Self-Monitoring of Blood Glucose: A Pilot Review: Impact of Computer Software Modifications on Compliance

Diabetes mellitus is a complicated disease that affects more than 20% of people aged 60 or older.1 According to the Centers for Disease Control and Prevention (CDC), 7% of the entire population in the U.S has diabetes.1 Health care costs associated with this disease, as well as its complications and treatments, are very high. According to data from 2002, 11% of federal health care funds were spent on diabetes alone, and the direct cost of diabetes was estimated to be $92 million for that year.2 Federal data from 2005 showed that this spending rate increased to 12%. This cost includes medications and testing supplies such as blood glucose test strips. Veterans Integrated System Network 3 (VISN 3) of the Department of Veterans Affairs dispensed approximately 4.7 million test strips with an estimated cost of $1.5 million for fiscal year 2006. Blood glucose test strips are prescribed for approximately 13,740 patients with stable type-2 diabetes who are not taking insulin in VISN 3. Clinical Practice Guidelines, developed jointly by the Veterans Health Administration and Department of Defense (VHA/DoD), recommend that (1) diabetic patients who are not using insulin limit blood glucose testing to twice weekly and use no more than 50 strips every 150 days, and (2) patients taking oral agents may be eligible for an increased number of strips for a limited time period for various indications (Table 1).3 Table 1 Management of Diabetes Mellitus According to the American Diabetes Association (ADA), the optimal frequency of self-monitoring of blood glucose (SMBG) is not known for patients with type-2 diabetes.4 Few data exist to support the routine use of SMBG for improving glycemic control in patients with diabetes who are not using insulin.5,6 Several review articles7–11 and a clinical trial, published in 2007,12 concluded that SMBG by patients who do not use insulin shows no clear effect on glycosylated hemoglobin (HbA1c) levels. The VHA/DoD guidelines were developed on the basis of clinical evidence showing that periodic HbA1c testing was usually sufficient for monitoring glycemic control.3,5,9,13 The guidelines also provide recommendations for SMBG in patients who are using insulin.3 As a result of the VHA/DoD recommendations, VISN 3 implemented guidelines that allow two test strips per week (about 24 strips every 90 days) for diabetic patients not using insulin. However, prior to November 1, 2006, because of the limitations of the available computer software package that allowed for a maximum 90-day supply and the contracted test strip package size of 50, our local VISN 3 guidelines stated that patients who were not using insulin were limited to 50 test strips for a 90-day period unless the health care provider could document that the patient needed additional strips. After November 1, 2006, the medical centers in VISN 3 implemented a modification of the computer software package that allowed more precise compliance with the VHA/DoD guidelines. Patients who were not using insulin could receive 50 strips for 180 days (two strips per week) unless more strips were warranted. The VISN 3 network’s P&T committee advised health care providers about the new software and guidelines on the limited use of strips for patients not using insulin.