Monday, November 22, 2010

Guest Blog: Home glucose testing in type 2 diabetes

Dr. Ed Pullen is a family physician who sees patients at Sound Family Medicine in Puyallup, WA. The following piece is excerpted from a previously published post on his blog,


Home glucose monitoring in non-insulin treated type 2 diabetes has not been shown in controlled studies to improve either blood sugar control or prevent complications of diabetes. Still, it is commonly used by diabetics and commonly recommended by physicians to diabetics as an important aspect of their care. What is the right thing to do? The answer is not simple.

As a pretty valid rule of thumb, we should only do a test in medicine if the results are going to be used to make a decision of some sort. In diabetics who use insulin before each meal, and vary the dose of insulin based on their blood sugar prior to the meal, measuring their blood sugar before each meal is done to obtain information on which to base a decision of how much insulin to inject. This is a classic case of using diagnostic information to make a therapeutic decision. On the other extreme, a person with type 2 diabetes who is either not on medication at all, or who is on a stable dose of oral medication, and has been well controlled over the last few doctor visits, is not going to alter his or her diabetes treatment in any way based on home blood sugar monitoring, and a good argument can be made that there is no need to be measuring home blood sugars.

In my practice I find many diabetic patients who find a good deal of comfort in checking their blood sugars more often than is needed to control their blood sugars. Some patients find daily, or even several times daily, blood sugar monitoring to be strong positive feedback that reinforces their good behavior regarding diet and exercise. Is this a good reason to do home blood sugar testing? More to the point, should third party payers, including Medicare, pay for this testing even though there is little or no evidence that it leads to better health outcomes?

I commonly am faced with non-insulin using diabetic patients who test several times daily, whose insurance companies decline to pay for this frequent testing based on lack of evidence that it is beneficial. Patients then ask me as their physician to explain to the insurer why they need to test several times a day. The reasons acceptable to the insurer usually include: insulin treatment, frequent hypoglycemia, and uncontrolled hyperglycemia. Most of these patients have none of these reasons. They just feel more confident when they know their blood sugars frequently. This can lead to patient dissatisfaction, and puts me in the awkward position of being perceived as not advocating for a patient. This issue has been a hot topic in the UK recently.

We are facing major issues regarding health care spending in America. There is great evidence that control of blood pressure, cholesterol and blood sugars in diabetes can lead to reduced health care costs. Still, with the cost of a single home blood sugar test running about $1, the cost of even once daily home blood sugar testing for a diabetic is $300 to $400 per year. There are approximately 25 million type 2 diabetics in the US. Many do not need to be testing home blood sugars. We need to do a better job of giving patients permission to test less or not at all, and yet encourage them to do the other things that do make a difference. Diabetic eye exams, blood pressure control, and lipid control all have much better evidence for morbidity and mortality prevention than does home blood sugar testing.