A study published in JAMA Internal Medicine found that 14% of type 2 diabetes patients not using insulin purchase enough test strips to measure blood glucose two or more times a day.
University of Michigan researchers noted that “low-value care worsens patient-centered outcomes and imparts a negative economic effect, which has prompted the Choosing Wisely campaign to promote a national dialogue on the judicious use of services that are deemed to be nonbeneficial.”
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Person testing blood glucose. Source: Getty
The study pointed out that clinicians should “avoid routine multiple daily self-glucose monitoring in adults with stable type 2 diabetes on agents that do not cause hypoglycemia.”
Researchers sought to quantify the rate of use and cost of self-monitoring blood glucose supplies that are potentially used inappropriately. Their primary focus was test strips, which are the most-costly supply for regular blood glucose monitoring.
To determine that, the study team performed a retrospective analysis of claims data from Jan. 1, 2013, to June 30, 2015, from the deidentified Clinformatics Data-Mart Database (OptumInsight), which includes commercial health insurance beneficiaries and Medicare Advantage beneficiaries.
Included in the analysis were adults who were not pregnant, continuously enrolled for a minimum of two years from Jan. 1, 2013, through Dec. 31, 2014, and had two office visits less than 181 days apart, or one emergency department visit or one hospitalization with a diagnosis of type 2 diabetes.
More than 370,000 patients, who had a mean age of 68.5, were followed for at least a year after filling a prescription for test strips, or for the calendar year of 2014 if no prescription was filled. Researchers only included patients with three or more claims for test strips, which suggested routine use, as well those with no claims for test strips within the one-year study period.
Results indicated that 23.4% filled three or more claims for test strips during the course of the year. Yet, more than half of those patients – 14% of the study population -- were determined to be potentially using the supplies inappropriately.
Overall, the study found that 32,773 patients were taking agents not considered to be a risk for causing hypoglycemia, such as metformin, and that 19, 047 actually had no claims for any antidiabetic medications.
Patients in those two groups used a median of 2.0 strips per day (interquartile range, 1.2-2.4) at a median claims cost for test strips of $325.54 (interquartile range, $0.00-$534.76) per person per year. The mean (SD) consumer copayment for test strips was $18.14 ($54.94) annually (median, $0.00 [interquartile range, $0.00-$0.00]).
The report pointed out that three different medical societies -- the American Academy of Family Physicians, the Society of General Internal Medicine and the Endocrine Society -- have issued guidance for physicians stating that such patients don't need to regularly test their sugar levels.
"One of my patients who didn't need to be testing daily told me that her previous doctor had told her to test his sugars two or three times a day," explained Kevin Platt, MD, the internal medicine resident who led the analysis. "These data show that over-testing is quite common -- and with the appropriate guidance can be reduced significantly."
The authors made several suggestions for reducing unnecessary blood sugar testing. Among them were clinical decision support in electronic medical records that create an alert when ordering test strips for patients who are taking non-hypoglycemic medications.
In addition, they recommended that data feedback, physician communication training, clinician scorecards, and pharmacist review “should be aligned with patient-centered strategies such as shared decision making and increased consumer cost sharing (eg, value-based insurance design) to effectively reduce low-value care, while preserving the use of self-monitoring of blood glucose when it is clinically indicated.”
