Improved glycemic control in intensively treated type 1 diabetic patients using blood glucose meters with storage capability and computer-assisted analyses

Applications of Clinical Decision Support Systems in Diabetes Care: Scoping Review

BACKGROUND

Providing comprehensive and individualized diabetes care remains a significant challenge in the face of the increasing complexity of diabetes management and a lack of specialized endocrinologists to support diabetes care. Clinical decision support systems (CDSSs) are progressively being used to improve diabetes care, while many health care providers lack awareness and knowledge about CDSSs in diabetes care. A comprehensive analysis of the applications of CDSSs in diabetes care is still lacking.

OBJECTIVE

This review aimed to summarize the research landscape, clinical applications, and impact on both patients and physicians of CDSSs in diabetes care.

METHODS

We conducted a scoping review following the Arksey and O'Malley framework. A search was conducted in 7 electronic databases to identify the clinical applications of CDSSs in diabetes care up to June 30, 2022. Additional searches were conducted for conference abstracts from the period of 2021-2022. Two researchers independently performed the screening and data charting processes.

RESULTS

Of 11,569 retrieved studies, 85 (0.7%) were included for analysis. Research interest is growing in this field, with 45 (53%) of the 85 studies published in the past 5 years. Among the 58 (68%) out of 85 studies disclosing the underlying decision-making mechanism, most CDSSs (44/58, 76%) were knowledge based, while the number of non-knowledge-based systems has been increasing in recent years. Among the 81 (95%) out of 85 studies disclosing application scenarios, the majority of CDSSs were used for treatment recommendation (63/81, 78%). Among the 39 (46%) out of 85 studies disclosing physician user types, primary care physicians (20/39, 51%) were the most common, followed by endocrinologists (15/39, 39%) and nonendocrinology specialists (8/39, 21%). CDSSs significantly improved patients' blood glucose, blood pressure, and lipid profiles in 71% (45/63), 67% (12/18), and 38% (8/21) of the studies, respectively, with no increase in the risk of hypoglycemia.

CONCLUSIONS

CDSSs are both effective and safe in improving diabetes care, implying that they could be a potentially reliable assistant in diabetes care, especially for physicians with limited experience and patients with limited access to medical resources.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.37766/inplasy2022.9.0061.

Self-monitoring of blood glucose (SMBG) and glycaemic control in Cameroon: Results of the International Diabetes Management Practices Study (IDMPS)

This study examined the relationship between self-monitoring of blood glucose (SMBG) and glycaemic control among patients from Cameroon. A minority of patients with diabetes owned a blood glucose meter; of these patients, most performed SMBG inconsistently. The lack of SMBG may be a contributing factor to the poor glycaemic control in the country.

Pathway to artificial pancreas systems revisited: moving downstream

Artificial pancreas (AP) systems, a long-sought quest to replicate mechanically islet physiology that is lost in diabetes, are reaching the clinic, and the potential of automating insulin delivery is about to be realized. Significant progress has been made, and the safety and feasibility of AP systems have been demonstrated in the clinical research center and more recently in outpatient "real-world" environments. An iterative road map to AP system development has guided AP research since 2009, but progress in the field indicates that it needs updating. While it is now clear that AP systems are technically feasible, it remains much less certain that they will be widely adopted by clinicians and patients. Ultimately, the true success of AP systems will be defined by successful integration into the diabetes health care system and by the ultimate metric: improved diabetes outcomes.

Historical perspectives in clinical pathology: a history of glucose measurement

This is the second in the series of historical articles dealing with developments in clinical pathology. As one of the most commonly measured analytes in pathology, the assessment of glucose dates back to the time of the ancient Egyptians. It was only in the 19th century that advances in chemistry led to the identification of the sugar in urine being glucose. The following century witnessed the development of more chemical and enzymatic methods which became incorporated into the modern analysers and point-of-care instruments which are as ubiquitous as the modern day cellphones. Tracking the milestones in these developments shows the striking paradigms and the many parallels in the development of other clinical chemistry methods.

Internet blood glucose monitoring systems provide lasting glycemic benefit in type 1 and 2 diabetes: a systematic review

Internet blood glucose monitoring systems (IBGMS) are associated with improved glycemic control in patients with type 2 diabetes (T2D) who are pharmacologically managed, using oral agents or insulin. IBGMS improves glycemic levels in patients with type 1 diabetes (T1D). IBGMS has not led to increased hypoglycemia. Mechanisms underlying IBGMS-associated glycemic improvement extend beyond optimizing insulin dose titration. The most important effects seem to be associated with increased patient self-motivation and improved patient-physician communication. IBGMS have been recommended in clinical practice guidelines, and their effectiveness and safety in trials suggest that this approach is appropriate for patients with T1D or T2D.

Consensus guidelines for glycemic monitoring in type 1/type 2 & GDM

Stringent monitoring of blood glucose in diabetes plays an important role as the treatment of the disease itself. Blood glucose monitoring (BGM) strategies such as measurement of Hb1Ac, Self-Monitoring of Blood Glucose (SMBG) and Continuous Glucose Monitoring (CGM) plays a vital role in achieving the important goal of preventing long term complications of diabetes. Although the use of BGM is recommended by various international guidelines in T1DM and T2DM, there is no consensus on the utility of BGM in India. So, there is a need to develop a guidance for uniform monitoring mechanism among the care givers taking into account the variations and challenges that are unique to Indian population. A committee was established that comprised of physicians, researchers and other healthcare professionals having expertise in diabetes treatment to oversee the formulation of guidelines on different monitoring and treatment aspects of diabetes. Extensive literature searches were conducted to identify and analyze the evidence available on BGM. An initial draft of BGM guidelines was presented to core members who discussed the subject matter and presented their opinion. This was then taken to wider expert audience to invite their comments that were incorporated in the initial draft. The first compilation was presented at a conference attended by nearly 200 experts. Again, their opinion was sought and the next version was prepared which was sent to core committee members for the final inputs. The Indian consensus guideline on BGM using Hb1Ac, SMBG and CGM as the primary tools was then finalized.

Self-monitoring of blood glucose in diabetes: from evidence to clinical reality in Central and Eastern Europe--recommendations from the international Central-Eastern European expert group

Self-monitoring of blood glucose (SMBG) is universally considered to be an integral part of type 1 diabetes management and crucial for optimizing the safety and efficacy of complex insulin regimens. This extends to type 2 diabetes patients on intensive insulin therapy, and there is also a growing body of evidence suggesting that structured SMBG is beneficial for all type 2 diabetes patients, regardless of therapy. However, access to SMBG can be limited in many countries in Central and Eastern Europe. A consensus group of diabetes experts from 10 countries in this region (with overlapping historical, political, and social environments)--Bulgaria, Croatia, Czech Republic, Hungary, Poland, Romania, Serbia, Slovakia, Slovenia, and Ukraine--was formed to discuss the role of SMBG across the spectrum of patients with diabetes. The group considered SMBG to be an essential tool that should be accessible to all patients with diabetes, including those with non-insulin-treated type 2 diabetes. The current article summarizes the evidence put forward by the consensus group and provides their recommendations for the appropriate use of SMBG as part of individualized patient management. The ultimate goal of these evidence-based recommendations is to help patients and providers in Central and Eastern Europe to make optimal use of SMBG in order to maximize the efficacy and safety of glucose-lowering therapies, to prevent complications, and to empower the patient to play a more active role in the management of their diabetes.

Using integrated bio-physiotherapy informatics in home health-care settings: A qualitative analysis of a point-of-care decision support system

The growing need to gain efficiencies within a home care setting has prompted home care practitioners to focus on health informatics to address the needs of an aging clientele. The remote and heterogeneous nature of the home care environment necessitates the use of non-intrusive client monitoring and a portable, point-of-care graphical user interface. Using a grounded theory approach, this article examines the simulated use of a graphical user interface by practitioners in a home care setting to explore the salient features of monitoring the activity of home care clients. The results demonstrate the need for simple, interactive displays that can provide large amounts of geographical and temporal data relating to patient activity. Additional emerging themes from interviews indicate that home care professionals would use a graphical user interface of this type for patient education and goal setting as well as to assist in the decision-making process of home care practitioners.

Current concepts in blood glucose monitoring

Blood glucose monitoring has evolved over the last century. The concept of adequate glycemic control and minimum glycemic variability requires an ideal, accurate and reliable glucose monitoring system. The search for an ideal blood glucose monitoring system still continues. This review explains the various blood glucose monitoring systems with special focus on the monitoring systems like self- monitored blood glucose (SMBG) and continuous glucose monitoring system (CGMS). It also focuses on the newer concepts of blood glucose monitoring and their incorporation in routine clinical management of diabetes mellitus.

Comparing patient-generated blood glucose diary records with meter memory in diabetes: a systematic review

AIMS

To synthesize evidence relating to comparisons between patient-generated blood glucose records and meter memory in diabetes and to identify any predictors of agreement.

METHODS

A systematic literature search was performed to identify articles comparing meter and diary records in those unaware of this assessment.

RESULTS

Eleven observational studies, covering patients with Type 1, Type 2 and gestational diabetes were included spanning 1984-2009. Failure to record blood glucose measurements in the diary was the most extensive 'error', but addition of values, which were not measured, was a greater cause for concern. When present to a high degree, 'errors' lead to decreased variability in diary records compared with meter records. Allowing for a minimal amount of disagreement, just over 50% of adult diaries can be considered as 'accurate/reliable'. Disagreements were most extensive in teenagers and young adults, but the pregnant populations were only slightly better. Agreement was not related to sex, number of insulin injections or duration of monitoring. Those who were younger were more likely to have 'errors', while those who monitored more frequently had more 'accurate' diaries.

CONCLUSIONS

The lack of meter-diary agreement suggests that the real reason for monitoring is not understood by many patients, raising issues about motivation, perceived need to impress healthcare providers and denial of poor control. Considering that diaries are used to inform decisions about therapy when HbA1c is raised or in pregnancy, when HbA1c is not suitable, there is significant cause for concern in relation to their clinical utility.

Glucose meters with built-in automated bolus calculator: gadget or real value for insulin-treated diabetic patients?

Self-monitoring of blood glucose is now widely recognized as efficacious to enhance and facilitate diabetes management. More than just a means of recording and storing data, some blood glucose meters (BGMs) are now designed with an embedded automated bolus calculator (ABC) with the goal to propose patients recommendations about insulin dosage. The growing literature in this field tends to claim that these new smart BGMs make patient's life easier and decision making safer. The main purpose of this review is to verify whether BGMs with a built-in ABC indeed improve the willingness and the ability of insulin-treated patients to make adequate therapeutic decisions and positively impact the metabolic control and the quality of life of ABC users. It appears that, as long as the education provided by caregivers remains a top priority, BGMs with a built-in ABC (more than just electronic gadgets) can be regarded as bringing real value to insulin-treated patients with diabetes.

Judging whether a patient is actually improving: more pitfalls from the science of human perception

Fallible human judgment may lead clinicians to make mistakes when assessing whether a patient is improving following treatment. This article provides a narrative review of selected studies in psychology that describe errors that potentially apply when a physician assesses a patient's response to treatment. Comprehension may be distorted by subjective preconceptions (lack of double blinding). Recall may fail through memory lapses (unwanted forgetfulness) and tacit assumptions (automatic imputation). Evaluations may be further compromised due to the effects of random chance (regression to the mean). Expression may be swayed by unjustified overconfidence following conformist groupthink (group polarization). An awareness of these five pitfalls may help clinicians avoid some errors in medical care when determining whether a patient is improving.

Contemporary management of patients with type 1 diabetes

The current standard of care for patients with type 1 diabetes (T1D) employs a system of intensive diabetes management aimed at near-normal glycemia, which reduces the risk of micro- and macrovascular complications. Optimal management is an ongoing process based on a patient-centered collaboration with a primary care clinician and a multidisciplinary diabetes team that provides diabetes management, including education and psychosocial support. Intensive diabetes therapy attempts to mimic physiologic insulin replacement. Over the past 15 years, there has been widespread use of multiple-dose insulin regimens using a variety of insulin analogs, administered either by injection or insulin pump therapy, together with medical nutrition therapy, frequent self-monitoring of blood glucose and, more recently, continuous logo glucose monitoring. It is now possible to achieve previously unattainable levels of glycemic control with less risk of severe hypoglycemia, and yet only a minority of patients achieves target hemoglobin A1c values. This review discusses contemporary management of T1D with a focus on health outcomes.

Prescription checking device promises to resolve intractable hypoglycemia

BACKGROUND

Satisfactory glycemic control, meeting American Diabetes Association recommendations, is often accompanied by unsatisfactory hypoglycemia. The converse is also true. We hypothesize that this diabetes treatment dilemma may be resolved by repeated, objective, prescription checks. To do this, a new, two-part device has been developed. It includes a personal diabetes database for the patient and a built-in diabetes prescription checker for the provider. Its goals are to enhance diabetes education and improve patient care.

RESEARCH DESIGN AND METHODS

The device includes a database and supporting software, all contained in a standard USB flash drive. Using the medical prescription, body weight, and recent self-monitored blood glucose (SMBG) data, prescription checks can be done at any time. To demonstrate the device's capabilities, an observational study was performed using data from 11 patients with type 1 diabetes mellitus, on intensified therapy, with a mean glycated hemoglobin A1c <7%, and who all suffered intractable hypoglycemia. Patients had performed SMBG contours on successive days at monthly intervals. Each contour included pre- and postmeal as well as bedtime measurements. The replicated contours were used to predict the patient's glycemic profile each month. Applying a built-in simulator to each profile, changes in the prescription were explored that were consistent with reducing the recalcitrant hypoglycemia.

RESULTS

A total of 110 glycemic profiles containing 822 profile points were explored. Of these profile points, 351 (43%) showed risks of hypoglycemia, whereas 385 (47%) fell outside desired ranges. With the simulated changes in the prescription, the predicted risks of hypoglycemia were reduced 2.5-fold with insignificant increases predicted in hemoglobin A1c levels of +0.6 +/- 0.9%.

CONCLUSIONS

A novel support tool for diabetes promises to resolve the diabetes treatment dilemma. Supporting the patient, it improves self-management. Supporting the provider, it reviews the medical prescription in light of objective outcomes and formalizes interventions for maximum safety and efficacy.

Home blood glucose monitoring in type 1 diabetes mellitus

OBJECTIVE: To determine which of two simplified blood glucose monitoring schemes promotes better metabolic control in type1 diabetic patients during 12 months of participation in educational groups. METHODS: A crossover clinical trial involving 21 patients divided into two groups was conducted. They were submitted to a two monitoring schemes:2 alternate daily preprandial measurements and 2 alternate daily pre-and postprandial measurements. The effectiveness of the schemes was evaluated based on HbA1c. Variations in mean HbA1c were analyzed by Friedman test. RESULTS: The groups were homogenous in terms of sociodemographic and clinical variables (p>0.05). Mean HbA1c levels ranged from 8.48 (±1.00) to 7.37 (±0.99) over time in Group A and from 9.89 (±0.86) to 8.34 (±1.06) in Group B. The analysis of the HbA1c showed a significant reduction in the first and last 6 months and over the 12 months of the study in two groups (p<0.05). The preprandial scheme demonstrated the largest number and highest percentage of significant drops in HbA1c. CONCLUSIONS: The two monitoring improved the metabolic control and the preprandial scheme was more effective.

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

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

International survey of insulin pump users: Impact of continuous subcutaneous insulin infusion therapy on glucose control and quality of life

AIMS

To record the characteristics and attitude of patients treated with continuous subcutaneous insulin infusion (CSII), and the impact on glycaemic control in a large number of CSII patients in routine daily life.

METHODS

A structured questionnaire was distributed to 36,450 CSII patients from Europe and North America to determine patient characteristics, therapy characteristics, medical results, complications and treatment satisfaction.

RESULTS

A 38% response rate was achieved, 92% from patients with Type 1 diabetes. The responses indicated that CSII users achieved good glycaemic control with a mean HbA(1c) level of 7.0+/-1.1%. A significant correlation was observed between HbA(1c) and the number of blood glucose measurements per day. Four to five blood glucose measurements are needed in a majority of patients to reach optimal glucose control in intensely treated diabetic patients. The clinical benefits of CSII therapy were matched by patient experience and improvements in quality of life. There were 5.74 episodes per patient year of hypoglycaemia needing assistance, although the number of serious adverse effects recorded was dependent on patient's self-reporting.

CONCLUSIONS

These data suggest patients using CSII therapy achieve good metabolic control, are highly satisfied, and experience an acceptably small number of complications.

Continued use of an integrated meter with electronic logbook maintains improvements in glycemic control beyond a randomized, controlled trial

BACKGROUND

Blood glucose monitoring is an important component of diabetes self-management for individuals with insulin-treated diabetes. Although patient-maintained logbooks are routinely used, glucose values may be inaccurately recorded or not recorded at all. Electronic logbooks may help overcome such problems. We conducted a randomized, controlled trial (RCT) to compare glycemic control in insulin-treated participants using integrated glucose meters and electronic logbooks (Electronic Group) with participants using conventional meters and paper logbooks (Paper Group), and to determine persistence of glycemic improvements during long-term observational follow-up.

METHODS

After a 4-week run-in, adult and pediatric participants (n = 205) with stable hemoglobin A(1C) (A1C) >or=8.0% were randomized, and their logbook data and A1C were monitored every 4 weeks for 16 weeks. After the RCT, patients selected their monitoring systems and resumed usual care. The four resulting subgroups, defined by whether patients continued or changed monitoring systems, were reassessed after 26-65 weeks.

RESULTS

During the RCT, mean A1C decreased -0.27% in the Paper Group and -0.35% in the Electronic Group. Repeated-measures analysis revealed that the mean decrease was significantly greater in the Electronic than the Paper Group (P = 0.022). From randomization through observational follow-up, participants consistently using integrated meters/logbooks had an A1C decrease of -0.36% (P = 0.008), whereas participants using conventional meters/logbooks throughout or switching meters returned to pre-enrollment A1C levels.

CONCLUSIONS

Compared to conventional monitoring systems, use of an integrated meter and electronic logbook resulted in modest, but significant and sustained, improvement in A1C in insulin-treated patients with suboptimal glycemic control during an RCT and observational follow-up.

Patterns of blood glucose monitoring in relation to glycemic control among patients with type 2 diabetes in the UK

AIMS

The objectives of this study were to compare patterns of blood glucose monitoring among patients with type 2 diabetes initiating therapy with insulin or oral medication and to examine the relationship between the quantity of prescribed monitoring strips and glycemic control.

METHODS

Data were obtained from the UK General Practice Research Database. Patients were eligible if they were identified as having type 2 diabetes, initiated therapy with insulin or an oral agent, and had 12-month postinitiation data. Differences in patient characteristics and number of test strips prescribed between the insulin (n=347) and oral cohorts (n=2436) were examined. Multivariate regressions examined the relationship between quantity of monitoring and glycemic control for a subset of patients (insulin, n=245; oral, n=1795) with available glycosylated hemoglobin (HbA1c) data.

RESULTS

During the 12-month postinitiation period, patients using insulin were prescribed approximately twice as many test strips compared with those patients using oral medication (149 vs. 78, P<.0001). Multivariate regressions revealed that individuals who initiated insulin therapy and were prescribed enough test strips to test at least once per day in the 6 months prior to the HbA1c test date had, on average, a 0.65% lower HbA1c value (P=.02) compared with individuals who were prescribed fewer test strips.

CONCLUSIONS

Results indicate significant differences in the prescription of blood glucose monitoring strips, with patients initiated on insulin prescribed almost twice as many test strips compared with patients initiated on orals. The greater number of blood glucose test strips prescribed was associated with lower HbA1c values for insulin patients.

Technology and intensive management in youth with type 1 diabetes: state of the art

Recent implementation of technologic advances in the management of pediatric type 1 diabetes creates an exciting time for the diabetes community. Safety and efficacy of new therapies are commonly demonstrated first in adult patients with pediatric studies following. This review covers recent advances in six main areas: blood glucose monitoring including continuous monitoring; point-of-care A1c testing; designer insulins; insulin delivery systems including insulin pumps; electronic communication; and telehealth.

Tissue response to subcutaneous implantation of glucose-oxidase-based glucose sensors in rats

Considerable progress in improved control of disturbed glucose metabolism can be expected by continuous glucose monitoring. The aim of the study was to evaluate in male Sprague-Dawley rats tissue response to implantation of a new amperometric glucose-oxidase-based glucose sensor (NTS) compared to a commercially available sensor system CGMS of MiniMed. Both sensors were tested under working conditions over a period of 3 days. Using NTS, glucose in interstitial fluid reflected glucose in arterial blood even in rapidly changing hyper- and hypoglycaemia whereas the CGMS did not detect the experimentally induced glucose changes adequately. Gene expression profiling was performed using Affymetrix chips. Acute phase response to injury by sensor application for a short time is indicated by down regulation of the increase in mRNA of proteases e.g. metallothionein-1alpha and matrix metalloprotease-3 at day 3. Improvement of anabolic situation is suggested by decrease in mRNA of insulin-like growth factor binding protein whereas increase of heme oxygenase and hypoxia-inducible factor may be related to defense mechanisms. Changes of mRNA together with slight fibrous capsule formation suggest good histocompatibility. Comparability of the patterns of changed mRNA in tissue surrounding SCGM with and without operating voltage as shown in dendrogram indicates no contribution of hydrogen peroxide to worsening biocompatibility. Beside established histological investigations of foreign body reaction weeks or months after implantation, gene expression profiling provides additional information to biocompatibility already early after implantation.

Self-monitoring of blood glucose levels requires intensive training for use of meters to obtain reliable and clinically relevant measurements

BACKGROUND

Anecdotal reports from pediatric sites have indicated that some blood glucose meters may display wrong and misleading numbers rather than error indications, when operated in deviation from the instructions for use (IFU), eg by manipulating the strip during the count-down phase.

METHODS

This study was performed with 60 patients with diabetes (32 female, 28 male, 21 type 1, 39 type 2, age (mean+/-SD): 56+/-11 years) who measured their blood glucose levels twice with five different blood glucose meters (Precision(R) Xceed [Abbott Medisense], Freestyle Mini [Abbott Medisense], Accu-Chek Comfort [Roche Diagnostics], Accu-Chek Aviva [Roche Diagnostics], and Ascensia Contour [Bayer Vital]). The first measurement was performed in accordance with the IFU, and the second by manipulating the test strip using a standardised inflexion/release procedure during the count-down phase. A standard glucose oxidase method (SuperGL) served as laboratory reference.

RESULTS

All meters worked in full compliance with current accuracy standards when operated according to the IFU. When manipulating the test strip, the results varied considerably: While changes in reliability were acceptable for two devices (Precision Xceed, Freestyle Mini), the other devices produced an unacceptable number of errors and a series of entirely wrong values without error indication.

CONCLUSIONS

The use of all devices is recommended when used according to the IFU. The use under the artificially induced impaired testing conditions is a major concern. This study underlines the importance of appropriate patient training regarding adherence to the IFU of glucose meters.

Fuzzy-based controller for glucose regulation in type-1 diabetic patients by subcutaneous route

This paper presents an advisory/control algorithm for a type-1 diabetes mellitus (TIDM) patient under an intensive insulin treatment based on a multiple daily injections regimen (MDIR). The advisory/control algorithm incorporates expert knowledge about the treatment of this disease by using Mamdani-type fuzzy logic controllers to regulate the blood glucose level (BGL). The overall control strategy is based on a two-loop feedback strategy to overcome the variability in the glucose-insulin dynamics from patient to patient. An inner-loop provides the amount of both rapid/short and intermediate/long acting insulin (RSAI and ILAI) formulations that are programmed in a three-shots daily basis before meals. The combined preparation is then injected by the patient through a subcutaneous route. Meanwhile, an outer-loop adjusts the maximum amounts of insulin provided to the patient in a time-scale of days. The outer-loop controller aims to work as a supervisor of the inner-loop controller. Extensive closed-loop simulations are illustrated, using a detailed compartmental model of the insulin-glucose dynamics in a TIDM patient with meal intake.

An integrated graphic scheme for the display of insulin prescription and blood glucose information

OBJECTIVE

This study was undertaken to determine whether use of an integrated graphic scheme for the display of insulin prescription and blood glucose information has an impact on simulated decision-making in clinical practice.

METHODS

Five test cases representing patients treated with multiple daily insulin regimens were selected from a database of stored blood glucose readings. Five endocrinologists made treatment recommendations based on review of aggregated readings and corresponding insulin prescriptions. Twenty subjects were randomized to complete two sets of sequential real-time data management exercises. One set focused on evaluation of insulin prescriptions and readings printed as entries in logbooks. The other focused on evaluation of displays of insulin doses and readings plotted out according to an integrated graphic scheme of representation.

RESULTS

Subjects were more likely to make correct decisions in four out of five test cases after reviewing displays. Subjects were less likely to make incorrect decisions in all of five test cases after reviewing displays. Completion times were 30-66% shorter for exercises involving review of displays.

CONCLUSION

An integrated graphic scheme that associates representations of insulin doses with metaphor graphic displays of aggregated blood glucose readings may facilitate decisionmaking in clinical practice.

Monitoring glycemic control: the cornerstone of diabetes care

BACKGROUND

Diabetes mellitus is associated with significant morbidity and mortality and escalating costs, and its prevalence is increasing to epidemic proportions. Studies have consistently documented the importance of glycemic control in delaying the onset and decreasing the incidence of both the short- and long-term complications of diabetes. Although glycemic control is difficult to achieve and challenging to maintain, its impact on disease outcomes is well worth the effort.

OBJECTIVE

This article reviews the importance of monitoring and tightly controlling blood glucose concentrations in patients with diabetes and the methods and tools available for achieving these goals.

METHODS

This clinical review was developed using 102 a MEDLINE search of the literature from 1990 to 2005 using the terms diabetes, glucose control, glucose monitoring, A(1c), and hypoglycemia.

RESULTS

The complications of diabetes can be prevented or sharply curtailed through tight glycemic control, which requires frequent monitoring of blood glucose levels, careful attention to diet and exercise, and the use of medications. The progressive nature of diabetes imposes the need for frequent and regular monitoring, leading to data-driven adjustments to therapy to maintain optimal glucose levels. Failure to achieve glycemic control is often the result of a failure to educate the patient about how to monitor blood glucose levels and the importance of accuracy in doing so.

CONCLUSIONS

Tight glycemic control requires an 102 educated and motivated patient, an appropriate treatment regimen, vigilant monitoring, and a close partnership between the patient and a multidisciplinary team of health care professionals to ensure accurate monitoring and appropriate actions. The growing array of monitoring devices contributes to this effort by providing increased convenience and accuracy.

How good is your glucose control?

BACKGROUND

Glycemic control is fundamental to the management of diabetes and maintenance of health. Popular measures of performance in glycemic control include A1c and self-monitoring of blood glucose (SMBG). As measures of performance, A1c has perspective, but it fails to recognize hypoglycemia, while SMBG lacking overall perspective finds use mainly by patients to simply evaluate their glycemic status and current response to therapy. An additional, preferably visual, measure of performance in diabetes management in general and glycemic control in particular is needed.

METHODS

To form a visual measure of performance, a graphical method of analysis from the statistician's toolbox (known as the lag plot) was adapted. It can utilize SMBG data sets from any source, including memory meters and registry databases in call centers. Data are retrieved, processed, formatted, and then plotted on a PC screen or printer. The resulting lag plots visually characterize the performance of glucose control achieved over periods (selectable by the user) from days to months. Supporting numerical statistics provide rigorous outcome measures that correlate with glycated hemoglobin.

RESULTS

Clinical use of the lag plot is illustrated in seven case studies spanning the range from no diabetes, through glucose intolerance, early-onset type 2 diabetes mellitus, type 1 diabetes, intensified therapy, pump therapy, and finally islet cell transplantation. Visual comparisons before and after action/referral show impacts of interventions, incidences of hypoglycemia, and changes in the polyglycemia of unstable diabetes. Statistical significance of observed changes are quantified.

CONCLUSIONS

The simple lag plot can empower patients and their providers to identify problems in glycemic control, seek proactive action, adopt beneficial strategies, evaluate outcomes, and, most importantly, rule out interventions with no benefit.

Self-monitoring of blood glucose in children and teens with diabetes

Improved metabolic control has unequivocally been demonstrated to delay the onset and slow the progression of microvascular complications in adolescents and adults with diabetes mellitus. Growing evidence also supports the association of tighter glucose control and more frequent blood glucose monitoring. Therefore, self-monitoring of blood glucose (SMBG) has become a fundamental part of diabetes care in children. Here, we review recent advances and ongoing trends in glucose monitoring in children with diabetes. Technologies have been developed to improve patient compliance with recommended monitoring, requiring less blood, involving less pain, and providing results more quickly. Alternate-site testing (AST) is also a potential means of improving patient compliance with SMBG by avoiding the sensitive fingertip area. The Continuous Glucose Monitoring System (CGMS) and the GlucoWatch Biographer are two recent tools that can track glucose levels continuously. However, inconsistency in their accuracy and precision remain challenges when using these technologies to guide management.

Predictors of control of diabetes: monitoring may be the key

The factors affecting glycated hemoglobin concentration were examined in a cohort of children attending diabetes camp. Multivariate regression analysis revealed that frequency of self-monitoring of blood glucose correlated with lower glycated hemoglobin, whereas the number of insulin types used correlated with increased glycated hemoglobin. Frequent self-monitoring of blood glucose promotes long-term metabolic control.

Facilitating access to glucometer reagents increases blood glucose self-monitoring frequency and improves glycaemic control: a prospective study in insulin-treated diabetic patients

AIMS

To investigate whether availability of glucometer reagents increases the frequency of self-blood glucose monitoring (SBGM) and improves glycaemic control in diabetic patients.

METHODS

Sixty-two insulin-treated diabetic patients were randomized to two groups, matched for age, gender, education, income, type and duration of diabetes, years of insulin treatment, number of daily insulin injections, and haemoglobin (Hb)A1c. All patients were given a glucometer, but one group (no cost, NC) was provided glucometer test strips free of charge. The other group (control, C) had to purchase strips as they found it necessary. Both groups of patients were followed longitudinally at 2-monthly intervals for 12 months with measurement of blood glucose and HbA1c, and the frequency of SBGM was determined by downloading the glucometer memory.

RESULTS

The SBGM frequency was significantly higher in the NC group vs. the C group during the first 4 months (2.0 +/- 0.2 tests/day vs. 1.4 +/- 0.1 tests/day, P<0.025). Mean HbA1c remained stable over the 12 months in the NC group, whereas an increase with time was observed in the C group. The difference in HbA1c between the two groups was significant (P<0.002) after 6 months. Random blood glucose measured at each visit and average glucose recorded by the glucometer were also lower in the NC group vs. the C group (P<0.005). There was a negative correlation between HbA1c and SBGM frequency, and HbA1c in patients testing at least twice a day was lower than in those testing less than twice a day (8.8 +/- 0.2% vs. 9.6 +/- 0.2%, P<0.001).

CONCLUSIONS

In this prospective study, having easy access to glucometer strips provided free of charge to patients increased SBGM frequency. The relationship between HbA1c and SBGM frequency supports the view that SBGM is an essential tool in diabetes management.

Frequency of blood glucose monitoring in relation to glycemic control in patients with type 2 diabetes

OBJECTIVE

The aim of the study was to investigate the relationship between blood glucose level, measured as HbA(1c), and frequency of self-monitoring in patients with type 2 diabetes. Daily self-monitoring is believed to be important for patients treated with insulin or oral agents to detect asymptomatic hypoglycemia and to guide patient and provider behavior toward reaching blood glucose goals.

RESEARCH DESIGN AND METHODS

A national sample of patients with type 2 diabetes was studied in the third National Health and Nutrition Examination Survey. Data on therapy for diabetes, frequency of self-monitoring of blood glucose, and HbA(1c) values were obtained by structured questionnaires and by clinical and laboratory assessments.

RESULTS

According to the data, 29% of patients treated with insulin, 65% treated with oral agents, and 80% treated with diet alone had never monitored their blood glucose or monitored it less than once per month. Self-monitoring at least once per day was practiced by 39% of those taking insulin and 5-6% of those treated with oral agents or diet alone. For all patients combined, the proportion of patients who tested their blood glucose increased with an increasing HbA(1c) value. However, when examined by diabetes therapy category, there was little relationship between HbA(1c) value and the proportion testing at least once per day or the proportion testing at least once per week.

CONCLUSIONS

In this cross-sectional study of patients with type 2 diabetes, the increase in frequency of self-monitoring of blood glucose with increasing HbA(1c) value was associated with the higher proportion of insulin-treated patients in higher HbA(1c) categories. Within diabetes therapy categories, the frequency of self-monitoring was not related to glycemic control, as measured by HbA(1c) level.

Interinstitutional variation in glycohemoglobin monitoring and glycemic control of diabetic patients

OBJECTIVES

To compare how frequently institutions monitor glycohemoglobin in diabetic patients, the level of glycemic control achieved and to identify institutional factors associated with higher rates of monitoring and lower glycohemoglobin levels.

METHODS

A total of 212 institutions retrospectively abstracted laboratory and outpatient records of up to 30 diabetic patients who had initial glycohemoglobin monitoring performed in their laboratories. Data from a cohort of 5586 diabetic patients and 17 365 assays were analyzed.

RESULTS

Overall, 31.3% of patients underwent glycohemoglobin monitoring at least quarterly, the frequency recommended by the American Diabetes Association (ADA) to stabilize patients at target hemoglobin A(1c) (HbA(1c)) levels. A total of 64.9% of patients were monitored at least semiannually, the ADA recommendation for patients with stable diabetes in glycemic control (final HbA(1c) level <7%). When we compared the top and bottom deciles of the 212 institutions, there was more than an eightfold difference in the proportion of patients monitored at least quarterly and more than a twofold difference in the proportion of patients monitored at least semiannually. Glycemic control was assessed by examining the value of the last glycohemoglobin determination on record after at least 8 months of management. For all 5586 diabetic patients, the median value of the last HbA(1c) assay was 7.4%. Comparing the top and bottom deciles, there was almost a fourfold difference among institutions in the proportion of diabetic patients in glycemic control. The use of reminders to order glycohemoglobin monitoring was associated with higher rates of semiannual monitoring (P <.05) and tighter glycemic control (P <.05). In addition, patients who were monitored more frequently experienced glycohemoglobin reductions of greater magnitude (P <.001). The presence of diabetes clinics and the use of rapid methods for testing glycohemoglobin were not associated with monitoring frequency or glycohemoglobin levels.

CONCLUSIONS

There is wide interinstitutional variation in the frequency with which diabetic patients are monitored and the level of glycemic control achieved. The use of prompting systems to remind providers to order glycohemoglobin monitoring was associated with more frequent monitoring and superior glycemic control.

The promise of technology in the management of the patient with diabetes

The advent of technology has brought many improvements in the management of individual aspects of the care of the patient with diabetes. However, the best management requires communication between systems to enable the clinician to coordinate these various aspects. This article reviews examples of the application of technology to the individual aspects of care. It also discusses the problems and promise of technology to improve overall care management.

Telemedical care reduces hypoglycemias and improves glycemic control in children and adolescents with type 1 diabetes

Education programs for intensive insulin therapy were found to be valuable in improving glycemic control, but, due to low prevalence of type 1 diabetes in children and adolescents, access to those programs varies considerably in rural areas. We report on a telemedical care program that overcomes geographical isolation of patients on intensive insulin therapy. Sixty-one children and adolescents under the age of 26 participated in a telemedical care program. They stored daily information on blood glucose, injected insulin, meals and exercise in a glucosemeter with electronic memory and transferred the data via modem go a remote diabetes center outside of the region. By individual telephone consultations from home, they reviewed the data with a diabetologist at the diabetes center and adjusted their intensive insulin therapy in order to achieve predefined treatment goals. Patients were trained for 19 (6-48) weeks in the program and measured blood glucose 4.9 (1.7-4.9) times daily. Compared to the run-in-period, mean blood glucose had decreased (167 to 158 mg/dL, p < 0.01), standard deviation of blood glucose had decreased (81 to 70 mg/dL, p < 0.001), and frequency of hypoglycemia had decreased (5.2 to 3.3 in 4 weeks, p = 0.01) at the end of the program. The proportion of blood glucose values within the target range (80-180 mg/dL) had increased (47-55%, p < 0.001). HbAlc was reduced by 0.4% (-3.8 to +2.2%, p < 0.05). Telemedical care for intensive insulin therapy is safe, can improve glycemic control, and reduce the number of hypoglycemias in children and adolescents with type 1 diabetes.