Home Glucose Testing in Type 2 Diabetics

This article originally appeared online at DrPullen.com.

Home glucose monitoring in non-insulin treated type 2 diabetes has not been shown with any degree of confidence 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 by 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 (ie, a sliding scale of insulin use, measuring their blood sugar before each meal is 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 steady dose of oral medication, and has been well controlled over the last few doctor visits, is not going to alter their diabetes treatment in any way based on home blood sugar monitoring, and a good argument can be made that they have 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 patient s 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 is 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?

The cost of home blood sugar testing is not insignificant, for my uninsured patients it is often cost prohibitive to test blood sugars frequently. For insured patient’s home blood sugar monitoring is usually paid for by insurance, so there is little incentive for them to affect cost savings by testing less often. Medicare in particular pays very well for home diabetes testing. 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 dissatisfaction by patients, and put me in the awkward position of being perceived as not advocating for a patient, when I have in fact suggested to the patient that they do less frequent home blood sugar testing. This issue has been a hot topic in the UK recently.

I suspect that some of this desire to do frequent home blood sugar testing stems from the initial diabetes education patients are given. Appropriately most new diabetics are taught how to test their blood sugars at home. Also often we initially ask patients to test fasting, pre-prandial and post-prandial blood sugars in order to get them initially on an appropriate regimen of diet and medications. I suspect that sometimes we don’t emphasize enough to new diabetics that they will likely want to reduce the frequency of home blood sugar testing after a stable regimen for treatment is achieved.

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 $3-400 / year. There are approximately 25 million type 2 diabetics in the US. Many need to be testing home blood sugars, but many do not. We need to do a better job of giving our well controlled non-insulin using diabetic patient’s 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.

A Note from Dr. Pullen:

Diabetes care is such a big part of my practice I’ve started a twitter page to my patients (or any of you who are interested) to get frequent helpful or encouraging information about diabtes by following me @diabetictweets Please visit and follow there.

Ed Pullen, MD, is a board-certified family physician practicing in Puyallup, WA. He blogs at DrPullen.com — A Medical Bog for the Informed Patient.

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