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Continual Proponents Limited Proponents Opponents Beliefs on recommendation of SMBG “It allows for, first, assessment of hypo- or hyperglycemia. Two, it reinforces patient behavior as it relates to nutrition, exercise, and diet. Three, it allows for appropriate medication adjustments… Four, if there is any sudden change in their glucose, their glucose status allows for us to intervene in between office visits” (15). “I think self-monitoring is helpful for patients who have uncontrolled blood sugars to move them in the direction of getting their blood sugars under control, with therapeutic interventions such as diet, exercise, and medications” (12). “I will tell them, ‘Based on recent evidence, there is no indication that you have to check your sugar to control your diabetes, because we are checking the three-month blood level. I think it’s okay, and I feel safe with you not doing this as long as you’re comfortable’” (5). Frequency of prescribing SMBG “[I advise checking] twice a day, morning and evening. Some people, if they are very well controlled, I will say, ‘You know what. Why don’t you check every other day’” (5). “I recommend that all sugars be done at fasting, first thing in the morning [initially]. After we get to a point where they are stable and we are not recommending daily sugar checks, I will recommend they check their sugars [only] if they are feeling sick…nauseous, or light-headed” (1). “I try to steer non-insulin dependent patients away from testing at home, mainly because it doesn’t change what I do. I monitor their diabetes based on the HbA1c and occasional sugar checks” (6). Beliefs on stopping SMBG “I never recommend that they stop completely” (3). “If they know what foods to eat… and their HbA1c is under great control, then there is really no reason for them to check their blood sugars” (17). “I don’t tend to ever start [SMBG] in some-one who is just on orals. Many times I am inheriting patients who are already on it and used to it, so I encourage them to stop. But, they don’t necessarily want to stop” (10). HbA1c = hemoglobin A1c; SMBG = self-monitoring of blood glucose.
Proponents Opponents Theme 1. Education for Lifestyle Change Patient Activation “Over and over again, I have noticed that people who check their blood sugar tend to be more engaged in the self-management of their diabetes” (14). “I tend to see the patients who keep monitoring are the ones who are generally more engaged around their self-care…. In my experience, [SMBG] has been mostly correlated with their level of activation rather than the disease” (10). Patient-Centered Care “If I have somebody who is pretty much in the action phase of wanting to control their disease and their blood sugar is in the >9 category, I would be more aggressive with them checking and trying to manipulate the diet. But I’m very patient-centered, so I would ask them, ‘On a scale from 1-10, how important is it for you to check your blood sugar?’ If they say it’s 7-8 or 9, I would say, ‘Okay, what is your ideal state of checking a blood sugar.’ Then, I would see what they would say and do a confidence scale, ‘On a scale from 1-10, how confident are you that you can check your blood sugar?’ Let’s say they say 4 times a week. If I can get them above a 7, then I would go for it” (4). “Usually, they are a bit hesitant [to stopping SMBG]…50% of patients don’t want to stop checking, because they are so used to it, so I will let them continue it. I won’t force them to stop” (5). Theme 2. Value-Based Care Affordability for Patients “I take into account that I know these strips are very expensive, and for many patients, that’s a barrier. So I may tell them to check just once a day but at different times during the day” (13). “This sounds painful and possibly expensive, you should stop and save your blood” (10). Health Care System Costs “It helps to give us more short-term strategies to fix things rather than waiting for a three-month follow-up, when things can get ahead of us too far” (12). “For those patients not on insulin, I think we are probably wasting a lot of money. We are doing tons of testing unnecessarily” (5). Theme 3. Patient Safety “If a person is having symptoms that suggest hypoglycemia, then I would use [SMBG]. If we were able to actually avoid the hypoglycemia, then we can avoid potential cognitive damage or an injury related to hypoglycemia, like loss of consciousness and a fall” (8). “I talk about a constellation of symptoms and when they might expect to feel those. It’s usually within a few hours of taking certain medicine or on days when they notice that they are skipping meals or that they are very sick from the cold. We talk a little bit about the general feeling of dizziness, lethargy, sweating, hunger, disorientation, and try to educate both the patient and whoever might be around them that these are signs or symptoms to look out for—to focus first on the intervention, which is go eat or drink something, but then also to check their blood sugar if they have time” (10). Theme 4. Considerations for Specific Patient Populations “For a patient in their eighties who may have some cognitive disability, measuring their blood sugars every day or a couple of times a week, especially if they are doing well, may not really be very useful” (13). “Some patients really need to see that number at certain times of the day, because it helps them become motivated to bring it down. Other ones, though, it’s the complete opposite. It interferes with their care, because they see it and they don’t understand” (6). SMBG = self-monitoring of blood glucose.
Additional Files
The Article in Brief
Physicians' Views of Self-Monitoring of Blood Glucose in Patients With Type 2 Diabetes Not on Insulin
Sonia A. Havele , and colleagues
Background Although evidence shows that routine self-monitoring of blood glucose in patients with non-insulin treated type 2 diabetes increases costs with few health benefits, some physicians continue to recommend it. This study examines to what extent and why physicians recommend self-monitoring of blood glucose.
What This Study Found Physicians continue to recommend routine self-monitoring of blood glucose for patients with non-insulin treated type 2 diabetes, in spite of its lack of effectiveness, because they believe it drives the lifestyle change needed to improve glycemic control. In a qualitative study of 17 primary care physicians, proponents stated that self-monitoring works best at initial diagnosis, facilitating education and self-management, a view that may be encouraged by the American Diabetes Association�s support of self-monitoring based on expert opinion. In contrast, opponents are concerned about lack of efficacy in lowering HbA1c, often citing peer-reviewed evidence to support their views, and believe office-based education encourages patient activation. Health care systems have been shown to view self-monitoring of blood glucose as cost-saving and relatively harmless, yet previous research shows that it can be painful, inconvenient, and depressing for patients.
Implications
- The authors suggest that targeting physician beliefs about the effectiveness of self-monitoring of blood glucose for patients with non-insulin treated type 2 diabetes, along with policy-based interventions, could reduce the practice.
