Optimizing technology for diabetes care
Optimizing technology for diabetes care
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At a glance
In the real world, primary-care clinicians have only a few short minutes they can devote during each appointment to helping diabetic patients improve glycemic control. The wise use of today's technology can help make the most of those minutes. The purpose of this article is to review some of the diabetes-related technologies available to patients and providers and to recommend strategies providers can use to optimize patient care.
Blood glucose monitors
With more than 60 models of blood glucose monitors on the market, most providers are unable to keep up with the details of all of them.1 In choosing a blood glucose monitor, consideration of patients' insurance coverage is extremely important in order to ensure that they will not have to pay out of pocket for test strips, which retail for an average cost of $1 each. Typically, as long as the patient uses a system that is included in the insurance plan's formulary, the copayment is affordable.
A good strategy to follow if you're not sure what system to prescribe is to write nonbranded prescriptions for a "blood glucose monitoring kit" and "blood glucose test strips." This gives the patient and the pharmacy some flexibility in choosing the brand based on features the patient prefers while keeping the copayment affordable.
The amount of digital storage in blood glucose monitors varies. Most providers focus on analyzing the most recent records. This is rational, not only because time is limited but also because clinicians need to respond to what is actually happening now, not what happened a month ago. Digital storage of blood glucose results will help to improve glycemic control only if these results are analyzed systematically.
Some monitor manufacturers provide free data-management software programs to patients, while others require that the programs be purchased separately. These programs allow patients to record a variety of aspects of their diabetes regimen, such as insulin types and dosages, carbohydrate amounts and physical activity.
Patients who rely on a monitor's digital memory (in lieu of a paper log) should be encouraged to download their results on a regular basis to analyze the data for patterns. A list of blood glucose results without corresponding information on medications, meal timing, carbohydrate intake and unusual physical activity is often more confusing than beneficial to diabetes management. In addition, the time and date stamp on the patient's monitor must be set correctly to interpret the electronic records.
In the clinic, using the monitor's memory to influence management decisions can be tricky. Once the intake process is complete and the patient is ready to be seen in the examination room, downloading the meter and reviewing the electronic data takes too long to be considered during that appointment. Moreover, scrolling back in the monitor's memory produces a string of meaningless numbers.
One practical approach is to include a meter download in the intake process. Typically, sales representatives from the manufacturing companies are eager to train clinic staff to download data from patients' blood glucose monitors. The provider can choose the amount of data and the preferred format for the printout, and staff members can present this report with the patient's intake history. Having this information at the beginning of the visit can mean the difference between a productive visit and a futile one.
Does patient self-monitoring improve glycemic control?
Although not exactly new technology, confusion still lingers regarding the usefulness of blood glucose monitoring. The literature in this area is controversial.2-7 Blood glucose monitoring is a standard of care in patients with type 1 diabetes and is recommended for patients with type 2 diabetes who take insulin.8 Clinicians typically use their own judgment when recommending monitoring to patients with type 2 diabetes who are not taking insulin. One factor to consider is whether the patient is at risk for hypoglycemia. (If the patient is taking a sulfonylurea, monitoring should be available to identify and/or prevent hypoglycemia.) Another factor influencing the decision to monitor is how the results will be used to improve glycemic control.
For example, if the patient's current treatment includes adjustment of basal insulin, the clinician may need only one fasting blood glucose result per day. If the current plan is to tailor carbohydrate amount or prandial therapy to target postprandial glycemic control, preprandial and postprandial blood glucose testing will be necessary. Because this technology is expensive, blood glucose results should be requested only when they will affect clinical decision making or patient self-management.
Most experts would agree that patients who are willing and able to adjust their lifestyle choices and diabetes treatment based on glucose results receive vastly more benefit from monitoring blood glucose than those who are not. Until patients can autonomously make lifestyle and treatment adjustments, diabetes educators can assist primary-care providers in training patients to analyze and interpret blood glucose test results.
Lancets and lancing devices
Most patients report that blood glucose monitoring is more difficult than taking insulin injections. Finger sticks are painful, and minimizing this pain may lead to improved patient adherence to the treatment plan. Three factors impact the finger-stick procedure: the amount of sample required by the monitoring system, the lancet device and the lancet itself.
The size of the blood sample required for monitoring has drastically decreased compared to the amount needed for first-generation monitoring systems. Most current systems require only ≤0.5 µL, approximately the size of the head of a pin.