Achieving Good Glycemic Control:The importance of Self Monitoring Blood

Glucose

by:

Nina Hibbard, CRNP Student

Auburn University/ Auburn Montgomery Joint Program

Aim

Provide practical guidance on improving diabetes

care through highlighting the need to:

• Understanding of importance of SMBG

• Improve overall control of diabetes patients

• See the affects of SMBG on HA1C values

Definition and Description of the Problem

• Diabetes has been identified as one of the top 20 priority areas for national action according to the Institute of Medicine

• 25.8 million children and adults in the United States which is 8.3% of the population that have diabetes

• Self Monitoring Blood Glucose (SMBG) is a very simple way patients can control short and long term affects of diabetes complications

Diabetes: a global call to action

The numbers of diagnosed diabetes is growing stronger each year

0

50

100

150

200

250

300

350

1985 2000 2025

Year

Glo

bal

pre

vale

nce

of

dia

bet

es (

mill

ion

s)

30 million

150 million

333 million

http://www.idf.org/home/

DiabeticRetinopathy

Leading causeof blindnessin adults1,2

DiabeticNephropathy

Leading cause of end-stage renal disease3,4

CardiovascularDisease

Stroke

2- to 4-fold increase in cardiovascular mortality and stroke5

DiabeticNeuropathy

Leading cause ofnon-traumatic lower extremity amputations7,8

8/10 individuals with diabetes die from CV events6

Diabetes is associated with serious complications

1UK Prospective Diabetes Study Group. Diabetes Res 1990; 13:1–11. 2Fong DS, et al. Diabetes Care 2003; 26 (Suppl. 1):S99–S102. 3The Hypertension in Diabetes Study Group. J Hypertens 1993; 11:309–317. 4Molitch ME, et al. Diabetes Care 2003; 26 (Suppl. 1):S94–S98. 5Kannel WB, et al. Am Heart J 1990; 120:672–676.

6Gray RP & Yudkin JS. Cardiovascular disease in diabetes mellitus. In Textbook of Diabetes 2nd Edition, 1997. Blackwell Sciences. 7King’s Fund. Counting the cost. The real impact of non-insulin dependent diabetes. London: British Diabetic Association, 1996. 8Mayfield JA, et al. Diabetes Care 2003; 26 (Suppl. 1):S78–S79.

0

2.5

5.0

7.5

10.0

Ind

ivid

ual

s re

po

rtin

g

‘ext

rem

e p

rob

lem

s’ (

%)

Diabetes

General population

Mobility Self-care Usualactivities

Pain/discomfort

Anxiety/depression

*Significant versus general population

**

*

*

*

Individuals suffering ‘extreme problems’ in quality of life

Williams R, et al. The true costs of type 2 diabetes in the UK. Findings from T2ARDIS and CODE-2 UK, 2002.

Department of Health. Health Survey for England 1996. London: HMSO, 1997.

Indirect costs

Direct costs

Co

st p

er y

ear

(US

$ b

illio

n)

0

20

40

60

80

100

120

19871 19922 19973

$98$92

$20

Estimated US costs Year

20024

$132140

Costs of diabetes are rising

1Huse DM, et al. JAMA 1989; 262:2708–2713. 2Javitt JC & Chiang Y-P. In Diabetes in America, 1995; 601–611. NIH Publication No. 95–1468.3American Diabetes Association. Diabetes Care 1998; 21:296–309. 4American Diabetes Association. Diabetes Care 2003; 26:917–932.

Antidiabetic drugs 7%

Hospitalizations55%

Other drugs 21%

Ambulatory care 18%

= €29 billion/year

Hospitalizations account for the majority of the costs of managing Diabetes

Jönsson B. Diabetologia 2002; 45 (Suppl.):S5–S12.

Microvascular complications

Myocardial infarction

HbA1c

37%

14%

Lowering HbA1c reduces the risk of complications

Deaths related to diabetes21%

1%

Stratton IM, et al. BMJ 2000; 321:405–412.

Two thirds of individuals do not achieve target HbA1c

Saydah SH, et al. JAMA 2004; 291:335–342.

Liebl A, et al. Diabetologia 2002; 45:S23–S28.

Barriers to achieving good glycemic control

Lack of clarity over definition of good glycemic control

Insufficient involvement of physician and team

Complexity of managing hyperglycemia relative to dyslipidemia and hypertension

Inadequate monitoring of glycemia

What is good glycemic control?

*Or fasting/preprandial plasma glucose < 110 mg/dL (6.0 mmol/L) where assessment of HbA1c is not possible

The Global Partnership recommends:

Aim for good glycemic control = HbA1c < 6.5%*

< 6.5%< 6.5%

Del Prato S, et al. Int J Clin Pract 2005; 59:1345–1355.

Frequent monitoring of glycemia is important

• Cornerstone of diabetes care

• Ensures best possible glycemic control by:

– assessing efficacy of therapy– guiding adjustments in diabetes

care regimen, including diet, exercise and medications

Who should monitor glycemia?

PatientSelf-monitoring of blood glucose

Healthcare professionalsRegular monitoring of HbA1c

+

Diabetes care teamCombined synergistic efforts of

team are crucial to ensure effective monitoring of glycemic control

Self-monitoring of blood glucose (SMBG)

• Regular SMBG increases the proportion of individuals achieving their glycemic targets

• Individuals should monitor postprandial glucose as part of their SMBG schedule

• Regular discussion of results with diabetes care team is essential

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Not Monitored

(37%)

Regular SMBG

Performers (21%)

Irregular SMBG

Performers (42%)

HbA1c 8.0

HbA1c > 8.0

Blonde L, et al. Diabetes Care 2002; 25:245–246.

Physician input leads to better outcomes in type 2 diabetes

17% Individuals whom the physician was directly involved in proactive diabetes care had a substantially improved chance of survival

Verlato G, et al. Diabetes Care 1996; 19:211–213.

Implementation

PLAN: Present to two groups

Group 1- Physician Group

Group 2- Patient Group

By presenting to two separate groups, the goal of the presentation is to make both more aware of the importance of SMBG and using this daily process as a useful tool in helping control diabetes in the short and long term.

Design

• Physician Group- Current preceptor group of 4 doctors

*Powerpoint *Evidence Based Research articles *Demonstrate SMBG *Enforce focus of management of patient more

efficiently with this SMBG information

• *Handouts provided for SMBG importance

Design

• Patient Group- Group of diabetes patients identified at local retirement community.

• *Verbal explanation and demonstration of SMBG provided

• *Handouts provided for reinforcement

• *Question and answer session

Delivery of Project

Margaret Newman’s Theory of Health as Expand Consciousness

• central thesis of this theory is that health is the expansion of consciousness

• asserts that every person in every situation, no matter how disordered and hopeless it may seem, is part of the universal process of expanding consciousness” (Newman, 1992, p.60).

The Behavior and Skill of SMBG

Physician Group

•Physicians will begin with a survey of how often they tell their patients to check blood glucoses

•SMBG demonstration

•Insurance discussion

The Behavior and Skill of SMBG

Patient Group

•Review of handouts

•Discussion

•Demonstration

•Insurance discussion

Evaluation of Project

Physician Group:

Negative: *Do not have time to teach the patient *Too expensive for the patient * A1C test gives all information needed

After discussion:Positive: *Realize the ease of local resources and meter companies to provide training *Understood insurance coverage of strips *Recognized useful in controlling medication regimen more efficiently

Evaluation of Project

Patient Group: (31 Participants)

Negative: * All patients did not have their own SMBG meter * Need not recognized. “My doctor keeps up with my blood sugar when I see him every three months.” * No understanding of insurance coverage

Positive: *All patients end of session had a SMBG meter *Need recognized for daily monitoring and communicating to physician of blood sugar logs *Relieved to know of insurance coverage

Conclusion

The educational project for SMBG awareness has been enjoyable and close to my heart. I truly have a passion for diabetes because it is very controllable with the right tools, support and education provided. This project is but the tip of the iceberg, but of great importance. I hope to continue to spread the news regarding SMBG and diabetes education for many years to come.

Acknowledgements

Primary Care Internists of Montgomery, P.C.Dr. Raghu Mukkamala and partners1722 Pine Street, Suite 309Montgomery, Al 36106

Eastdale Estates Retirement Community1500 Eastdale CircleMontgomery, Al, 36117