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Title: The%20Reality%20of%20Diabetes%20Care


1
  • The Reality of Diabetes Care
  • Terri Sasse, RN, CDE

2
(No Transcript)
3
Agenda
  • Diabetes Overview
  • Patient Monitoring of Blood Sugar
  • Features and Benefits of Monitors
  • Hands-on Experience with Monitors
  • Case Study

4
Program Information
ACPE 384-000-07-017-L04 Release Date
8-6-07 Expires 8-6-2010
STAT Educational Services, a division of
National Pharmacy Technician Association
Inc., is accredited by the Accreditation Council
for Pharmacy Education (ACPE) as a provider of
continuing pharmacy education.
5
Objectives
  • Participants will be able to
  • Know data of the prevalence and incidence of
    diabetes
  • Describe the evolution and current technology for
    measuring blood glucose levels
  • Identify the importance of blood glucose
    monitoring in diabetes management
  • Recognize the various features and benefits of
    commercially available blood glucose monitors
  • Discuss how to assist patients in selecting a
    blood glucose monitoring system
  • Understand variables that may affect the
    performance of blood glucose monitoring systems

6
Diabetes Prevalence
  • 20.8 million people have diabetes
  • 6.2 million are undiagnosed
  • 41 million have
  • pre-diabetes

7
Diabetes Incidence
8
Trends in Growth
  • Aging population
  • Increase in overweight population
  • Adults
  • Children
  • Influx of high risk groups
  • Increased diagnosis

9
Evolution of Glucose Testing
  • 1948-Urine testing strips developed using glucose
    oxidase as enzyme
  • Limitations
  • qualitative only
  • differences in renal threshold
  • affected by interfering substances
  • poorly correlated to blood glucose

10
BG Meter Technology-1970s
  • Color Reflectance or Reflectance Photometry
  • Chemical reaction between glucose and an enzyme
    produces a color change on test strip
  • Color change is proportional to amount of glucose
    in sample
  • Electrochemical or Biosensor
  • An electrochemical reaction which generates an
    electrical current proportional to the amount of
    glucose

Accuracy of Blood Glucose Measurement at
www.powerpak.com. 2003
11
Current Technology Segmentation
  • Photometric 25
  • Lifescan Basic/Profile/Surestep
  • Accu-Chek Active/Compact
  • Prestige IQ Smart System
  • Biosensor 75
  • Lifescan Ultra
  • Therasense Freestyle
  • TrueTrack Smart System
  • Accu-Chek Advantage

25
75
12
Benefits of Self-Monitoring
  • Benefits both Type 1 and Type 2 patients with
    diabetes
  • DCCT Type 1
  • United Kingdom Prospective Diabetes Study Type 2

ADA Standards of Medical Care in Diabetes,
Diabetes Care, Vol. 27, January 2004, pg.
S15-S35.
13
Importance of BG Monitoring
  • Cornerstone of diabetes self-management
  • Individualizes diabetes self-care
  • Empowers the patient
  • Reinforces good behaviors

14
Frequency of Testing
  • Type of Diabetes
  • Overall glycemic control
  • Changes in therapies
  • Changes in lifecycle

ADA Standards of Medical Care in Diabetes,
Diabetes Care, Vol. 27, January 2004, pg. S15-S35.
15
ADA Guidelines for Testing
  • As needed to achieve glycemic goals
  • Fasting
  • Preprandial/Postprandial
  • 3 am
  • Periodically alternate testing times
  • Test when symptomatic

ADA Standards of Medical Care in Diabetes,
Diabetes Care, Vol 27, January 2004, pg S15-S35.
16
AAFP Guidelines for Testing
  • Type 1 taking insulin-
  • test 3-4x day
  • Type 2 taking insulin and orals
  • -test 3-4x/day
  • Orals only with A1C out of target range-test
    2-4x/day

American Academy of Family Physicians, 2004
17
What are the goals?
  • ADA recommendations
  • Preprandial plasma glucose 90-130mg/dL
  • Postprandial plasma glucose lt180mg/dL
  • A1C lt7
  • All goals are individualized
  • Based on certain populations

ADA Standards of Medical Care in Diabetes,
Diabetes Care, Vol 27, Jan 2004, pg. S15-S35.
18
Measures of Glycemic Control
  • Self-monitoring (SMBG)
  • Glycosylated hemoglobin
  • Total hemoglobin
  • Hemoglobin A1c
  • Urine ketone testing

19
Advantages of Monitoring
Glycosylated Hemoglobin
SMBG
  • Marker of glycemic control
  • Evaluation of self-monitoring
  • Correlation with long-term complications
  • Immediate results
  • Evaluation of changes
  • Enhanced patient independence

20
Relationship between HbA1c and Average Blood
Glucose (DCCT)
330 300 270 240 210 180 150 120 90 60
13 12 11 10 9 8 7 6 5 4
High Risk for Complications
  • Average BG
  • HbA1c

Good Control Low Risk for Complications
Normal Range Low Risk for Complications
21
Elevated Postprandial Glucose Levels
  • Earliest abnormality in type 2 diabetes
  • Contributes to elevations in HbA1c
  • Best predictor of HbA1c
  • Contributes to both microvascular and
    macrovascular complications

22
Targeting Postprandial and Fasting Glucose Levels
Lowers HbA1c in Type 2 Diabetes
10
24 Reduction
8
HbA1c
9.4
6
7.1
4
2
0
Fasting Alone
Fasting Plus Postprandial
Ohkubo Y, et al. Diabetes Res Clin Pract.
199528103-117.
23
The Reality of Diabetes Care
  • lt2 of American adults with diabetes receive
    optimal quality of care
  • Majority of patients with Type 2 diabetes have
    only fair to poor metabolic care
  • Fasting glucose levels of 200mg/dL or higher
  • HbA1c levels of 9-10 (lt7 is target)
  • Postprandial glucose levels average 300mg/dL
  • Beckles, GL., et al. Diabetes Care,
    1998211432-1438 ADA, Diabetes Care,
    199821(supple 1) Colwell JA. Ann Intern med.
    1996124 (1pt2)131-135 Abraira C, et al.
    Diabetes Care. 1992151560-1571 Klein R, et al.
    Am J Epidemiol. 1987126415-428 CowieCC, et al.
    Diabetes in America. 2nd Edition

24
The Right Meter for the Right Patient
25
Customer Confusion!
26
Unbranded Meter Scripts
  • Nearly 50 of meter scripts are not brand
    specific

GfK Market Measures Therapeutic Class Studies
Blood Glucose Monitoring Study V (2005) -
GfK Market Measures Roper 2006 US Diabetes
Patient Market Study
27
Patients Reasons for Selecting a BG Meter
47
18
13
6
2006 Roper Global US Diabetes Program at GFK NOP
World Health, August September 2006
28
Lowest CoPay Prevalence by Test Strips
Commercial Insurance
51
19
12
9
8
05/07 Top Commercial Plans by TRx Volume
29
Features and Benefits
  • Meter
  • Size of meter
  • Test time
  • Calibration or coding procedure
  • Data management options
  • System specifications
  • Test Strips
  • Size of test strips
  • Packaging of test strips
  • Amount of blood required
  • Blood sampling sites

30
Comparison of Leading BGM Systems
Test Strips Test Strips Data Management Data Management
Sample Size Required Test Speed Test Memory Averaging
Accu-Chek Aviva 0.6 micorliters 5 seconds 500 7, 14- 30-Day
Ascensia Contour 0.6 microliters 5 seconds 480 14-Day
Freestyle Flash 0.3 microliters 7 seconds 250 14-Day
One Touch Ultra 2 1 microliter 5 seconds 500 7, 14 - 30-Day
TrueTrack 1 microliter 10 seconds 365 14- 30-Day
31
Advanced Blood Glucose Monitoring Systems
TrueTrack SmartSystem
FreeStyle Flash
One Touch Ultra 2
Accu-Chek Aviva
32
Information Blood Glucose Systems
Accu-Chek Complete
One Touch UltraSmart
FreeStyle Tracker
33
Store Brand Offerings
TrueTrack Smart System
ReliOn Ultima
Kroger
34
Accuracy of Blood Glucose Monitoring Systems
  • FDA Approval process involves showing substantial
    equivalence between the investigative device and
    a device that is currently on the market
  • FDA requires Human Factors Studies
  • International Standardization Organization

U.S. FDA Center for Devices and Radiologic
Health, 1997, Guidance Glucose Document
35
Industry Standards for Accuracy
  • FDA recognizes National Committee for Clinical
    Laboratory Standards1
  • ADA goal /- 10 at ranges 30-400mg/dL2
  • Clinically acceptable is /- 15 of the standard
    laboratory value3
  • Most patients with some formal training can
    obtain results within 20 of the lab reference4
  • Most meter result errors are user related5
  • \
  • 1 NCCLS Method Comparison and Bias Estimation
    Using Patient Samples
  • EP9-A Vol. 15 No. 17
  • 2 ADA Consensus Statement. Diabetes
    Care 1987 195-99
  • 3-5 Ibid.

36
Variables that can affect the Accuracy of BGM
  • User Variables
  • Poor technique
  • -27-48 poor vision
  • -25 loss of sensation
  • -language constraints
  • -insufficient sample size
  • Soiled meter
  • Lack of calibration
  • Lack of hand-washing
  • System Variables
  • Heat or Cold
  • Defective Strips
  • Humidity
  • Pharmacological Factors
  • Oxygen content
  • Glucose content (60-200mg/dL)
  • Dehydration
  • Interfering Substances

Accuracy of Blood Glucose Measurement. Available
at http//www.powerpak.com/CE/accuracy_bgm/pharmac
y /references.cfm
37
Promoting Accurate Testing
  • Review and understand manufacturers instructions
    for use
  • Practice using control solution
  • Assess user technique
  • Understand system specifications
  • Proper storage and maintenance
  • Limitations of procedure
  • Utilize manufacturer technical support

A Core Curriculum for Diabetes Education, 5th
edition, AADE, Chicago, IL
38
Hands-on Experience with Monitors
39
Helping your Patients
  • Assess the physical needs
  • Visual limitations
  • Dexterity limitations
  • Assess the financial needs
  • Cash or reimbursement
  • Assess the lifestyle needs
  • Active vs. Sedentary
  • Assess the plan of care
  • Frequency of testing

40
Case Study
  • TS is a patient with Type 2 diabetes who has been
    self managing with meal planning and physical
    activity. Her labwork showed an A1c level of 9
    and her physician has referred her to a diabetes
    educator so that she can learn about BG
    monitoring and how her daily choices affect her
    glucose results. TS has poor vision, arthritis
    and is very afraid of sticking herself to get
    blood for a BG test.

41
Case Study
  • In order to help TS select a monitor, what are 2
    things you need to consider?
  • What specific features and benefits should you
    look for in a monitoring system to assist TS in
    selecting a meter?

42
Conclusions
  • Clinical studies support the benefits of BG
    monitoring in helping patients achieve glycemic
    goals
  • Optimal diabetes control helps to delay or
    prevent complications
  • Manufacturers focus on designing meters that are
    easy to use
  • and meet individual lifestyle needs
  • When used according to instructions, blood
    glucose monitoring
  • provides valuable information for managing
    diabetes care

43
Questions/Comments
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