Last Friday I received my chunky copy of the Nov/Dec issue of "The Diabetes Educator," the AADE's professional journal, and discovered a comprehensive 18-page article on the topic, "Does Patient Blood Glucose Monitoring Improve Diabetes Control? A Systematic Review of the Literature."
Second reaction: Wow. Detailed charts of the results of 29 different studies, and the major conclusions are --
* "SMBG (self-monitoring of blood glucose) may be effective in controlling blood glucose for patients with Type 2 diabetes."
* "There is a need for studies that implement all the components of the process for self-regulation of SMBG to assess whether patient use of SMBG will improve HbA1c levels."
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Given these rather inconclusive conclusions, what is perhaps more important are the statements made in the article's "Implications" section:
Further studies are needed "emphasizing the importance of the behavioral processes that underlie a volitional action such as SMBG."
"Failure of blood glucose control in personalized medicine represents a failure of the medical care system, not a failure of the patient."
Wow again. The authors are admitting that clinical studies on SMBG are likely getting lukewarm results because medical providers are failing to educate patients on how to use their meters in a way that actually results in better glucose control!
In a separate, excellent commentary provided by CDE Martha Funnell, she explains in two pages what we can make of all this: "The efficacy of SMBG for for patients with Type 2 not using insulin remains controversial..." because it has not traditionally been "viewed in the broader context of diabetes self-management rather than as a single behavior... Very few studies have examined SMBG as a component (of lifestyle along with) behavioral modifications in food intake, exercise, or medications."
One might say that the ADA's Dr. Kahn was referring to these inconclusive studies when he delivered his "anti-technology" speech last month, i.e. does it make sense to keep bombarding patients with sophisticated new meter models packed with features they'll never use, when they don't understand the models they've already got? Of course not.
But I believe that line of thinking can definitely lead to drawing the wrong conclusions. I mean, we wouldn't want to halt progress on developing new and better CAT Scan technology just because many doctors may not be making the best use of the machines they have now, right? Or we wouldn't wish to stop researching better ways to treat lupus just because some of the current methods haven't yet reached their full potential...
What I'm saying is, I think the authors of this McAndrew et al study have hit the nail on the head by recognizing that SMBG has to be viewed in the context of a patient's full diabetes care regime. The technology IS extremely valuable. It CAN have a significant impact on patient's long-term health, IF it is delivered with the proper education, and with a view toward addressing the patient's WHOLE LIFE.
The message must come through that simply using a meter or other device is not going to "take care of your diabetes." Each patient has to actually know how to act on the information their meter provides.
To this end, Martha offers educators seven practical tips that I think we can all appreciate:
- Stress the importance of SMBG as data needed by the patient for decisionmaking, not as something done primarily for the benefit of the provider.
- Emphasize that the results are not a judgment of the patients'self-management efforts but simply a number they can use to make informeddecisions.
- Assist patients to identify blood glucose goals and actions to take toachieve those goals.
- Identify strategies for overcoming barriers to monitoring.
- Assist patients in dealing with the impact of results that are notreflective of their efforts from both psychological and behavioralperspectives.
- Help patients identify strategies to obtain the support they need for SMBGfrom members of their families and health care team.
- Role-play responses to negative comments about the results from members oftheir family and health care team.
OK, all you Patient Experts out there: Got any other ideas on how CDEs can help us use glucose monitoring technology to our best advantage?