NICE guidelines for blood glucose monitoring

[chrismbee]

There has been much debate, in various threads, regarding self-monitoring of blood glucose, especially for non-T1's (T2's, la-di-da inbetweenies et al) with a worrying diversity of support from GP's and/or PCT's (aka the postcode lottery).
So, I thought I'd ask NICE directly for their comments. Here's their reply:

[FONT=&quot]"Dear Chris,[/FONT]

[FONT=&quot]Thank you for contacting the National Institute for Health and Clinical Excellence (NICE).[/FONT]

[FONT=&quot]NICE?s recommendations on this subject are published in the following piece of guidance:[/FONT]

[FONT=&quot]http://guidance.nice.org.uk/CG87"[/FONT]


Now, I reckon that this just about covers all types of diabetes ......

 

[AlisonM]

Yep NICE covers all sorts of diabetes. The trouble is, it seems to me, it's not actually aimed at helping patients but at keeping costs down. This doesn't just affect diabetics either, but all kinds of illnesses and conditions. We've all seen the effects on cancer patients who can't get the treatment that might save their lives because NICE says it costs too much.

 

[Northerner]

In order to get to the relevant bit, try here:

http://www.nice.org.uk/nicemedia/live/11983/40803/40803.pdf

and go to section 8.1.5 'From evidence to recommendations', in particular recommendation R23:

Self-monitoring of plasma glucose should be available:
to those on insulin treatment
to those on oral glucose lowering medications to provide information on hypoglycaemia
to assess changes in glucose control resulting from medications and lifestyle changes
to monitor changes during intercurrent illness
to ensure safety during activities, including driving.

and R24

Assess at least annually and in a structured way:
self-monitoring skills
the quality and appropriate frequency of testing
the use made of the results obtained
the impact on quality of life
the continued benefit
the equipment used.

Basically, testing is expensive, so let people know how to do it properly and keep in touch to see how they are doing. Sounds pretty clear to me! 🙂

 

[chrismbee]

That is what you see when you follow the link, given to me by those "nice" people.
Precisely my point - it is there in B&W (although only until 2012, in Hampshire!) that testing is recommended for control of diabetes.
I wonder if our T>1 compadr?s could use this to combat any reluctance on the part of their HCP's?

YOU CAN'T MANAGE WHAT YOU DON'T MEASURE

(a shortened form of that wonderful quote from Lord Kelvin, posted elsewhere)

 

[fruitloaf]

Basically, testing is expensive, so let people know how to do it properly and keep in touch to see how they are doing. Sounds pretty clear to me! 🙂

very true, this bit is all too often ignored. There is a lot of emphasis on getting test strips prescribed but those that do have them are not told how to interpret the results that they get, as recent questions on here have shown. It's wasteful of resources and potentially dangerous. The information given to patients about when to test and what to do with results is very poor and there is no clear evidence about what they should be doing.

'you can't manage what you don't measure' - maybe in some cases but far more importantly:

'you shouldn't measure what you can't manage'

 

[Robster65]

The biggest problem seems to be that the only true 'experts' reside in diabetic clinics at hospitals but the strips are prescribed by GPs and their half-educated (sometimes) nurses, who probably don't have a working knowledge of how to interpret test results.

SO they just think it's an occasional check of BG and like to reign in the quantities, while the DSNs need a structured testing regime, requiring quite a few strips as and when.

It probably won't improve unless there's a move towards local clinics with properly trained and experienced nurses.

ROb

 

[Northerner]

very true, this bit is all too often ignored. There is a lot of emphasis on getting test strips prescribed but those that do have them are not told how to interpret the results that they get, as recent questions on here have shown. It's wasteful of resources and potentially dangerous. The information given to patients about when to test and what to do with results is very poor and there is no clear evidence about what they should be doing.

'you can't manage what you don't measure' - maybe in some cases but far more importantly:

'you shouldn't measure what you can't manage'

But I think what seems to happen a lot is that people are motivated to test, and fund themselves initially, and find out how to test appropriately from one or more of the huge number of proven methods available (it's not rocket science). Then these people go to their GPs and demonstrate that testing is effective in helping them manage their diabetes and request strips on prescription so they can continue - and are turned down point blank and told they don't need to with the evidence of its value in front of their eyes. All the recommendations say that such motivated individuals should be provided with the means to self monitor and this is being ignored.

No-one would agree that people should be given strips without proper instruction (although clearly that practice exists also, but more rarely) - that would indeed be wasteful - but for people who are serious about actively particip[ating in the management of their diabetes it should not be a blank refusal. Of course, some HCPs know that if they do allow strips for motivated people they will then have to follow up and understand the results, costing them more time and money. That policy does not have the best interest of the patient at heart.

As for asking questions, that's inevitable. Diabetes is complex and a constant learning process so there are bound to be occasions when people need a helping hand from people with more experience - otherwise we wouldn't exist as a forum.

 

[mcdonagh47]

In order to get to the relevant bit, try here:

http://www.nice.org.uk/nicemedia/live/11983/40803/40803.pdf

and go to section 8.1.5 'From evidence to recommendations', in particular recommendation R23:

A timely reminder. Reading the threads on T2 testing I was going to point out that NICE Guidelines GUARANTEE testing strips to getting on for 75% of T2s ( the 40% of us on insulin and the probably 30% on sulfs like Gliclazide ).

Its only NEW t2s who are currently being told "they don't need to test" in many places. And no it is not just cost. The most medics genuinely believe T2 diabetes should be measured/managed via the HbA1c and that SMBG is irrelevant. That's the result of the UKPDS - the mammoth study of T2 diabetes that took place in the 1990s and is still being interpreted. The UKPDS showed that the risk of complications fell dramatically with A1cs under 6.5. So the HbA1c was elevated into the status of a shibboleth. Unfortunately the UKPDS didn't seem to include any research on testing ( it was coparatively new in the early 90s) otherwise the medics might now be singing a different tune.
The typical medical STRATEGY for T2s is to get a a1c of 6.5 or thereabouts but they don't seem to grasp that SMBG is an important TACTIC in achieving that.

Anyway most T2s are testing and the majority are guaranteed strips by the NICE guidelines.

 

[mcdonagh47]

very true, this bit is all too often ignored. There is a lot of emphasis on getting test strips prescribed but those that do have them are not told how to interpret the results that they get, as recent questions on here have shown. It's wasteful of resources and potentially dangerous. The information given to patients about when to test and what to do with results is very poor and there is no clear evidence about what they should be doing.

Puts me in mind of a meeting of the local support group about seven years ago. The speaker was a Doc from a local hospital. When this subject came up he said "Most of my Type 2 patients don't understand the test numbers and don't know what to do with them".

He wasn't too pleased when a certain somebody said ,"That's your fault mate !"

 

[Northerner]

Thanks for those points Mcdonagh, I'd always wondered what proportion of T2s were on insulin. Also, should they really be relying on old studies - relative to the pace of available technology? Like the story about the Doc!

 

[fruitloaf]

but why can't they be told how to test appropriately when they are given the glucose meter? that would seem most sensible.
I think the scenario of people being given glucose meters without clear instructions is very common (when I was given one my practise nurse didn't even open the box never mind tell me when to test!). The experience of many people here seems to be that their practise nurse tells the to follow a low fat diet and test the blood sugars at various times. Contientious patients who are keen to test then realise after some testing that actually eating a high carbohydrate meal leads to high glucose results. This leads to a poor relationship between HCP and patient as patient is confused about high glucose results on the recommended diet. This may then cause anxiety about high results.
Prescribing more test strips will not change any of this except for existing patients who have a good understanding of the disease.
I'm certainly not critisising people for asking questions only using it as an example of the poor quality of information given by HCP. We are here to help but we shouldn't be doing their job for them.

 

[Northerner]

You are right, of course that people shouldn't be given meters and left to their own devices. I think that atually happens a lot with Type 1s - it happened to me. Basically I was told to test before meals and before bed - ifor the first few months I wasn't told anything about adjusting insulin either, another piece of madness IMHO, but that's by the by. What we are talking about here, on this forum, is helping the members who have already shown willingness to learn how to test, not the vast number of people who don't even know (or perhaps care) that places like this exist.

I think you are making good points, but they are a little idealistic and are not going to be implemented in the near future with the pressure on health service resources, so people are given the minimum advice in most cases, if indeed they are provided with meters (as T2s). All T1s will get meters and probably most get the advice I got.

I don't know why people aren't given appropriate instruction, or why the general dietary information is so out of kilter with reality, but it's not something I can do anything about except by helping the people here understand more.

 

[fruitloaf]

... meanwhile the less contientious patients, without support and advice or clear instructions become quickly disheartened but realise they can make a bit of money on the side selling their test strips on ebay...probably.

 

[benniesmum]

T2 Testing

What seems to be happening, is that ALL T2s who are on metformin only are having strips removed because they don't have a high risk of hypos. I just had mine withdrawn (without even the courtesy of a call/note from my doctor), even though I use them to keep my Hba1C at/below 6.5.

It absolutely is about saving money in the short term, as this is a big expense. I got quoted a 'recent study' that 'showed' there was little or no benefit in T2s testing. Which is probably because of lack of training in HOW to test effectively. But there seems to be no flexibility for those of us who DO know how and do it effectively.

As most of us only get an HbA1c once a year, I can see a huge bubble of diabetic complications soming down the line, which will be a great deal more expensive both in money and human misery. But short termism seems to be the name of the game with the NHS at the moment, sadly.

 

[Northerner]

What seems to be happening, is that ALL T2s who are on metformin only are having strips removed because they don't have a high risk of hypos. I just had mine withdrawn (without even the courtesy of a call/note from my doctor), even though I use them to keep my Hba1C at/below 6.5.

It absolutely is about saving money in the short term, as this is a big expense. I got quoted a 'recent study' that 'showed' there was little or no benefit in T2s testing. Which is probably because of lack of training in HOW to test effectively. But there seems to be no flexibility for those of us who DO know how and do it effectively.

As most of us only get an HbA1c once a year, I can see a huge bubble of diabetic complications soming down the line, which will be a great deal more expensive both in money and human misery. But short termism seems to be the name of the game with the NHS at the moment, sadly.

There's quite a lengthy report here which sheds some light on this attitude from the healthcare profession:

http://www.npc.nhs.uk/merec/cardio/diabetes2/merec_bulletin_vol21_no5.php

Basically, the HCPs are told to look not only at managing blood sugar levels (HbA1c), but blood pressure and cholesterol and claims there is little benefit in reducing HbA1c below 7.5% (despite other evidence to the contrary re: complications), particularly if the other numbers are not so good. That's just a basic summary of course, and it is worth reading if you've got a spare hour or so, but basically if your HbA1c is better than 7.5% and you are on metformin or D&E then it's not worth spending money on strips for you...

However, it does say that targets should be agreed with the individual, so if you are happier getting your HbA1c in the 6s then this should be discussed with you - not a blanket removal of strips from everyone. I suspect they use the blanket removal approach and see who complains, because this is far cheaper and easier than calling each individual in.

 

[Blythespirit]

Always a hot topic this and thanks for all the links given here. Interesting to note that all T2's on sulphs such as Gliclazide are supposed to be guarenteed testing strips on prescription as it was when I was first prescribed Gliclazide that my megre allowance of 51 strips every 3 months was stopped.

I was never given a meter til I was prescibed Byetta recently and bought the majority of my own strips since diagnosis. The above mentioned allowance took me 5 years begging to get and only lasted a little over a year til it was stopped. I was never told how to use my results. Worked that out on my own. Also, my results were ignored by my health care team as they only acted on my HbA1c reults, and only then by increasing meds and not offering any other advice. An A1c result could look okay but be made up of lots of hypos and hypers, which in itself is not good.

How are we supposed to manage our condition and keep ourselves healthy if we are not given the tools and knowledge to do so?

Just off to drive blindfold down the M1. So long as I eventually arrive at my destination it doesn't matter how many times I crash on the way. 😱 XXXXX

 

[trophywench]

Ah well of course, if the NHS and the DVLA's rules don't meld, you can hardly blame your PCT or the DVLA can you? I think it's utterly unreasonable of you to expect them to agree; if you choose to want to have a driving licence and use it, then it's your choice. The fact that this now entails extra costs on your part to buy your strips is again up to you. If you don't wish to follow the driving regulations then you can give up your driving licence and then you needn't test. Why anyone with a brain would ever want to bodge holes in their fingers is completely beyond me anyway! So just return your licence to swansea and your problem is solved, and that's for the price of one second class stamp - FAR cheaper than those nasty strips.

That's the trouble with people today - they all seem to think they have 'rights'. Tsskk; silly people!

I was going to answer in quite a different way but I don't think the sort of language I really had in mind would be accepted by the forums software, but hopefully you'll decipher how I really feel ........

 

[cherrypie]

It is obvious that Type2's who join forums are trying to manage their diabetes to the best of their ability and should be given test strips. The trouble is that PCT's interpret the guidelines. They don't all educate us so how could we possibly understand? We would all be gibbering wrecks according to them if we tested frequently.
I think that Type2's should be educated as to how to use the meter, how to interpret their results and if after 6months they are not making some progress then the HCP should ask themselves why and what they can do to help.

There are competitions at my surgery,(we are not denied strips), between some Type2's in the waiting area as to who has got the highest reading since their last appointment. A food diary and results should be necessary for repeating the strips so that the HCP can explain how to interpret the results.

 

[Northerner]

It is obvious that Type2's who join forums are trying to manage their diabetes to the best of their ability and should be given test strips. The trouble is that PCT's interpret the guidelines. They don't all educate us so how could we possibly understand? We would all be gibbering wrecks according to them if we tested frequently.
I think that Type2's should be educated as to how to use the meter, how to interpret their results and if after 6months they are not making some progress then the HCP should ask themselves why and what they can do to help.

There are competitions at my surgery,(we are not denied strips), between some Type2's in the waiting area as to who has got the highest reading since their last appointment. A food diary and results should be necessary for repeating the strips so that the HCP can explain how to interpret the results.

Oh my goodness! Competitions? Do the 'winners' realise they are the biggest losers? I am in total agreement, in fact I was discussing this at my recent review. It turns out my consultant actually wrote the guidelines used by my PCT and they reflect what you have just said - whether this means that individual GPs follow them or not I'm not sure, and I suspect they can get away with not providing strips and education to a lot of people simply by telling them they don't need them and relying on the patient's respect for their authority.

I think what angers me most is when a person has been denied strips, has taken it upon themselves to buy strips and learn how to use the results, taken these results to the doctor and is still refused strips.

 

[sweetsatin]

I too had my test strips stops without my knowledge, i found out when i went for my repeat prscription.
I went to see my dn to ask why... Her reply was cost cutting, i did say that the NFS's (National Service Frameworks) and i quote:
self-management is the cornerstone of effective diabetes care.
In keeping with the principles of The NHS Plan, and The Expert Patient, the primary goal is to enable the person with diabetes, or at risk of developing diabetes, to manage their own lifestyle and diabetes, by providing support and structured education as well as drugs and treatments. Diabetes exemplifies the critical importance of this approach ? all the evidence suggests that a partnership between the person with diabetes and their clinical and support team can improve outcomes and quality of life.
How can we do this without the test strips diet control or not i need to test when eating different foods and as for saying type2's don't have hypos rubbish i have had a few..Without my test strips i can't manage my diabetes....On a good note i got my script for test strips. 🙂
I also told her i have bought them in the past because of this cost cutting thing not that i can afford to buy them, it was a case of having to have them.