Self-management of Blood Glucose (SMBG) and type 2 diabetes – a review. Diabetes is an expensive disease. People with diabetes incur medical costs that are 2-3 times higher than those without diabetes. Blood glucose monitoring strips (at approximately one dollar per strip) are a costly part of this financial burden. It has been reported that in some publicly funded drug plans in Canada blood glucose test strips are among the top 5 classes in terms of total expenditure with costs exceeding those for all oral anti-diabetes drugs combined (1).
The purpose of this article will be to review the recent changes to the Ontario drug benefit blood glucose test strip reimbursement policy, recommendations for SMBG (Clinical Practice Guidelines, 2013) and some of the research which supports these changes.
The diabetes educator can play a key role in recommending whether SMBG is indicated and meets best practice.
The Canadian Diabetes Association (2011) has an excellent briefing document for healthcare providers on self-monitoring of blood glucose for people with type 2 diabetes (2). The purpose of this report is twofold – to provide the CDA’s position on SMBG and to address the issue of provision of strips in a cost effective manner.
Some of the key points in this document include:
- Self-management of diabetes remains the cornerstone of care
- Some level of SMBG is appropriate for many with type 2 diabetes
- Diabetes is not a homogenous condition
- We need to differentiate between the numerous oral hypoglycemic agents (Table 1) as some put individuals at higher risk of hypoglycemia
- The CDA website (www.diabetes.ca) provides a SMBG tool for healthcare providers and 2 tools for people with diabetes. These will help to identify best individual practices for SMBG.
Table 1. Pharmacotherapy: risk of hypoglycemia
[box color=”blue” icon=”none”]
Pharmacotherapy with a lower risk of hypoglycemia (Group 1)
- Pioglitazone, rosiglitazone
- Saxagliptin, sitagliptin
- Liraglutide, exenatide
[box color=”blue” icon=”none”]
Pharmocotherapy with a higher risk of hypoglycemia (Group2)
- Gliclazide, glimepiride
- Nateglinide, repaglinide
- Chlorpropamide, tolbutamide
In this document the CDA suggests a minimum government reimbursement for 15 test strips per month for those in Group 1 and 30 strips per month for those in Group 2. The report also points out that where exceptions need to be made there should be a mechanism in place to facilitate this.
Recent changes in Ontario coverage
The Ontario Ministry of Health and Long-Term Care has announced changes to the public coverage of blood glucose strips for monitoring of diabetes for clients with type 2 diabetes. The changes were effective as of August 1, 2013.
The changes will be as follows:
- Those on insulin once per day and oral hyperglycemic agent(s) will have coverage of up to 3000 strips per year. The CDA Clinical Practice Guidelines (2013) suggest testing at least once per day and at variable times.
- Those on insulin (more than once per day) will have coverage of up to 3000 strips per year. The CDA suggests testing at least 3x per day.
- Those who use oral anti-diabetes medications which confer a high risk of hypoglycemia will have coverage for up to 400 strips per year. The CDA suggests testing when symptomatic of hypoglycemia or at times when hypoglycemia has occurred.
- Those who use oral anti-diabetes medications which confer a low risk of hypoglycemia will have coverage for up to 200 strips per year. The CDA suggests testing 1-2x per week to ensure glycemic targets are being met between A1C tests.
- Those who are controlled by lifestyle alone and meeting glycemic targets will be allowed up to 200 strips per year. The CDA suggests that daily SMBG is not usually required.
Research findings to support these changes
Type 2 on insulin
A large nonrandomized study of individuals with stable type 2 diabetes using insulin found that testing at least 3 times per day was associated with improved glycemic control (3). More frequent testing (pre and 2 hour post prandial) is often required to reduce risk of hypoglycemia.
Type 2 not on insulin
The studies have found the following:
- A small benefit in those performing SMBG compared to those who did not (A1C reduction 0.2% to 0.5%)
- A greater benefit in those whose A1C was >8%
- SMBG is most effective in those persons with type 2 diabetes within the first 6 months of diagnosis
- There is no evidence to suggest that SMBG affects general health-related quality of life
- Most trials in those with A1C <8% did not include educational or therapeutic intervention in response to blood glucose values and so the results are of limited value.
Trials that included educational or therapeutic intervention in response to blood glucose values
- STeP trial – this study (published in 2011) included 483 poorly controlled type 2 clients with diabetes (not on insulin with A1C > or = 7.5%. They were randomly assigned to an active control group or a structured testing group (STG). Although the frequency of testing did not differ between the two groups the STG completed a 7-point SMBG profile prior to each study visit (ac and pc each meal and at bedtime). The study took one year and visits took place at months 1, 3, 6, 9, and 12. The STG group were given instruction on how to address problematic blood sugars with physical activity, portion sizes and/or meal composition. The STG group doctors were also involved in medication adjustments. At study completion there was a reduction of 1.2% in the STG group versus 0.9% in the control group and less glycemic excursion in the STG group. The authors concluded that meaningful test results contribute to positive action (4).
- St Carlos Study – this study compared the benefits of self-monitoring and A1C algorithms in newly diagnosed patients with type 2 diabetes. Participants were recruited between 2006 and 2007 (n= 62 in the control group and 99 in the SMBG group). Those in the self-monitoring group kept a 6 –point profile every 3 days (ac and pc each meal). After blood sugars were stabilized they kept 1 profile every 1 or 2 weeks depending on type of treatment. At the end of the year study there was a significantly greater reduction in median A1C and BMI in the intervention group. The authors concluded by suggesting a 6-point profile every 3 days at the beginning of treatment followed by 1 profile every 2 weeks. This works out to 144 strips per year for a client whose blood sugars remain stable. They also felt that the word “intensive treatment” be modified away from the use of insulin to reflect the intensity with which we work to achieve glycemic goals (5).
- The ROSES TRIAL (role of self-monitoring of blood glucose and intensive education study) – this was a six-month trial (published in 2011) led by diabetes nurses and it compared the role of self-monitoring of blood glucose (n=46) with usual care (no monitoring with standard care, with n=16). Most of the patients were on metformin (100% of the usual care group and 93.5% of the study group). Patients were taught how to modify their lifestyle (meal carbohydrate content and level of physical activity) according to blood glucose results. Monitoring was performed about 12 times per month (ac and pc each meal on separate days). Results were discussed during face-to-face encounters every 3 months and monthly telephone calls. After six months there was a significantly greater reduction in mean A1C (1.2% reduction in the experimental group versus a 0.7% reduction in the control group) and body weight in the self monitoring group than the control group. The authors concluded that a timely and efficient use of monitoring results is able to improve metabolic control (6).
The changes in the Ontario drug benefit blood glucose test strip reimbursement policy are a good step in containing the cost of this expensive tool. Not every client with diabetes needs to monitor. For the majority who will benefit the diabetes educator is the key person to help set up a meaningful testing schedule. This will involve when and how often to test as well as strategies of how to deal with glucose levels outside of glycemic targets. This will go a long way in this time of limited health care dollars.
- Cameron C et al. Cost effectiveness of self-monitoring of blood glucose in patients with type 2 diabetes managed without insulin. CMAJ 2010; 182: 28-34.
- Canadian Diabetes Association. Self-Monitoring of Blood Glucose in People with Type 2 Diabetes: Canadian Diabetes Association Briefing Document for Healthcare Providers. CJD 2011; 317- 319.
- Sheppard P et al. Pre- and post-prandial capillary glucose self-monitoring achieves better glycemic control than pre-prandial only monitoring. A Study in Insulin Treated diabetic patients. Practical Diabetes Int 2005;22:15-22.
- Polonsky WH et al. Structured self-monitoring of blood glucose significantly reduces A1C levels in poorly controlled noninsulin-treated Type 2 diabetes: results from the Structured Testing Program study. Diabetes Care 2011;34:262-267.
- Duran A et al. Benefits of self-monitoring blood glucose in the management of new-onset Type 2 diabetes mellitus: The St Carlos Study, a prospective randomized clinic-based interventional study with parallel groups. Journal of Diabetes 2010; 2: 203-211.
- Franciosi M et al. ROSES: role of self-monitoring of blood glucose and intensive education in patients with Type 2 diabetes not receiving insulin. A pilot randomized clinical trial. Diabetic Medicine 2011; 28: 789-796.