Intensive structured self-monitoring of blood glucose and glycemic control in noninsulin-treated type 2 diabetes: the PRISMA randomized trial

Drug Interference in Self-Monitoring of Blood Glucose and the Impact on Patient Safety: We Can Only Guard Against What We Are Looking for

Self-monitoring of blood glucose is a key aspect of diabetes management. Depending on the technology used, however, various substances can jeopardize the reliability of the measurements and precipitate complications with potentially life-threatening consequences when blood glucose was deemed well-controlled. As such, it is important for all involved to be aware of those factors. Officially suggested procedures for testing and alternatives have each their own advantages and limitations, and interferences may be found beyond the substances to be tested provided by the various pertinent institutions. This article reviews these pros and cons and illustrates how interference testing beyond established standards contributes to patient safety. Once identified, interfering substances are included in product labeling and healthcare professionals and users need to be trained to be aware of these risks.

How can tuberculosis services better support patients with a diabetes co-morbidity? A mixed methods study in the Philippines

BACKGROUND

People with diabetes mellitus (DM) have an estimated two- to three-times greater risk of adverse tuberculosis (TB) treatment outcomes compared to those without DM. Blood glucose control is a primary aim of managing DM during TB treatment, yet TB programmes are not generally adapted to provide DM services. The purpose of this study was to understand perceptions and the lived experiences of diabetic patients in TB treatment in the Philippines, with a view to informing the development of disease co-management strategies.

METHODS

This mixed methods study was conducted within a prospective cohort of adults newly-starting treatment for drug-sensitive and drug-resistant TB at 13 public TB clinics in three regions of the Philippines. Within the subset of 189 diabetic persons who self-reported a prior DM diagnosis, or were diagnosed by screenings conducted through the TB clinic, longitudinal blood glucose data were used to ascertain individuals' glycaemic control (controlled or uncontrolled). Univariable logistic regression analyses exploring associations between uncontrolled glycaemia and demographic and clinical factors informed purposive sampling of 31 people to participate in semi-structured interviews. All audio-recorded data were transcribed and thematic analysis performed.

RESULTS

Participants - both with controlled and uncontrolled blood glucose - were knowledgeable about diabetes and its management. However, a minority of participants were aware of the impact of DM on TB treatment and outcomes. Many participants newly-diagnosed with DM at enrolment in TB treatment had not perceived any diabetic symptoms prior and would have likely not sought clinical consult otherwise. Access to free glucose-lowering medications through TB clinics was a key enabling resource. However, participants expressed fear of side effects and interrupted access to glucose-lowering medications, and a preference for phytotherapy. Many participants felt that physical and financial impacts of TB and its treatment were challenges to DM management.

CONCLUSIONS AND RECOMMENDATIONS

Results of this study indicate that public TB clinics can provide diabetic patients with additional health care resources and education to address co-morbidity. TB programmes might consider identifying patients with complicated DM, and offering diabetic monitoring and management, as DM and diabetic complications may compound the burden of TB and its treatment.

Evaluation of a digital tool supporting therapeutic decision making for the personalized management of patients with type 2 diabetes not treated with insulin: A pilot study

AIMS

To investigate the benefits of using the Personalized Treatment Tool (PTT), a web-based clinical decision support tool assisting the diabetologist in the evaluation of patient's clinical characteristics and SMBG data, in the management of patients with non-insulin treated type 2 diabetes and inadequate glucose control.

METHODS

We conducted a single-center, 16-week, cluster-randomized controlled trial.

RESULTS

Eighty-two patients with 64.3 ± 9.4 years of age, disease duration 13.2 ± 9.1 years and HbA1c 7.8 ± 0.6%, 41 in the PTT group and 41 in the control group, completed the study. At follow-up, changes in indicators of glucose control and variability were not statistically different between the two groups. However, when considering the subgroup of patients on a single anti-diabetes drug at baseline (9 in the PTT group, 14 in the control group), changes in HbA1c and CGM-derived TIR 70-140 mg/dl, 24-hour MSG, GRADE, and HBGI were significantly improved in the PTT group compared to the control group.

CONCLUSION

When performed in a structured manner and used to modify the diabetes therapy through an algorithm-driven digital tool, SMBG can lead to significant improvements of glycemic control and variability in patients with type 2 diabetes not treated with insulin.

Quality improvement strategies for diabetes care: Effects on outcomes for adults living with diabetes

BACKGROUND

There is a large body of evidence evaluating quality improvement (QI) programmes to improve care for adults living with diabetes. These programmes are often comprised of multiple QI strategies, which may be implemented in various combinations. Decision-makers planning to implement or evaluate a new QI programme, or both, need reliable evidence on the relative effectiveness of different QI strategies (individually and in combination) for different patient populations.

OBJECTIVES

To update existing systematic reviews of diabetes QI programmes and apply novel meta-analytical techniques to estimate the effectiveness of QI strategies (individually and in combination) on diabetes quality of care.

SEARCH METHODS

We searched databases (CENTRAL, MEDLINE, Embase and CINAHL) and trials registers (ClinicalTrials.gov and WHO ICTRP) to 4 June 2019. We conducted a top-up search to 23 September 2021; we screened these search results and 42 studies meeting our eligibility criteria are available in the awaiting classification section.

SELECTION CRITERIA

We included randomised trials that assessed a QI programme to improve care in outpatient settings for people living with diabetes. QI programmes needed to evaluate at least one system- or provider-targeted QI strategy alone or in combination with a patient-targeted strategy. - System-targeted: case management (CM); team changes (TC); electronic patient registry (EPR); facilitated relay of clinical information (FR); continuous quality improvement (CQI). - Provider-targeted: audit and feedback (AF); clinician education (CE); clinician reminders (CR); financial incentives (FI). - Patient-targeted: patient education (PE); promotion of self-management (PSM); patient reminders (PR). Patient-targeted QI strategies needed to occur with a minimum of one provider or system-targeted strategy.

DATA COLLECTION AND ANALYSIS

We dual-screened search results and abstracted data on study design, study population and QI strategies. We assessed the impact of the programmes on 13 measures of diabetes care, including: glycaemic control (e.g. mean glycated haemoglobin (HbA1c)); cardiovascular risk factor management (e.g. mean systolic blood pressure (SBP), low-density lipoprotein cholesterol (LDL-C), proportion of people living with diabetes that quit smoking or receiving cardiovascular medications); and screening/prevention of microvascular complications (e.g. proportion of patients receiving retinopathy or foot screening); and harms (e.g. proportion of patients experiencing adverse hypoglycaemia or hyperglycaemia). We modelled the association of each QI strategy with outcomes using a series of hierarchical multivariable meta-regression models in a Bayesian framework. The previous version of this review identified that different strategies were more or less effective depending on baseline levels of outcomes. To explore this further, we extended the main additive model for continuous outcomes (HbA1c, SBP and LDL-C) to include an interaction term between each strategy and average baseline risk for each study (baseline thresholds were based on a data-driven approach; we used the median of all baseline values reported in the trials). Based on model diagnostics, the baseline interaction models for HbA1c, SBP and LDL-C performed better than the main model and are therefore presented as the primary analyses for these outcomes. Based on the model results, we qualitatively ordered each QI strategy within three tiers (Top, Middle, Bottom) based on its magnitude of effect relative to the other QI strategies, where 'Top' indicates that the QI strategy was likely one of the most effective strategies for that specific outcome. Secondary analyses explored the sensitivity of results to choices in model specification and priors.  Additional information about the methods and results of the review are available as Appendices in an online repository. This review will be maintained as a living systematic review; we will update our syntheses as more data become available.

MAIN RESULTS

We identified 553 trials (428 patient-randomised and 125 cluster-randomised trials), including a total of 412,161 participants. Of the included studies, 66% involved people living with type 2 diabetes only. Participants were 50% female and the median age of participants was 58.4 years. The mean duration of follow-up was 12.5 months. HbA1c was the commonest reported outcome; screening outcomes and outcomes related to cardiovascular medications, smoking and harms were reported infrequently. The most frequently evaluated QI strategies across all study arms were PE, PSM and CM, while the least frequently evaluated QI strategies included AF, FI and CQI. Our confidence in the evidence is limited due to a lack of information on how studies were conducted.  Four QI strategies (CM, TC, PE, PSM) were consistently identified as 'Top' across the majority of outcomes. All QI strategies were ranked as 'Top' for at least one key outcome. The majority of effects of individual QI strategies were modest, but when used in combination could result in meaningful population-level improvements across the majority of outcomes. The median number of QI strategies in multicomponent QI programmes was three.  Combinations of the three most effective QI strategies were estimated to lead to the below effects:  - PR + PSM + CE: decrease in HbA1c by 0.41% (credibility interval (CrI) -0.61 to -0.22) when baseline HbA1c < 8.3%; - CM + PE + EPR: decrease in HbA1c by 0.62% (CrI -0.84 to -0.39) when baseline HbA1c > 8.3%;  - PE + TC + PSM: reduction in SBP by 2.14 mmHg (CrI -3.80 to -0.52) when baseline SBP < 136 mmHg; - CM + TC + PSM: reduction in SBP by 4.39 mmHg (CrI -6.20 to -2.56) when baseline SBP > 136 mmHg;  - TC + PE + CM: LDL-C lowering of 5.73 mg/dL (CrI -7.93 to -3.61) when baseline LDL < 107 mg/dL; - TC + CM + CR: LDL-C lowering by 5.52 mg/dL (CrI -9.24 to -1.89) when baseline LDL > 107 mg/dL. Assuming a baseline screening rate of 50%, the three most effective QI strategies were estimated to lead to an absolute improvement of 33% in retinopathy screening (PE + PR + TC) and 38% absolute increase in foot screening (PE + TC + Other).

AUTHORS' CONCLUSIONS

There is a significant body of evidence about QI programmes to improve the management of diabetes. Multicomponent QI programmes for diabetes care (comprised of effective QI strategies) may achieve meaningful population-level improvements across the majority of outcomes. For health system decision-makers, the evidence summarised in this review can be used to identify strategies to include in QI programmes. For researchers, this synthesis identifies higher-priority QI strategies to examine in further research regarding how to optimise their evaluation and effects. We will maintain this as a living systematic review.

The Efficacy and Frequency of Self-monitoring of Blood Glucose in Non-insulin-Treated T2D Patients: a Systematic Review and Meta-analysis

BACKGROUND

Self-monitoring of blood glucose (SMBG) is a useful tool in diabetes management, but its efficacy and optimal application in type 2 diabetes (T2D) patients treated without insulin have been controversial. We aimed to evaluate the efficacy of SMBG in controlling blood glucose levels in non-insulin-treated T2D patients and to determine the optimal frequency and the most appropriate population to benefit from SMBG.

METHODS

Eligible publications from January 2000 to April 2022 were retrieved from PubMed, Embase, Cochrane Library, and ClinicalTrials.gov databases. Randomized controlled trials comparing SMBG with no SMBG or structured SMBG (S-SMBG, SMBG with defined timing and frequency of glucose measurements) were included. Meta-analyses and sub-analyses were performed to assess the efficacy, optimal frequency, and most appropriate population for SMBG. Risk of bias was assessed regarding randomization, allocation sequence concealment, blinding, incomplete outcome data, selective outcome reporting, and other biases.

RESULTS

Twenty-two studies involving 6204 participants were identified, including 17 comparing SMBG with no SMBG and 4 comparing SMBG with S-SMBG. SMBG reduced HbA1c (MD -0.30%, 95% CI -0.42 to -0.17) compared with no SMBG, and S-SMBG performed better than SMBG (MD -0.23%, 95% CI -0.38 to -0.07). Subgroup analyses showed that HbA1c control was better with SMBG at 8-11 times weekly (MD -0.35%, 95% CI -0.51 to -0.20) compared with other frequencies and with lifestyle adjustments (MD -0.37%, 95% CI -0.50 to -0.23) than with no adjustments. No significant differences in HbA1c were observed between baseline HbA1c subgroups (≤ 8% and > 8%, P = 0.63) and between diabetes duration subgroups (≤ 6 years and > 6 years, P = 0.72), respectively.

DISCUSSION

SMBG was effective for controlling HbA1c in non-insulin-treated T2D patients, although lacking detailed monitoring design. Better outcomes were seen with SMBG at 8-11 times weekly and lifestyle adjustment based on SMBG results.

TRIAL REGISTRATION

PROSPERO (CRD42021285604).

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

Background

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

Purpose

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

Data sources

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

Study selection

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

Data extraction and analysis

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

Data synthesis

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

Limitations

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

Conclusion

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

PROSPERO registration

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

Glycaemic management in diabetes: old and new approaches

HbA_1c is the most used parameter to assess glycaemic control. However, evidence suggests that the concept of hyperglycaemia has profoundly changed and that different facets of hyperglycaemia must be considered. A modern approach to glycaemic control should focus not only on reaching and maintaining optimal HbA_1c concentrations as early as possible, but to also do so by reducing postprandial hyperglycaemia, glycaemic variability, and to extend as much as possible the time in range in near-normoglycaemia. These goals should be achieved while avoiding hypoglycaemia, which, should it occur, should be reverted to normoglycaemia. Modern technology, such as intermittently scanned glucose monitoring and continuous glucose monitoring, together with new drug therapies (eg, ultra-fast insulins, SGLT2 inhibitors, and GLP-1 receptor agonists), could help to change the landscape of glycaemia management based on HbA_1c in favour of a more holistic approach that considers all the different aspects of this commonly oversimplified pathophysiological feature of diabetes.

Determinants of blood glucose control among people with Type 2 diabetes in a regional hospital in Ghana

Aims

To assess the determinants of glycaemic control among patients with Type 2 diabetes mellitus (T2DM) presenting at the Greater Accra Regional Hospital, Ghana.

Methods

The study employed semi-structured questionnaires and review of clinical records of patients 16 years and above with Type 2 Diabetes.

Results

The mean age of participants was 56.6 ± 13.8 years, with majority (71.6%) being females. A total of 161 (59.4%) of patients had poor glycaemic control (HbA1c ≥8.1%; 95% CI: 53.6 to 65.3%). Poor glycaemic control was significantly associated with high body mass index of the patient (AOR 13.22; 95% CI: 1.95 to 89.80), having only elementary education (AOR 5.22, 95% CI 2.12–12.86, p<0.0001) and being on insulin therapy (AOR 2.88; 95% CI: 1.05 to 7.88). On the other hand, seldom coffee intake (AOR: 0.27; 95% CI: 0.11 to 0.64), high physical activity (AOR 1.57, 95% CI 1.06–2.35, p = 0.025) and having a cardiovascular disease (AOR: 0.15; 95% CI: 0.05 to 0.46) appeared to positively influence glycaemic control. Self-monitoring of blood glucose and diet interventions did not appear to influence glycaemic control.

Conclusions

The study results showing that a high proportion of patients attending the Diabetes Clinic with uncontrolled diabetes has serious implications for the management of T2DM diabetes as it suggests that current hospital-based treatment measures are less effective. Comprehensive management of T2DM targeting all the key factors identified in this study and incorporating a multispectral collaborative effort based on holistic approach, combined with non-pharmacological components are strongly warranted.

Effects of physician's diabetes self-management education using Japan Association of Diabetes Education and Care Diabetes Education Card System Program and a self-monitoring of blood glucose readings analyzer in individuals with type 2 diabetes: An exploratory, open-labeled, prospective randomized clinical trial

AIMS/INTRODUCTION

This 6-month, single-center, prospective, open-labeled, randomized trial was designed to investigate whether physicians' diabetes self-management education using an education tool developed by the Japan Association of Diabetes Education and Care and a self-monitoring of blood glucose (SMBG) analyzer improves glycemic control in individuals with type 2 diabetes receiving insulin and SMBG.

MATERIALS AND METHODS

Participants were randomized into intervention (I) and control (C) groups. Both groups received physicians' diabetes self-management education at each hospital visit, whereas the Japan Association of Diabetes Education and Care education tool and the SMBG readings analyzer was used in group I, but not group C. All participants filled out a diabetes treatment-related quality of life form and an original questionnaire on SMBG use with five questions (Q1-Q5) before and after the study period.

RESULTS

A total of 76 individuals were recruited and randomized. Glycated hemoglobin (HbA1c) was significantly improved during the study period in group I, whereas no significant change was observed in group C. The change in HbA1c was greater in group I, although it did not reach statistical significance. The diabetes treatment-related quality of life total score was not changed in either group. Interestingly, the score of Q1 ("How important is SMBG to you?") in the SMBG questionnaire was unchanged in group I, whereas it was significantly decreased in group C. HbA1c change was independently associated with changes in insulin dose and SMBG Q1 score.

CONCLUSION

Greater HbA1c-lowering by physicians' diabetes self-management education using the Japan Association of Diabetes Education and Care education tool and SMBG analyzer in individuals with type 2 diabetes receiving insulin and SMBG was suggested, but not confirmed.

Structured self-monitoring of blood glucose is associated with more appropriate therapeutic interventions than unstructured self-monitoring: A novel analysis of data from the PRISMA trial

AIMS

To investigate the relationship between single therapeutic interventions and indicatorsofglycemic control in the PRISMA trial, a large study comparing the effects of intensive structured SMBG (ISM) vs. active control (AC) in non-insulin-treated type 2 diabetes (T2D).

METHODS

Information was collected at four time points, corresponding to months 3, 6, 9, and 12 and visits 2, 3, 4, and 5, respectively. Data on therapeutic interventions, HbA_1c levels and the number of hypoglycemic episodes at each visit were analyzed.

RESULTS

Intensification of drug therapy occurred in 20.3% vs. 15.6%, and no change in 71.8% vs. 78.7% of visits for the ISM and AC groups, respectively. On the other hand, de-intensification and redistribution of drugs and/or drug dose occurred in a similar proportion of visits. Intensification of drug therapy in both groups was associated with significant reductions in HbA_1c vs. the previous visit, while de-intensification of therapy led to a significant increase in HbA_1c in the AC group only.

CONCLUSIONS

Our data strongly support that structured SMBG has clinical value in reducing HbA_1c in non-insulin-treated T2D and suggest that this clinical benefit may be mediated by more appropriate and timely changes in drug therapy.

Distinct associations of self-monitoring of blood glucose with glycemic control and hypoglycemia between groups of recently diagnosed and long-term follow-up type 2 diabetes: The Taiwan Diabetes Registry

BACKGROUND

We investigated the uses and frequency of self-monitoring of blood glucose (SMBG) with glycemic control and hypoglycemia in two groups of type 2 diabetes (T2D) (recently diagnosed and long-term follow-up) using real-world data in Taiwan (the Taiwan Diabetes Registry).

METHODS

Patients with T2D recently diagnosed within 6 months (n = 3297, mean age 54.4 ± 13.9 years) and T2D patients with long-term follow-up (n = 1201, mean age 65.5 ± 12.1 years, mean diabetes duration 14.3 ± 7.8 years) from the Taiwan Diabetes Registry were analysed. All patients were interviewed by certified diabetes educators. Information about SMBG and hypoglycemia was recorded. Demography, personal history, and laboratory data were obtained from electronic medical records. Logistic regression analyses were used to examine the associations of SMBG with glycated haemoglobin (HbA1c) <7% and hypoglycemia.

RESULTS

Mean HbA1c values were 8.4 ± 2.5 and 7.6 ± 1.4%, respectively, in the recently diagnosed and long-term follow-up T2D groups. The self-reported rates of hypoglycemic events within 3 months were 10.5% and 19.0%, respectively. SMBG was associated with higher odds of HbA1c <7% (OR 1.21, 95% CI 1.01-1.44) in patients with recently diagnosed T2D, but with lower odds of HbA1c <7% in T2D patients with long-term follow-up (OR 0.60, 95% CI 0.44-0.82). In both study populations, SMBG was independently associated with hypoglycemia (OR 3.90 [95% CI 2.99-5.08] and OR 3.93 [95% CI 2.73-5.66], respectively). The aforementioned findings were consistent across the strata of SMBG frequency.

CONCLUSION

We reported different associations between SMBG and glycemic control in patients recently diagnosed with T2D and in T2D patients with long-term follow-up. SMBG was associated with higher detection of hypoglycemic episodes in both study populations.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Systematic Review of Self-Monitoring of Blood Glucose in Patients with Type 2 Diabetes

BACKGROUND

The benefit of self-monitoring of blood glucose in reducing HbA1c in non-insulin-treated participants remains unclear. HbA1c may be improved in this population with self-monitoring.

OBJECTIVE

To conduct a meta-analysis of the effect in non-insulin-treated participants with type 2 diabetes of self-monitoring of blood glucose versus usual care, structured versus unstructured self-monitoring of blood glucose on glycemic control, and use of self-monitoring of blood glucose readings used to adjust therapy versus usual care.

METHODS

Medline, Embase, and Cochrane Central were electronically searched to identify articles published from January 1, 2000, to June 3, 2020. Trials investigating changes in HbA1c were selected. Screening was performed independently by two investigators. Two investigators extracted HbA1c at baseline and follow-up for each trial.

RESULTS

Nineteen trials involving 4,965 participants were included. Overall, self-monitoring of blood glucose reduced HbA1c. Preplanned subgroup analysis showed that using self-monitoring of blood glucose readings to adjust therapy contributed significantly to the reduction. No significant improvement in HbA1c was shown in self-monitoring of blood glucose without therapy adjustment. The same difference was observed in structured versus unstructured self-monitoring of blood glucose.

DISCUSSION

HbA1c is improved with therapy adjustment based on structured self-monitoring of blood glucose readings. Implications are for clinicians to prescribe structured self-monitoring of blood glucose to modify therapy adjustment based on the readings and not prescribe unstructured self-monitoring of blood glucose. Participants with suboptimal glycemic control may benefit most. A self-monitoring of blood glucose regimen that improves clinical- and cost-effectiveness is presented. Future studies can investigate this regimen specifically.

Sampling of fluid through skin with magnetohydrodynamics for noninvasive glucose monitoring

Out of 463 million people currently with diabetes, 232 million remain undiagnosed. Diabetes is a threat to human health, which could be mitigated via continuous self-monitoring of glucose. In addition to blood, interstitial fluid is considered to be a representative sample for glucose monitoring, which makes it highly attractive for wearable on-body sensing. However, new technologies are needed for efficient and noninvasive sampling of interstitial fluid through the skin. In this report, we introduce the use of Lorentz force and magnetohydrodynamics to noninvasively extract dermal interstitial fluid. Using porcine skin as an ex-vivo model, we demonstrate that the extraction rate of magnetohydrodynamics is superior to that of reverse iontophoresis. This work seeks to provide a safe, effective, and noninvasive sampling method to unlock the potential of wearable sensors in needle-free continuous glucose monitoring devices that can benefit people living with diabetes.

Diabetes management intervention studies: lessons learned from two studies

Introduction

Several clinical studies investigated improvements of patient outcomes due to diabetes management interventions. However, chronic disease management is intricate with complex multifactorial behavior patterns. Such studies thus have to be well designed in order to allocate all observed effects to the defined intervention and to exclude effects of other confounders as well as possible.

This article aims to provide challenges in interpreting diabetes management intervention studies and suggests approaches for optimizing study implementation and for avoiding pitfalls based on current experiences.

Main body

Lessons from the STeP and ProValue studies demonstrated the difficulty in medical device studies that rely on behavioral changes in intervention group patients. To successfully engage patients, priority should be given to health care professionals being engaged, operational support in technical issues being available, and adherence being assessed in detail.

Another difficulty is to avoid contamination of the control group with the intervention; therefore, strict allocation concealment should be maintained. However, randomization and blinding are not always possible. A limited effect size due to improvements regarding clinical endpoints in the control group is often caused by the Hawthorne effect. Improvements in the control group can also be caused with increased attention paid to the subjects. In order to reduce improvements in the control group, it is essential to identify the specific reasons and adjust study procedures accordingly. A pilot phase is indispensable for this. Another option is to include a third study arm to control for enhanced standard of care and study effects. Furthermore, retrospective data collection could be a feasible option. Adaptive study designs might reduce the necessity of a separate pilot study and combine the exploratory and confirmatory stages of an investigation in one single study.

Conclusion

There are several aspects to consider in medical device studies when using interventions that rely on changes in behavior to achieve an effective implementation and significant study results. Improvements in the control group may reduce effect sizes and limit statistical significance; therefore, alternatives to the traditional randomized controlled trials may be considered.

Self-monitoring of blood glucose in association with glycemic control in newly diagnosed non-insulin-treated diabetes patients: a retrospective cohort study

The benefits of self-monitoring of blood glucose (SMBG) on glycemic control among type 2 diabetes (T2DM) patients not receiving insulin remains controversial. This study aimed to examine the association between SMBG and glycemic control in these patients. This retrospective longitudinal study enrolled 4987 eligible patients from a medical center in Taiwan. Data were collected from electronic medical records at 0 (baseline), 3, 6, 9, and 12 (end-point) months after enrollment. Patients were assigned to the early SMBG group or to the non-user group depending on whether they performed SMBG at baseline. Differences in glycated hemoglobin (HbA1c) reduction between groups at each time-point were assessed using SMBG group-by-time interaction in generalized estimating equations models, which were established using backward elimination method for multivariate regression analysis. Subgroup analyses for patients using non-insulin and insulin secretagogues were performed additionally. The estimated maximal difference in HbA1c reduction between groups (early SMBG users vs. non-users) was 0.55% at 3 months. Subgroup analyses showed maximal differences of 0.61% and 0.52% at 3 months in the non-insulin and insulin secretagogues groups, respectively. SMBG group-by-time interaction was statistically significant at 3 months and lasted for 12 months. The finding suggests that performing SMBG at disease onset was positively associated with better glycemic control in newly diagnosed non-insulin-treated T2DM patients, regardless whether non-insulin secretagogues or insulin secretagogues were used.

Insulin pump therapy and continuous glucose monitoring in adults with type 2 diabetes: where are we now?

Technology in diabetes is rapidly evolving, with the aim of helping affected people to safely optimize their blood glucose control. New technologies are now considered as an essential tool for managing glycemia predominantly in people with type 1 diabetes, and clinical trials have demonstrated that in these subjects the use of continuous subcutaneous insulin infusion (CSII) and continuous glucose monitoring (CGM) systems are associated with improved glycemic control along with a better quality of life. Literature regarding technologies and type 2 diabetes is relatively lacking, but innovations may have an important role also in the management of these patients. Some studies in adults with type 2 diabetes have shown benefits with the use of CGM in terms of glycemic variability and improved therapeutic adjustments. Clinical trials about CSII and CGM use in type 2 diabetes may have some pitfalls and future studies are needed to assess how these advanced systems could improve clinical outcomes and also ensure cost-effectiveness in this population. In this narrative review, we aim to highlight the most relevant studies on this topic and to focus on the potential role of new technological devices in type 2 diabetes management.

Technology-Assisted Self-Monitoring of Lifestyle Behaviors and Health Indicators in Diabetes: Qualitative Study

BACKGROUND

Self-monitoring is key to successful behavior change in diabetes and obesity, and the use of traditional paper-based methods of self-monitoring may be time-consuming and burdensome.

OBJECTIVE

This study aimed to explore participant experiences while using technology-assisted self-monitoring of lifestyle behaviors and health indicators among overweight or obese adults with type 2 diabetes.

METHODS

Qualitative data collected from the intervention group of a 6-month, three-arm (control, paper diary, and technology-assisted self-monitoring groups) randomized clinical trial were analyzed. Study participants in the intervention group monitored their diet, exercise, and weight using the LoseIt! app, and their blood glucose levels using a glucometer and the Diabetes Connect app. Semistructured group discussions were conducted at 6 weeks (n=10) from the initiation of the behavioral lifestyle intervention and again at 6 months (n=9). All group interviews were audiotaped and transcribed verbatim. Using a combination of thematic and comparative analysis approaches, two trained professionals coded the transcriptions independently and then discussed and concluded common themes for the 6-week and 6-month discussions separately.

RESULTS

The sample (n=10), which primarily involved African American participants (n=7) and female participants (n=8), had a mean age of 59.4 years. The following eight themes emerged: (1) perceived benefits of technology-assisted self-monitoring; (2) perceived ease of use (eg, barriers: technical difficulties and lack of self-discipline; facilitators: help from family, friends, and the program); (3) use of technology-assisted self-monitoring; (4) facilitators of engaging in healthy lifestyle behaviors (eg, visualization and awareness of calorie input/expenditure); (5) positive lifestyle change; (6) barriers of engaging in healthy lifestyle behaviors (eg, event influence); (7) learning curve; and (8) monitored data sharing. The first six of these themes were shared between the 6-week and 6-month timepoints, but the codes within these themes were not all the same and differed slightly between the two timepoints. These differences provide insights into the evolution of participant thoughts and perceptions on using technology for self-monitoring and subsequent behavioral lifestyle changes while participating in lifestyle interventions. The findings from the 6-week and 6-month data helped to paint a picture of participant comfort and the integration of technology and knowledge overtime, and clarified participant attitudes, difficulties, behavioral processes, and modifications, as well as health indicators that were experienced throughout the study.

CONCLUSIONS

Although there were some barriers, participants were able to identify various individual and external facilitators to adjust to and engage in technology-assisted self-monitoring, and it was concluded that the technology-assisted self-monitoring approach was beneficial, safe, and feasible to use for positive lifestyle change. These patient perspectives need to be considered in future research studies when investigating the effectiveness of using technology-assisted self-monitoring, as well as in clinical practice when recommending technology-assisted self-monitoring of lifestyle behaviors and health indicators to improve health outcomes.

Effect of a standard schema of self-monitoring blood glucose in patients with poorly controlled, non-insulin-treated type 2 diabetes mellitus: A controlled longitudinal study

The effect of self-monitoring of blood glucose (SMBG) on glycemic control with regard to non-insulin-treated Type 2 diabetes mellitus (NIT-Type 2 DM) is still a controversial topic. Against this backdrop, we sought to compare the effect of a continuous short-term SMBG schema with as-usual treatment, based on changes in oral antidiabetic treatment in patients with poorly controlled Type 2 DM. We reviewed 492 NIT-Type 2 DM record charts, selecting 27 patients, with poor glycemic control, who were thought to self-monitor their blood glucose levels (SMBG group). We then compared them with 27 patients treated with modifying drugs or diets to achieve and maintain the glycemic target (Control Group). Haemoglobin A1c (HbA1c) and fasting plasma glucose (FPG) were evaluated at baseline, after 3 and 6 months. HbA1c values decreased after 3 and 6 months in the SMBG group (P < 0.001 on both occasions) and in the control group (P < 0.05 and P < 0.01, respectively), but without a significant difference between the two groups when compared at the same time. The FPG progressively decreased in both groups, reaching a significant difference in the SMBG group after 3 months and in the control group after 6 months, and without a significant difference between the two groups. The SMBG schema used in our study could be adopted for target groups before proceeding to the next therapeutic enhancement drug step, representing a useful tool that can help diabetic patients in raising awareness of and treating their disease.

How conclusive is the CONCLUDE trial?

The development of basal insulin analogues has reduced the risk of hypoglycaemia in insulin-treated individuals with type 2 diabetes. Insulin degludec and insulin glargine 300 U/ml (glargine U300) represent an evolution of basal insulin analogues, both of them reducing the risk of hypoglycaemia as compared with that associated with glargine U100. However, whether degludec and glargine U300 are equivalent with respect to glycaemic control and risk of hypoglycaemia remains to be fully ascertained. In the CONCLUDE trial, 1609 individuals with type 2 diabetes were randomised to either degludec 200 U/ml (degludec U200) or glargine U300. In this issue of Diabetologia (https://doi.org/10.1007/s00125-019-05080-9) the investigators report that during the maintenance period, HbA_1c improved to a similar extent in the two groups with no significant difference in the rate of overall hypoglycaemia (the primary endpoint of the study), while rates of nocturnal symptomatic and severe hypoglycaemia (secondary endpoints) were lower with degludec U200 than with glargine U300. These results, although of great interest to the clinician, need to be carefully interpreted as they cannot be considered as conclusive. First, the primary endpoint was not met and, therefore, analyses of secondary endpoints remain exploratory. Even assuming that degludec is superior to glargine in reducing the risk of hypoglycaemia, the mechanism(s) accounting for such an advantage remain elusive and potential differences in pharmacokinetics and pharmacodynamics difficult to appreciate because of methodological issues. The study design had to be amended because of lack of reliability of the glucometers initially used in the trial, particularly in the low blood glucose ranges, so the potential implications of these changes in the subsequent conduct of the trial cannot be excluded. Finally, comparison with the BRIGHT trial, the only other available head-to-head study, is complicated by differences between the two studies in the primary endpoint (HbA_1c reduction vs reduction of the risk of hypoglycaemia), study population (insulin-experienced vs insulin-naive) and concomitant glucose-lowering medications. In spite of all this, CONCLUDE teaches us an important lesson regarding the need, particularly in the clinical setting, to monitor the reliability of the glucometers the diabetic individual uses to adjust his/her insulin dose. Insufficient precision or inappropriate use of the glucometer can easily offset any minute advantage a new insulin can offer with respect to glycaemic control and risk of hypoglycaemia.

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

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 HbA_1c 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 HbA_1c were determined for each 3-month period. Responders were participants with an improvement in HbA_1c 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] HbA_1c 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 HbA_1c (-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] HbA_1c 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.

Evaluating the impact of self-monitoring of blood glucose frequencies on glucose control in patients with type 2 diabetes who do not use insulin: A systematic review and meta-analysis

AIMS

International diabetes guidelines have not established the frequencies of self-monitoring of blood glucose in patients with type 2 diabetes (T2D) who do not use insulin. The present study aimed to assess the impact of self-monitoring of blood glucose (SMBG) frequencies on the glucose control and other outcomes in non-insulin-treated patients with T2D.

METHODS

A literature search was performed in four databases. Randomised controlled trials with ≥6-month follow-up duration that compared the impact of different frequencies of SMBG on glycated haemoglobin A1c (HbA1c) were included. Studies with abstract only or reported effects of SMBG as a secondary outcome were excluded.

RESULTS

Of the 1557 studies identified, 12 RCTs with a total of 3350 patients were analysed. Overall, performing SMBG for 8 to 14 times per week was correlated with a better HbA1c control at 6 months (MD -0.46%, 95% CI -0.54 to -0.39) and 12 months (MD -0.20%, 95% CI -0.29 to -0.11). However, up to seven measurements of SMBG per week did not significantly affect glycaemic control. In addition, performing SMBG between 8 and 14 times per week was also associated with improved BMI (MD -0.46, 95% CI -0.84 to -0.08). When the results of SMBG were applied to adjust diabetes medication, a significant reduction in HbA1c levels was observed in the intervention arm compared to the control arm.

CONCLUSIONS

Eight to 14 measurements of SMBG per week were associated with an improved glycaemic control and a reduced BMI in patients with T2D not using insulin.

Self-Monitoring of Blood Glucose in Youth-Onset Type 2 Diabetes: Results From the TODAY Study

OBJECTIVE

To determine whether self-monitoring of blood glucose (SMBG) is associated with lower HbA_1c in youth with type 2 diabetes taking oral medications only or after starting insulin for persistently elevated HbA_1c.

RESEARCH DESIGN AND METHODS

Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) study participants (n = 699) taking oral medications were asked to perform SMBG twice daily. After reaching primary outcome (PO) (HbA_1c ≥8% [64 mmol/mol]) over 6 months or an inability to wean from temporary insulin because of metabolic decompensation), insulin glargine was started. HbA_1c and percent of SMBG (SMBG%) (percent days when the meter was used one or more times) before and after PO were analyzed.

RESULTS

SMBG declined over time and was inversely related to HbA_1c (P < 0.0001). Of 298 youth who reached PO and started insulin, 282 had SMBG data. At PO, mean ± SD age was 15.8 ± 2.3 years, BMI 35.5 ± 7.9 kg/m², and HbA_1c 9.6 ± 2.0% (81 ± 21.9 mmol/mol); 65.3% were female. Median SMBG% was 40% at PO, which increased to 49% after 6 months and fell to 41% after 1 year on insulin. At PO, 22% of youth checked ≥80% of days, which increased to 25% and fell to 19% after 6 and 12 months using insulin, respectively. At PO, compared with those who checked <80%, youth who checked ≥80% were younger and with a lower BMI, HbA_1c, and blood pressure. SMBG ≥80% was associated with ≥1% reduction in HbA_1c at 6 and 12 months after insulin initiation.

CONCLUSIONS

Low SMBG adherence was common and associated with higher HbA_1c. Optimal SMBG frequency in youth using or not using insulin, and whether less frequent SMBG is a marker for overall worse self-care, require further study.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

PDM-ProValue meets cardiovascular outcome trials in diabetes

Novel studies have increased our knowledge regarding optimal treatment options in diabetes. Key studies that have broadened our knowledge about optimal treatment options in diabetes in recent years are cardiovascular outcome trials (CVOTs) and studies investigating aspects of digitalisation and monitoring of glucose (e.g. PDM-ProValue). We aimed at highlighting similarities between the two important pillars for a successful diabetes management. We emphasise the need for a consideration of both approaches in future clinical trial designs and protocols.

Frequency of self-monitoring of blood glucose in relation to weight loss and A1C during intensive multidisciplinary weight management in patients with type 2 diabetes and obesity

OBJECTIVE

We evaluated the relationship between frequency of self-monitoring of blood glucose (SMBG) and body weight, A1C, and cardiovascular risk factors in patients with type 2 diabetes (T2D) and obesity enrolled in a 12-week intensive multidisciplinary weight management (IMWM) program.

RESEARCH DESIGN AND METHODS

We conducted a retrospective analysis of 42 patients who electronically uploaded their SMBG data over 12 weeks of an IMWM program and divided them into tertiles based on their average frequency of SMBG per day. Mean (range) SMBG frequencies were 2.3 (1.1-2.9) times/day, 3.4 (3-3.9) times/day, and 5 (4-7.7) times/day in the lowest, middle, and highest tertiles, respectively. Anthropometric and metabolic parameters were measured at baseline and after 12 weeks of intervention.

RESULTS

Participants in the highest tertile achieved a median change (IQR) in body weight of -10.4 kg (-7.6 to -14.4 kg) compared with -8.3 kg (-5.2 to -12.2 kg), and -6.9 kg (-4.2 to -8.9 kg) in the middle and lowest tertiles, respectively (p=0.018 for trend). Participants in the highest tertile had a median change (IQR) in A1C of -1.25% (-0.6 to -3.1%) compared with -0.8% (-0.3% to -2%) and -0.5% (-0.2% to -1.2%) in the middle and lowest tertiles, respectively (p=0.048 for trend). The association between change in body weight and SMBG frequency remained significant after adjusting for age, sex, baseline body mass index, diabetes duration, and use of insulin therapy.

CONCLUSIONS

Increased frequency of SMBG during IMWM is associated with significantly better weight loss and improvement of A1C in patients with T2D and obesity. These findings may suggest future clinical recommendations aimed at increasing SMBG frequency to achieve the most favorable outcomes.

Patient work from a context and time use perspective: a mixed-methods study protocol

INTRODUCTION

Self-management is widely promoted but less attention is focused on the work required from patients. To date, many individuals struggle to practise self-management. 'Patient work', a concept that examines the 'work' involved in self-management, is an approach to understanding the tasks, effort, time and context from patient perspective. The purpose of our study is to use a novel approach combining non-obstructive observations via digital devices with in-depth qualitative data about health behaviours and motivations, to capture the full range of patient work experienced by people with type 2 diabetes and chronic comorbidities. It aims to yield comprehensive insights about 'what works' in self-management, potentially extending to populations with other chronic health conditions.

METHODS AND ANALYSIS

This mixed-methods observational study involves a (1) prestudy interview and questionnaires, (2) a 24-hour period during which participants wear a camera and complete a time-use diary, and a (3) poststudy interview and study feedback. Adult participants living with type 2 diabetes with at least one chronic comorbidity will be recruited using purposive sampling to obtain a balanced gender ratio and of participants using insulin and those using only oral medication. Interviews will be analysed using thematic analysis. Data captured by digital devices, diaries and questionnaires will be used to analyse the duration, time, context and patterns of health-related behaviours.

ETHICS AND DISSEMINATION

The study was approved by the Macquarie University Human Research Ethics Committee for Medical Sciences (reference number 5201700718). Participants will carry a wallet-sized card that explains the purpose of the study to third parties, and can remove the camera at any stage. Before the poststudy interview begins, participants will view the camera images in private and can delete any images. Should any images be used in future publications or presentations, identifying features such as human faces and names will be obscured.

Use of Blood Glucose Meters Featuring Color Range Indicators Improves Glycemic Control in Patients With Diabetes in Comparison to Blood Glucose Meters Without Color (ACCENTS Study)

BACKGROUND

The ability of patients to improve glycemic control depends partly on their ability to interpret and act on blood glucose results. We investigated whether switching people with diabetes to blood glucose meters (BGMs) featuring a color range indicator (CRI) could improve glycemic control compared to remaining on their current BGM without color.

METHODS

163 adults with type 1 (T1D) or type 2 diabetes (T2D) and a hemoglobin A1c (A1c) of 7.5-11% were randomized to: One Touch Verio™ (Verio), OneTouch Verio Flex™ (Flex), or controls remaining on their current BGM. Diabetes nurses had standard conversations about diabetes management with all subjects at baseline. No changes in medication, insulin dosing, or SMBG frequency were recommended.

RESULTS

After 12 weeks, subjects who switched to Verio or Flex meters with CRI (n = 108) had a mean change in A1c 0.36% lower than controls (n = 55) ( P = .017). A1c reductions were greatest in T1D subjects (n = 45), with a decrease of 0.50% ( P = .004). T1D subjects using Verio meters (n = 25) contributed a 0.59% reduction compared to controls ( P < .008), whereas T1D subjects using Flex meters (n = 20) had a clinical meaningful reduction in A1c of 0.40% without reaching statistical significance ( P > .05). Verio and Flex users reported taking more action and easier understanding of diabetes management compared to previous BGMs.

CONCLUSIONS

This study demonstrated that switching patients to BGMs featuring a CRI resulted in improvements in glycemic control compared to subjects using currently marketed BGMs that do not use a CRI. Registration: Clinicaltrials.gov NCT02929654 https://clinicaltrials.gov/ct2/show/NCT02929654.

Comparative effectiveness of telemonitoring versus usual care for type 2 diabetes: A systematic review and meta-analysis

AIMS

This study evaluated clinical effectiveness of telemonitoring on the management of patients with type 2 diabetes.

METHODS

We searched Ovid-Medline, Ovid-EMBASE, and the Cochrane Library to identify randomized controlled trials that compared telemonitoring and usual care in patients with type 2 diabetes.

RESULTS

Thirty-eight studies (6855 patients) were included. Telemonitoring was associated with a significant decrease in glycated haemoglobin levels compared to usual care (weighted mean difference -0.42%, 95% confidence interval -0.56 to -0.27) but there was evidence of heterogeneity (I²= 96.9%). Telemonitoring was associated with a significant glycated haemoglobin reduction when biological data were transmitted through a web-based device weekly, when voice feedback was performed daily or immediately and when patients were provided with counselling. Telemonitoring also reduced glycated haemoglobin level in studies that monitored patients' medication adherence, provided counselling, education and alarm message. The rate of achieving glycated haemoglobin levels of < 7% was 1.8 times higher in the telemonitoring group compared to the usual care group (risk ratio 1.83, 95% confidence interval 1.35 to 2.47, I²= 0%). There was also significant reduction in systolic blood pressure (weighted mean difference -1.33 mm Hg) and body mass index (weighted mean difference -0.25 kg/m²), but the clinical relevance of these results can be questioned. The data available on patient satisfaction, quality of life, medication adherence, prescription changes, stress and depression were limited.

CONCLUSIONS

Telemonitoring interventions may be a better option than usual care in improving glycated haemoglobin control of patients with type 2 diabetes. Further studies should assess clinical benefit according to specific delivery modes of the intervention and patient-reported outcomes.

Aspects of Multicomponent Integrated Care Promote Sustained Improvement in Surrogate Clinical Outcomes: A Systematic Review and Meta-analysis

OBJECTIVE

The implementation of the Chronic Care Model (CCM) improves health care quality. We examined the sustained effectiveness of multicomponent integrated care in type 2 diabetes.

RESEARCH DESIGN AND METHODS

We searched PubMed and Ovid MEDLINE (January 2000-August 2016) and identified randomized controlled trials comprising two or more quality improvement strategies from two or more domains (health system, health care providers, or patients) lasting ≥12 months with one or more clinical outcomes. Two reviewers extracted data and appraised the reporting quality.

RESULTS

In a meta-analysis of 181 trials (N = 135,112), random-effects modeling revealed pooled mean differences in HbA1c of -0.28% (95% CI -0.35 to -0.21) (-3.1 mmol/mol [-3.9 to -2.3]), in systolic blood pressure (SBP) of -2.3 mmHg (-3.1 to -1.4), in diastolic blood pressure (DBP) of -1.1 mmHg (-1.5 to -0.6), and in LDL cholesterol (LDL-C) of -0.14 mmol/L (-0.21 to -0.07), with greater effects in patients with LDL-C ≥3.4 mmol/L (-0.31 vs. -0.10 mmol/L for <3.4 mmol/L; Pdifference = 0.013), studies from Asia (HbA1c -0.51% vs. -0.23% for North America [-5.5 vs. -2.5 mmol/mol]; Pdifference = 0.046), and studies lasting >12 months (SBP -3.4 vs. -1.4 mmHg, Pdifference = 0.034; DBP -1.7 vs. -0.7 mmHg, Pdifference = 0.047; LDL-C -0.21 vs. -0.07 mmol/L for 12-month studies, Pdifference = 0.049). Patients with median age <60 years had greater HbA1c reduction (-0.35% vs. -0.18% for ≥60 years [-3.8 vs. -2.0 mmol/mol]; Pdifference = 0.029). Team change, patient education/self-management, and improved patient-provider communication had the largest effect sizes (0.28-0.36% [3.0-3.9 mmol/mol]).

CONCLUSIONS

Despite the small effect size of multicomponent integrated care (in part attenuated by good background care), team-based care with better information flow may improve patient-provider communication and self-management in patients who are young, with suboptimal control, and in low-resource settings.

'Knowing where I am': self-monitoring of blood glucose in diabetes

Although the prevalence of all types of chronic conditions is increasing, diabetes is one of the few long-term metabolic disorders that individuals can successfully manage, monitor and control on a day-to-day basis. Self-monitoring of blood glucose (SMBG) is considered an essential component of diabetes self-care management. When used appropriately, SMBG can help to identify factors associated with hyper- and hypoglycaemia, facilitate learning, and empower people with diabetes to make changes to improve their glycaemic control. SMBG can be a useful tool for healthcare providers, who can teach individuals to monitor glucose at specific times to assess the effectiveness of medications and guide medication management. However, there is an ongoing debate regarding whether, as is the case with type 1 diabetes, all people with type 2 diabetes should also be given the opportunity to learn about the value of, and skills required to, monitor blood glucose as appropriate to their specific needs.

Effects of Structured Versus Unstructured Self-Monitoring of Blood Glucose on Glucose Control in Patients With Non-insulin-treated Type 2 Diabetes: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

The use of self-monitoring of blood glucose (SMBG) in patients with non-insulin-treated type 2 diabetes is debated. Meta-analyses of randomized clinical trials (RCTs) suggest a small reduction of HbA1c in patients using SMBG, without considering potential confounders, such as SMBG regimen and use of SMBG data to adjust diabetes medications.

METHODS

A meta-analysis was performed including RCTs in patients with non-insulin-treated type 2 diabetes, with an intervention of ≥24 weeks and HbA1c as the primary endpoint, to verify the effect of SMBG (vs no monitoring), structured SMBG (vs unstructured), and of SMBG-driven therapy adjustments.

RESULTS

In RCTs (n = 8) comparing SMBG with no SMBG (1277 and 1072 patients, respectively), SMBG reduced HbA1c by -0.17% (95% CI -0.25 to -0.09%, P < .003). The reduction in HbA1c was greater in RCTs (n = 3) in which SMBG data were used to adjust diabetes medications (HbA1c decrease: -0.3% [95% CI -0.49 to -0.1%]) than in RCTs (n = 6) where SMBG data were not used for this purpose (HbA1c decrease: -0.1% [95% CI -0.2 to 0.0%]) ( P < .005). In the RCTs comparing structured and unstructured SMBG (757 and 750 patients, respectively), in which structured SMBG data were also used to adjust diabetes medications, the HbA1c difference between groups at study end was -0.27% (95% CI -0.49 to -0.04%, P < .018).

CONCLUSIONS

In RCTs performed in non-insulin-treated patients with type 2 diabetes, SMBG is associated with a significant, although small, reduction in HbA1c. HbA1c reduction was greater with structured SMBG and when structured SMBG data were used to adjust diabetes therapy.

Use of a Novel, Remotely Connected Diabetes Management System Is Associated with Increased Treatment Satisfaction, Reduced Diabetes Distress, and Improved Glycemic Control in Individuals with Insulin-Treated Diabetes: First Results from the Personal Diabetes Management Study

BACKGROUND

The ability to automatically transfer data to clinicians and receive timely guidance in therapy adjustments through remote and in-office consults can positively impact patients' perceptions about quality of care, which is positively associated with clinical outcomes. We assessed the impact of using the Accu-Chek Connect diabetes management system on treatment satisfaction, diabetes distress, and glycemic control in adults with type 1 diabetes and insulin-treated type 2 diabetes.

SUBJECTS AND METHODS

This 6-month, prospective, multicenter, single-arm study assessed the impact of using the system on treatment satisfaction and glycemic control among 87 adults with insulin-treated diabetes (multiple daily insulin injections and basal only), with 8.8% ± 1.6% glycated hemoglobin (HbA1c) at baseline. The Diabetes Treatment Satisfaction Questionnaire-status (DTSQs) and Diabetes Distress Scale (DDS) were administered at baseline, and the Diabetes Treatment Satisfaction Questionnaire-change (DTSQc) and DDS at 6 months. Changes in HbA1c, average blood glucose (BG), and other metrics were also assessed.

RESULTS

Improvements in DTSQc scores were observed at 6 months with a total mean (standard deviation) score of 14.3 ± 5.1. Significant reductions in total mean DDS scores from baseline to 6 months were also observed, from 2.0 ± 0.8 to 1.7 ± 0.7, P < 0.0001. A significant reduction in regimen-related distress was notable, from "moderate distress" (2.4 ± 1.0) to "not distressed" (1.9 ± 0.9), P < 0.0001). Significant reductions in mean HbA1c (-0.9 ± 1.6, P < 0.0001) and mean BG (-24.8 ± 50.8, P < 0.0001) were observed.

CONCLUSIONS

Use of the Accu-Chek Connect diabetes management system is associated with increased treatment satisfaction and improved glycemic control among individuals with insulin-treated diabetes. NCT02600845 ( www.clinicaltrials.gov ).

Improved Glycemic Control in a Patient Group Performing 7-Point Profile Self-Monitoring of Blood Glucose and Intensive Data Documentation: An Open-Label, Multicenter, Observational Study

INTRODUCTION

Regular self-monitoring of blood glucose (SMBG) is recommended as an integral part of therapy for all patients with diabetes treated with insulin. In the current study, the effects on glycemic control of taking 7-point SMBG profiles and using a diabetes management system (DMA) on a smartphone were investigated.

METHODS

In a 12-week, open-label, multicenter, observational study, 51 patients [26 with type 1 diabetes mellitus (T1DM) and 25 with type 2 diabetes mellitus (T2DM)] were instructed to perform SMBG at least seven times a day using DMA combined with the iBGStar ^® SMBG system. HbA1c was measured at regular visits to the study sites. Patients reviewed and managed their data as well as their treatment on their own and there were no further assistance or treatment recommendations. Adverse events (AEs) were recorded throughout.

RESULTS

Overall, mean (SD) change from baseline in HbA1c at week 12 was -0.46 (0.57)% [-5 (6) mmol/mol (p < 0.0001)]. The change in HbA1c was observed in patients with T1DM [-0.27 (0.45)% (-3 [5] mmol/mol; p = 0.0063)] and T2DM [-0.65 (0.62)% (-7 [7] mmol/mol; p < 0.0001)]. The change in HbA1c was not correlated with an increased number of hypoglycemic events (blood glucose less than 55 mg/dL). The majority of AEs were symptomatic hypoglycemic events (42 events; nine patients).

CONCLUSIONS

Glycemic control can be improved, without receiving any recommendations or advice on insulin dose, by performing daily 7-point SMBG profiles and using electronic documentation with a smartphone app. These results must be confirmed in a larger controlled trial, but they already strengthen the importance of structured SMBG in diabetes therapy.

FUNDING

Sanofi.

Self-monitoring of blood glucose among patients with diabetes in Jordan: Perception, adherence, and influential factors

AIMS

To investigate the self-monitoring of blood glucose (SMBG) adherence among Jordanian patients with diabetes and to identify the predictive factors.

METHODS

A cross-sectional survey was carried out in 18 hospitals and healthcare centers covering south, north, and middle of Jordan. All patients with diabetes attending endocrinology clinics from May to December, 2015 were approached. The questionnaires were distributed by trained pharmacists and were self-administered.

RESULTS

A total of 1079 participants completed the survey. Only 59% of participants were SMBG adherent. Predictors of SMBG adherence were treatment regimen; insulin with oral hypoglycemic agents (p=0.044, CI 1.023-5.274, OR=2.323) or insulin only (p=0.005, CI 1.225-3.115, OR=1.953), and health education on how to use the SMBG meter (p<0.001, CI 10.538-32.497, OR=18.506). The frequency of SMBG was significantly associated with the treatment regimen, with patients who were taking oral hypoglycemic agents (p<0.001) or insulin therapy (p=0.004) tested more frequently as compared to others. Additionally, the frequency of testing was significantly associated with the reason of performing SMBG (p<0.001). Frequency of daily testing was the highest among patients who performed SMBG to know if they were hypoglycemic (48.9%) or hyperglycemic (48.0%), or to inform their doctors (28.4%).

CONCLUSIONS

SMBG adherence was suboptimal. Predictors of SMBG adherence were treatment regimen and health education about the SMBG meter.

Self-monitoring of Blood Glucose in Non-Insulin Treated Type 2 Diabetes (The SMBG Study): study protocol for a randomised controlled trial

BACKGROUND

The benefit of Self-monitoring of Blood Glucose (SMBG) in people with non-insulin treated type 2 diabetes remains unclear with inconsistent evidence from randomised controlled trials fuelling the continued debate. Lack of a consistent finding has been attributed to variations in study population and design, including the SMBG intervention. There is a growing consensus that structured SMBG, whereby the person with diabetes and health care provider are educated to detect patterns of glycaemic abnormality and take appropriate action according to the blood glucose profiles, can prove beneficial in terms of lowering HbA1c and improving overall well-being. Despite this, many national health agencies continue to issue guidelines restricting the use of SMBG in non-insulin treated type 2 diabetes.

METHODS

The SMBG Study is a 12 month, multi-centre, randomised controlled trial in people with type 2 diabetes not on insulin therapy who have poor glycaemic control (HbA1c ≥58 mmol/mol / 7.5%). The participants will be randomised into three comparative groups: Group 1 will act as a control group and receive their usual diabetes care; Group 2 will undertake structured SMBG with clinical review every 3 months; Group 3 will undertake structured SMBG with additional monthly telecare support from a trained study nurse. A total of 450 participants will be recruited from 16 primary and secondary care sites across Wales and England. The primary outcome measure will be HbA1c at 12 months with secondary measures to include weight, BMI, total cholesterol and HbA1c levels at 3, 6, 9 and 12 months. Participant well-being and attitude towards SMBG will be monitored throughout the course of the study. Recruitment began in December 2012 with the last participant visit due in September 2016.

DISCUSSION

This study will attempt to answer the question of whether structured SMBG provides any benefits to people with poorly controlled type 2 diabetes who are not being treated with insulin. The data will also clarify whether the telecare support provides additional value. The overall acceptability of SMBG as a tool for self-management will be assessed.

TRIAL REGISTRATION

UKCRN 12038 (Registered March 2012). ISRCTN21390608 (Retrospectively registered 15^th May 2014).

Assessing the Performance of a Noninvasive Glucose Monitor in People with Type 2 Diabetes with Different Demographic Profiles

BACKGROUND

Noninvasive glucose-monitoring devices represent an exciting frontier in diabetes research. GlucoTrack® is a noninvasive device that indirectly measures glucose fluctuation in the earlobe tissue. However, GlucoTrack measurements may be susceptible to effects of quasi-stable factors that may be affected by demographic profiles. The current study, thus, examined device performances in people with type 2 diabetes with different demographic profiles, focusing on age, gender, body mass, and whether the earlobe is pierced.

MATERIALS AND METHODS

Clinical trials were conducted on 172 type 2 adult diabetic subjects. Device performance was clinically evaluated using the Clarke error grid (CEG) analysis and statistically assessed using absolute relative difference (ARD).

RESULTS

CEG analysis revealed that 97.6% of glucose readings were within the clinically acceptable CEG A + B zones. Mean and median ARD were 22.3% and 18.8%, respectively. Likelihood ratio and parametric bootstrap tests revealed that there were no significant differences in ARD values across age, gender, body mass, and whether the earlobe was pierced, indicating that the accuracy of GlucoTrack remains consistent across the tested demographic profiles.

CONCLUSIONS

Our results suggest that GlucoTrack performance does not depend on demographic profiles of its users and it is thus suitable for various people with type 2 diabetes.

Effects of structured testing versus routine testing of blood glucose in diabetes self-management: A randomized controlled trial

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.

Insulin: Making Sense of Current Options

Newer insulin products have advanced the evolution of insulin replacement options to more accurately mimic natural insulin action. There are new, modified, and concentrated insulins; administration devices calibrated for both increased concentrations and administration accuracy to improve adherence and safety; and inhaled insulin. There are new combinations of longer-acting basal insulin and rapid-acting insulin or glucagon like protein-1 receptor agonists. Existing insulin replacement designs and methods can be updated using these tools to improve efficacy and safety. Individualized decisions to use them should be based on patient physiologic needs, self-care ability, comorbidities, and cost considerations.

Self-Monitoring Utilization Patterns Among Individuals in an Incentivized Program for Healthy Behaviors

Background

The advent of digital technology has enabled individuals to track meaningful biometric data about themselves. This novel capability has spurred nontraditional health care organizations to develop systems that aid users in managing their health. One of the most prolific systems is Walgreens Balance Rewards for healthy choices (BRhc) program, an incentivized, Web-based self-monitoring program.

Objective

This study was performed to evaluate health data self-tracking characteristics of individuals enrolled in the Walgreens’ BRhc program, including the impact of manual versus automatic data entries through a supported device or apps.

Methods

We obtained activity tracking data from a total of 455,341 BRhc users during 2014. Upon identifying users with sufficient follow-up data, we explored temporal trends in user participation.

Results

Thirty-four percent of users quit participating after a single entry of an activity. Among users who tracked at least two activities on different dates, the median length of participating was 8 weeks, with an average of 5.8 activities entered per week. Furthermore, users who participated for at least twenty weeks (28.3% of users; 33,078/116,621) consistently entered 8 to 9 activities per week. The majority of users (77%; 243,774/315,744) recorded activities through manual data entry alone. However, individuals who entered activities automatically through supported devices or apps participated roughly four times longer than their manual activity-entering counterparts (average 20 and 5 weeks, respectively; P<.001).

Conclusions

This study provides insights into the utilization patterns of individuals participating in an incentivized, Web-based self-monitoring program. Our results suggest automated health tracking could significantly improve long-term health engagement.

Interferences and Limitations in Blood Glucose Self-Testing: An Overview of the Current Knowledge

In general, patients with diabetes performing self-monitoring of blood glucose (SMBG) can strongly rely on the accuracy of measurement results. However, various factors such as application errors, extreme environmental conditions, extreme hematocrit values, or medication interferences may potentially falsify blood glucose readings. Incorrect blood glucose readings may lead to treatment errors, for example, incorrect insulin dosing. Therefore, the diabetes team as well as the patients should be well informed about limitations in blood glucose testing. The aim of this publication is to review the current knowledge on limitations and interferences in blood glucose testing with the perspective of their clinical relevance.