Reviewing the Literature on SMBG

Last Friday I received my chunky copy of the Nov/Dec issue of “The Diabetes Educator,” the AADE’s professional journal, and discovered a comprehensive 18-page article on the topic, “Does Patient Blood Glucose Monitoring Improve Diabetes Control? A Systematic Review of the Literature.”

Fingerstick_check First reaction: Wow. I can’t believe the professional community is still asking itself this question.

Second reaction: Wow. Detailed charts of the results of 29 different studies, and the major conclusions are –

* “SMBG (self-monitoring of blood glucose) 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.”

Given these rather inconclusive conclusions, what is perhaps more important are the statements made in the article’s “Implications” section:

Further studies are needed “emphasizing the importance of the behavioral processes that underlie a volitional action such as SMBG.”

And…

Failure of blood glucose control in personalized medicine represents a failure of the medical care system, not a failure of the patient.

Wow again. The authors are admitting that clinical studies on SMBG are likely getting lukewarm results because medical providers are failing to educate patients on how to use their meters in a way that actually results in better glucose control!

In a separate, excellent commentary provided by CDE Martha Funnell, she explains in two pages what we can make of all this: “The efficacy of SMBG for for patients with Type 2 not using insulin remains controversial…” because it has not traditionally been “viewed in the broader context of diabetes self-management rather than as a single behavior… Very few studies have examined SMBG as a component (of lifestyle along with) behavioral modifications in food intake, exercise, or medications.”

D’oh.

One might say that the ADA’s Dr. Kahn was referring to these inconclusive studies when he delivered his “anti-technology” speech last month, i.e. does it make sense to keep bombarding patients with sophisticated new meter models packed with features they’ll never use, when they don’t understand the models they’ve already got? Of course not.

But I believe that line of thinking can definitely lead to drawing the wrong conclusions. I mean, we wouldn’t want to halt progress on developing new and better CAT Scan technology just because many doctors may not be making the best use of the machines they have now, right? Or we wouldn’t wish to stop researching better ways to treat lupus just because some of the current methods haven’t yet reached their full potential…

What I’m saying is, I think the authors of this McAndrew et al study have hit the nail on the head by recognizing that SMBG has to be viewed in the context of a patient’s full diabetes care regime. The technology IS extremely valuable. It CAN have a significant impact on patient’s long-term health, IF it is delivered with the proper education, and with a view toward addressing the patient’s WHOLE LIFE.

The message must come through that simply using a meter or other device is not going to “take care of your diabetes.” Each patient has to actually know how to act on the information their meter provides.

To this end, Martha offers educators seven practical tips that I think we can all appreciate:

  • Stress the importance of SMBG as data needed by the patient for decision
    making, not as something done primarily for the benefit of the provider.
  • Emphasize that the results are not a judgment of the patients’
    self-management efforts but simply a number they can use to make informed
    decisions.
  • Assist patients to identify blood glucose goals and actions to take to
    achieve those goals.
  • Identify strategies for overcoming barriers to monitoring.
  • Assist patients in dealing with the impact of results that are not
    reflective of their efforts from both psychological and behavioral
    perspectives.
  • Help patients identify strategies to obtain the support they need for SMBG
    from members of their families and health care team.
  • Role-play responses to negative comments about the results from members of
    their family and health care team.

OK, all you Patient Experts out there: Got any other ideas on how CDEs can help us use glucose monitoring technology to our best advantage?

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11 Responses

  1. Rachel
    Rachel December 11, 2007 at 7:22 am | | Reply

    Excellent points have been made. I agree that SMBG is an important tool in decision making – whether it inspires someone to exercise or whether it inspires someone to speak up when “adverse trends” appear.

  2. Eric Link
    Eric Link December 11, 2007 at 9:12 am | | Reply

    For people in our programs, we see results when we deliver education along w/ the glucose values. Without context, the BG is just a number. W/ context and education, it is a useful tool for changing regiment and behavior. Simple as that. Our system of programs for helping people managed are centered around this idea, that’s what makes us different than ‘disease management’; we are about helping people do their best self management w/ the least effort possible.

  3. CB
    CB December 11, 2007 at 9:47 am | | Reply

    Amy, this is both interesting and disturbing news. As someone who’s used SMBGs since the beginning and been involved with the design and evaluation of non-medical equipment “experiments”, I’d have to say it’s close to outrageous that the 29 studies summarized by the Diabetes Educator article can’t/don’t effectively answer this question. Admittedly, such a study would be difficult to design, but come on, it’s not impossible, and the impossible only takes a little longer. I would love to read the article, but the journal’s requiring me to pay $25 to do so at their web site seems equally outrageous. My guess is the 29 studies subject to the article’s meta-analysis were created to answer other research questions and not, “does using a SMBG device improve a D’s health (as measured by A1c or BG values).” My question, like yours, is why in the more than two decades that SMBG devices have been promoted and used, is this still a question. My sense is there may be three reasons: (1) the manufacturers of the devices may not have really wanted a statistically-definitive answer available – they created a huge market without such a study, which might be jeopardized by the study’s results (because if the result was negative or merely inconclusive, insurance companies might not reimburse). (2) Thankfully, for whatever reasons, insurance carriers bought into our using BG monitors quite a while ago and have reimbursed Ds for their use (never mind that the cost of BG strips is suspiciously high). If the insurance companies hadn’t agreed to pay without such a study, such a study would have been completed a long time ago. And (3) use of SMBGs is too commonsensical a foundation for proper D care to necessitate an expensive experiment to answer the obvious (except possibly for Dr. Kahn) – as they say, you can’t manage what you don’t measure. Now if only more Ds understood how to actually use their SMBGs to their health advantage.

  4. Sarahs
    Sarahs December 11, 2007 at 10:05 am | | Reply

    What about all of those people who CAN’T utilize data from SMBG? A lot of Type 2 diabetics are poor undereducated minorities or immigrants who have little resources or ability to draw a conclusion based on a number. As a Type 1 diabetic, I know how hard it can be to manage diabetes, and I’m university educated.

    A better idea is to put that money into programs that will do the work for those people who really are too slow to help themselves. Food banks that severe healthy meals, free community centres that offer exercise programs and staff nurses, a required fitness and lifestyle assessment in order to receive a welfare cheque. Put healthy meals and exercise back in schools.

    It is no longer survival of the fittest anymore. We are supposed to help those who are not able to help themselves. Although some Type 2 diabetics simply don’t want to change their habits, many simply *can’t* or they already would have. It’s not rocket science to know what is healthy and what is not, there has to be something else holding these people back, like a lack of resources, education, or a mental deficiency.

    Make it easy for people to do things right, give them little choice, and things should get done.

    If it is really lifestyle changes that make diabetes care better in cases such as this, it may be OK to sidestep the middleman and go striaght for the pot.

  5. CB
    CB December 11, 2007 at 10:58 am | | Reply

    Having just been able to read the article, I now understand that the article’s objective was perform a review of recent studies that examined the impact of SMBG on A1c levels for type 2 Ds, not type 1s. I still believe my previous comment holds, but since the article is only looking at T2s (the evidence about SMBGs impact for T1s is apparently a foregone conclusion), it’s perhaps more understandable that the empirical evidence isn’t as definitive for T2s as it is for us T1s. In my own case, the value of SMBG comes only from using the test results as one part of my “system” for understanding my D and what to do about it(always an art not a science), if I’m too high or low. My system is behavioral, recognizing (but not always understanding) that almost everything I do in some way influences my BG.

  6. WC
    WC December 11, 2007 at 11:32 am | | Reply

    I don’t understand why you rail against the industry lumping T1 and T2 into the same group, yet you cover topics like this that obviously have no bearing on T1.

  7. jan
    jan December 11, 2007 at 12:02 pm | | Reply

    Access to CDE’s as a necessity for Type 2′s would be a good place to start.

    And family care MD’s actually asking to see a patient’s log would help too.

    I have moved a bit since my diagnosis and none of the family doctors EVER asked if I had a meter or used one! Never offered a prescription for the test strips either.

    Amy is right to include Type 2′s. We need all the education we can get on our own.

  8. Russell Scott
    Russell Scott December 11, 2007 at 1:22 pm | | Reply

    When I was diagnosed as Type 2 I had to demand my GP schedule me for training. I then had to request an ENDO be part of my diabetic team. I look at self testing as a way to keep score(me against the BAD GUY). I just wish the training had been completely covered by my insurance. I had to pay half.

  9. AmyT
    AmyT December 11, 2007 at 10:59 pm | | Reply

    Ooh, am I guilty of “lumping” here? Touché, WC.

    I suppose I should have clarified that the studies in question focus primarily on T2 patients, but the larger issues lap over into the T1 community as well. The point I am making, about the need for education and a “systems approach” to treating diabetes, applies to ALL patients.

  10. Sharlene Emerson
    Sharlene Emerson December 13, 2007 at 12:10 pm | | Reply

    I read Amy’s comments about blood glucose monitoring. As Educator’s we have been learning a lot about monitoring and equipment. The key to determining effectiveness is doing randomized control trials while looking at education and decision making related to the glucose results. Maybe then we can design programs that meet the needs of people who have to monitor. Posted some of my own comments about monitoring at “My Diabetes Partner” blog.
    http://mydiabetespartner.org/?p=142#comment-97

  11. Dan Fahey
    Dan Fahey December 14, 2007 at 7:32 am | | Reply

    I’m a type 1 diabetic of 40 years, whose wife has recently become pre-diabetic. Her doctor told her that they’d “watch it.”

    I suggested she get a blood glucose monitor, and developed a simple regimen for its use so she’d have some results to show her doctor.

    She got hooked on having a tangible number that she could relate to, and I helped her make dietary modifications [that I knew would work] and she got excited when her blood sugars responded favorably. Over the course of 6 months, she lost 26 lbs, and her readings 2 hours after meals were most often <140. When they weren’t, she could generally recognize why not.

    I’ve always felt that diabetics on insulin had the advantage since they could adjust dosages so readily, but I’ve been impressed by how my wife has been able, without the benefit of insulin or pills, to modify her BGs. Though she’s still considered pre-diabetic, I believe that such a protocol is applicable to type 2 diabetics too.

    The key is in systematically making adjustments to the data from one’s tests. Another may be in finding a fellow diabetic [like me for my wife]who can be a fairly consistent resource [your doctor simply isn't that person].

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