Millions of Low-Risk Type 2 Diabetes Patients May Be Over-Testing

Miriam E. Tucker

December 11, 2018

Many patients with type 2 diabetes are over-monitoring their blood glucose levels, new research suggests.

The findings, from a retrospective analysis of claims data, were published online December 10 in JAMA Internal Medicine by Kevin D. Platt, MD, of the University of Michigan, Ann Arbor, and colleagues.   

As part of the Choosing Wisely campaign, in 2013 the Endocrine Society listed routine multiple daily self-monitoring of blood glucose in adults with stable type 2 diabetes on medications that don't cause hypoglycemia as an unbeneficial practice to be avoided, or so-called "low-value care."

The recommendation is evidence-based: a 2012 Cochrane review of 12 randomized trials showed that the practice did not improve glycemic control or quality of life, or reduce hypoglycemia (among patients not at risk for it in the first place).

The American Academy of Family Physicians and Society of General Internal Medicine have also issued guidance for physicians stating that such patients don't need to regularly test their glucose levels.

Nonetheless, Platt and colleagues found that nearly one in seven patients with type 2 diabetes not using insulin had filled three or more claims over a 1-year period during January 2013 through June 2015.

"Low-value care worsens patient-centered outcomes and imparts a negative economic effect," they write.

This unnecessary practice will cost patients time — and sometimes worry — while their insurance plans pay hundreds of dollars a year for their supplies, they add. Multiplied over the millions of Americans who have type 2 diabetes, the findings could mean millions of unneeded blood glucose tests and millions of dollars spent for no good reason, say the researchers.

One strategy to encourage more judicious use of self-monitoring of blood glucose might involve clinical decision support in electronic medical records with an alert for a test strip prescription in a patient taking nonhypoglycemia-inducing medications, Platt and colleagues suggest.

Other possible interventions include data feedback, physician communication training, clinician scorecards, and pharmacist review, all 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."

Inappropriate Test Strip Use Common

Platt and colleagues note the aim of their study "was to quantify the rate of use and cost of self-monitoring blood glucose supplies that are potentially used inappropriately, specifically focusing on test strips, the most costly supply for regular blood glucose monitoring."

The study involved data for 370,740 claims from the de-identified Clinformatics Data Mart Database (OptumInsight), which includes beneficiaries of both commercial health insurance and Medicare Advantage plans. Patients receiving insulin prescriptions were excluded.

The analysis was limited to individuals with either three or more, or zero, claims for test strip prescriptions within a 1-year period.

Of 86,747 patients who filled three or more claims for test strips during 1 year, 59.7% (51,820) were deemed to be potentially using them inappropriately.

Overall, 37.8% of the 86,747 patients (32,773) were only taking drugs that don't cause hypoglycemia, and 21.9% (19,047) had no claims for any glucose-lowering medications. 

Those two groups were using an average of two test strips per day at a cost of $325.54 per person per year with a mean annual co-pay of $18.14.

"Despite a lack of clinical evidence and being identified as a low-value service by the Choosing Wisely initiative, a substantial percentage of patients with type 2 diabetes may still be inappropriately self-monitoring blood glucose," the authors say.

In a statement from the University of Michigan, Platt says: "These data show that over-testing is quite common — and with the appropriate guidance can be reduced significantly."

For patients who test daily but don't have to, their healthcare providers should tell them they have the option to stop and offer more helpful tests, such as HbA1c, he and his colleagues add.

Senior author A. Mark Fendrick, MD, also of the University of Michigan, noted that "healthcare costs and access to care are an important issue for many Americans."

"The savings that result from reducing the use of unnecessary care — such as needless home blood sugar testing — can create 'headroom' to spend more on those clinical services that we need to buy more often."

Platt has reported no relevant financial relationships.

JAMA Intern Med. Published online December 10, 2018. Abstract

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