A prospective study to evaluate the benefits of long-term self-monitoring of blood glucose in diabetic children

A focus on blood glucose monitoring: relation to glycemic control and determinants of frequency

OBJECTIVE

To re-examine the relation of blood glucose monitoring to glycemic control among adolescents with type 1 diabetes and to evaluate the relation of demographic, behavioral, and psychosocial characteristics of adolescents who monitor more and less frequently.

RESEARCH DESIGN AND METHODS

Participants were 132 adolescents with type 1 diabetes (average age = 12 yr) and their parents, recruited from Children's Hospital of Pittsburgh. Adolescents were interviewed annually for five consecutive years after routine clinic appointments. At each assessment, data from blood glucose meters were downloaded and glycosylated hemoglobin A1c was recorded from medical records.

RESULTS

More frequent blood glucose monitoring was related to better glycemic control. Adolescents who monitored more frequently were younger, from higher social status families, on insulin pumps, and had higher self-efficacy. Age-related declines in blood glucose monitoring occurred among adolescents with low self-esteem, high stressful life events, and lower parental support.

CONCLUSIONS

Given the importance of blood glucose monitoring for good glycemic control, future research should enhance adolescents' self-efficacy for monitoring and intervene with those who are at risk for age-related declines in blood glucose monitoring.

On what evidence-base do we recommend self-monitoring of blood glucose?

Self-monitoring of blood glucose (SMBG) has been considered one major breakthrough in diabetes therapy because, for the first time, patients were able to determine their blood glucose levels during daily life. It seems obvious that this must be of advantage to disease management and clinical outcome, but it has become a nightmare for those trying to provide evidence. Randomised controlled trials have yielded inconsistent results on a benefit of SMBG-based treatment strategies not only in type 2 but - surprisingly - also in type 1 and gestational diabetes. Despite this, SMBG is being considered indispensible in intensive insulin treatment, but is being debated for other clinical settings. When considering the non-RCT based reasons for recommending SMBG in type 1 and gestational diabetes it becomes apparent that the same reasons also apply to type 2 diabetes.

Hemoglobin A1c self-recording in the management of diabetes mellitus. A pilot study

HbA1c evaluates glycemic control 3-6 weeks retrospectively. To achieve improvements in glycemic control we have tested a patient-administered HbA1c control program in 12 (11 type I) diabetic patients. In the program, HbA1c was estimated once a month for 12 months and the results were mailed to the patient who recorded them in a specially designed HbA1c chart. The results in the probands were compared with 24 matched (22 type I) diabetic patients. The results showed that HbA1c fell significantly (p less than 0.01) during the year in the probands, from 8.84 +/- 1.12% to 7.48 +/- 0.95%, and was unchanged in the controls (8.41 +/- 1.78% and 8.17 +/- 1.74%, respectively). Accordingly, HbA1c self-recording improves glycemic control in diabetic patients.

Self blood glucose monitoring in type 2 diabetes. A financial impact analysis based on UK primary care

BACKGROUND

UK consensus guidelines recommend limited use of self-monitoring of blood glucose (SMBG) in patients with type 2 diabetes using diet and exercise, metformin and/or a glitazone. This analysis quantifies the usage of and costs associated with SMBG in type 2 diabetes according to treatment regimen.

METHODS

Prevalence data for diabetes were assessed using UK Quality and Outcomes Framework returns for 2006/2007. Data on current SMBG prescribing expenditure were extracted from UK Prescription Pricing Agency Data for 2007. Prescribing data were extracted from the records of 40,651 patients with diabetes on the IMS Disease Analyzer (MediPlus) database. These were combined to arrive at mean usage and expenditure data per patient, broken down by treatment type. The analysis assumes that it is appropriate to use patients' treatment regimen alone to compare the frequency of SMBG in clinical practice with the frequency recommended in treatment guidelines; it does not take into account other valid reasons for SMBG.

RESULTS

Mean national expenditure on SMBG was 73.64 pound sterling per patient per year. Estimated mean weekly test strip usage by treatment was 2.5 (diet), 2.6 (glitazone monotherapy), 3.1 (metformin monotherapy) and 3.5 (sulphonylurea monotherapy). Combination oral therapy ranged from 3.3 to 4.1. Mean annual expenditure in patients with an identified treatment type was 62.06 pound sterling per patient, ranging from 9.83 pound sterling for diet-treated patients to 37.87 pound sterling for those on triple therapy, with insulin-treated patients incurring costs 3-5 times higher.

CONCLUSIONS

Based on the assumptions that the treatment regimen is the sole factor in determining the appropriate level of SMBG frequency, this study demonstrates that the use of SMBG exceeds current guidelines in certain treatment groups. The study estimates that the potential savings of up to 17 million pound sterling could be made each year if guidelines were followed more closely. There is a need for further research into SMBG use in patients with type 2 diabetes.

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.

[Evaluation of 2 home monitoring schemes in patients with type 1 diabetes mellitus]

The goal of this study was to evaluate the effectiveness of two monitoring schemes(blood and urine) in the metabolic control of type 1 diabetic patients, in biweekly therapeutic adjustments, along 6 months of participation in the educational groups. A sample of 34 patients was divided in two groups. The interventions proposed to group A were daily blood glucose monitoring, during three consecutive days for each period (before breakfast, before lunch, before dinner and before bed) and biweekly in the dawn. For the other group B was proposed daily urine glucose monitoring, during three consecutive days for each period (before breakfast, before lunch, before dinner and before bed). These schemes were used to construct glycemic profile and to determine the therapeutic adjustments. The results evidenced that there was no significant statistical difference in the metabolic control after proposed intervention in each group. In spite of this, the monitoring facilitated the educational process and the considerations about the use of more intensive monitoring schemes.

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.

Home blood glucose monitoring: effectiveness in a general population of patients who have non-insulin-dependent diabetes mellitus

OBJECTIVE

To determine whether home blood glucose monitoring as used by non-insulin-dependent diabetes mellitus patients followed in primary care nonresearch clinics improves glycemic control or reduces utilization of the outpatient laboratory.

DESIGN

A retrospective chart review for 229 patients receiving outpatient supplies for home testing of either blood or urine.

SETTING

A variety of nonresearch clinics at a Veterans Affairs Medical Center, a teaching hospital affiliated with an academic university medical center.

PATIENTS

Outpatient veterans followed in diabetes, primary care, internal medicine, or endocrine clinics.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The mean glycosylated hemoglobin for an unselected group monitoring glycemic control by urine testing only was 11.32% and for those using blood monitoring was 11.37%. Frequency and duration of monitoring had no apparent impact on glucose control. There was no decrease in the utilization of the laboratory among those patients practicing home blood glucose monitoring.

CONCLUSIONS

For non-insulin-dependent diabetic patients followed in a nonresearch clinic setting, the benefits of home blood glucose monitoring remain to be proven.

Change in glycemia in a four-year interval in younger-onset insulin-dependent diabetes

Hyperglycemia is an important risk factor for the development of retinopathy and nephropathy in people with diabetes mellitus. There are few population-based data on changes in glycemia over time. The purpose of this study was to examine changes in glycemia, as measured by glycosylated hemoglobin in 1980 to 1982 and in 1984 to 1986, in a large population-based study of people who were diagnosed to have diabetes before the age of 30 years and who used insulin (n = 697). Glycosylated hemoglobin was measured by a microcolumn technique at both examinations. There was a significant (P < .001) fall in the mean glycosylated hemoglobin from 10.8 to 10.1% over the 4-year interval of the study. In contrast, there was no change in the glycosylated hemoglobin (6.2%) in a similarly aged nondiabetic comparison group over the same period. The decrease in mean glycosylated hemoglobin over the 4-year period in the diabetic group was associated with several characteristics of diabetes management. These include changes in the insulin regimen (going from intermediate- or long-acting insulin only to combinations with short-acting insulin), an increase in the number of doses of insulin per day, and a higher frequency of self-monitoring of blood glucose level. It was also associated with an increased number of reported insulin reactions. These data suggest that recent changes in treatment and management of diabetes may be related to a significant decrease in glycemia.

The Role of the Pharmacist in the Care of the Ambulatory Diabetic Patient

The management of diabetes often includes significant changes in diet, exercise patterns, social activities, and medication-taking behavior. Many of these changes are a burden on patients and their families. The best approach to the management of a person with diabetes is an approach that empowers the patient. Pharmacists often are in the best position within the health care team to facilitate patient empowerment. A few pharmacists have taken advantage of this niche to open a variety of practices serving the needs of people with diabetes. At the Philadelphia, PA, Veterans Administration Medical Center (VAMC), a Pharmacy Diabetes Clinic was established with diabetes-related research as its primary goal. Educational and skill development services also are offered to patients. The same pharmacist involved in the Philadelphia VAMC Pharmacy Diabetes Clinic has recently begun the process of setting up an adjunct pharmacy service for people with diabetes within an existing community practice. Rough comparisons between these two practice settings are discussed, including the differences in available data, clinic objectives, and administrative aspects.

Data source automation: new technology for the management of patient-generated test results

Self-monitoring of blood glucose is widely accepted by patients today, but its usefulness to clinicians has been seriously limited by our inability to interpret the patient-generated data. It is difficult or impossible to make optimal use of hand-kept diaries, no matter how compulsively kept. Patterns elude us, summaries are inaccurate, and large blocks of data are almost entirely ignored. To remedy these problems, data source automation--the automatic recording of data at their site of origin--is being applied to diabetes. Meters will measure blood glucose and memorize the result, date, and time of day. One system even allows the patient to record insulin dosage, exercise, and diet. The advantage of these systems lies in their potential for data management. Recognition of patterns of blood glucose concentration, easy longitudinal comparison of data, and aggregation of large data bases are all facilitated by computerized manipulation of the stored data. In-hospital use of glucose meters can have better documented quality control. It is possible to communicate data to physicians by telephone modem. Effective use of these systems, though, requires convenient software; and their acceptance in actual clinical practice must be demonstrated. But data management capabilities, as they are refined and brought into common use, could significantly improve diabetic management.

Seasonal variation of haemoglobin A1 in children with insulin-dependent diabetes mellitus

The results of three controlled trials performed on children with insulin-dependent diabetes mellitus were examined for evidence of seasonal variation in concentrations of glycosylated haemoglobin (HbA1). All three studies showed lower levels during the summer months. Multiple regression analysis showed that the month of sampling accounted for a significant proportion of the total variance in HbA1 levels (P less than 0.001 in all three studies). We suggest that exercise, dietary changes and the frequency of minor illnesses may all contribute to this fluctuation which has important implications for the design of clinical trials in childhood diabetes.

Impact of blood glucose monitoring on diabetic control: obstacles and interventions

Despite frequent use in the management of diabetes mellitus, self-monitoring of blood glucose (SMBG) is not achieving its potential therapeutic impact. Among the behavioral factors which may interfere with the improvement of diabetic control through SMBG are noncompliance and inadequate utilization of obtained blood glucose data. This paper reviews the research concerning these issues, including estimates of the prevalence and clinical significance of each of these limiting factors and an evaluation of assessment and intervention strategies which have been investigated. The methodological problems encountered in attempts to demonstrate that SMBG behaviors affect diabetic control are discussed. Although the existing research literature provides very weak evidence linking SMBG behaviors and diabetic control, the author asserts that it is premature to conclude that such relationships cannot be established and maintained.

Self-monitoring of blood glucose by adolescents with diabetes: technical skills and utilization of data

Two studies of adolescent patients were conducted to determine their technical skills and utilization of data obtained by self-monitoring of blood glucose (SMBG). In Study 1, direct observations of 58 adolescents revealed an overall SMBG technical accuracy score of 82%. Most frequent errors were not cleaning fingers (45%), not placing blood on strips correctly (21%), and wiping strip at wrong time (14%). Technical performance was inversely correlated with blood glucose concentration, but was unrelated to other variables. In Study 2, a questionnaire was used to determine SMBG practices among 64 adolescents. Although the majority of patients reported doing daily SMBG, most did not record results in logbooks every time or utilize such data for self-management. No significant relationships were found between SMBG behaviors and other variables. We conclude that periodic evaluation and retraining are required for maintenance of SMBG skills and that methods to enhance utilization of SMBG data be developed for this patient population.

Blood glucose monitoring by children at home: a comparison of methods

The accuracy of measurements of blood glucose performed at home by the index children and/or parents was compared using the Boehringer Mannheim reagent strips, Ames Visidex-2 strips, an Ames Glucometer and a Boehringer Mannheim Reflolux reflectance meter. Capillary plasma samples, collected simultaneously, were later analysed by a Beckman glucose oxidase analyser. The coefficient of correlation between the self-monitored results (SMR) and the laboratory-analysed results (LAR) ranged from 0.59 to 0.92, the composite being 0.74. The mean difference between the SMR and the LAR was 1.0 mmol/l. The occurrence of potential errors of management due to incorrect SMR results was determined. On four occasions, the SMR was greater than 6 mmol/l when the LAR was less than 3 mmol/l, and on 36 occasions a discrepancy greater than 50% occurred between the two values, without resulting hypoglycaemia.

Management of diabetes mellitus

The past decade has seen a rapid advancement in our understanding of diabetes and in our ability to treat it. A new diagnostic classification has been established. Guidelines for diet therapy have been revised. New oral hypoglycemic agents have been approved for use, and the rationale for using oral agents expanded. Insulin therapy has been expanded by development of human insulin and new modes of injection, including insulin pumps. Several new techniques are available for monitoring control of diabetes.

Sustained improvement in diabetic control on long-term self-monitoring of blood glucose

The benefits of self-monitoring of blood glucose (SMBG) were assessed in 38 Chinese adults on conventional insulin regimens who had been performing SMBG for a mean duration of 26 months (range 15-40). For analysis patients were divided into 2 groups. Group A consisted of 27 insulin-requiring patients who were referred for SMBG because of poor control or young age (less than or equal to 35 years). Group B consisted of 11 IDDM patients who were on SMBG from diagnosis. Mean age and duration of SMBG were similar in the 2 groups though group A had longer duration of disease. In group A, mean haemoglobin A1 (HbA1) decreased from 12.4 +/- 0.5% before SMBG to 10.9 +/- 0.5% at 6 months (P less than 0.005), 10.7 +/- 0.5% at 12 months (P less than 0.005) and 10.3 +/- 0.4% after long-term SMBG. This was accompanied by a significant reduction in insulin requirement from 0.82 +/- 0.07 U/kg/day to 0.72 +/- 0.07 U/kg/day (P less than 0.05). In group B, insulin requirement progressively decreased in the first 6 months. At 12 months, mean HbA1 was 9.0 +/- 0.5% and insulin requirement was 0.58 +/- 0.08 U/kg/day. No significant change in HbA1 or insulin requirement was observed beyond the first year. After long-term SMBG, 82% of patients in group B had good control (HbA1 less than or equal to 10%) compared to 45% only in group A (P less than 0.05). Long-term SMBG is associated with sustained improvement in diabetic control and is particularly beneficial if introduced to diabetic patients right from diagnosis.

Metabolic rhythms in adolescents with diabetes

Metabolic rhythms were studied over 24 hours in eight adolescents with insulin dependent diabetes before and two months after attempting to improve diabetic control with home blood glucose monitoring. A significant improvement in blood glucose concentration was observed, although 24 hour mean concentrations remained grossly abnormal. This improvement was accompanied by significant falls in blood glycerol and total ketone bodies concentrations and a significant rise in blood lactate concentration. Without attention to other factors affecting diabetic control, the introduction of home blood glucose monitoring produces only a small improvement in control.

Relationship between hypoglycemic symptoms and blood glucose levels due to self-monitoring in summer camp for diabetic children in Japan

In a summer camp for 47 diabetic children in Kinki district, Japan, in 1984, the relationship between hypoglycemic symptoms and blood glucose levels by self-monitoring was analyzed. During the 7-day camp, self-monitoring of blood glucose (SMBG) was carried out 599 times in total, 12.7 times per camper. SMBG due to hypoglycemic complaints amounted to 371. 154 measurements out of 371 indicated blood glucose levels under 80 mg/dl, but 78 monitorings were found to be over 200 mg/dl. Fatigue or weakness were the most frequent hypoglycemic symptoms, as was hunger sensation, each reaching approximately 40% in frequency. In most complaints of tremor, the blood glucose level was critically low. Prompt measurement of blood glucose is indeed necessary to properly treat diabetic children with 'hypoglycemic' symptoms.