and the user-friendliness of the instrument.

RESULTS

The imprecision obtained by the patients (coefficients of variation [CVs] of 3.2-8.1%) were generally higher compared to that by the MLT (CVs of 2.3-5.9%). Three of the nine instruments did not achieve the quality goal based on the recommendation in the International Organization for Standardization's ISO 15197 guideline in the hands of diabetes patients. The bias from the comparison method ranged from -10.4% to +3.2%. There were significant lot-to-lot variations and hematocrit effects for some of the instruments. Temperature difference between the instruments and the test strip caused deterioration of the quality in one instrument. The user-friendliness was in general acceptable.

CONCLUSIONS

The quality of instruments for SMBG seems to have improved during recent years, although there are still analytical problems. A standardized evaluation protocol is necessary and should be regularly revised taking into account the development of new technology and the needs of the patients.

Self-Monitoring of Blood Glucose (SMBG) in insulin- and non-insulin-using adults with diabetes: consensus recommendations for improving SMBG accuracy, utilization, and research

Current clinical guidelines for diabetes care encourage self-monitoring of blood glucose (SMBG) to improve glycemic control. Specific protocols remain variable, however, particularly among non-insulin-using patients. This is due in part to efficacy studies that neglect to consider (1) the performance of monitoring equipment under real-world conditions, (2) whether or how patients have been taught to take action on test results, and (3) the physiological, behavioral, and social circumstances in which SMBG is carried out. As such, a multidisciplinary group of specialists, including several endocrinologists, a health psychologist, a diabetes nurse practitioner, and a patient advocate (the Panel), discuss within this review article how the potential of SMBG might be fully realized in today's healthcare environment. The resulting recommendations cover technological, clinical, behavioral, and research considerations with the aim of achieving short- and long-term benefits, ranging from fewer hypoglycemic episodes to lower complication-related costs. The panel also made suggestions for designing future studies that increase the ability to discern optimal models of SMBG utilization for individuals with diabetes who may, or may not, use insulin.

Frequency of self-monitoring of blood glucose in patients with type 2 diabetes: association with hypoglycaemic events

OBJECTIVE

The objective of this study is to describe current self-monitoring of blood glucose (SMBG) practice for patients with type 2 diabetes by treatment type and adherence with healthcare professional advice concerning SMBG. In addition, the study aims to investigate the association of SMBG and self-reported episodes of low blood glucose.

DESIGN AND SETTING

This cross-sectional survey design study was carried out on patients with type 2 diabetes aged 18 years or over, attending community pharmacies in 97 sites across the United Kingdom.

METHODS

Patients picking up a prescription for blood glucose test strips or diabetes medicine from a community pharmacist were asked to complete a questionnaire. The pharmacist was available to assist if requested. Questions included: self-reports of frequency of blood glucose testing; type of diabetes treatment; advice given by healthcare professionals about frequency of blood glucose testing; frequency of episodes of low blood glucose; and last known HbA(1c) level. The final sample size was 554 respondents, who were grouped for analysis as follows: those being treated with insulin, either alone or with any oral medication (n = 167); those being treated with sulfonylureas, either alone or with any oral medication (n = 187); and those being treated with any other medication, or controlled by diet and exercise alone (n = 202).

RESULTS

Frequency of SMBG was higher in patients using insulin (median 10 times per week, Q (1), Q (3) = 4.5, 14) than in patients on treatments other than insulin (four times per week, Q (1), Q (3) = 2, 7, p < 0.001). SMBG was carried out at the same frequency in patients not treated with insulin regardless of whether they were prescribed sulfonylureas. Greater frequency of SMBG was associated with self-reports of one or more episodes of low blood glucose in the previous six months.

CONCLUSIONS

Among patients with type 2 diabetes, those treated with insulin used SMBG at a greater frequency than those not treated with insulin. Increased frequency of testing was associated with increased frequency of self-reported episodes of low blood glucose, even among patients not taking insulin or sulfonylureas. This raises the possibility that episodes of hypoglycaemia may not be accurately identified, leading to unnecessary fear, or conversely that treatment is not being adjusted to avoid such morbidity. Although further work is needed to explore this association in a representative, prospective cohort of patients, possible explanations for reports of low-blood glucose should be discussed with patients using SMBG more frequently to ensure they are able to accurately identify episodes of hypoglycaemia.

Medication adherence and racial differences in A1C control

OBJECTIVE

The purpose of this study was to examine medication adherence and other self-management practices as potential determinants of higher glycemic risk among black relative to white patients.

RESEARCH DESIGN AND METHODS

We used a retrospective, longitudinal repeated-measures design to model the contribution of medication adherence to black-white differences in A1C among type 2 diabetic patients at a large multispecialty group practice. We identified 1,806 adult (aged >/=18 at diagnosis) patients (467 black and 1,339 white) with newly initiated oral hypoglycemic therapy between 1 December 1994 and 31 December 2000. Race was identified using an electronic medical record and patient self-report. Baseline was defined as the 13 months preceding and included the month of therapy initiation. All patients were required to have at least 12 months of follow-up.

RESULTS

At initiation of therapy, black patients had higher average A1C values compared with whites (9.8 vs. 8.9, a difference of 0.88; P < 0.0001). Blacks had lower average medication adherence during the first year of therapy (72 vs. 78%; P < 0.0001). Although more frequent medication refills were associated with lower average A1C values, adjustment for adherence did not eliminate the black-white gap.

CONCLUSIONS

We found persistent racial differences in A1C that were not explained by differences in medication adherence. Our findings suggest that targeting medication adherence alone is unlikely to reduce disparities in glycemic control in this setting. Further research is needed to explore possible genetic and environmental determinants of higher A1C among blacks at diagnosis, which may represent a critical period for more intensive intervention.