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Agarwal S, Simmonds I, Myers AK. The Use of Diabetes Technology to Address Inequity in Health Outcomes: Limitations and Opportunities. Curr Diab Rep 2022; 22:275-281. [PMID: 35648277 PMCID: PMC9157044 DOI: 10.1007/s11892-022-01470-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/21/2022] [Indexed: 01/05/2023]
Abstract
PURPOSE OF REVIEW The management of diabetes has been revolutionized by the introduction of novel technological treatments and modalities of care, such as continuous glucose monitoring, insulin pump therapy, and telehealth. While these technologies have demonstrated improvement in health outcomes, it remains unclear whether they have reduced inequities from racial/ethnic minority or socioeconomic status. We review the current literature to discuss evidence of benefit, current limitations, and future opportunities of diabetes technologies. FINDINGS While there is ample evidence of the health and psychological benefit of diabetes technologies in large populations of people with type 1 and type 2 diabetes, there remain wide disparities in the use of diabetes technologies, which may be perpetuating or widening inequities. Multilevel barriers include inequitable prescribing practices, lack of support for social determinants of health, mismatch of patient preferences and care models, and cost. We provide a review of disparities in diabetes technology use, possible root causes of continued inequity in outcomes, and insight into ways to overcome remaining gaps.
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Affiliation(s)
- Shivani Agarwal
- Fleischer Institute for Diabetes and Metabolism, Albert Einstein College of Medicine-Montefiore Medical Center, Bronx, NY USA
- NY Regional Center for Diabetes Translational Research, Albert Einstein College of Medicine, Bronx, NY USA
| | - Iman Simmonds
- Department of Cardiology, CORE Yale, New Haven, CT 06510 USA
| | - Alyson K. Myers
- Department of Medicine, Division of Endocrinology, North Shore University Hospital, Manhasset, NY USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY USA
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Pfoh ER, Linfield D, Speaker SL, Roufael JS, Yan C, Misra-Hebert AD, Rothberg MB. Patient Perspectives on Self-Monitoring of Blood Glucose When not Using Insulin: a Cross-sectional Survey. J Gen Intern Med 2022; 37:1673-1679. [PMID: 34389935 PMCID: PMC9130377 DOI: 10.1007/s11606-021-07047-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 07/14/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Professional societies have recommended against use of self-monitoring blood glucose (SMBG) in non-insulin-treated type 2 diabetes (NITT2D) to control blood sugar levels, but patients are still monitoring. OBJECTIVE To understand patients' motivation to monitor their blood sugar, and whether they would stop if their physician suggested it. DESIGN Cross-sectional in-person and electronic survey conducted between 2018 and 2020. PARTICIPANTS Adults with type 2 diabetes not using insulin who self-monitor their blood sugar. MAIN MEASURES The survey included questions about frequency and reason for using SMBG, and the impact of SMBG on quality of life and worry. It also asked, "If your doctor said you could stop checking your blood sugar, would you?" We categorized patients based on whether they would stop. To identify the characteristics independently associated with desire to stop SMBG, we performed a logistic regression using backward stepwise selection. KEY RESULTS We received 458 responses. The common reasons for using SMBG included the doctor wanted the patient to check (67%), desire to see the number (65%), and desire to see if their medications were working (61%). Forty-eight percent of respondents stated that using SMBG reduced their worry about their diabetes and 61% said it increased their quality of life. Fifty percent would stop using SMBG if given permission. In the regression model, respondents who said that they check their blood sugar levels because "I was told to" were more likely to want to stop (AOR: 1.69, 95%CI: 1.11, 2.58). Those that used SMBG due to habit and to understand their diabetes better had lower odds of wanting to stop (AOR: 0.33, 95%CI: 0.18-0.62; AOR: 0.60, 95%CI: 0.39-0.93, respectively). CONCLUSIONS Primary care physicians should discuss patients' reasons for using SMBG and offer them the option of discontinuing.
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Affiliation(s)
- Elizabeth R Pfoh
- Center for Value-Based Care Research, Cleveland Clinic, 9500 Euclid Avenue, G10, Cleveland, OH, 44195, USA.
| | - Debra Linfield
- Center for Value-Based Care Research, Cleveland Clinic, 9500 Euclid Avenue, G10, Cleveland, OH, 44195, USA
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Sidra L Speaker
- Center for Value-Based Care Research, Cleveland Clinic, 9500 Euclid Avenue, G10, Cleveland, OH, 44195, USA
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Joud S Roufael
- College of Public Health, Kent State University, Kent, OH, USA
| | - Chen Yan
- Center for Value-Based Care Research, Cleveland Clinic, 9500 Euclid Avenue, G10, Cleveland, OH, 44195, USA
| | - Anita D Misra-Hebert
- Center for Value-Based Care Research, Cleveland Clinic, 9500 Euclid Avenue, G10, Cleveland, OH, 44195, USA
- Healthcare Delivery and Implementation Science Center, Cleveland Clinic, Cleveland, OH, USA
| | - Michael B Rothberg
- Center for Value-Based Care Research, Cleveland Clinic, 9500 Euclid Avenue, G10, Cleveland, OH, 44195, USA
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Kimura M, Toyoda M, Saito N, Takahashi M, Isozumi K, Kato E, Kawanami D, Fukagawa M. The Importance of Patient and Family Engagement, the Needs for Self-Monitoring of Blood Glucose (SMBG) - Our Perspectives Learned Through a Story of SMBG Assistive Devices Made by a Husband of the Patient with Diabetes. Diabetes Metab Syndr Obes 2022; 15:1627-1638. [PMID: 35642182 PMCID: PMC9148577 DOI: 10.2147/dmso.s363762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 05/13/2022] [Indexed: 11/23/2022] Open
Abstract
Despite some negative reports regarding the need for the self-monitoring of blood glucose (SMBG), including the issue of cost-effectiveness, there are still many users, and in diabetes treatment, which is largely dependent on the patient's self-care, SMBG remains an important tool in establishing such self-care habits, with several reports supporting this notion. In addition, devices are needed to assist in SMBG for patients with diabetes who have difficulty performing SMBG, such as the elderly or those with visual impairment. In current diabetes care, it is reported that patient-centered care that respects the preferences, needs, and values of individual patients and personalized care that consider the characteristics and comorbidities of each patient are important. Through a case study of a patient with diabetes who had difficulty performing SMBG due to visual impairment, we learned of the needs of SMBG and its assistive devices and the importance of patient and family engagement with emphasis on patient-centered and personalized care. We herein report what we learned through this case in the form of perspectives. Through this report, we hope that medical professionals involved in diabetes care will learn of the importance and needs of these issues and apply them to their actual clinical practice.
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Affiliation(s)
- Moritsugu Kimura
- Division of Nephrology, Endocrinology and Metabolism, Department of Internal Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
- Correspondence: Moritsugu Kimura, Division of Nephrology, Endocrinology and Metabolism, Department of Internal Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan, Tel +81-463-93-1121 (ext. 2490), Fax +81-463-91-3350, Email
| | - Masao Toyoda
- Division of Nephrology, Endocrinology and Metabolism, Department of Internal Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Nobumichi Saito
- Division of Nephrology, Endocrinology and Metabolism, Department of Internal Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Makiko Takahashi
- Division of Nephrology, Endocrinology and Metabolism, Department of Internal Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Konomi Isozumi
- Division of Nephrology, Endocrinology and Metabolism, Department of Internal Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Eri Kato
- Seichi Clinic, Isehara, Kanagawa, Japan
| | - Daiji Kawanami
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology and Metabolism, Department of Internal Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
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Lyon V, LeRouge C, Fruhling A, Thompson M. Home testing for COVID-19 and other virus outbreaks: The complex system of translating to communities. Health Syst (Basingstoke) 2021; 10:298-317. [PMID: 34745591 PMCID: PMC8567871 DOI: 10.1080/20476965.2021.1952905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 06/25/2021] [Indexed: 10/20/2022] Open
Abstract
Home testing is an emerging innovation that can enable nations and health care systems to safely and efficiently test large numbers of patients to manage COVID-19 and other viral outbreaks. In this position paper, we explore the process of moving home testing across the translational continuum from labs to households, and ultimately into practice and communities for optimal public health impact. We focus on the four translational science drivers to accelerate the implementation of systems-wide home testing programmes 1) collaboration and team science, 2) technology, 3) multilevel interventions, and 4) knowledge integration. We use the Socio Ecological Model (SEM) as a framework to illustrate our vision for the ideal future state of a comprehensive system of stakeholders utilising tech-enabled home testing for COVID-19 and other virus outbreaks, and we suggest SEM as a tool to address key translational readiness and response questions.
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Affiliation(s)
- Victoria Lyon
- Department of Family Medicine, Primary Care Innovation Lab, University of Washington, Seattle, Washington, USA
| | - Cynthia LeRouge
- Department of Family Medicine, Primary Care Innovation Lab, University of Washington, Seattle, Washington, USA
- Department of Information Systems & Business Analytics, Florida International University, Miami, FL, USA
| | - Ann Fruhling
- School of Interdisciplinary Informatics, University of Nebraska, Omaha, NE, USA
| | - Matthew Thompson
- Department of Family Medicine, Primary Care Innovation Lab, University of Washington, Seattle, Washington, USA
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Evidence-Based Decision Making 7: Health Economics in Clinical Research. Methods Mol Biol 2021. [PMID: 33871861 DOI: 10.1007/978-1-0716-1138-8_27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
Abstract
The pressure for health-care systems to provide more resource-intensive health care and newer more costly therapies is significant, despite limited health-care budgets. As such, demonstration that a new therapy is effective is no longer sufficient to ensure that it is funded within publicly funded health-care systems. The impact of a therapy on health-care costs is also an important consideration for decision makers who must allocate scarce resources. The clinical benefits and costs of a new therapy can be estimated simultaneously using economic evaluation; the strengths and limitations of which are discussed herein. In addition, within this chapter, we discuss the important economic outcomes that can be collected within a clinical trial (alongside the clinical outcome data) enabling consideration of the impact of the therapy on overall resource use, thus enabling performance of an economic evaluation, if the therapy is shown to be effective.
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Tai JCJ, Wong LZ, Richardson A. Self-Monitoring of Blood Glucose for Patients With Type 2 Diabetes in Primary Care: A Single-Centre, 10-Year Retrospective Analysis. Cureus 2021; 13:e15597. [PMID: 34277218 PMCID: PMC8272934 DOI: 10.7759/cureus.15597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2021] [Indexed: 11/05/2022] Open
Abstract
Background While type 1 diabetics often require self-monitoring of blood glucose (SMBG), the evidence for tight blood glucose monitoring in non-insulin treated type 2 diabetes mellitus (T2DM) patients is limited. In addition to its lack of cost-effectiveness, unnecessary blood glucose monitoring may also result in anxiety and decreased quality of life. In this retrospective audit, we assessed SMBG prescribing practice at one general practice against guidelines from the National Institute for Health and Care Excellence (NICE). Methods A systematic search of T2DM patients diagnosed at a general practice in London, United Kingdom, in the last 10 years was undertaken. A total of 146 patients fulfilled these criteria, of which 100 patients were randomly selected for inclusion in this audit. Medical notes were reviewed and collated for analysis. Results Only 85% of patients with T2DM were being managed in accordance with the NICE guidelines on SMBG, while 15% were not. It was more common for patients who did not need monitoring to be inappropriately prescribed SMBG (10%) than it was for patients who needed monitoring to be under-prescribed SMBG (5%). The reasons for prescribing SMBG were often left undocumented. Conclusion Adherence to the NICE guidelines is subpar. Recommended solutions include educating healthcare professionals involved in the prescribing of SMBGs, regular reviews of the continued necessity of SMBG, and digital alerts on e-prescribing systems.
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Affiliation(s)
- Justina Cheh Juan Tai
- General Practice and Primary Care, University College London Medical School, London, GBR
| | - Liang Zhi Wong
- General Practice and Primary Care, University College London Medical School, London, GBR
| | - Adrian Richardson
- General Practice and Primary Care, NHS Haringey North Central London Clinical Commissioning Group (CCG), London, GBR
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Nichols J, Mamdani M, Gomes T, Shah BR, Casey CG, Yu CH. Impact of Clinical Practice Guidelines on Blood Glucose Test Strip Prescription Rates in Manitoba and Saskatchewan (Canada): An Interrupted Time-Series Analysis. Can J Diabetes 2020; 45:557-565.e2. [PMID: 33558147 DOI: 10.1016/j.jcjd.2020.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 11/09/2020] [Accepted: 11/19/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Our aim in this study was to assess the impact of the Diabetes Canada Dissemination & Implementation strategy on population-level prescription rates of blood glucose test strips. METHODS We extracted all diabetes-related drugs and test strip claims in Manitoba and Saskatchewan between January 1, 2000 and September 30, 2015 from the Canadian Institute for Health Information's National Prescription Drug Utilization Information System. The primary outcome was the proportion of the cohort in each quarter who had been dispensed strips in accordance with the Diabetes Canada 2013 guidelines. We conducted an interrupted time-series analysis examining prescribing trends overall and by drug groups. RESULTS The overall average sample size per quarter was 57,576 (standard deviation [SD]=12,320) and 49,533 (SD=10,206) individuals; the average age was 62.1 (SD=0.3) and 63.8 (SD=0.3) years, and the average proportion of total beneficiaries in the sample was 12.7% (SD=1.9%) and 12.6% (SD=1.7%) for Manitoba and Saskatchewan, respectively. On average preintervention, 27.9% (SD=0.68%, Manitoba) and 31.9% (SD=0.73%, Saskatchewan) of the sampled patients used strips according to the guidelines. On average postintervention, 26.5% (SD=0.29%, Manitoba) and 30.6% (SD=0.53%, Saskatchewan) of the patients used strips according to the guidelines. None of the interrupted time-series models reached statistical significance (p values ranging from 0.44 to 0.98 for Manitoba and 0.13 to 0.81 for Saskatchewan, depending on drug group). CONCLUSIONS The guideline and its Dissemination & Implementation strategy did not change strip prescribing. Potential reasons include complexity of the recommendations, lack of penetrance to primary care physicians and/or disagreement with recommendations.
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Affiliation(s)
| | - Muhammad Mamdani
- Unity Health Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada, ICES, Toronto, Ontario, Canada; Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Tara Gomes
- Unity Health Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada, ICES, Toronto, Ontario, Canada; Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Baiju R Shah
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | | | - Catherine H Yu
- Diabetes Canada, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada.
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Oluma A, Mosisa G, Abadiga M, Tsegaye R, Habte A, Abdissa E. Predictors of Adherence to Self-Care Behavior Among Patients with Diabetes at Public Hospitals in West Ethiopia. Diabetes Metab Syndr Obes 2020; 13:3277-3288. [PMID: 33061490 PMCID: PMC7520154 DOI: 10.2147/dmso.s266589] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 08/20/2020] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Diabetes is a typical chronic disease that needs integrated and multifaceted approaches. Self-care practices are fundamental to achieve good blood glucose control and prevent long-term complications. Therefore, the aim of the study was to determine the level and predictors of adherence to self-care behavior among patients with diabetes on follow-up at public hospitals of western Ethiopia. PATIENTS AND METHODS The cross-sectional study design was employed on a sample of 423 diabetic patients on follow-up at public hospitals of western Ethiopia. A systematic random sampling method was employed. The data were entered into Epi data version 3.1 and exported into Statistical Package for the Social Sciences window version 24 for analysis. All variables significant at p-value <0.05 in the bivariable were entered in multivariate regression analysis. Backward stepwise goodness of fit was used to ascertain the suitable variables in multiple linear regression analysis. Finally, multivariate linear regression analysis with adjusted B, CI at 95%, and the significance level was set at p <0.05. All predictive variables were reported in terms of adjusted R2. RESULTS The overall mean and standard deviation of adherence to self-care behavior was 23.09 ±6.55. Among the study participants, 42.70% had good self-care behavior. Self-efficacy (B=0.106, p<0.001), home blood glucose test (B=0.075, p<0.001), exercise per week (0.035, P<0.002), meal planning (B=0.039, P<0.001), dietary restriction (B=0.077, P<0.001), duration of diabetes<4 years (B=0.030, P<0.013), non-pharmacological intervention (B=0.055, P<0.011), and good appetite (B=0.039, P<0.045) were significant variables associated with adherence to self-care behaviors. CONCLUSION The overall level of adherence to self-care behavior was low. Therefore, we recommended that it is better if the national health policymaker focused on dietary management modality that engages patients' behavior change to develop self-care practices and closely monitoring of glucose level. Also, we recommended an additional longitudinal study incorporating a qualitative study that focused on behavioral changes.
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Affiliation(s)
- Adugna Oluma
- School of Nursing and Midwifery, Institute of Health Sciences, Wollega University, Nekemte, Ethiopia
| | - Getu Mosisa
- School of Nursing and Midwifery, Institute of Health Sciences, Wollega University, Nekemte, Ethiopia
| | - Muktar Abadiga
- School of Nursing and Midwifery, Institute of Health Sciences, Wollega University, Nekemte, Ethiopia
| | - Reta Tsegaye
- School of Nursing and Midwifery, Institute of Health Sciences, Wollega University, Nekemte, Ethiopia
| | - Ashenafi Habte
- School of Nursing and Midwifery, Institute of Health Sciences, Wollega University, Nekemte, Ethiopia
| | - Eba Abdissa
- School of Nursing and Midwifery, Institute of Health Sciences, Wollega University, Nekemte, Ethiopia
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Siegel KR, Ali MK, Zhou X, Ng BP, Jawanda S, Proia K, Zhang X, Gregg EW, Albright AL, Zhang P. Cost-effectiveness of Interventions to Manage Diabetes: Has the Evidence Changed Since 2008? Diabetes Care 2020; 43:1557-1592. [PMID: 33534729 DOI: 10.2337/dci20-0017] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 04/03/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To synthesize updated evidence on the cost-effectiveness (CE) of interventions to manage diabetes, its complications, and comorbidities. RESEARCH DESIGN AND METHODS We conducted a systematic literature review of studies from high-income countries evaluating the CE of diabetes management interventions recommended by the American Diabetes Association (ADA) and published in English between June 2008 and July 2017. We also incorporated studies from a previous CE review from the period 1985-2008. We classified the interventions based on their strength of evidence (strong, supportive, or uncertain) and levels of CE: cost-saving (more health benefit at a lower cost), very cost-effective (≤$25,000 per life year gained [LYG] or quality-adjusted life year [QALY]), cost-effective ($25,001-$50,000 per LYG or QALY), marginally cost-effective ($50,001-$100,000 per LYG or QALY), or not cost-effective (>$100,000 per LYG or QALY). Costs were measured in 2017 U.S. dollars. RESULTS Seventy-three new studies met our inclusion criteria. These were combined with 49 studies from the previous review to yield 122 studies over the period 1985-2017. A large majority of the ADA-recommended interventions remain cost-effective. Specifically, we found strong evidence that the following ADA-recommended interventions are cost-saving or very cost-effective: In the cost-saving category are 1) ACE inhibitor (ACEI)/angiotensin receptor blocker (ARB) therapy for intensive hypertension management compared with standard hypertension management, 2) ACEI/ARB therapy to prevent chronic kidney disease and/or end-stage renal disease in people with albuminuria compared with no ACEI/ARB therapy, 3) comprehensive foot care and patient education to prevent and treat foot ulcers among those at moderate/high risk of developing foot ulcers, 4) telemedicine for diabetic retinopathy screening compared with office screening, and 5) bariatric surgery compared with no surgery for individuals with type 2 diabetes (T2D) and obesity (BMI ≥30 kg/m2). In the very cost-effective category are 1) intensive glycemic management (targeting A1C <7%) compared with conventional glycemic management (targeting an A1C level of 8-10%) for individuals with newly diagnosed T2D, 2) multicomponent interventions (involving behavior change/education and pharmacological therapy targeting hyperglycemia, hypertension, dyslipidemia, microalbuminuria, nephropathy/retinopathy, secondary prevention of cardiovascular disease with aspirin) compared with usual care, 3) statin therapy compared with no statin therapy for individuals with T2D and history of cardiovascular disease, 4) diabetes self-management education and support compared with usual care, 5) T2D screening every 3 years starting at age 45 years compared with no screening, 6) integrated, patient-centered care compared with usual care, 7) smoking cessation compared with no smoking cessation, 8) daily aspirin use as primary prevention for cardiovascular complications compared with usual care, 9) self-monitoring of blood glucose three times per day compared with once per day among those using insulin, 10) intensive glycemic management compared with conventional insulin therapy for T2D among adults aged ≥50 years, and 11) collaborative care for depression compared with usual care. CONCLUSIONS Complementing professional treatment recommendations, our systematic review provides an updated understanding of the potential value of interventions to manage diabetes and its complications and can assist clinicians and payers in prioritizing interventions and health care resources.
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Affiliation(s)
- Karen R Siegel
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Mohammed K Ali
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA.,Hubert Department of Global Health and Department of Family and Preventive Medicine, Emory University, Atlanta, GA
| | - Xilin Zhou
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Boon Peng Ng
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA.,College of Nursing and Disability, Aging and Technology Cluster, University of Central Florida, Orlando, FL
| | - Shawn Jawanda
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Krista Proia
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Xuanping Zhang
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Edward W Gregg
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Ann L Albright
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Ping Zhang
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
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Williams DM, Parsons SN, Dunseath GJ, Stephens JW, Luzio SD, Owens DR. The impact of structured self-monitoring of blood glucose on glycaemic variability in non-insulin treated type 2 diabetes: The SMBG study, a 12-month randomised controlled trial. Diabetes Metab Syndr 2020; 14:101-106. [PMID: 31995784 DOI: 10.1016/j.dsx.2020.01.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 01/10/2020] [Accepted: 01/10/2020] [Indexed: 01/30/2023]
Abstract
BACKGROUND AND AIMS There is inconsistent evidence supporting the self-monitoring of blood glucose (SMBG) in people with non-insulin treated type 2 diabetes (T2D). Structured SMBG protocols have a greater impact on glycaemic control than unstructured SMBG and may improve measures of glycaemic variability (GV), though few previous studies have reported on specific GV outcomes. Our aim was to determine the impact of structured SMBG on simple measures of GV in people with T2D. METHODS Participants undertook structured SMBG over 12 months, with HbA1c recorded at baseline and at 3-monthly follow-up. For each participant, the mean blood glucose (MBG), fasting blood glucose (FBG), standard deviation BG (SD-BG), coefficient of variation of BG (CV-BG), mean absolute glucose change (MAG) and HbA1c were determined for each 3-month period. Responders were participants with an improvement in HbA1c of ≥5 mmol/mol (0.5%) over 12 months. RESULTS Data from two hundred and thirty-one participants were included for analysis. Participants had a baseline median [interquartile range] HbA1c 68.0 [61.5-75.5] mmol/mol (8.4%). Participants demonstrated significant improvements in the MBG (-1.25 mmol/L), FBG (-0.97 mmol/L), SD-BG (-0.44 mmol/L), CV-BG (-1.43%), MAG (-0.97 mmol/L), and HbA1c (-7.0 mmol/mol) (all p < 0.001) at 12 months compared to these measures collected within the first 3 months of SMBG. Responders had a significantly higher baseline median [interquartile range] HbA1c of 70.0 [63.0-78.0] mmol/mol compared to 61.0 [56.5-66.0] mmol/mol in non-responders (P < 0.001). CONCLUSIONS Structured SMBG improved all the observed measures of GV. These results support the use of structured SMBG in people with non-insulin treated T2D.
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Affiliation(s)
- David M Williams
- Diabetes Research Group, Diabetes Research Unit Cymru, Swansea University Medical School, Swansea University, SA2 8PP, UK; Department of Diabetes & Endocrinology, Morriston Hospital, Swansea, SA6 6NL, UK.
| | - Sharon N Parsons
- Diabetes Research Group, Diabetes Research Unit Cymru, Swansea University Medical School, Swansea University, SA2 8PP, UK
| | - Gareth J Dunseath
- Diabetes Research Group, Diabetes Research Unit Cymru, Swansea University Medical School, Swansea University, SA2 8PP, UK
| | - Jeffrey W Stephens
- Diabetes Research Group, Diabetes Research Unit Cymru, Swansea University Medical School, Swansea University, SA2 8PP, UK; Department of Diabetes & Endocrinology, Morriston Hospital, Swansea, SA6 6NL, UK
| | - Stephen D Luzio
- Diabetes Research Group, Diabetes Research Unit Cymru, Swansea University Medical School, Swansea University, SA2 8PP, UK
| | - David R Owens
- Diabetes Research Group, Diabetes Research Unit Cymru, Swansea University Medical School, Swansea University, SA2 8PP, UK
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Peiffer V, Yock CA, Yock PG, Pietzsch JB. Value-Based Care: A Review of Key Challenges and Opportunities Relevant to Medical Technology Innovators. J Med Device 2019. [DOI: 10.1115/1.4042794] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Developed countries struggle with high healthcare spending, and cost is often cited as a barrier to the introduction of new patient care technologies. The core objective of this review article is to help familiarize medical technology innovators with trends in the health economic environment and the implications for the adoption of new technologies. We review and discuss this topic in language accessible to medical technology innovators. We assess macrolevel developments in healthcare spending and highlight measures already taken to control spending. We discuss practical implications for anyone involved in healthcare innovation. Two observations are central to this discussion: (1) the U.S. spends significantly more on healthcare per capita than any other developed country; (2) across developed countries, healthcare spending has risen steadily over the past two decades. Nevertheless, higher spending has not always led to improvements in health. As a result, innovators need to be prepared to navigate an outcomes-oriented and value-based environment that is being defined by the emerging requirements of various healthcare stakeholders. Practically, new products should aim to improve health outcomes at a cost deemed “good value” and/or reduce cost for one or multiple stakeholders. Opportunities also exist for tools that enable cost/outcomes tracking, which will help demonstrate value to providers, insurers, and patients.
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Affiliation(s)
| | - Cynthia A. Yock
- Byers Center for Biodesign, Stanford University, Stanford, CA 94305
| | - Paul G. Yock
- Byers Center for Biodesign, Stanford University, Stanford, CA 94305
| | - Jan B. Pietzsch
- Wing Tech, Inc., Menlo Park, CA 94025; Byers Center for Biodesign, Stanford University, Clark Center (E100) 318 Campus Drive, Stanford, CA 94305 e-mail:
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Falk J, Friesen KJ, Okunnu A, Bugden S. Patterns, Policy and Appropriateness: A 12-Year Utilization Review of Blood Glucose Test Strip Use in Insulin Users. Can J Diabetes 2017; 41:385-391. [PMID: 28410881 DOI: 10.1016/j.jcjd.2016.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 11/30/2016] [Accepted: 12/08/2016] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Considerable attention has been paid to the rising costs of the use of blood glucose test strips (BGTS). Insulin users have generally been treated as a single homogeneous group, resulting in policies that cap usage (8.2 strips/day) in provincial drug insurance programs. The objective of this study was to conduct a utilization review of BGTS by insulin users and to evaluate use patterns against current insulin use patterns and BGTS policy. METHODS BGTS usage was examined in a cohort of insulin users with type 1 and type 2 diabetes over a 12-year period (2001 to 2013) using the population-based administrative data in Manitoba, Canada. RESULTS Total BGTS strip use increased by 121%, from $4.3 to $9.5 million. However, the number of insulin users also increased by 115%. Use has been stable at 1.5 strips per day per person since 2004 by insulin users with type 2 diabetes but has risen from 1.9 to 3.0 strips per day per person in those with type 1 diabetes. Mean daily test strip use was below the number of daily tests recommended for patients using insulin as per the current Canadian guidelines, with 11% and 15% of insulin users with type 1 and type 2 diabetes not claiming any BGTS use and a further 15% (type 1) and 28% (type 2) using fewer than 1 strip per day. CONCLUSIONS BGTS use per insulin user has been stable for most of the past decade, and the vast majority of use falls well below provincial insurance caps. The amount of low-level testing (0 to <1 strip/day) suggests that greater attention should be directed to ensuring a safe level of testing by all insulin users.
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Affiliation(s)
- Jamie Falk
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kevin J Friesen
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Anuoluwapo Okunnu
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Shawn Bugden
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.
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Hua X, Lung TWC, Palmer A, Si L, Herman WH, Clarke P. How Consistent is the Relationship between Improved Glucose Control and Modelled Health Outcomes for People with Type 2 Diabetes Mellitus? a Systematic Review. PHARMACOECONOMICS 2017; 35:319-329. [PMID: 27873225 PMCID: PMC5306373 DOI: 10.1007/s40273-016-0466-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
BACKGROUND There are an increasing number of studies using simulation models to conduct cost-effectiveness analyses for type 2 diabetes mellitus. OBJECTIVE To evaluate the relationship between improvements in glycosylated haemoglobin (HbA1c) and simulated health outcomes in type 2 diabetes cost-effectiveness studies. METHODS A systematic review was conducted on MEDLINE and EMBASE to collect cost-effectiveness studies using type 2 diabetes simulation models that reported modelled health outcomes of blood glucose-related interventions in terms of quality-adjusted life-years (QALYs) or life expectancy (LE). The data extracted included information used to characterise the study cohort, the intervention's treatment effects on risk factors and model outcomes. Linear regressions were used to test the relationship between the difference in HbA1c (∆HbA1c) and incremental QALYs (∆QALYs) or LE (∆LE) of intervention and control groups. The ratio between the ∆QALYs and ∆LE was calculated and a scatterplot between the ratio and ∆HbA1c was used to explore the relationship between these two. RESULTS Seventy-six studies were included in this research, contributing to 124 pair of comparators. The pooled regressions indicated that the marginal effect of a 1% HbA1c decrease in intervention resulted in an increase in life-time QALYs and LE of 0.371 (95% confidence interval 0.286-0.456) and 0.642 (95% CI 0.494-0.790), respectively. No evidence of heterogeneity between models was found. An inverse exponential relationship was found and fitted between the ratio (∆QALY/∆LE) and ∆HbA1c. CONCLUSION There is a consistent relationship between ∆HbA1c and ∆QALYs or ∆LE in cost-effectiveness analyses using type 2 diabetes simulation models. This relationship can be used as a diagnostic tool for decision makers.
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Affiliation(s)
- Xinyang Hua
- School of Population and Global Health, University of Melbourne, Level 4, 207 Bouverie Street, Carlton, VIC, 3053, Australia
| | - Thomas Wai-Chun Lung
- School of Population and Global Health, University of Melbourne, Level 4, 207 Bouverie Street, Carlton, VIC, 3053, Australia
- The George Institute for Global Health, University of Sydney, Lidcombe, NSW, Australia
| | - Andrew Palmer
- Menzies Research Institute, University of Tasmania, Hobart, TAS, Australia
| | - Lei Si
- Menzies Research Institute, University of Tasmania, Hobart, TAS, Australia
| | - William H Herman
- School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Philip Clarke
- School of Population and Global Health, University of Melbourne, Level 4, 207 Bouverie Street, Carlton, VIC, 3053, Australia.
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Vaughan EM, Moreno JP, Hyman D, Chen TA, Foreyt JP. Efficacy of oral versus insulin therapy for newly diagnosed diabetes in low-income settings. ARCHIVES OF GENERAL INTERNAL MEDICINE 2017; 1:17-22. [PMID: 29517061 PMCID: PMC5836790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 11/13/2023]
Abstract
BACKGROUND There are conflicting recommendations and highly variable practices regarding the level of A1c to initiate insulin for individuals with newly diagnosed diabetes. This is complicated in low-income settings where adverse reactions or negative perceptions of insulin are often magnified. OBJECTIVES Compare the clinical outcomes of insulin and Oral Agents (OAs) in low-income settings in the United States. METHODS We conducted a retrospective chart review in community clinics serving low -income individuals with newly diagnosed type 2 diabetes who were initiated on insulin or OAs. The primary outcome was change of hemoglobin A1c (A1c) from baseline to 12 months. Secondary outcomes consisted of other clinical measures including Emergency Department (ED) visits. RESULTS A total of 18% (88/489) of patients were started on insulin. The adjusted average decrease of A1c from baseline was greater in the OA group (insulin: -1.97% vs. OA: -2.52%; p<0.001). In a subset analysis of individuals with A1cs >11%, significantly more patients were started on OAs (insulin: n=51, OA: n=93; p<0.001) and A1c improvements were similar at 12 months (insulin: -5.06% [12.94% to 7.88%] OA: -4.62% [12.57% to 7.96%]; p=0.846). Baseline A1c predicted insulin initiation (p<0.001): For every one-unit increase in baseline A1c, the odds of insulin initiation increased by 47.5%. Individuals in the insulin group had more ED visits per year (0.169 vs. 0.0025; p<0.005). CONCLUSIONS Given the positive clinical outcomes of OAs even with markedly elevated A1c levels in addition to the healthcare system benefits, they are a promising initial therapy for low-income adults with newly diagnosed type 2 diabetes.
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Affiliation(s)
| | - Jennette P Moreno
- Department of Pediatrics-Nutrition, USDA/ARS Children’s Nutrition Research Center, Baylor College of Medicine, Houston, TX 77030, USA
| | - David Hyman
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Tzu-An Chen
- Center for Translational Injury Research (CeTIR), The University of Texas Health Science Center, Houston, TX, USA
| | - John P Foreyt
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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Nishimura A, Harashima SI, Fujita Y, Tanaka D, Wang Y, Liu Y, Inagaki N. Effects of structured testing versus routine testing of blood glucose in diabetes self-management: A randomized controlled trial. J Diabetes Complications 2017; 31:228-233. [PMID: 27653670 DOI: 10.1016/j.jdiacomp.2016.08.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 08/03/2016] [Accepted: 08/22/2016] [Indexed: 10/21/2022]
Abstract
AIMS To compare the effects of structured and routine testing regimens used in self-monitoring of blood glucose (SMBG) on glycemic control and diabetes self-management in insulin-naïve type 2 diabetes patients. METHODS Sixty-two outpatients with insulin-naïve type 2 diabetes were randomly allocated into two less-frequent SMBG usage groups: a structured testing group (STG) and a routine testing group (RTG). Subjects in STG measured 7-points on SMBG for 3 consecutive days once every two months without daily testing; subjects in RTG measured SMBG 3 times each week before breakfast on Monday and Friday and before dinner on Wednesday. The primary endpoint was HbA1c reduction. The secondary endpoints were change in body weight, blood pressure, treatment change, and self-management performance change. RESULTS HbA1c levels were significantly decreased by 0.32% (3.50mmol/mol) in STG, partly because physicians changed medications more actively. In contrast, body weight and systolic/diastolic blood pressure were significantly reduced by 0.94kg and 6.8/4.7mmHg, respectively, in RTG, possibly related to the increased diet and exercise score in RTG. CONCLUSIONS Structured testing without daily testing is beneficial for glycemic control; routine testing 3 times a week is more helpful for daily self-management. In low SMBG frequency usage, these two regimens can be utilized according to individual diabetic conditions.
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Affiliation(s)
- Akiko Nishimura
- Department of Human Health Sciences, Graduate School of Medicine, Kyoto University, 53 Shogoin Kawahara-cho, Sakyo-ku, Kyoto-city, Kyoto 606-8507, Japan
| | - Shin-Ichi Harashima
- Department of Diabetes, Endocrinology and Nutrition, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto-city, Kyoto 606-8507, Japan.
| | - Yoshihito Fujita
- Department of Diabetes, Endocrinology and Nutrition, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto-city, Kyoto 606-8507, Japan
| | - Daisuke Tanaka
- Department of Diabetes, Endocrinology and Nutrition, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto-city, Kyoto 606-8507, Japan
| | - Yu Wang
- Department of Diabetes, Endocrinology and Nutrition, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto-city, Kyoto 606-8507, Japan
| | - Yanyan Liu
- Department of Diabetes, Endocrinology and Nutrition, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto-city, Kyoto 606-8507, Japan
| | - Nobuya Inagaki
- Department of Diabetes, Endocrinology and Nutrition, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto-city, Kyoto 606-8507, Japan
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Reduction in self-monitoring of blood glucose in type 2 diabetes: an observational controlled study in east London. Br J Gen Pract 2016; 65:e256-63. [PMID: 25824186 DOI: 10.3399/bjgp15x684421] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Self-monitoring of blood glucose (SMBG) confers no benefit for many people with type 2 diabetes not being treated with insulin. It accounts for 21% of diabetes prescribing costs. AIM To improve care quality at reduced cost for type 2 diabetes by reducing unnecessary SMBG. DESIGN AND SETTING Non-randomised, observational controlled study in two intervention clinical commissioning groups (CCGs) and one control CCG in east London. METHOD In total, 19,602 people with type 2 diabetes not being treated with insulin were recruited from two intervention CCGs; 16,033 were recruited from a control CCG. The intervention (from 2010 to 2013) comprised implementation of a locally developed guideline, including IT support and peer feedback of performance. Data on practice prescribing SMBG testing strips were gathered using GP electronic health records. Information on costs were obtained via the ePACT electronic database. RESULTS Over 4 years, in all non-insulin type 2 diabetes treatment groups, use of SMBG was reduced in the two intervention CCGs from 42.8% to 16.5%, and in the control CCG from 56.4% to 47.2%. In people on metformin alone or no treatment, intervention CCGs reduced SMBG use from 29.6% to 6.0%, and in the control CCG use dropped from 47.1% to 38.7% (P<0.001). From 2009 to 2012 the total cost of all SMBG prescribing (type 1 and type 2 diabetes, including users of insulin) was reduced by 4.9% (£62,476) in the two intervention CCGs and increased in the control CCG by 5.0% (£42,607); in England, the total cost increased by 13.5% (£19.4 million). In total, 20% (3865 of 19 602) fewer patients used SMBG in the intervention CCGs. CONCLUSION This low-cost programme demonstrated a major reduction in unnecessary prescribing of SMBG, along with cost savings. If replicated nationally, this would avoid unnecessary testing in 340 000 people and prescribing costs that total £21.8 million.
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Padwal R, McAlister FA, Wood PW, Boulanger P, Fradette M, Klarenbach S, Edwards AL, Holroyd-Leduc JM, Alagiakrishnan K, Rabi D, Majumdar SR. Telemonitoring and Protocolized Case Management for Hypertensive Community-Dwelling Seniors With Diabetes: Protocol of the TECHNOMED Randomized Controlled Trial. JMIR Res Protoc 2016; 5:e107. [PMID: 27343147 PMCID: PMC4938881 DOI: 10.2196/resprot.5775] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 04/03/2016] [Indexed: 12/22/2022] Open
Abstract
Background Diabetes and hypertension are devastating, deadly, and costly conditions that are very common in seniors. Controlling hypertension in seniors with diabetes dramatically reduces hypertension-related complications. However, blood pressure (BP) must be lowered carefully because seniors are also susceptible to low BP and attendant harms. Achieving “optimal BP control” (ie, avoiding both undertreatment and overtreatment) is the ultimate therapeutic goal in such patients. Regular BP monitoring is required to achieve this goal. BP monitoring at home is cheap, convenient, widely used, and guideline endorsed. However, major barriers prevent proper use. These may be overcome through use of BP telemonitoring—the secure teletransmission of BP readings to a health portal, where BP data are summarized for provider and patient use, with or without protocolized case management. Objective To examine the incremental effectiveness, safety, cost-effectiveness, usability, and acceptability of home BP telemonitoring, used with or without protocolized case management, compared with “enhanced usual care” in community-dwelling seniors with diabetes and hypertension. Methods A 300-patient, 3-arm, pragmatic randomized controlled trial with blinded outcome ascertainment will be performed in seniors with diabetes and hypertension living independently in seniors’ residences in greater Edmonton. Consenting patients will be randomized to usual care, home BP telemonitoring alone, or home BP telemonitoring plus protocolized pharmacist case management. Usual care subjects will receive a home BP monitor but neither they nor their providers will have access to teletransmitted data. In both telemonitored arms, providers will receive telemonitored BP data summaries. In the case management arm, pharmacist case managers will be responsible for reviewing teletransmitted data and initiating guideline-concordant and protocolized changes in BP management. Results Outcomes will be ascertained at 6 and 12 months. Within-study-arm change scores will be calculated and compared between study arms. These include: (1) clinical outcomes: proportion of subjects with a mean 24-hour ambulatory systolic BP in the optimal range (110-129 mmHg in patients 65-79 years and 110-139 mmHg in those ≥80 years: primary outcome); additional ambulatory and home BP outcomes; A1c and lipid profile; medications, cognition, health care use, cardiovascular events, and mortality. (2) Safety outcomes: number of serious episodes of hypotension, syncope, falls, and electrolyte disturbances (requiring third party assistance or medical attention). (3) Humanistic outcomes: quality of life, satisfaction, and medication adherence. (4) Economic outcomes: incremental costs, incremental cost-utility, and cost per mmHg change in BP of telemonitoring ± case management compared with usual care (health payor and societal perspectives). (5) Intervention usability and acceptability to patients and providers. Conclusion The potential benefits of telemonitoring remain largely unstudied and unproven in seniors. This trial will comprehensively assess the impact of home BP telemonitoring across a range of outcomes. Results will inform the value of implementing home-based telemonitoring within supportive living residences in Canada. Trial Registration Clinicaltrials.gov NCT02721667; https://clinicaltrials.gov/ct2/show/NCT02721667 (Archived by Webcite at http://www.webcitation.org/6i8tB20Mc)
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Affiliation(s)
- Raj Padwal
- Department of Medicine, University of Alberta, Edmonton, AB, Canada.
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Tavares R, Duclos M, Brabant MJ, Checchin D, Bosnic N, Turvey K, Terres JAR. Differences in self-monitored, blood glucose test strip utilization by therapy for type 2 diabetes mellitus. Acta Diabetol 2016; 53:483-92. [PMID: 26972690 PMCID: PMC4877426 DOI: 10.1007/s00592-015-0823-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 12/02/2015] [Indexed: 11/03/2022]
Abstract
AIMS To determine whether blood glucose test strip (BGTS) utilization in patients with type 2 diabetes (T2D) is associated with the type of diabetes therapy, classified according to hypoglycemic risk. METHODS A retrospective, longitudinal (2006-2012) study of Canadian private drug plans (PDP) and Ontario Public Drug Programs (OPDP) prescription claims was conducted. Analyses were restricted to patients with T2D with or without a claim for BGTS. Daily BGTS utilization (TS/patient/day) was evaluated by diabetes therapy classified by hypoglycemic risk. Multivariate analyses were conducted to identify determinants of BGTS utilization. RESULTS The T2D cohort comprised 5,759,591 observations from 1,949,129 claimants. Mean BGTS utilization was 0.84 TS/patient/day and differed between PDP and OPDP (0.66 vs. 1.00). Daily utilization was greatest in patients receiving therapy associated with a pre-defined high risk of hypoglycemia [insulin: basal + bolus (2.16), premixed (1.65), basal (1.16), other insulin regimens (2.13), and sulfonylureas (0.74)] versus non-sulfonylurea non-insulin-based regimens (0.52). For non-insulin therapy, BGTS utilization was greater for patients on multiple non-insulin therapies versus monotherapy (0.74 vs. 0.53 TS/patient/day). In multivariate analyses, drivers for BGTS utilization included insulin use, previous BGTS use, and female gender. Previous diabetes therapy and duration of therapy were negatively correlated with BGTS utilization. CONCLUSIONS BGTS utilization varies depending on the type of therapy used to treat T2D according to hypoglycemic risk. Decision making regarding BGTS needs to account for robust analyses of current utilization and its value in those settings, including in patients not receiving diabetes therapy and the prevalence of circumstances conducive to more intensive monitoring.
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Affiliation(s)
- Ruben Tavares
- GlaxoSmithKline, 7333 Mississauga Road North, Mississauga, ON, L5N 6L4, Canada.
| | - Marc Duclos
- IMS Brogan, a unit of IMS Health, Kirkland, QC, Canada
| | | | - Daniella Checchin
- GlaxoSmithKline, 7333 Mississauga Road North, Mississauga, ON, L5N 6L4, Canada
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Serwylo O, Friesen K, Falk J, Bugden S. Opportunity Cost and Policy: A Utilization Review of Self-monitoring of Blood Glucose in Manitoba, Canada. Clin Ther 2016; 38:929-35. [DOI: 10.1016/j.clinthera.2016.02.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 02/01/2016] [Accepted: 02/09/2016] [Indexed: 10/22/2022]
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Niven DJ, Mrklas KJ, Holodinsky JK, Straus SE, Hemmelgarn BR, Jeffs LP, Stelfox HT. Towards understanding the de-adoption of low-value clinical practices: a scoping review. BMC Med 2015; 13:255. [PMID: 26444862 PMCID: PMC4596285 DOI: 10.1186/s12916-015-0488-z] [Citation(s) in RCA: 206] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 09/15/2015] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Low-value clinical practices are common in healthcare, yet the optimal approach to de-adopting these practices is unknown. The objective of this study was to systematically review the literature on de-adoption, document current terminology and frameworks, map the literature to a proposed framework, identify gaps in our understanding of de-adoption, and identify opportunities for additional research. METHODS MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, the Cochrane Database of Abstracts and Reviews of Effects, and CINAHL Plus were searched from 1 January 1990 to 5 March 2014. Additional citations were identified from bibliographies of included citations, relevant websites, the PubMed 'related articles' function, and contacting experts in implementation science. English-language citations that referred to de-adoption of clinical practices in adults with medical, surgical, or psychiatric illnesses were included. Citation selection and data extraction were performed independently and in duplicate. RESULTS From 26,608 citations, 109 were included in the final review. Most citations (65%) were original research with the majority (59%) published since 2010. There were 43 unique terms referring to the process of de-adoption-the most frequently cited was "disinvest" (39% of citations). The focus of most citations was evaluating the outcomes of de-adoption (50%), followed by identifying low-value practices (47%), and/or facilitating de-adoption (40%). The prevalence of low-value practices ranged from 16% to 46%, with two studies each identifying more than 100 low-value practices. Most articles cited randomized clinical trials (41%) that demonstrate harm (73%) and/or lack of efficacy (63%) as the reason to de-adopt an existing clinical practice. Eleven citations described 13 frameworks to guide the de-adoption process, from which we developed a model for facilitating de-adoption. Active change interventions were associated with the greatest likelihood of de-adoption. CONCLUSIONS This review identified a large body of literature that describes current approaches and challenges to de-adoption of low-value clinical practices. Additional research is needed to determine an ideal strategy for identifying low-value practices, and facilitating and sustaining de-adoption. In the meantime, this study proposes a model that providers and decision-makers can use to guide efforts to de-adopt ineffective and harmful practices.
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Affiliation(s)
- Daniel J Niven
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, T1Y 6J4, Canada. .,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, T2N 4Z6, Canada.
| | - Kelly J Mrklas
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, T2N 4Z6, Canada.
| | - Jessalyn K Holodinsky
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, T2N 4Z6, Canada.
| | - Sharon E Straus
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, M5B 1T8, Canada.
| | - Brenda R Hemmelgarn
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, T2N 4Z6, Canada. .,Department of Medicine, University of Calgary, Calgary, Alberta, T2N 4Z6, Canada.
| | - Lianne P Jeffs
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, M5B 1T8, Canada.
| | - Henry Thomas Stelfox
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, T1Y 6J4, Canada. .,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, T2N 4Z6, Canada. .,Department of Medicine, University of Calgary, Calgary, Alberta, T2N 4Z6, Canada.
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Khazrai YM, Buzzetti R, Del Prato S, Cahn A, Raz I, Pozzilli P. The addition of E (Empowerment and Economics) to the ABCD algorithm in diabetes care. J Diabetes Complications 2015; 29:599-606. [PMID: 25795559 DOI: 10.1016/j.jdiacomp.2015.03.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Revised: 02/05/2015] [Accepted: 03/01/2015] [Indexed: 12/22/2022]
Abstract
The ABCD (Age, Body weight, Complications, Duration of disease) algorithm was proposed as a simple and practical tool to manage patients with type 2 diabetes. Diabetes treatment, as for all chronic diseases, relies on patients' ability to cope with daily problems concerning the management of their disease in accordance with medical recommendations. Thus, it is important that patients learn to manage and cope with their disease and gain greater control over actions and decisions affecting their health. Healthcare professionals should aim to encourage and increase patients' perception about their ability to take informed decisions about disease management and to improve patient self-esteem and feeling of self-efficacy to become agents of their own health. E for Empowerment is therefore an additional factor to take into account in the management of patients with type 2 diabetes. E stands also for Economics to be considered in diabetes care. Attention should be paid to public health policies as well as to the physician faced with the dilemma of delivering the best possible care within the problem of limited resources. The financial impact of the new treatment modalities for diabetes represents an issue that needs to be addressed at multiple strata both globally and nationally.
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Affiliation(s)
| | | | | | - Avivit Cahn
- Department of Internal Medicine, Hadassah University Hospital, Jerusalem, Israel
| | - Itamar Raz
- Department of Internal Medicine, Hadassah University Hospital, Jerusalem, Israel
| | - Paolo Pozzilli
- Department of Endocrinology and Diabetes, University Campus Bio-Medico, Rome, Italy; Centre of Diabetes, St. Bartholomew's and The London School of Medicine, Queen Mary, University of London, UK.
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Park HS, Cho H, Kim HS. Development of Cell Phone Application for Blood Glucose Self-Monitoring Based on ISO/IEEE 11073 and HL7 CCD. Healthc Inform Res 2015; 21:83-94. [PMID: 25995960 PMCID: PMC4434067 DOI: 10.4258/hir.2015.21.2.83] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 04/17/2015] [Accepted: 04/22/2015] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES The objectives of this research were to develop and evaluate a cell phone application based on the standard protocol for personal health devices and the standard information model for personal health records to support effective blood glucose management and standardized service for patients with diabetes. METHODS An application was developed for Android 4.0.3. In addition, an IEEE 11073 Manager, Medical Device Encoding Rule, and Bluetooth Health Device Profile Connector were developed for standardized health communication with a glucometer, and a Continuity of Care Document (CCD) Composer and CCD Parser were developed for CCD document exchange. The developed application was evaluated by five healthcare professionals and 87 users through a questionnaire comprising the following variables: usage intention, effort expectancy, social influence, facilitating condition, perceived risk, and voluntariness. RESULTS As a result of the evaluation of usability, it was confirmed that the developed application is useful for blood glucose self-monitoring by diabetic patients. In particular, the healthcare professionals stated their own views that the application is useful to observe the trends in blood glucose change through the automatic function which records a blood glucose level measured using Bluetooth function, and the function which checks accumulated records of blood glucose levels. Also, a result of the evaluation of usage intention was 3.52 ± 0.42 out of 5 points. CONCLUSIONS The application developed by our research team was confirmed by the verification of healthcare professionals that accurate feedback can be provided to healthcare professionals during the management of diabetic patients or education for glucose management.
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Affiliation(s)
- Hyun Sang Park
- Department of Medical Informatics, Kyungpook National University, Daegu, Korea
| | - Hune Cho
- Department of Medical Informatics, Kyungpook National University, Daegu, Korea
| | - Hwa Sun Kim
- Department of Medical information Technology, Daegu Haany University, Gyeongsan, Korea
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Brennan VK, Mauskopf J, Colosia AD, Copley-Merriman C, Hass B, Palencia R. Utility estimates for patients with Type 2 diabetes mellitus after experiencing a myocardial infarction or stroke: a systematic review. Expert Rev Pharmacoecon Outcomes Res 2015; 15:111-23. [PMID: 25555462 DOI: 10.1586/14737167.2015.965152] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
A systematic review identified studies eliciting utility decrements from myocardial infarction (MI) and stroke in patients with Type 2 diabetes mellitus (T2DM) and examined their use in economic models of new diabetes treatments. In 16 utility studies in patients with T2DM, utility decrements in the first year ranged from 0.017 to 0.226 for MI and from 0.034 to 0.590 for stroke. Sixteen of 19 economic evaluations of new treatments for T2DM included utility decrements for an MI and/or stroke from one of the 16 utility studies. Decrements for MI ranged from 0.012 to 0.180 in the first year. Decrements for stroke ranged from 0.044 to 0.690 in the first year. Utility studies in patients with T2DM provide little information about changes in utility decrements by time since the event and by disease severity. Cost-effectiveness studies do not always indicate how these values were used in the analysis.
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Abstract
The pressure for health care systems to provide more resource intensive health care and newer, more costly, therapies is significant, despite limited health care budgets. As such, demonstration that a new therapy is effective is no longer sufficient to ensure that it is funded within publicly funded health care systems. The impact of a therapy on health care costs is also an important consideration for decision-makers who must allocate scarce resources. The clinical benefits and costs of a new therapy can be estimated simultaneously using economic evaluation, the strengths and limitations of which are discussed herein. In addition, this chapter includes discussion of the important economic outcomes that can be collected within a clinical trial (alongside the clinical outcome data) enabling consideration of the impact of the therapy on overall resource use, thus enabling performance of an economic evaluation, if the therapy is shown to be effective.
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Brennan VK, Colosia AD, Copley-Merriman C, Mauskopf J, Hass B, Palencia R. Incremental costs associated with myocardial infarction and stroke in patients with type 2 diabetes mellitus: an overview for economic modeling. J Med Econ 2014; 17:469-80. [PMID: 24773097 DOI: 10.3111/13696998.2014.915847] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To identify cost estimates related to myocardial infarction (MI) or stroke in patients with type 2 diabetes mellitus (T2DM) for use in economic models. METHODS A systematic literature review was conducted. Electronic databases and conference abstracts were screened against inclusion criteria, which included studies performed in patients who had T2DM before experiencing an MI or stroke. Primary cost studies and economic models were included. Costs were converted to 2012 pounds sterling. RESULTS Fifty-four studies were identified: 13 primary cost studies and 41 economic evaluations using secondary sources for complication costs. Primary studies provided costs from 10 countries. Estimates for a fatal event ranged from £2482-£5222 for MI and from £4900-£6694 for stroke. Costs for the year a non-fatal event occurred ranged from £5071-£29,249 for MI and from £5171-£38,732 for stroke. Annual follow-up costs ranged from £945-£1616 for an MI and from £4704-£12,926 for a stroke. Economic evaluations from 12 countries were identified, and costs of complications showed similar variability to the primary studies. DISCUSSION The costs identified within primary studies varied between and within countries. Many studies used costs estimated in studies not specific to patients with T2DM. Data gaps included a detailed breakdown of resource use, which affected the ability to compare data across countries. CONCLUSIONS In the development of economic models for patients with T2DM, the use of accurate estimates of costs associated with MI and stroke is important. When country-specific costs are not available, clear justification for the choice of estimates should be provided.
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Olry de Labry Lima A, Moya Garrido MN, Espín Balbino J. Systematic review of economic evaluation studies and budget impact on ambulatory monitoring of capillary glucose in type 2 diabetics. Prim Care Diabetes 2014; 8:13-21. [PMID: 24360230 DOI: 10.1016/j.pcd.2013.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Revised: 11/11/2013] [Accepted: 11/21/2013] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Antonio Olry de Labry Lima
- Escuela Andaluza de Salud Pública, Granada, Spain; CIBER en Epidemiología y Salud Pública (CIBERESP), Spain.
| | - María Natividad Moya Garrido
- Escuela Andaluza de Salud Pública, Granada, Spain; Departamento de Medicina preventiva y Salud Pública, Universidad de Sevilla, Spain
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Gucciardi E, Fortugno M, Senchuk A, Beanlands H, McCay E, Peel EE. 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. BMC Endocr Disord 2013; 13:46. [PMID: 24119213 PMCID: PMC3853160 DOI: 10.1186/1472-6823-13-46] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Accepted: 09/18/2013] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Enza Gucciardi
- School of Nutrition, Ryerson University, 350 Victoria Street, Toronto, Ontario, M5B 2K3, Canada
| | - Mariella Fortugno
- School of Nutrition, Ryerson University, 350 Victoria Street, Toronto, Ontario, M5B 2K3, Canada
| | - Andrea Senchuk
- School of Nutrition, Ryerson University, 350 Victoria Street, Toronto, Ontario, M5B 2K3, Canada
| | - Heather Beanlands
- Daphne Cockwell School of Nursing, Ryerson University, Toronto, Ontario, Canada
| | - Elizabeth McCay
- Daphne Cockwell School of Nursing, Ryerson University, Toronto, Ontario, Canada
| | - Elizabeth E Peel
- School of Life & Health Sciences, Aston University, Birmingham, UK
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St John A, Price CP. Economic Evidence and Point-of-Care Testing. Clin Biochem Rev 2013; 34:61-74. [PMID: 24151342 PMCID: PMC3799220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Health economics has been an established feature of the research, policymaking, practice and management in the delivery of healthcare. However its role is increasing as the cost of healthcare begins to drive changes in most healthcare systems. Thus the output from cost effectiveness studies is now being taken into account when making reimbursement decisions, e.g. in Australia and the United Kingdom. Against this background it is also recognised that the health economic tools employed in healthcare, and particularly the output from the use of these tools however, are not always employed in the routine delivery of services. One of the notable consequences of this situation is the poor record of innovation in healthcare with respect to the adoption of new technologies, and the realisation of their benefits. The evidence base for the effectiveness of diagnostic services is well known to be limited, and one consequence of this has been a very limited literature on cost effectiveness. One reason for this situation is undoubtedly the reimbursement strategies employed in laboratory medicine for many years, simplistically based on the complexity of the test procedure, and the delivery as a cost-per-test service. This has proved a disincentive to generate the required evidence, and little effort to generate an integrated investment and disinvestment business case, associated with care pathway changes. Point-of-care testing creates a particularly challenging scenario because, on the one hand, the unit cost-per-test is larger through the loss of the economy of scale offered by automation, whilst it offers the potential of substantial savings through enabling rapid delivery of results, and reduction of facility costs. This is important when many health systems are planning for complete system redesign. We review the literature on economic assessment of point-of-care testing in the context of these developments.
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Affiliation(s)
| | - Christopher P Price
- Department of Primary Care Health Sciences, University of Oxford, United Kingdom
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McBrien KA, Manns B. Approach to economic evaluation in primary care: review of a useful tool for primary care reform. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2013; 59:619-627. [PMID: 23766042 PMCID: PMC3681445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
OBJECTIVE To present an overview of the methods of economic evaluation in health care, using examples of studies applicable to primary care. SOURCES OF INFORMATION The main concepts discussed in this article were derived from expert opinion and substantiated with well respected textbooks and comprehensive Canadian guidelines. Examples of cost-effectiveness estimates were taken from the published literature. MAIN MESSAGE We describe the basic principles of economic evaluation and provide an introduction to its interpretation, using examples of studies applicable to primary care. CONCLUSION A basic understanding of health economics will allow primary care practitioners to begin to incorporate economic data, including that from economic evaluations when they are available, into resource planning for their practices.
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Affiliation(s)
- Kerry A McBrien
- University of Calgary, Medicine, Teaching, Research & Wellness Bldg, Ground Floor, Room 3E35, 3280 Hospital Dr NW, Calgary, AB T2N 4Z6, Canada.
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Malanda UL, Bot SD, Nijpels G. Self-monitoring of blood glucose in noninsulin-using type 2 diabetic patients: it is time to face the evidence. Diabetes Care 2013; 36:176-8. [PMID: 23264289 PMCID: PMC3526213 DOI: 10.2337/dc12-0831] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
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 this two-part point-counterpoint narrative, Malanda et al. and Polonsky and Fisher take opposing views on the utility of SMBG to be valuable for individuals with type 2 diabetes not using insulin. In the narrative below, Malanda et al. suggest that the evidence for potentially beneficial SMBG-induced effects on glycemic control, hypoglycemic periods, and potential harms in type 2 diabetic patients who are not treated with insulin does not justify the use of SMBG. Moreover, the use of SMBG is associated with huge costs, which should be better redirected to effective strategies to improve health for this category of patients. -William T. Cefalu, MD Editor in Chief, Diabetes Care.
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Affiliation(s)
- Uriëll L Malanda
- Dutch National Institute for Public Health and the Environment, Bilthoven, the Netherlands.
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Mansell K, Blackburn D, Taylor J, Jiricka K. Pharmacists Providing Education to Help Optimize Frequency of Self-Monitoring of Blood Glucose in Non-Insulin Dependent Type 2 Diabetes Mellitus. Can J Diabetes 2012. [DOI: 10.1016/j.jcjd.2012.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
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.
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Affiliation(s)
- Wendelin Schramm
- GECKO Institute for Medicine, Informatics, and Economics, Heilbronn University, Heilbronn, Germany.
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Bansback N, Tsuchiya A, Brazier J, Anis A. Canadian valuation of EQ-5D health states: preliminary value set and considerations for future valuation studies. PLoS One 2012; 7:e31115. [PMID: 22328929 PMCID: PMC3273479 DOI: 10.1371/journal.pone.0031115] [Citation(s) in RCA: 159] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2011] [Accepted: 01/03/2012] [Indexed: 11/17/2022] Open
Abstract
Background The EQ-5D is a preference based instrument which provides a description of a respondent's health status, and an empirically derived value for that health state often from a representative sample of the general population. It is commonly used to derive Quality Adjusted Life Year calculations (QALY) in economic evaluations. However, values for health states have been found to differ between countries. The objective of this study was to develop a set of values for the EQ-5D health states for use in Canada. Methods Values for 48 different EQ-5D health states were elicited using the Time Trade Off (TTO) via a web survey in English. A random effect model was fitted to the data to estimate values for all 243 health states of the EQ-5D. Various model specifications were explored. Comparisons with EQ-5D values from the UK and US were made. Sensitivity analysis explored different transformations of values worse than dead, and exclusion criteria of subjects. Results The final model was estimated from the values of 1145 subjects with socio-demographics broadly representative of Canadian general population with the exception of Quebec. This yielded a good fit with observed TTO values, with an overall R2 of 0.403 and a mean absolute error of 0.044. Conclusion A preference-weight algorithm for Canadian studies that include the EQ-5D is developed. The primary limitations regarded the representativeness of the final sample, given the language used (English only), the method of recruitment, and the difficulty in the task. Insights into potential issues for conducting valuation studies in countries as large and diverse as Canada are gained.
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Affiliation(s)
- Nick Bansback
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada.
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Ghosh P, Kandhare AD, Raygude KS, Kumar VS, Rajmane AR, Adil M, Bodhankar SL. Determination of the long term diabetes related complications and cardiovascular events using UKPDS risk engine and UKPDS outcomes model in a representative western Indian population. ASIAN PACIFIC JOURNAL OF TROPICAL DISEASE 2012. [DOI: 10.1016/s2222-1808(12)60237-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Tunis SL. 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. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2011; 9:351-365. [PMID: 21892840 DOI: 10.2165/11594270-000000000-00000] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
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.
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Affiliation(s)
- Sandra L Tunis
- Independent Health Economics Research Consultant, Indianapolis, IN, USA
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Klarenbach S, Cameron C, Singh S, Ur E. Cost-effectiveness of second-line antihyperglycemic therapy in patients with type 2 diabetes mellitus inadequately controlled on metformin. CMAJ 2011; 183:E1213-20. [PMID: 21969406 DOI: 10.1503/cmaj.110178] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Metformin is widely accepted as first-line pharmacotherapy for patients with type 2 diabetes mellitus when glycemic control cannot be achieved by lifestyle interventions alone. However, uncertainty exists regarding the optimal second-line therapy for patients whose diabetes is inadequately controlled by metformin monotherapy. Increased use of newer, more costly agents, along with the rising incidence of type 2 diabetes, carries significant budgetary implications for health care systems. We conducted this analysis to determine the relative costs, benefits and cost-effectiveness of options for second-line treatment of type 2 diabetes. METHODS We used the United Kingdom Prospective Diabetes Study Outcomes Model to forecast diabetes-related complications, quality-adjusted life-years and costs of alternative second-line therapies available in Canada for adults with type 2 diabetes inadequately controlled by metformin. We obtained clinical data from a systematic review and mixed treatment comparison meta-analysis, and we obtained information on costs and utilities from published sources. We performed extensive sensitivity analyses to test the robustness of results to variation in inputs and assumptions. RESULTS Sulphonylureas, when added to metformin, were associated with the most favourable cost-effectiveness estimate, with an incremental cost of $12 757 per quality-adjusted life-year gained, relative to continued metformin monotherapy. Treatment with other agents, including thiazolidinediones and dipeptidyl peptidase-4 inhibitors, had unfavourable cost-effectiveness estimates compared with sulphonylureas. These results were robust to extensive sensitivity analyses. INTERPRETATION For most patients with type 2 diabetes that is inadequately controlled with metformin monotherapy, the addition of a sulphonylurea represents the most cost-effective second-line therapy.
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Allan GM, Korownyk C, Ivers N. Routine self-monitoring of blood glucose. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2011; 57:1015. [PMID: 21918144 PMCID: PMC3173421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- G Michael Allan
- Department of Family Medicine at the University of Alberta in Edmonton, Canada
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Self-Monitoring of Blood Glucose Levels in Persons with Type 2 Diabetes Not Requiring Insulin: Routine Use Is Not Recommended. Can J Diabetes 2011. [DOI: 10.1016/s1499-2671(11)51003-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Johnson JA. Reflections on Self-Monitoring of Blood Glucose: Why Do We Recommend the Things We Do? Can Pharm J (Ott) 2010. [DOI: 10.3821/1913-701x-143.5.216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Jeffrey A. Johnson
- From the School of Public Health, University of Alberta, Li Ka Shing Center for Health Research Innovation, Edmonton, Alberta. Contact:
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Butalia S, Rabi DM. To test or not to test? Self-monitoring of blood glucose in patients with type 2 diabetes managed without insulin. OPEN MEDICINE : A PEER-REVIEWED, INDEPENDENT, OPEN-ACCESS JOURNAL 2010; 4:e114-6. [PMID: 21686300 PMCID: PMC3116684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/09/2010] [Accepted: 03/15/2010] [Indexed: 11/23/2022]
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Self-monitoring of blood glucose for individuals with type 2 diabetes not using insulin: Leaving no cornerstone unturned. Can J Diabetes 2010. [DOI: 10.1016/s1499-2671(10)41004-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Cameron C, Virani A, Dean H, Evans M, Dolovich L, Dahl M. Utilization and Expenditure on Blood Glucose Test Strips in Canada. Can J Diabetes 2010. [DOI: 10.1016/s1499-2671(10)41008-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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