We recently took a look at some not-so-kosher ways to get your hands on cheap test strips. Today, we're looking at how you can get the most mileage out of a limited number of these costly strips.
One if by land... and two if by... oh crap. There's only one lantern! How on earth will Paul Revere get the memo if the British come by sea? It might be funny if people's lives weren't on the line, but that's exactly the position that the vast majority of people with diabetes (PWDs) find themselves in these days.
Simply put, they're being limited to one test strip per day, almost a symbolic signal of the status of the diabetes invasion by those writing the rules about how patients obtain needed medical supplies.
For a number of years now, the Centers for Medicare & Medicaid Services have set the following limits for test strips: one per day for PWDs on oral medications and three per day for PWDs who use insulin. And where the Feds have led, commercial insurance has followed.
We could spend all day arguing about how effective testing is, and how many strips per day various PWDs on various therapies should have to stay healthy. But we're not going to talk about the ideal world today. We're going to talk about how to maximize the number of strips we are given in the real world.
One is the Loneliest Number
The fact is that 74% of PWDs in our country are type 2s who don't take insulin to control their diabetes. That's 14 million people. For this rather large crowd, our health system provides a strip a day. What can you do with a strip a day?
Frankly, nothing useful.
Or can you?
Most PWDs limited to a single strip use it to check their morning blood sugar, a strategy that doesn't provide much information, as an isolated number is meaningless. If you test once per day, odds are you'll never learn much about your diabetes, much less take control of it.
But think outside the vial for a moment. You have one strip per day. Who says you have to use it every day? What if you shook things up a little? Saved your strips up for a day or two, or more, and redeployed them in a different way?
This concept is called "structured testing," and it creates patterns that give blood sugar results context. And context gives numbers power. Here's my favorite example: suppose you checked your blood sugar two hours after a meal and found it to be 362 mg/dL. What do you know about the meal?
If you said 1) that the meal had too many carbs or 2) you counted the carbs wrong or 3) you took your meds wrong or 4) your meds aren't up to the task — you'd be wrong.
You know nothing at all. Well, nothing beyond the fact that you're high. But you know nothing about the meal itself, because you don't know where your blood sugar was before the meal. Yeah, if you were at 112 mg/dL two hours ago, the meal kicked you in the ass, and one of the four things above is likely to blame. But what if you were at 439 mg/dL before the meal? There's still a problem to be fixed. But it had nothing to do with the meal.
Two at a Time
The concept behind Testing in Pairs is that you should view finger stick testing as a small-scale clinical study, looking at the before-and-after effects of something on blood sugar. That something could include food, activity, sleep, or stress. So pairs are commonly before and after meals, before and after exercise, or at bedtime and the next morning to investigate what happens with your blood sugar overnight.
Of course it's a narrow view, and if you have only one strip per day, you can only test one pair every other day. But it beats the hell out of the traditional and futile one test per day. While Testing in Pairs adds a lot of power to the testing paradigm, it takes a great deal of time for patterns to emerge. Looking at breakfast trends for a week. Then lunch trends for a week. Then you drop your morning strip in the toilet by accident, and you've just lost half your pair for two days...
Or Maybe 21 at a Time?
More recently, Roche launched another creative way to learn more with fewer strips. (Does this mean Roche is reading the handwriting on the wall when it comes to adequate strip supplies for the foreseeable future?)
It's called the Accu-Chek 360° View Tool. It's not a waaaaay cool new gadget, device, machine, or physical object of any kind, as you might expect when you hear someone talk about a "tool." It's just an 8½ x 11 inch two-sided sheet of paper with orange, green, grey, yellow, purple, and blue ink. It looks like an accounting school acid trip. One entire side is the instructions. There are nine steps that, at a glance, look overwhelming enough to put you into a twelve-step program.
Hey, no one ever said diabetes was going to be easy.
But while the "tool" looks overwhelming, it's really just a glorified log book. And here's the best part: it's only a three-day log book. The 360° View Tool guides you through a three-day intensive testing period. Seven finger sticks a day over three days. Before and after every meal, and at bedtime. That gives you and your doc a snapshot of blood sugar trends around all meals for three days, plus your overnight readings twice.
You log the numbers, but also graph them visually on the tool. That gives your doc a quick view of what's happening in your diabetes world. It's a view that fits better into the short office visit world we live in. Also, the mere act of filling out the form is a learning experience for you, as well as info for your doc. At one strip a day, you could do it every three weeks.
How well does it actually work? Damn well. A clinical study headed up by none other than Polonsky himself shows that using the tool lowers A1C levels. And a second study featuring the tool showed that it significantly increased the effectiveness of docs themselves, who are otherwise trying to make sense of a myriad of different reports from different meters, or trying to review a blood-smudged log book in 90 seconds, searching for patterns.
The Danger Zone... of Structured Testing
Personally, I think that structured testing is a great idea for anyone with limited test strips who takes diabetes medications that have no risk of hypoglycemia. Uh... and just who would that be, exactly? Well, not most of those 14 million people who get one strip per day, that's for sure. Because the problem with diabetes medications is that they are designed to lower blood sugar, and as such, most of them occasionally lower it too much. With the exception of metformin, most entry-level diabetes drugs (the ones insurance plans insist that PWDs "fail" on before paying for more sophisticated ones) carry a significant risk of low blood sugar.
I like structured testing. I like the power it gives to finger sticks, and I like the way it makes the most out of not enough. But I'd like it better if we gave people what they really need, and I worry about some PWDs falling into the habit of not carrying their meters with them (Hey, I don't need to test for three more weeks...), or being out of strips, and then having lows.
On one hand health plans insist on only covering first-line meds that carry a risk of low blood sugar; while at the same time they refuse to pay for strips to mitigate that risk.
Come on, Boys, you shouldn't be allowed to have it both ways. Still, for the real world that we live in today, structured testing is the best game in town.