Physicians’ Views of Self-Monitoring of Blood Glucose in Patients With Type 2 Diabetes Not on Insulin

Listening To The Voices Of Physicians And Patients About SMBG

Lawrence Fisher, Ph.D., ABPP and William H. Polonsky, Ph.D., CDE

We find Havele, et al.'s study of SMBG with adults who are not using insulin to be of considerable interest on two counts. First, it highlights the inconsistent results found among studies directed at determining the effect of SMBG on patient management and glycemic control. Unfortunately, and despite the prominence of recent studies, the issue regarding SMBG's actual clinical utility remains uncertain. Second, it provides input from practicing clinicians about their reasons for continuing SMBG despite the contrasting empirical data. What are we to make of these apparent contradictory results?

What is unique in this report are the views provided by practicing clinicians. Our reading suggests that some physicians find SMBG helpful for patients not on insulin who are poorly controlled, whose blood sugars are unstable, who are at risk for hypoglycemia, who are otherwise symptomatic, and who need objective confirmation that changes in their disease management directly affect their glucose numbers. These reports are similar to our own experiences (e.g., the STEP study), namely that carefully targeted SMBG use with selected patients can be effective when the goals include patient activation, education, prevention and, ultimately, glycemic control.

We have argued previously that the simple act of blood glucose testing alone probably has little or no clinical value, and it may therefore be viewed as a cost and management burden. In contrast, SMBG can be significantly helpful when it is initiated for a defined purpose with a defined population (STEP Study). Uniformly banning support for all SMBG risks throwing out the baby with the bathwater - that is, eliminating SMBG without consideration of its targeted value.

In contrast with their conclusions, we argue that Havele, et al's qualitative findings actually provide additional support for the careful use of SMBG in adults not using insulin. Rather than conclude that "policy-based" and other interventions should be employed to "reduce this practice," we argue that perhaps those physicians who use SMBG in this population could help document when and for whom SMBG can be most effective. In clinical settings in which time and resources are at a premium, physicians rarely engage in activities with no direct clinical payoff. Evidently, many physicians (and perhaps many patients) find SMBG to be clinically useful, not because they are unaware of recent negative studies, but because their experience recommends its true value. The voices of these physicians and patients need to be heard as well.

Competing interests: None declared