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Self monitoring of blood glucose in non-insulin treated type 2 diabetes
- Subrata K Mallik (22 April 2008)
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Self-monitoring of blood glucose: The cost to patients
- Monika M. Safford, Louise B. Russell, PhD, Rutgers University, USA (2 May 2008)
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Musings of an Insulin Junkie.
- Robert Matz (28 May 2008)
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Subrata K Mallik, Locum Consultant Endocrinologist Prince Charles Hospital, Merthyr Tydfil CF47 9DT
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I thank Simon et al for the article. I agree, self monitoring of blood glucose(SMBG) is not routinely necessary in non-insulin treated type 2 diabetes. However, learning how to measure blood glucose correctly is a part of initial diabetic education. SMBG in a willing cooperative patient may be useful during adjustments in dosage of medications or adding new ones and during illness etc, provided the tests are done correctly and appropriate advice sought from the diabetes team. Those who are on metformin, glitazones or sitagliptin/exenatide probably do not need SMBG as risk of hypo is low and HbA1c every 3 to 6 months should be sufficient. Those on sulphonylurea are at higher risk of hypo and hence SMBG, perhaps 2 to 3 times a week, is likely to be useful and blood glucose testing before and during longdistance driving, before exercise etc may be desirable. An intelligent patient may be able to find out the effect of medication, diet, exercise etc on blood glucose and may motivate them to pursue life style changes etc more stringently. SMBG done incorrectly may make the patient more anxious thereby adversely affecting quality of life. With appropriate education and training in willing cooperative patients, in appropriate circumstances, are likely to be beneficial in long-term outcomes in non-inslin treated type 2 diabetic and will probably be worth the cost. Competing interests: None declared |
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Monika M. Safford, Associate Professor of Medicine University of Alabama at Birmingham, 35294-4410 USA, Louise B. Russell, PhD, Rutgers University, USA
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In BMJ published online 17 April 2008, Simon, et al., analyze the cost-effectiveness of glucose self-monitoring by patients with non-insulin treated type 2 diabetes (1). They found that it raised costs to the National Health Service (NHS) without benefiting patients’ glycemic control. Counting only those items that occasioned an outlay by the NHS, less intensive self-monitoring cost ₤92 more than standardised usual care, and more intensive self-monitoring cost ₤84 more. Financial cost to the health system is, however, but one perspective that needs to be considered in weighing the benefits and costs of an intervention. An important finding in the study was that patients who self -monitored were more anxious and depressed than control patients. We would like to point out an additional cost: the time it takes to self-monitor the prescribed 3 times daily for 2 days each week (2). A published estimate of that time, made by diabetes educators, is available – 3 minutes per self-monitoring episode for experienced patients with type 2 diabetes controlled by oral agents (3). While three minutes is trivial, summing the time over a year and attaching a monetary value places it in a somewhat different light. Self- monitoring at the prescribed frequency would require 15.6 hours annually. Economic reasoning shows that, for working-age adults, the wage rate represents not only the gain from working an hour, but the opportunity cost of an hour spent on unpaid activities, and can thus be used to translate time costs into monetary terms (4). Conservatively valued at the 2005-2006 adult minimum wage (about ₤5), 15.6 hours is worth ₤78, nearly as much as the additional NHS costs of the intervention. Valued at the average wage rate, time costs would substantially exceed the NHS costs. We present these estimates because we think those who develop self- care recommendations need to recognize the time requirements placed on patients. While the NHS does not pay these costs, they affect patients’ willingness to comply with recommendations. In this case, time costs may help explain why the percentages of patients still self-monitoring at the end of the first year had dropped to 67% in the less intensive group and 52% in the more intensive group (2). For patients who stopped monitoring, the staff effort paid for by the NHS, and some of the supplies, were wasted. Time costs reinforce the conclusions reached by Simon, et al. Self- monitoring did not reduce average patients’ blood sugar, lowered their quality of life, and cost not only the NHS but also patients substantially more than usual care. Louise B. Russell, Ph.D. Rutgers University Monika M. Safford, M.D. University of Alabama at Birmingham References 1. Simon J, Gray A, Clarke P, Wade A, Neil A, Farmer A on behalf of the DiGEM Trial Group. Cost effectiveness of self monitoring of blood glucose in patients with non-insulin treated type 2 diabetes: economic evaluation of data from the DiGEM trial. BMJ 2008, e-published ahead of print 17 April 2008. 2. Farmer A, Wade A, Goyder E, Yudkin P, French D, Craven A, et al. Impact of self monitoring of blood glucose in the management of patients with non-insulin treated diabetes: open parallel group randomised trial. BMJ 2007;335;132-139. 3. Russell LB, Suh D-C, Safford MM. Time requirements for diabetes self-management: too much for many? J Fam Pract 2005;54;52-56. 4. Varian HR. Intermediate microeconomics: a modern approach. 3rd ed. New York: WW Norton, 1993, 171. Competing interests: None declared |
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Robert Matz, Professor--Medicine Mount Sinai Medical Center, 1 Gustave Levy Pl. New York,NY 10019
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Of course the critical issue is how well the non-insulin using diabetic is controlled. Many are carried as NIDDM (non-insulin dependant diabetes) long past the time when they should be on added insulin or only insulin. Intermittent fs Blood Glucose measurements help determine when the oral agents are no longer as effective as needed and lead to an earlier addition of or switch to insulin. Reliance solely on the HgbA1c is a blunt tool and by the time it rises much valuable time in the course of diabetic complications may have passed--as we all know from seeing diabetics who present with complications at the time of diagnosis. A prudent policy in relation to SBGM (self blood glucose monitoring) in NIDDM is the strived for goal. Competing interests: None declared |
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