Home glucose monitoring in type 2 diabetes: is it a waste of time?

An educational program for insulin self-adjustment associated with structured self-monitoring of blood glucose significantly improves glycemic control in patients with type 2 diabetes mellitus after 12 weeks: a randomized, controlled pilot study

BACKGROUND

Self-monitoring of blood glucose (SMBG) has been recommended as a useful tool for improving glycemic control, but is still an underutilized strategy and most diabetic patients are not aware of the actions that must be taken in response to its results and do not adjust their treatment. The purpose of this study was to evaluate the effectiveness and safety of an educational program for insulin self-adjustment based on SMBG in poorly controlled patients with type 2 diabetes (T2DM).

METHODS

A prospective, randomized, controlled 12-week intervention study was conducted on poorly controlled insulin-requiring patients with T2DM. Twenty-three subjects were randomized to two educational programs: a 2-week basic program with guidance about SMBG and types and techniques of insulin administration (group A, n = 12) and a 6-week program including the basic one and additional instructions about self-titration of insulin doses according to a specific protocol (group B, n = 11). Patients were reviewed after 12 weeks and baseline to endpoint changes in glycated hemoglobin (A1C), insulin doses, body weight and incidence of hypoglycemia were compared by paired and independent Student t-tests.

RESULTS

After 12 weeks, there was a significant reduction in A1C only in group B, but group comparison showed no significant difference (p = 0.051). A higher percentage of subjects in group B achieved an A1C near the treatment target (<7.5%) than in group A. Daily insulin dose increased non-significantly in the two groups and there was no significant difference in the incidence of hypoglycemia or body weight changes between groups.

CONCLUSIONS

Training for self-titrating insulin doses combined with structured SMBG can safely improve glycemic control in poorly controlled insulin-treated T2DM patients. This strategy may facilitate effective insulin therapy in routine medical practice, compensating for any reluctance on the part of physicians to optimize insulin therapy and thus to improve the achievement of recommended targets of diabetes care.

Self-monitoring of blood glucose in non-insulin treated patients with type 2 diabetes: a systematic review and meta-analysis

OBJECTIVE

To assess the effect of self-monitoring of blood glucose (SMBG) on glycaemic control in non-insulin treated patients with type 2 diabetes by means of a systematic review and meta-analysis.

RESEARCH DESIGN AND METHODS

MEDLINE and the Cochrane Controlled Trials Register were searched from inception to January 2009 for randomised controlled trials comparing SMBG with non-SMBG or more frequent SMBG with less intensive SMBG. Electronic searches were supplemented by manual searching of reference lists and reviews. The comparison of SMBG with non-SMBG was the primary, the comparison of more frequent SMBG with less intensive SMBG the secondary analysis. Stratified analyses were performed to evaluate modifying factors.

MAIN OUTCOME MEASURES

The primary endpoint was glycated haemoglobin A(1c) (HbA(1c)), secondary outcomes included fasting glucose and the occurrence of hypoglycaemia. Using random effects models a weighted mean difference (WMD) was calculated for HbA(1c) and a risk ratio (RR) was calculated for hypoglycaemia. Due to considerable heterogeneity, no combined estimate was computed for fasting glucose.

RESULTS

Fifteen trials (3270 patients) were included in the analyses. SMBG was associated with a larger reduction in HbA(1c) compared with non-SMBG (WMD -0.31%, 95% confidence interval -0.44 to -0.17). The beneficial effect associated with SMBG was not attenuated over longer follow-up. SMBG significantly increased the probability of detecting a hypoglycaemia (RR 2.10, 1.37 to 3.22). More frequent SMBG did not result in significant changes of HbA(1c) compared with less intensive SMBG (WMD -0.21%, 95% CI -0.57 to 0.15).

CONCLUSIONS

SMBG compared with non-SMBG is associated with a significantly improved glycaemic control in non-insulin treated patients with type 2 diabetes. The added value of more frequent SMBG compared with less intensive SMBG remains uncertain.

Self-monitoring of blood glucose in diabetes mellitus: arguments for an individualized approach

BACKGROUND

The utility of glucose self-monitoring in different types and stages of diabetes is controversial, as there is only sparse relevant evidence from randomized controlled clinical trials. In this analysis, the authors aim to develop individualized recommendations based on clinical needs and the available literature.

METHODS

The PubMed database was searched for articles that appeared up to 30 September 2008 containing the terms "measurement," "control","monitoring," and "hypoglycemia"; the retrieved articles were supplemented by other articles that were cited in them. A directed search was also made for the recommendations of the German, European, American, and international diabetological societies. Conclusions were then drawn about the useful modalities and extent of glucose self-monitoring on the basis of the clinical features of the major types of diabetes and the main treatment strategies for them.

RESULTS

With the exception of intensified treatment strategies (which rely on blood-sugar regulation with insulin), only a few evidence-based recommendations can be derived from randomized clinical trials and meta-analyses. Nonetheless, a strategy for self-monitoring according to the patient's individual needs can be derived from the characteristics of therapeutic regimens: depending on the type of diabetes from which the patient suffers, the predicted number of glucometer strips required for self-monitoring will vary from almost none to roughly 400 per month.

CONCLUSIONS

The decision to use glucose self-monitoring, as well as the type and extent of self-monitoring that will be used, should be based on the individual patient's type of diabetes, treatment regimen, and clinical characteristics. Like any other type of therapeutic intervention, self-monitoring should have a well-documented, rational justification.

Blood glucose monitoring is associated with better glycemic control in type 2 diabetes: a database study

BACKGROUND

The value of self-monitoring blood glucose (SMBG) in type 2 diabetes is controversial.

OBJECTIVE

To determine SMBG testing rates are positively associated with glycemic control in veterans on oral hypoglycemic agents (OHA).

DESIGN

Observational database study.

SUBJECTS

Southwestern Healthcare Network veterans taking OHA in 2002 and followed through the end of 2004.

MEASUREMENTS

OHA and glucose test strip (GTS) prescriptions were derived from pharmacy files. Subjects were categorized into five groups according to their end-of-study treatment status: group 1 (no medication changes), group 2 (increased doses of initial OHA), group 3 (started new OHA), group 4 (both OHA interventions), and group 5 (initiated insulin). We then used multiple linear regression analyses to examine the relationship between the SMBG testing rate and hemoglobin A1c (HbA1c) within each group.

RESULTS

We evaluated 5,862 patients with a mean follow-up duration of 798 +/- 94 days. Overall, 44.2% received GTS. Ultimately, 47% of subjects ended up in group 1, 21% in group 2, 9% in group 3, 8% in group 4, and 16% in group 5. A univariate analysis showed no association between the SMBG testing rate and HbA1c. However, after stratifying by group and adjusting for initial OHA dose, we found that more frequent testing was associated with a significantly lower HbA1c in groups 1, 4, and 5. The effect ranged from -0.22% to -0.94% for every ten GTS/week.

CONCLUSIONS

Higher SMBG testing rates were associated with lower HbA1c, but only when stratifying the analyses to control for treatment intensification.

A trial of empowerment-based education in type 2 diabetes--global rather than glycaemic benefits

We have assessed the effect of a structured, empowerment-based educational system ("LAY or "Look After Yourself") for patients with type 2 diabetes. A randomised controlled trial (RCT) was conducted, testing the system against standard support. Using 3 centres, 89 patients participated in the study. Outcome measures included glycated haemoglobin (HbA(1c)), body mass index (BMI) and a variety of quantitative psychological and educational measures. Assessment was made at 6 months ("short-term") and 12 months ("long-term") post-intervention. The educational programme was associated with benefits in HbA(1c) levels (p=0.005), illness attitudes (p=0.04), and perceived treatment effectiveness (p=0.03) at 6 months follow-up compared to controls. At 12 months however, only illness attitudes (p=0.01), and self-monitoring (p=0.002) showed benefit. A combined outcome measure showed positive benefit for the educational programme both at 6 months (p=0.001) and 12 months (p=0.002). This structured educational programme, aimed at encouraging self-help, was associated with only limited benefits in glycaemic control, but there were significant educational and psychological benefits. Diabetes education should be regarded as having broad patient-based positive outcomes, and should not be expected to have lasting benefits on glycaemic control.

Does patient blood glucose monitoring improve diabetes control? A systematic review of the literature

OBJECTIVE

The purpose of this systematic review was 2-fold: first, to perform a comprehensive review of relevant studies on the impact of self-monitoring of blood glucose (SMBG) on HbA1c levels for patients with type 2 diabetes mellitus and, second, to explore mediators and moderators within a self-regulation framework.

DATA SOURCES

Five databases-Medline, PsychInfo, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing & Allied Health Literature (CINAHL)-were searched.

STUDY SELECTION

Cross-sectional, longitudinal, and randomized control trials from 1990 to 2006, which included patients with type 2 diabetes not on insulin, were reviewed. In total, 6,769 studies were screened for inclusion, 89 were retrieved for detailed analysis, and 29 met criteria for inclusion in the review.

DATA EXTRACTION

Data on the impact of SMBG on HbA1c, potential mediators and moderators, study design and participants, and limitations of each study were retrieved.

DATA SYNTHESIS

Twenty-nine studies were included in this review: 9 cross-sectional studies, 9 longitudinal studies, and 11 randomized controlled trials. Evidence from the cross-sectional and longitudinal studies was inconclusive. Evidence from randomized controlled trials suggests that SMBG may lead to improvements in glucose control. Very few studies examined potential mediators or moderators of SMBG on HbA1c levels.

CONCLUSIONS

SMBG may be effective in controlling blood glucose for patients with type 2 diabetes. There is a need for studies that implement all the components of the process for self-regulation of SMBG to assess whether patient use of SMBG will improve HbA1c levels.

Self-reported medication and lifestyle adherence in Hungarian patients with Type 2 diabetes

BACKGROUND

Type 2 diabetes is a complex disorder that requires the patient to pay constant attention to diet, physical activity, glucose monitoring and medication.

OBJECTIVE

To evaluate the medication, lifestyle adherence and factors associated to these in Type 2 diabetes in Hungarian patients.

SETTING

Fourteen community pharmacies in Hungary between March and May 2004.

METHOD

A questionnaire was given to every tenth Type 2 diabetic patient who presented to one of the 14 pharmacies included in this study with a prescription for oral antidiabetics, oral antidiabetics and insulin or exclusively insulin. For the latter two groups, the prerequisite for inclusion in the study was also that their diabetes had developed after the age of 35 and that at some in their treatment regimen they had taken only oral antidiabetics. These latter two criteria were controlled in the patient's general practitioners' (GP) database. General and diabetes-related data were collected in the questionnaire, and the adherence and lifestyle of the participant were assessed. An adapted and validated Hungarian version of the EQ-5D (EuroQol Group, 1993) quality-of-life questionnaire was also included. Descriptive and chi(2) test statistical methods and two sample t-test were used. A significance level of P<0.05 was considered to be significant.

MAIN OUTCOME MEASURE

Patient self-reported adherence to diet, physical activity, self monitoring of blood glucose, purchasing of drug(s), drug regimen, association of demographic factors, treatment, lifestyle and quality of life on adherence.

RESULTS

Of the 220 questionnaires distributed to diabetic patients, 151 were returned, of which 142 were evaluated (nine did not satisfy the above-mentioned inclusion criteria). With respect to the factors assessed, sub-optimal adherence was assessed for: diet (76.8%), physical activity (33.8%), self-monitoring of blood glucose (81%), drug purchasing (20.4%) and drug taking (52.1%). Smokers comprised 14.8% of the respondents, while 8.5% were heavy drinkers. Fewer than five meals a day were eaten by 46.5% of the patients, and about 43.6% of the patients did not self-monitor blood glucose. The results indicate few significant associations between at least one of the four main areas of adherence (diet, physical activity, purchasing of drug(s), drug regimen) and body mass index, GP consultation frequency, quality-of-life parameters and EQ-5D index.

CONCLUSION

The adherence of Hungarian Type 2 diabetics in some areas does not reach optimal levels, especially for diet, self-monitoring, drug purchasing and adherence to drug taking.

Role of self-monitoring of blood glucose in glycemic control

OBJECTIVE

To examine the role of self-monitoring of blood glucose (SMBG) in the management of diabetes mellitus.

METHODS

Current trends and published evidence are reviewed.

RESULTS

Despite the widespread evidence that lowering glycemic levels reduces the risks of complications in patients with diabetes, little improvement in glycemic control has been noted among patients in the United States and Europe in recent years. Although SMBG has been widely used, considerable controversy surrounds its role in achieving glycemic control. The high cost of test strips has made considerations regarding appropriate recommendations for SMBG a priority, especially in light of the current climate of health-care cost-containment. Existing clinical recommendations lack specific guidance to patients and clinicians regarding SMBG practice intensity and frequency, particularly for those patients not treated with insulin. Previous studies of the association between SMBG and glycemic control often found weak and conflicting results.

CONCLUSION

A reexamination of the role of SMBG is needed, with special attention to the unique needs of patients using different diabetes treatments, within special clinical subpopulations, and during initiation of SMBG versus its ongoing use. Further understanding of the intensity and frequency of SMBG needed to reflect the variability in glycemic patterns would facilitate more specific guideline development. Educational programs that focus on teaching patients the recommended SMBG practice, specific glycemic targets, and appropriate responses to various blood glucose readings would be beneficial. Continuing medical education programs for health-care providers should suggest ways to analyze patient SMBG records to tailor medication regimens. For transfer or communication of SMBG reports to the clinical staff, a standardized format that extracts key data elements and allows quick review by health-care providers would be useful. Because the practice of SMBG is expensive, the cost-effectiveness of SMBG needs to be carefully assessed.

Strategies for improving glycemic control: effective use of glucose monitoring

Despite the increasing prevalence of diabetes, improved understanding of the disease, and a variety of new medications, glycemic control does not appear to be improving. Self-monitoring of blood glucose (SMBG) is one strategy for improving glycemic control; however, patient adherence is suboptimal and proper education and follow-up are crucial. Patients need to understand why they are being asked to self-test, what their glycemic targets are, and what they should do based on the results of self-monitoring. Patients also must be taught proper technique and must be given specific recommendations regarding frequency and timing for self-monitoring. Situations in which SMBG is essential or should be more frequent include self-adjustment of insulin doses, changes in medications, lack of awareness of hypoglycemia, gestational diabetes, illness, or when hemoglobin A1c (HbA1c) values are above target. SMBG should include postprandial monitoring to identify glycemic excursions after meals, to indicate the need for lifestyle adjustments, and to provide patient feedback on dietary choices.

Characteristics Associated with Neuropathy and/or Retinopathy in a Hospital Outpatient Diabetic Clinic

BACKGROUND

The incidence of diabetes is increasing worldwide and with it the risk of diabetic complications. The aim of this study was to characterise parameters associated with neuropathy and/or retinopathy in a hospital outpatient diabetic clinic population.

METHOD

A structured questionnaire addressing diabetes related factors and demography was administered to a cross-sectional sample of patients (n = 290) with type 1 and type 2 diabetes attending a hospital diabetic outpatient clinic. Additional clinical measures were obtained from patient medical files and computerised records. Logistic regression analysis was used to identify characteristics associated with the presence of complications.

RESULTS

When controlling for other predictors, increasing age (P < 0.01), type 1 diabetes (P = 0.05), longer duration of diabetes (P < 0.01), increased serum triglyceride levels (P = 0.03), HbA1c (>8%; P = 0.03), self-reported low physical activity levels (P = 0.05) and being a smoker (P = 0.01) were positively related to retinopathy and/or neuropathy. Patients within the study population had reasonably well controlled BP and serum lipids, thus explaining the absence of these particular variables from the list of predictor parameters. Other factors including diabetes knowledge, home blood glucose monitoring, gender, body mass index, clinic attendance and occupational status were not significantly associated with retinopathy or neuropathy in the present study population.

CONCLUSIONS

Pharmacists and other health practitioners who are in a position to be involved in the care and management of patients with diabetes should raise awareness of complications, particularly amongst patients who present with the above risk factors and provide necessary counselling and advice as required.

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

BACKGROUND

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

OBJECTIVES

The objective of this review was to assess the effects of SMBG in patients with type 2 diabetes mellitus who are not using insulin.

SEARCH STRATEGY

Studies were obtained from searches of multiple electronic bibliographic databases supplemented with hand searches of references of retrieved articles. Date of last search: September 2004.

SELECTION CRITERIA

We included randomised controlled trails investigating the effects of SMBG compared with usual care and/or with self-monitoring of urine glucose in patients with type 2 diabetes who where not using insulin. Included studies should have used at least one of the following outcome measures: glycaemic control, quality of life, well-being, patient satisfaction, or hypoglycaemic episodes.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data from included studies and assessed study quality. Data from the studies were compared to decide whether they were sufficiently homogeneous to pool in a meta-analysis.

MAIN RESULTS

Six randomised controlled trials were included in the review. Four trials compared SMBG with usual care, one trial compared SMBG with self-monitoring of urine glucose and there was one three-armed trial comparing SMBG with self-monitoring of urine glucose and usual care. Because of the differences in patient characteristics, interventions and outcomes between the studies, it was not possible to perform a meta-analysis. The methodological quality of studies was low. Two of the six studies reported a significant lowering effect of self-monitoring of blood glucose on HbA1c. However, one of these studies had a co-intervention with education on diet and lifestyle. There were few data on the effects of other outcomes and these effects were not statistically significant.

AUTHORS' CONCLUSIONS

From this review we concluded that self-monitoring of blood glucose might be effective in improving glycaemic control in patients with type 2 diabetes who are not using insulin. To assess the potential beneficial effects of SMBG in these patients a large and well-designed randomised controlled trial is required. This long-term trial should also investigate patient-related outcomes like quality of life, well-being and patient satisfaction, and provide adequate education to the patient to allow SMBG to be effective.

Self-monitoring of blood glucose as part of a multi-component therapy among non-insulin requiring type 2 diabetes patients: a meta-analysis (1966-2004)

OBJECTIVE

To determine if therapeutic management programs that include self-monitoring of blood glucose result in greater HbA1c reduction in non-insulin-requiring type 2 diabetes patients compared to programs without blood glucose self-monitoring.

RESEARCH DESIGN AND METHODS

Electronic databases including MEDLINE (1966-2004), Cochrane Database of Systematic Reviews, EMBASE (1950-2004), Centre for Reviews and Dissemination (CRD) and the Online Index Journals of the American Diabetes Association (ADA 1978-2004) were searched. Personal collections of investigators were also explored. Randomized controlled trials comparing HbA1c reduction in therapies with and without blood glucose self-monitoring among adult, non-insulin-treated type 2 diabetes patients were selected. Studies on patients who are pregnant, taking insulin, troglitazone or experimental drugs were excluded. Out of 14 potentially useful randomized controlled trials on self-monitoring of blood glucose in non-insulin treated type 2 diabetes patients, eight studies with a total of 1307 subjects were included in the analysis. Two independent reviewers assessed the quality of studies.

MAIN OUTCOME MEASURE

The effect of SMBG was assessed by means of meta-analysis of the difference in HbA1c reduction between self-monitoring and non-self-monitoring groups.

RESULTS

Antidiabetic therapies that included blood glucose self-monitoring as part of a multi-component management strategy produced a mean additional HbA(1c) reduction of -0.39% (95%CI: -0.54%, -0.23%) under the fixed effects model and -0.42% (95%CI: -0.63%, -0.21%) under the random effects model, when compared to therapies that did not. Heterogeneity among studies was not statistically significant.

CONCLUSION

Multi-component diabetes management programs with self-monitoring of blood glucose result in better glycemic control among non-insulin-using type 2 diabetes patients.

Structured treatment and teaching of patients with Type 2 diabetes mellitus and impaired cognitive function--the DICOF trial

BACKGROUND

Patient education is integral part of any diabetes therapy in Germany, but elderly patients are not able to follow the variety of topics comprising standard treatment and teaching programmes (TTP), primarily due to impaired neuropsychological function. This leads to deficits in diabetes knowledge and hindered ability for diabetes self-management.

AIM

To evaluate structured TTP for geriatric patients with impaired cognitive function.

PATIENTS AND METHODS

A neuropsychological examination was performed on all patients over 54 years [n=102, age 68.6 +/- 8.7 years, diabetes duration 10.3 (0.03-35.4) years, HbA1c 10.3 +/- 1.7% (HPLC, Diamat, NR 4.5-6.3%), cognitive function 87.7 +/- 12.3 IQ points] who took part in TTP for insulin therapy. Patients with impaired cognitive function participated either in the standard TTP of Berger [n = 35, age 67.6 +/- 8.9 years, diabetes duration 9.9 (0.04-35.4) years, HbA1c 10.3 +/- 2.0%] or in the specialized structured geriatric DICOF-TTP [n=33, age 70.4 +/- 8.2 years, diabetes duration 10.4 (0.03-24.9) years, HbA1c 10.7 +/- 1.8%].

RESULTS

After TTP there were no differences in knowledge and ability for diabetes self-management (standard/DICOF: knowledge 11.0 +/- 2.6 vs. 12.2 +/- 2.7 points, P = 0.11; handling 14.9 +/- 3.3 vs. 15.9 +/- 2.5 points, P = 0.18). However, patients who took part in the DICOF programme showed better scores in satisfaction with the education programme [standard/DICOF 44.7 (31-57) vs. 52.5 (45-59) points, P < 0.001]. Six months later the DICOF participants showed better results regarding diabetes self-management (standard/DICOF: handling 12.5 +/- 4.1 vs. 15.9 +/- 3.1 points, P = 0.001). Both groups showed HbA1c decrease (8.3 +/- 1.4 vs. 8.5 +/- 1.3%, P=0.62) and similar incidence of acute complications.

CONCLUSIONS

Elderly patients with impaired cognitive function should take part in specialized structured TTP. This leads to both better satisfaction with the education programme and an improved ability for diabetes self-management.

The Value of Home Monitoring Kits in Diabetes, Hypertension, Asthma, and Oral Anticoagulation Therapy

Home monitoring devices encourage people to actively participate in their health care management. In addition, access to more data may help to make better decisions, which may ultimately lead to better health outcomes. The primary focus of this article will be on blood glucose, blood pressure, prothrombin time, and peak flow meters. The empirical evidence on the accuracy and usefulness of these home monitoring devices is discussed. Based on the evidence from the literature, erroneous reporting of the readings by the patients is a major concern. Therefore, primary practitioners are encouraged to consult with patients’ log books and their meters (if memory feature is available), instead of relying solely on self-reported values. Patients also need to be educated and trained adequately about the proper measurement technique and relevance and interpretation of the readings. Continuing education is necessary regarding the behavioral and therapeutic changes patients should carry out in accordance with performing regular home monitoring.

Self-monitoring of blood glucose significantly improves metabolic control in patients with type 2 diabetes mellitus: the Auto-Surveillance Intervention Active (ASIA) study

OBJECTIVE

Self monitoring of blood glucose (SMBG) in type 2 diabetes is a topic of current interest (imbalance between increased health-care costs and improvement in compliance with treatment and diet). An open label randomized prospective study was designed to compare changes in metabolic control over 6 months in patients managed with usual recommendations alone (conventional assessment group) or combined with SMBG.

RESEARCH DESIGN AND METHODS

Patients not treated with insulin or previously self monitored, 40 to 75 years of age, with a diagnosis of type 2 diabetes > 1 year and standardized HbA(1c) level > =7.5 and< =11% were randomized to either a control group or SMBG group. They were followed up every 6 weeks over 24 weeks. Patients in the SMBG group were given the same device (Ascensia Esprit Discmeter, Bayer) and were required to perform at least 6 capillary assays a week (3 different days of the week, including weekend). Management of patients was standardized, including drugs, diet and physical activity. The primary efficacy criterion was change in HbA(1c) level in Intent To Treat (ITT) patients. Assays were performed at baseline, at 3 and 6 months using the calibrated DCA 2000(R) device (Bayer).

RESULTS

Two hundred sixty five general practitioners randomized 988 patients (ITT Population), but 689 patients were evaluable for the primary criterion. At the endpoint, HbA(1c) was lower in the SMBG group (8.1 +/- 1.6%) than in the conventional treatment group (8.4 +/- 1.4%, P=0.012). The change in HbA(1c) levels between baseline and endpoint was classified into two classes: improvement if a change > 0.5% occurred, stability or worsening in case of a change< =0.5%; 57.1% of patients in the SMBG group vs 46.8% in the control group had an improvement in HbA(1c) level (P=0.007) after 3 months. A steady state was reached during the last 3 months. A multivariate logistic regression analysis was performed and identified factors predictive of improvement in HbA(1c) levels: HbA(1c) at baseline: odd ratio (OR)=1.749 (P<0.001), SMBG group (reference value: SMBG group): OR=0.665 (P=0.015), duration of diabetes: OR=0.953 (P=0.001) and BMI: OR=0.962 (P=0.039).

CONCLUSIONS

This study is the first multicenter, controlled, prospective trial conducted on a large number of patients demonstrating that SMBG was statistically associated with a better quality of metabolic control than usual traditional recommendations alone in type 2 diabetes.

Intensified blood glucose monitoring improves glycemic control in stable, insulin-treated veterans with type 2 diabetes: the Diabetes Outcomes in Veterans Study (DOVES)

OBJECTIVE

To examine the effect of intensified self-monitored blood glucose (SMBG) testing on glycemic control.

RESEARCH DESIGN AND METHODS

Subjects with stable, insulin-treated type 2 diabetes performed SMBG using an electronic blood glucose meter before all meals and at bedtime for 8 weeks. Baseline data were collected on demographics, clinical characteristics, diet, and exercise. HbA(1c) was measured at baseline, at 4 weeks, and at 8 weeks. After the intensified monitoring period, subjects resumed their usual monitoring. HbA(1c) was then measured at 24, 37, and 52 weeks. Multivariate linear regression was used to determine the effect of monitoring on glycemic control.

RESULTS

A total of 201 subjects completed the monitoring period. The baseline HbA(1c) (8.10 +/- 1.67%) decreased during the monitoring period by 0.30 +/- 0.68% (P < 0.001) at 4 weeks and by 0.36 +/- 0.88% (P < 0.001) at 8 weeks. Although entry HbA(1c) and compliance independently predicted the week 8 HbA(1c) (r = 0.862, P < 0.001), standardized regression analysis found that compliance with the SMBG protocol influenced the week 8 HbA(1c) more than age, sex, BMI, exercise level, carbohydrate consumption, or treatment intensity at baseline. However, SMBG benefited only subjects whose testing compliance exceeded 75% or with an entry HbA(1c) >8.0%. Decreases in HbA(1c) (-0.31 +/- 1.17%, P = 0.001) persisted in the 159 subjects followed for 52 weeks.

CONCLUSIONS

Intensified blood glucose monitoring improved glycemic control in a large cohort of stable, insulin-treated veterans with type 2 diabetes. SMBG provided a strong stimulus for improved self-care resulting in clinically important and sustained reductions in HbA(1c).

Assessing diabetic control--reliability of methods available in resource poor settings

AIMS AND METHODS

To examine the reliability of random venous or capillary blood glucose testing, random urine glucose testing, and a current symptom history in predicting a high HbA1c in Type 2 diabetic patients taking oral hypoglycaemic agents in a poorly controlled rural African population.

RESULTS

For a cut-off point for HbA1c of > or = 8%, for random venous plasma glucose of > or = 14 mmol/L (present in 47.2% of subjects), specificity was 97.1% (95% CI 85.1-99.9), sensitivity 56.8% (48.8-64.5) and positive predictive value (PPV) 98.9% (94.2-99.9). HbA1c > or = 8% is predicted by a random capillary blood glucose of 17 mmol/L (present in 28.4% of subjects) with specificity 100% (90.0-100.0), PPV 100% (93.7-100.0) and sensitivity of 34.3% (27.2-42.1). HbA1c > or = 8% is predicted by the presence of heavy glycosuria (> or = 55 mmol/L) (present in 35.6%) with specificity 94.1% (80.3-99.3), sensitivity of 41.9% (34.1-49.9) and PPV 97.1% (89.9-99.6). Polyuria/nocturia (present in 31.3%) was the only symptom found to be associated with poor control, with a specificity for predicting HbA1c of > or = 8% of 81.5% (61.9-93.7), PPV 89.1% (76.4-96.4) and sensitivity 30.6% (22.9-39.1).

CONCLUSIONS

Where resources are short, random glucose testing can be used to detect a significant proportion of those with the worst control with a high degree of specificity enabling primary care staff to modify treatment safely. Where facilities are limited capillary blood or urine testing with reagent strips, may be substituted for venous plasma testing in the laboratory. A symptom history was insufficient to replace biochemical testing, but where this is unavailable, urinary symptoms may be helpful.

Self-monitoring of blood glucose levels and glycemic control: the Northern California Kaiser Permanente Diabetes registry

PURPOSE

We sought to evaluate the effectiveness of self-monitoring blood glucose levels to improve glycemic control.

SUBJECTS AND METHODS

A cohort design was used to assess the relation between self-monitoring frequency (1996 average daily glucometer strip utilization) and the first glycosylated hemoglobin (HbA1c) level measured in 1997. The study sample included 24,312 adult patients with diabetes who were members of a large, group model, managed care organization. We estimated the difference between HbA1c levels in patients who self-monitored at frequencies recommended by the American Diabetes Association compared with those who monitored less frequently or not at all. Models were adjusted for age, sex, race, education, occupation, income, duration of diabetes, medication refill adherence, clinic appointment "no show" rate, annual eye exam attendance, use of nonpharmacological (diet and exercise) diabetes therapy, smoking, alcohol consumption, hospitalization and emergency room visits, and the number of daily insulin injections.

RESULTS

Self-monitoring among patients with type 1 diabetes (> or = 3 times daily) and pharmacologically treated type 2 diabetes (at least daily) was associated with lower HbA1c levels (1.0 percentage points lower in type 1 diabetes and 0.6 points lower in type 2 diabetes) than was less frequent monitoring (P < 0.0001). Although there are no specific recommendations for patients with nonpharmacologically treated type 2 diabetes, those who practiced self-monitoring (at any frequency) had a 0.4 point lower HbA1c level than those not practicing at all (P < 0.0001).

CONCLUSION

More frequent self-monitoring of blood glucose levels was associated with clinically and statistically better glycemic control regardless of diabetes type or therapy. These findings support the clinical recommendations suggested by the American Diabetes Association.

[Cost-effectiveness analysis of self-monitoring of blood glucose in type 2 diabetics]

OBJECTIVE

Compare the cost-effectiveness of self-monitoring of blood glucose (MBG) with your non-use.

DESIGN

Descriptive and retrospective study covering the period 1995-97 in the 597 type-2 diabetes patients: 286 practicing MBG on a stable basis and 311 not doing so. All are registered in seven health districts in the territorial ambit of Tortosa Primary Care. Were quantified the direct costs in relation to consumption of reagent strips for the practice of MBG, outpatients visits in your primary care center, derivations to specialist of reference and complementary test according to recommendations of the European NIDDM Policy Group in the population user of MBG and no-user; the annual cost increment, the average annual cost and the total annual cost in the population user of MBG and in the application of a ideal model of quantitative and qualitative cover according to clinical recommendations of the Gedaps; and the cost-effectiveness.

RESULTS

While the 78% of the total diabetic population satisfy some clinical indication for prescribing MBG, only the 42.5% practice the MBG. The consumption of reagent strips rising of 8% to 15% of the global cost of the diabetic population. In the application of the ideal model of cover, this cost increase up the 30% of global cost. The effectiveness obtained, an 27%, not are significantly different in the population user of MBG and no user. The cost-effectiveness in the user of MBG increased of 210.789 ptes/year to 213.148 ptes/year; and no-user of 162.019 ptes/year to 162.051 ptes/year. The application of ideal model of cover and the gain of an effectiveness near to possible level of efficiency imply an descent average of cost-effectiveness of approximately 60%: 78.904 ptes/year in user MBG and 54.682 ptes/year in no-user.

CONCLUSIONS

1. We choose in the presents conditions the option of no-user MBG. 2. The average cost-effectiveness per diabetic patient will increase by the needs of accommodate the therapy to new standards of metabolic control. 3. Are clear opportunity for the improve the management and to motivate an efficient use of technology associate to defects of public sanitary market. 4. The model of ideal cover associated to greater effectiveness are necessary for to unify the economic and clinic efficiency.

Can plasma fructosamine substitute for glycated haemoglobin (HbA1c) estimation in the assessment of diabetic control?

The 'gold standard' marker of overall glycaemic control in diabetes mellitus is the level of glycated haemoglobin (HbA1c). It is, however, an expensive and technically difficult assay and is rarely appropriate to tropical laboratories. Plasma fructosamine measurement is cheaper and easier, though it reflects shorter-term glycaemia. We have measured both indices of control in a group of 154 diabetic patients. There was close correlation between the two measurements (r = 0.6506, P < 0.001), but many patients with abnormal HbA1c levels had normal fructosamine levels. This resulted in an assay sensitivity (compared with HbA1c as gold standard) of only 30%, though specificity was 98%. We conclude that fructosamine measurement cannot be regarded as a substitute for HbA1c determination.

Home monitoring of blood glucose (HMBG) in Type-2 diabetes mellitus in a developing country

The cost-effectiveness of home monitoring of blood glucose (HMBG) in Type-2 diabetes in a developing country was evaluated. A total of 64 uncomplicated Type-2 diabetic individuals of higher middle class to rich socio-economic status were studied. Thirty-two were allocated to conventional monthly hospital visits group-I (Gr-I) and 32 to HMBG with hospital visits at 3 monthly intervals group-II (Gr-II). In Gr-I, compared to baseline, HbA1c values decreased by 0.76% (95% CI 0.11-1.42) after 9 months and by 0.95% (95% CI 0.12-1.77) after 15 months but lost significance after 18 months follow-up. On the other hand, in Gr-II patients, HbA1c decreased significantly from baseline from 3 months and remained so at 18 months when it was decreased by 1.37% (95% CI 0.25-2.49). Hypoglycaemic episodes per patient year follow-up were significantly lower among Gr-II patients (0.172 vs. 0.354, P = 0.03). Considering the cost for conveyance, wage loss, investigation, institutional cost, glucometer and test strips, the total cost per patient was quite similar in both groups. The present study suggests that HMBG with proper diabetes education may be cost-effective at least in selected groups of individuals with Type-2 diabetes, even in a developing country such as Bangladesh.

Frequency of blood glucose monitoring in relation to glycaemic control: observational study with diabetes database

OBJECTIVES

To investigate patterns of self monitoring of blood glucose concentration in diabetic patients who use insulin and to determine whether frequency of self monitoring is related to glycaemic control.

SETTING

Diabetes database, Tayside, Scotland.

SUBJECTS

Patients resident in Tayside in 1993-5 who were using insulin and were registered on the database and diagnosed with insulin dependent (type 1) or non-insulin dependent (type 2) diabetes before 1993.

MAIN OUTCOME MEASURES

Number of glucose monitoring reagent strips dispensed (reagent strip uptake) derived from records of prescriptions. First recorded haemoglobin A1c concentration in the study period, and reagent strips dispensed in the previous 6 months.

RESULTS

Among 807 patients with type 1 diabetes, 128 (16%) did not redeem any prescriptions for glucose monitoring reagent strips in the 3 year study period. Only 161 (20%) redeemed prescriptions for enough reagent strips to test glucose daily. The corresponding figures for the 790 patients with type 2 diabetes who used insulin were 162 (21%; no strips) and 131 (17%; daily tests). Reagent strip uptake was influenced both by age and by deprivation category. There was a direct relation between uptake and glycaemic control for 258 patients (with recorded haemoglobin A1c concentrations) with type 1 diabetes. In a linear regression model the decrease in haemoglobin A1c concentration for every extra 180 reagent strips dispensed was 0.7%. For the 290 patients with type 2 diabetes who used insulin there was no such relation.

CONCLUSIONS

Self monitoring of blood glucose concentration is associated with improved glycaemic control in patients with type 1 diabetes. Regular self monitoring in patients with type 1 and type 2 diabetes is uncommon.

Epidemiology and determinants of blood glucose self-monitoring in clinical practice

The aim of this study was to describe the epidemiology of self-monitoring of blood glucose and to identify specific characteristics of those subgroups of diabetic patients treated with insulin that are most likely to monitor their blood glucose according to medical recommendations. Data were collected on 1384 insulin-treated patients, enrolled from 35 diabetic outpatient clinics and 49 general practitioners' offices between December 1993 and June 1994. Seventeen Italian regions out of 20 were included in the study. Our data show that 418 (31%) diabetic patients treated with insulin had never practised blood glucose self-monitoring. In addition, only 242 patients (18.2%) self-monitored their glycemia with a mean frequency of at least once a day (29.7% among insulin-dependent diabetes mellitus (IDDM) and 13.9%, among insulin-treated non-insulin-dependent diabetes mellitus (NIDDM-IT) patients). Patients' characteristics associated with a higher probability of practising blood glucose self-monitoring were age below 50 years, being treated at a diabetic outpatient clinic, hypertension, need of three or more insulin injections per day, history of hypoglycemic episodes, ability to self-manage insulin doses. Our study calls for vigorous efforts aimed at promoting the incorporation of clearly-defined educational programs at each level of care, in order to improve the motivation and self-care of diabetic patients. Furthermore, studies are necessary to identify subgroups of diabetic patients that truly need to self-monitor blood glycemia, and to assess the efficacy of the practice of self-monitoring of blood glucose in improving metabolic control and reducing acute and long-term diabetic complications.