When new diabetes products are launched, we're always happy to offer some personal perspective into what it's really like to use them in the real world. Today, our correspondent Wil Dubois offers some insight on the new Roche Accu-Chek Aviva Expert meter that was FDA-approved about a year ago, and just recently in mid-September became available by prescription.

What's the big deal? Well, this new glucometer is the first in the U.S. to include a calculator for your active insulin... that has huge potential!

Here's what Wil has to say about this new tool:


I can't recall the last time a piece of D-gear had me so excited before I even laid hands on it. From the instant I heard that the new insulin calculating-and-tracking Accu-Chek Aviva Expert blood glucose meter from Roche Diabetes Care was coming to our shores, I couldn't wait to get my paws on one. At last, a meter sporting easy math and pump-like insulin on board (IOB) tracking for those of us on pens and syringes!

But when I opened the box holding my latest toy and found not one, not two, not three, but four manuals explaining how to use it, I began to think I should have been more careful what I wished for...

Hands On

This meter is simultaneously small and large. The footprint of the device is a hair over two inches by four inches, but it's thick. Like one inch thick. With the ridiculously oversized Aviva test strip canister and the excellent FastClix lancing device, the carry case is a fat, hard-to-pocket four-inch wide, six-inch tall monster.

And not only is the meter fat, it's lazy, too.

The first thing you notice when you turn it on (either by pressing the "On" button or by sticking a test strip into its mouth) is how damn long the meter takes to spool up. It takes a full five seconds via switch, and when using a strip there's the same five seconds plus another four seconds while the meter flashes a "check code" message.

WTF? A coded meter? Seriously?

Well, yes and no. Expert uses Aviva strips, a line that started life off as a coded product. Now all Aviva strips have the same code, and share a universal code chip, but the Expert meter still has a legacy "check code" reminder. I'm sure it was cheaper for Roche to leave it there rather than re-write the meter's code and re-submit it to regulatory authorities worldwide, but it drives me nuts. I can't tell you how many strips I wasted because I put the blood on them too early (thus slowing myself down still further by getting an "E-56 Sample Applied Early" error message, requiring a retest with a new strip).  Arrrrrrgh!

I'm sure Roche thinks I have 10 seconds to spare every time I test, but I don't. Expert is an annoyingly slow meter. Any meter that takes longer to get ready to go on a date than it takes me to lance my finger is not a D-device I want to have a long-term relationship with.

So my first impressions of Expert were negative, but would her feature set overcome my displeasure with her fat and lazy personality?

Customizable Features

Just like an insulin pump, the meter's Bolus Advisor feature sports up to eight customizable time slots where the insulin-to-carb ratios, insulin sensitivities, and glucose targets can be different. The Expert tracks IOB (Insulin On Board) to avoid stacking doses, and can even evaluate your current blood sugar and insulin on board and advise you how many carbs are needed to get you back on a level keel when you're low.

While Expert can't provide a curved correction factor for increased insulin delivery with increasingly high elevations in blood glucose—like the last generation of the Cosmo insulin pump did—Expert does have a "health event" feature that allows users to program five pre-set overrides to help you calculate how much to increase or decrease insuin delivery by up to 50%. They're named Exercise 1, Exercise 2, Stress, Illness, and Premenstrual. The name tags are not customizable; one Roche exec told me I could always use the premenstrual program for the effects of alcohol.

{There are so many snarky things I could say about that thought that I find myself overwhelmed by the possibilities.}

Moving on, beyond the Bolus Advisor, the Expert boasts a number of optional features that might come in handy, depending on your needs, personality, and other gear. For instance, the meter has an alarm clock for reminders that can be action-based (for example, alarming two hours after bolus advice), time-based, or day-based. It can even remind you of doctor's visits and lab appointments, if you enter those datapoints.

The meter has a backlight for night use, but no strip port light. The backlight has three brightness settings, but sadly always defaults to the medium level, rather than the last one used, requiring the blinded and befuddled night user to lower the intensity by stabbing at a button on the face of the meter.

And although you'd better get bifocals, because they are small, the Expert has some of the best on-device history screens I've ever seen, and the meter can download to desktop software as well.

Manuals, Manuals, Manuals

Now about those four included manuals... First there's the 294-page Standard Owner's Booklet. Then there's the 103-page Training Handbook, a 50-page Advanced Owner's Booklet, and a 66-page Getting Started Guide.

Holy crap.



How's the quality of these books? Well, on about the third page of the big book we are advised not to eat our test strips. Seriously. I'm not kidding. It really does say that, and it pretty much goes downhill from there.

Is Expert really that hard to use? No, I don't think so. There are a lot of features and options, some of which have to be programmed and some of which can be left turned off. After all, for all practical purposes, it's an insulin pump without the insulin. I found the programming to be tedious, but no worse than the typical insulin pump. I guess the take-away message here is that this meter is going to take awhile to set up, but once done, it's not overly complex to operate.

Thumbs-Down on Practicality

I don't think I've ever wanted to like a piece of D-gear more than I wanted to like the Expert. It should have been perfect for me and my pen-based therapy. It should have lightened my gear load, made my diabetes management simpler, easier, and more accurate. But in the end, I couldn't wait for my review period to be over. I couldn't stand the Expert. It's too bulky, too slow, and I wasn't at all happy with the results.

The extraordinarily complex algorithm used by the Expert meter to crunch the math often gave me different results than my current system of RapidCalc, even though I entered the same program settings, and I had a number of bad outcomes after following the Expert meter's advice. That said, I think that if I'd used Expert longer, understood its logic better, and got it fine-tuned, it could have given me good results.

But I couldn't stand the operational side of the machine long enough to do that.

I found the ritual of entering data to get bolus advice to be tedious in general, with too many steps overall, and it was especially annoying to have to scroll up and down to enter carbs from a meal. I'm probably spoiled from using the easy touch-screen slider on RapidCalc, but there must be some way to get carb data into the system more quickly than Roche does here. For instance, the Snap pump uses scrolling, and I don't remember being aggravated with their system. Related to this, on the Expert, IOB is not easy to view. You have to turn the meter on. Scroll to Bolus Advice. Select. Then search the screen to find the info. That's a lot of steps, especially with the frustratingly slow start-up.

Another complaint I have is that while you can enter a meal without a fingerstick (although a warning flag pops up) there's no way to manually enter a blood sugar reading without a test. This drove me crazy, because even though you aren't "supposed to," I frequently take corrections based on CGM data. I guess this limitation sort of makes sense; it is a meter after all, but I found myself skipping corrections I'd normally take because of the hassle factor. But there is also a deeper problem with this.

While the Roche strips are widely available on most health plans, getting enough strips to actually use this meter right is not so easy. To truly manage pen or syringe-based therapy with a calculating meter would take 8-12 strips a day (or fewer with some CGM readings), but most health plans drag their feet over giving American PWDs more than 3 strips a day. With no way to enter BG data into the Expert manually, the calculating and tracking features are unusable much of the time.

Another possible nail in Expert's coffin, both for me and for others, is the Aviva strips themselves, which have a stated accuracy of plus or minus 15 points when readings are below 75 and a 20% accuracy when the readings are north of 75 mg/dL — in other words, performance on the lower end of what's considered acceptable in a modern meter.

Given the need for accurate meters, especially for people on insulin pens that dose by half-unit, it's sad that the device couldn't have been built around a better strip.

How to Find the Expert

OK, assuming you aren't swayed by my review and still want an Aviva Expert for yourself, there's more you should know.

As it turns out, you can't just run out to the store and buy an Expert meter. It's classified as a free prescription device that requires an Rx from your doctor thanks to its complex insulin-calculating nature. Roche is not selling the meters, but rather giving them out to doctors' offices in five-packs to then give out to patients at no cost. Don't get too excited, that's not anything earth-shattering -- as most of us with diabetes know firsthand, the money-maker isn't the meter itself, it's the strips. That's where Pharma gets us, and nothing is different here with the Expert.

You can go to the Roche Accu-Chek page to actually start the whole process of obtaining an Expert by getting a printable prescription form to take to your doc. Word is that once you get your doctor on board, then he or she must also sign a "Statement of Understanding" form that lays out the rules of training and prescribing.... Yes, there are rules, and I have to assume that's all a precautionary hoop needed to protect those prescribing this calculating-on-its-own meter. So, that's how that all works. A bit fussy.

Final Verdict

Upshot: It's nice to have the math on the number soup done for me, just too bad it took so long the soup got cold. And no one wants cold soup.





In the end, I couldn't have been happier to pack this meter and its four manuals back into its box and get back to something simpler, lighter, smaller, faster, and more accurate.

It's a pity, though. I really wanted it to work out. The idea of the Expert is awesome. But Roche's execution is far from an expert piece of work.