Challenging evidence and assumptions: is there a role for self-monitoring of blood glucose in people with type 2 diabetes not using insulin?

The impact of structured self-monitoring of blood glucose on clinical, behavioral, and psychosocial outcomes among adults with non-insulin-treated type 2 diabetes: a systematic review and meta-analysis

Background

Self-monitoring of blood glucose (SMBG) is considered of little clinical benefit for adults with non-insulin-treated type 2 diabetes, but no comprehensive review of a structured approach to SMBG has been published to date.

Purpose

To conduct a systematic review and meta-analysis of the impact of sSMBG on HbA1c, treatment modifications, behavioral and psychosocial outcomes, and; examine the moderating effects of sSMBG protocol characteristics on HbA1c.

Data sources

Four databases searched (November 2020; updated: February 2022).

Study selection

Inclusion criteria: non-randomized and randomized controlled trials (RCTs) and prospective observational studies; reporting effect of sSMBG on stated outcomes; among adults (≥18 years) with non-insulin-treated type 2 diabetes. Studies excluded if involving children or people with insulin-treated or other forms of diabetes.

Data extraction and analysis

Outcome data extracted, and risk of bias/quality assessed independently by two researchers. Meta-analysis was conducted for RCTs, and moderators explored (HbA1c only).

Data synthesis

From 2,078 abstracts, k=23 studies were included (N=5,372). Risk of bias was evident and study quality was low. Outcomes assessed included: HbA1c (k=23), treatment modification (k=16), psychosocial/behavioral outcomes (k=12). Meta-analysis revealed a significant mean difference favoring sSMBG in HbA1c (-0·29%, 95% CI: -0·46 to -0·11, k=13) and diabetes self-efficacy (0.17%, 95% CI: 0.01 to 0.33, k=2). Meta-analysis revealed no significant moderating effects by protocol characteristics.

Limitations

Findings limited by heterogeneity in study designs, intervention characteristics, and psychosocial assessments.

Conclusion

A small positive effect of sSMBG on HbA1c and diabetes self-efficacy was observed. Narrative synthesis of sSMBG intervention characteristics may guide future implementation.

PROSPERO registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020208857, identifier CRD42020208857.

Evaluation of Patient Satisfaction and Clinical Efficacy of Using Blood Glucose Meters Featuring Color-Coded Indicators in Patients With Type 1 Diabetes: An Observational Hospital-Based Study

Introduction Because of the difficulties in interpreting the level of blood glucose using the traditional numeric glucometers, the blood glucose meters featuring color-coded range indicators (CRI) offered a simple way to understand and interpret blood glucose readings. Therefore, this study aimed to assess glucose monitoring satisfaction (GMS) and clinical efficacy of blood glucose meters featuring color-coded in patients with Type 1 Diabetes (T1DM) in Saudi Arabia. Methods T1DM patients who switched to color-coded Medisafe Fit Smile glucometer were included in this study. Demographic data, clinical characteristics, glycemic parameters were collected. A trained interviewer collected the GMS survey at baseline and 12 weeks. At the end of the study, patient-reported satisfaction with the Medisafe Fit Smile color-coded features (MSCF) survey was collected.  Results This study included 62 T1DM patients with a mean age of 17.8 (±3.1), and the majority had three or more confirmed hypoglycemic episodes per month. Compared to baseline data, we showed a significant improvement in the mean hemoglobin A1C level (8.43 [±1.2] versus 8.36 [±1.1], p<0.001), with a significantly lower frequency of hypoglycemic episodes (2.74 [±1.1] versus 2.0 [±0.78], p<0.001) after 12 weeks of using glucometer featuring CRI. Most importantly, significant improvements in the GMS survey subdomains of openness (p<0.001), emotional burden (p<0.001), behavioral burden (p<0.001), but not trust (p=0.71) were detected at the end of the study with a significantly higher total GMS survey of 4.33 (±0.13) after using blood glucose meters featuring CRI compared to the lower score of 2.84 (±0.22) at baseline (p<0.001). Furthermore, patient satisfaction with the MSCF survey revealed evidence of satisfaction among the TIDM patients at the end of the study. Conclusion The current study confirmed that individuals with T1DM may benefit from blood glucose meters featuring CRI device exposure. Also, using a glucometer featuring CRI was associated with a high level of satisfaction with blood glucose measures and significant improvement in the glycemic parameters. However, definitely, further studies are needed to confirm whether the long-term use of the CRI-based blood glucose meters will produce improved results in the GMS survey.

Cost-effectiveness of professional-mode flash glucose monitoring in general practice among adults with type 2 diabetes: Evidence from the GP-OSMOTIC trial

AIM

To assess the cost-effectiveness of professional-mode flash glucose monitoring in adults with type 2 diabetes in general practice compared with usual clinical care.

METHODS

An economic evaluation was conducted as a component of the GP-OSMOTIC trial, a pragmatic multicentre 12-month randomised controlled trial enrolling 299 adults with type 2 diabetes in Victoria, Australia. The economic evaluation was conducted from an Australian healthcare sector perspective with a lifetime horizon. Health-related quality of life (EQ-5D) and total healthcare costs were compared between the intervention and the usual care group within the trial period. The 'UKPDS Outcomes Model 2' was used to simulate post-trial lifetime costs, life expectancy and quality-adjusted life years (QALYs).

RESULTS

No significant difference in health-related quality of life and costs was found between the two groups within the trial period. Professional-mode flash glucose monitoring yielded greater QALYs (0.03 [95% CI: 0.02, 0.04]) and a higher cost (A$3807 [95% CI: 3604, 4007]) compared with usual clinical care using a lifetime horizon under the trial-based monitoring frequency, considered not cost-effective (incremental cost-effectiveness ratio = A$120,228). The intervention becomes cost-effective if sensor price is reduced to lower than 50%, or monitoring frequency is decreased to once per year while maintaining the same treatment effect on HbA_1c .

CONCLUSIONS

Including professional-mode flash glucose monitoring every 3 months as part of a management plan for people with type 2 diabetes in general practice is not cost-effective, but could be if the sensor price or monitoring frequency can be reduced.

Impact of quarterly professional-mode flash glucose monitoring in adults with type 2 diabetes in general practice (GP-OSMOTIC): Secondary psychological and self-care outcomes of a pragmatic, open-label, 12-month, randomised controlled trial

AIMS

To investigate the impact of quarterly professional-mode flash glucose monitoring on psychological outcomes in adults with type 2 diabetes in primary care.

METHODS

The GP-OSMOTIC trial randomised 299 adults with type 2 diabetes in 25 general practices to quarterly use of professional-mode flash glucose monitoring (sensor worn for 14 days; data discussed at clinic visit) or usual care. At baseline and 12 months, participants completed validated measures: general emotional well-being (WHO-5), diabetes-specific quality of life (DIDP), satisfaction with glucose monitoring (GME-Q), self-care activities (SDSCA) and perceived involvement in clinical care (PICS). Linear mixed-effects models examined between-group differences at 12 months.

RESULTS

At 12 months, there were no clinically important between-arm differences in any secondary psychological or self-care outcomes. Per protocol analyses showed no clinically significant between-group differences.

CONCLUSIONS

The GP-OSMOTIC intervention had no significant impact, at 12 months, on general emotional well-being, diabetes-specific quality of life or satisfaction with glucose monitoring, suggesting no added psychological burden. Lack of positive impact on self-reported self-care activities or perceived involvement in clinical care may warrant closer attention to the fidelity of intervention delivery, the context (e.g. the nature of clinician-patient interactions) and/or the sensitivity of the measures, as these will help plan future studies.

A Digital-First Model of Diabetes Care

If we were to create the diabetes care experience anew, there is little doubt that it would not resemble the current bricks-and-mortar way we do things currently. For however a future model of care is designed, it would assume a digital-first approach, whereby the modern conveniences of digitally-mediated services we have experienced in other industries would be reflected in our diabetes care. To this end, our diabetes data would be liberated, transparent to those that need it, but safe and secure otherwise. We would have access to new tools that create insights that lower the burden, not add to it. And access to care would be just in time, convenient, and from a distance when needed. What is stopping a digital-first model is complex and deeply seated, but not insurmountable with engagement from industry, regulators, and care providers that are all willing to modernize the way care is delivered. Personal human interaction will continue to play an important part in the care for millions of people living with diabetes, no matter the sophistication of these digital services. What these technologies will provide is the human capacity to deal with the higher need, vulnerable people for whom access to timely care is an issue. Moreover, it will provide choice for an increasingly diverse population that seeks options for the form, and the delivery, of their personalized care.

Effect of structured self-monitoring of blood glucose, with and without additional TeleCare support, on overall glycaemic control in non-insulin treated Type 2 diabetes: the SMBG Study, a 12-month randomized controlled trial

AIM

To examine the impact of structured self-monitoring of blood glucose, with or without TeleCare support, on glycaemic control in people with sub-optimally controlled Type 2 diabetes.

METHODS

We conducted a 12-month, multicentre, randomized controlled trial in people with established (>1 year) Type 2 diabetes not on insulin therapy, with sub-optimal glycaemic control [HbA_1c ≥58 to ≤119 mmol/mol (≥7.5% to ≤13%)]. A total of 446 participants were randomized to a control group (n =151) receiving usual diabetes care, a group using structured self-monitoring of blood glucose alone (n =147) or a group using structured self-monitoring of blood glucose with additional monthly 'TeleCare' support (n =148). The primary outcome was HbA_1c at 12 months.

RESULTS

A total of 323 participants (72%) completed the study; 116 (77%) in the control group, 99 (67%) in the self-monitoring of blood glucose alone group and 108 (73%) in the self-monitoring of blood glucose plus TeleCare group. Compared to baseline, the mean HbA_1c was lower in all groups at 12 months, with reductions of 3.3 mmol/mol (95% CI -5.71 to -0.78) or 0.3% (95% CI -0.52 to -0.07; P=0.01) in the control group, 11.4 mmol/mol (95% CI -14.11 to -8.76) or 1.1% (-1.29 to -0.81; P<0.0001) in the group using self-monitoring of blood glucose alone and 12.8 mmol/mol (95% CI -15.34 to -10.31) or 1.2% (95% CI -1.40 to -0.94; P<0.0001) in the group using self-monitoring of blood glucose plus TeleCare. This represents a reduction in HbA_1c of 8.9 mmol/mol (95% CI -11.97 to -5.84) or 0.8% (95% CI -1.10 to -0.54; P≤0.0001) with structured self-monitoring of blood glucose compared to the control group. Participants with lower baseline HbA_1c , shorter duration of diabetes and higher educational achievement were more likely to achieve HbA_1c ≤53 mmol/mol (7.0%).

CONCLUSIONS

Structured self-monitoring of blood glucose provides clinical and statistical improvements in glycaemic control in Type 2 diabetes. No additional benefit, over and above the use of structured self-monitoring of blood glucose, was observed in glycaemic control with the addition of once-monthly TeleCare support. (Clinical trial registration no.: ISRCTN21390608).

GP-OSMOTIC trial protocol: an individually randomised controlled trial to determine the effect of retrospective continuous glucose monitoring (r-CGM) on HbA1c in adults with type 2 diabetes in general practice

INTRODUCTION

Optimal glycaemia can reduce type 2 diabetes (T2D) complications. Observing retrospective continuous glucose monitoring (r-CGM) patterns may prompt therapeutic changes but evidence for r-CGM use in T2D is limited. We describe the protocol for a randomised controlled trial (RCT) examining intermittent r-CGM use (up to 14 days every three months) in T2D in general practice (GP).

METHODS AND ANALYSIS

General Practice Optimising Structured MOnitoring To achieve Improved Clinical Outcomes is a two-arm RCT asking 'does intermittent r-CGM in adults with T2D in primary care improve HbA1c?'

PRIMARY OUTCOME

Absolute difference in mean HbA1c at 12 months follow-up between intervention and control arms.

SECONDARY OUTCOMES

(a) r-CGM per cent time in target (4-10 mmol/L) range, at baseline and 12 months; (b) diabetes-specific distress (Problem Areas in Diabetes).

ELIGIBILITY

Aged 18-80 years, T2D for ≥1 year, a (past month) HbA1c>5.5 mmol/mol (0.5%) above their individualised target while prescribed at least two non-insulin hypoglycaemic therapies and/or insulin (therapy stable for the last four months). Our general glycaemic target is 53 mmol/mol (7%) (patients with a history of severe hypoglycaemia or a recorded diagnosis of hypoglycaemia unawareness will have a target of 64 mmol/mol (8%)).Our trial compares r-CGM use and usual care. The r-CGM report summarising daily glucose patterns will be reviewed by GP and patient and inform treatment decisions. Participants in both arms are provided with 1 hour education by a specialist diabetes nurse.The sample (n=150/arm) has 80% power to detect a mean HbA1c difference of 5.5 mmol/mol (0.5%) with an SD of 14.2 (1.3%) and alpha of 0.05 (allowing for 10% clinic and 20% patient attrition).

ETHICS AND DISSEMINATION

University of Melbourne Human Ethics Sub-Committee (ID 1647151.1). Dissemination will be in peer-reviewed journals, conferences and a plain-language summary for participants.

TRIAL REGISTRATION NUMBER

>ACTRN12616001372471; Pre-results.

Effect of treatment guidance using a retrospective continuous glucose monitoring system on glycaemic control in outpatients with type 2 diabetes mellitus: A randomized controlled trial

Objectives

To assess the effect of treatment guidance based on data from a continuous glucose monitoring (CGM) device on glycaemic control, and patient satisfaction, in patients with type 2 diabetes mellitus (T2DM).

Methods

Patients with poorly-controlled T2DM treated with insulin were randomly assigned to the intervention or nonintervention group. Continuous blood-glucose levels were recorded for 4–5 days using a CGM device on three separate occasions during the 8-month study period. The intervention group received treatment guidance based on the CGM data; the nonintervention group received advice based on blood glucose and glycosylated haemoglobin (HbA_1c) levels.

Results

A total of 34 patients were enrolled in the study. The mean ± SD baseline HbA_1c was 8.2 ± 1.2% in the intervention group and 8.2 ± 0.9% in the nonintervention group. At the study end, there was no significant difference in the change from baseline of HbA_1c between the two groups. There was also no significant difference in the change from baseline in the Diabetes Treatment Satisfaction Questionnaire score between the two groups.

Conclusions

The present study did not demonstrate that treatment guidance using retrospective CGM data was effective for improving glycaemic control and therapeutic satisfaction in Japanese patients with T2DM.

Explaining engagement in self-monitoring among participants of the DESMOND Self-monitoring Trial: a qualitative interview study

BACKGROUND

The Diabetes Education and Self-Management for Ongoing and Newly Diagnosed (DESMOND) Self-monitoring Trial reported that people with newly diagnosed type 2 diabetes attending community-based structured education and randomized to self-monitoring of blood glucose (SMBG) or urine monitoring had comparable improvements in biomedical outcomes, but differences in satisfaction with, and continued use of monitoring method, well-being and perceived threat from diabetes.

OBJECTIVES

To explore experiences of SMBG and urine monitoring following structured education. We specifically addressed the perceived usefulness of each monitoring method and the associated well-being.

METHODS

Qualitative semi-structured interviews with 18 adults with newly diagnosed type 2 diabetes participating in the DESMOND Self-monitoring Trial (SMBG, N=10; urine monitoring, N=8)~12 months into the trial. Analysis was informed by the constant comparative approach.

RESULTS

Interviewees reported SMBG as accurate, convenient and useful. Declining use was explained by having established a pattern of managing blood glucose with less frequent monitoring or lack of feedback or encouragement from health care professionals. Many initially positive views of urine monitoring progressively changed due to perceived inaccuracy, leading some to switch to SMBG. Perceiving diabetes as less serious was attributable to lack of symptoms, treatment with diet alone and-in the urine-monitoring group-consistently negative readings. Urine monitoring also provided less visible evidence of diabetes and of the effect of behaviour on glucose.

CONCLUSIONS

The findings highlight the importance for professionals of considering patients' preferences when using self-monitoring technologies, including how these change over time, when supporting the self-care behaviours of people with type 2 diabetes.

Glycaemic control and self-management behaviours in Type 2 diabetes: results from a 1-year longitudinal cohort study

AIM

To better understand the associations between changes in self-management behaviours and glycaemic control.

METHODS

We conducted a prospective observational study of 295 adult patients with Type 2 diabetes evaluated at baseline, 6 and 12 months. Four self-management behaviours were evaluated using the Summary of Diabetes Self-Care Activities instrument, which assesses healthy diet, physical activity, medication taking and self-monitoring of blood glucose. Using hierarchical linear regression models, we tested whether changes in self-management behaviours were associated with short-term (6-month) or long-term (12-month) changes in glycaemic control, after controlling for demographic and clinical characteristics.

RESULTS

Improved diet was associated with a decrease in HbA1c level, both at 6 and 12 months. Improved medication taking was associated with short-term improvement in glycaemic control, while increased self-monitoring of blood glucose frequency was associated with a 12-month improvement in HbA1c . Completely stopping exercise after being physically active at baseline was associated with a rise in HbA1c level at 6-month follow-up. Interaction analysis indicated that a healthy diet benefitted all participant subgroups, but that medication taking was associated with glycaemic control only for participants living in poverty and more strongly for those with lower educational levels. Finally, a higher self-monitoring of blood glucose frequency was associated with better glycaemic control only in insulin-treated participants.

CONCLUSIONS

Even after adjusting for potential confounders (including baseline HbA1c ), increased frequency of healthy diet, medication taking and self-monitoring of blood glucose were associated with improved HbA1c levels. These self-management behaviours should be regularly monitored to identify patients at risk of deterioration in glycaemic control. Barriers to optimum self-management should be removed, particularly among socio-economically disadvantaged populations.

Blood glucose self-monitoring patterns in Mexican Americans: further lessons from the Starr County Border Health Initiative

BACKGROUND

The purpose was to describe patterns of home self-monitoring of blood glucose (SMBG) in Mexican Americans with type 2 diabetes mellitus enrolled in a diabetes self-management education protocol. Research questions were as follows: (1) What were the patterns and rates of home glucose self-monitoring over the 6-month course of the study? (2) What were the differences in monitoring rates between experimental and control groups? (3) What were the relationships between rates of monitoring and glycosylated hemoglobin (A1C), gender, and years with diabetes?

SUBJECTS AND METHODS

We used a randomized (by group) repeated-measures pretest/posttest control group design. Glucometer data from an experimental group (diabetes self-management education plus nurse case management) and a comparison group (diabetes self-management education only) were analyzed. Data were collected at baseline and at 3 and 6 months.

RESULTS

Overall average SMBG rates were low. Experimental and control group monitoring levels were not significantly different. More females than males never monitored glucose values, but more females than males checked at least one time per week. Those participants who checked their glucose levels more than once per week had diabetes for a longer period of time. Rates of monitoring were not strongly associated with A1C levels at 3 and 6 months, but at 6 months A1C levels were statistically significantly different based on whether or not individuals monitored their glucose levels (P=0.03, n=71).

CONCLUSIONS

SMBG rates were low in this study despite SMBG education and access to free glucometers and test strips. The lower rates of SMBG may reflect the effects of unexpected environmental challenges, but exact causes remain unclear. Reasons for low rates of SMBG need to be explored further, especially in underserved communities.

The Diabetes Self-Management Questionnaire (DSMQ): development and evaluation of an instrument to assess diabetes self-care activities associated with glycaemic control

Background

Though several questionnaires on self-care and regimen adherence have been introduced, the evaluations do not always report consistent and substantial correlations with measures of glycaemic control. Small ability to explain variance in HbA_1c constitutes a significant limitation of an instrument’s use for scientific purposes as well as clinical practice. In order to assess self-care activities which can predict glycaemic control, the Diabetes Self-Management Questionnaire (DSMQ) was designed.

Methods

A 16 item questionnaire to assess self-care activities associated with glycaemic control was developed, based on theoretical considerations and a process of empirical improvements. Four subscales, ‘Glucose Management’ (GM), ‘Dietary Control’ (DC), ‘Physical Activity’ (PA), and ‘Health-Care Use’ (HU), as well as a ‘Sum Scale’ (SS) as a global measure of self-care were derived. To evaluate its psychometric quality, 261 patients with type 1 or 2 diabetes were assessed with the DSMQ and an established analogous scale, the Summary of Diabetes Self-Care Activities Measure (SDSCA). The DSMQ’s item and scale characteristics as well as factorial and convergent validity were analysed, and its convergence with HbA_1c was compared to the SDSCA.

Results

The items showed appropriate characteristics (mean item-total-correlation: 0.46 ± 0.12; mean correlation with HbA_1c: -0.23 ± 0.09). Overall internal consistency (Cronbach’s alpha) was good (0.84), consistencies of the subscales were acceptable (GM: 0.77; DC: 0.77; PA: 0.76; HU: 0.60). Principal component analysis indicated a four factor structure and confirmed the designed scale structure. Confirmatory factor analysis indicated appropriate fit of the four factor model. The DSMQ scales showed significant convergent correlations with their parallel SDSCA scales (GM: 0.57; DC: 0.52; PA: 0.58; HU: n/a; SS: 0.57) and HbA_1c (GM: -0.39; DC: -0.30; PA: -0.15; HU: -0.22; SS: -0.40). All correlations with HbA_1c were significantly stronger than those obtained with the SDSCA.

Conclusions

This study provides preliminary evidence that the DSMQ is a reliable and valid instrument and enables an efficient assessment of self-care behaviours associated with glycaemic control. The questionnaire should be valuable for scientific analyses as well as clinical use in both type 1 and type 2 diabetes patients.