Primary care implications of the new SMBG consensus statement

A  recent review of randomised controlled trials showed that there is significant benefit with self-monitoring of blood glucose (SMBG) in people with diabetes (Moore and McQuay, 2005). However, there are currently no specific guidelines for primary care teams that give clinical advice on how to achieve good glycaemic control or that explicitly recommend provision of the materials that allow for SMBG. While the new General Medical Services (nGMS) contract sets HbA_1c targets through quality indicators (Department of Health [DoH], 2004) and the National Institute for Clinical Excellence (NICE) has emphasised the need for SMBG (NICE, 2002), guidance is not provided on how to achieve these targets or implement the guidance at practice level.

A recent consensus statement (Owens et al, 2004; updated in Owens et al, 2005; Tables 1 and 2) hopes to provide a framework that puts SMBG into context and demonstrates how it is beneficial to people with diabetes. It is hoped that the results of the consensus will lead to change not only in day-to-day general practice, but also in the way in which primary care teams educate people with diabetes. People with diabetes should then understand and feel able to take control and self-monitor blood glucose – helping them achieve improved outcomes.

What the results mean in practice
Little guidance currently exists on SMBG for primary care professionals. This, in part, may explain the variations in patient care that exist in general practice. In one practice, for example, SMBG may not be offered at all unless a patient asks specifically about it, while at another, SMBG may be offered to all patients with diabetes, as an adjunct to good quality care.

Top-down decisions from primary care organisations (PCOs) add to the variation regarding the costs of SMBG strips, which means that some areas are restricting the supply of strips regardless of patient need. Without doubt, these factors have led to an inequality of patient care.

The SMBG consensus helps to address this variation, collecting scientific research to give healthcare professionals – across a range of disciplines including those directly involved in PCO decisions – a theoretical base to work from. The updated document (Owens et al, 2005) represents a major step forward and gives an authoritative and standardised viewpoint that can now be applied nationwide. It will effectively change the working practice of the primary care professional, providing guidelines that can be applied throughout the healthcare system, regardless of where the patient is seen.

The consensus will allow healthcare professionals in primary care to give clearer guidance to people with diabetes on how, and how often, blood glucose should be monitored. It also serves to provide a framework for good practice. Its universal approach should address the inequality in the way people with diabetes are treated across the country.

This empowerment represents a whole new approach to diabetes care and promotes the self-management of the disease (DoH, 2001). It respects the rights of people with diabetes and allows them to decide for themselves what is appropriate for their needs at that particular time based on an informed decision.

The consensus encourages standardisation of access to all monitoring facilities for every patient, wherever they live in the country. It also puts the individual patient at the centre of care, emphasising the requirement to assess need on an individual basis – deciding the frequency of SMBG according to that assessment only.

Another important practical implication of the consensus is that people with type 1 or type 2 diabetes need to be able to monitor more frequently both in times of illness and when therapy has been changed, so that they can know how their blood glucose levels are responding.

The impact on the nGMS contract
The nGMS contract was introduced in April 2004 (DoH, 2004). It has a Quality and Outcomes Framework that rewards practices for achieving levels of process and outcome in various domains. There are 99 points that can be achieved through the fulfilment of 18 indicators in the clinical sphere of diabetes. None specifically mention SMBG; because of this, general practitioners (GPs) and nurses are left without explicit clinical guidelines on how to achieve good glycaemic control. However, 27 of the points relate to HbA_1c levels, of which 16 points will be awarded for achieving an HbA_1c of 7.4% or less in 50% of the people with diabetes on the practice register and 11 points will be awarded for obtaining an HbA_1c of 10% or less in 85% of people (Table 3).

The 3 points for HbA_1c process and the 27 points for HbA_1c quality indicate the importance of good glycaemic control in high-quality diabetes management. There is a sound evidence base to show the value of good glycaemic control, as measured by HbA_1c, in the prevention of long-term complications in diabetes (UK Prospective Diabetes Study [UKPDS] Group, 1998).

SMBG is an essential procedure to achieve these important treatment goals and prevent disease complications. It can enable those with poor overall glycaemic control to monitor their day-to-day blood glucose levels, to understand the relationship between their prescribed treatment, food intake and physical activity and to achieve concordance between these various factors to achieve near normal glycaemic control. For people with diabetes who require insulin treatment, SMBG is mandatory to enable appropriate insulin dose adjustments to be made, to optimise glycaemic control and to achieve the HbA_1c targets stated in the Quality and Outcomes Framework, all of which will protect the future quality of life by reducing the risk of complications (Diabetes Control and Complications Trial Research Group, 1993).

Type 2 diabetes
Blood glucose levels tend to be more predictable in people with type 2 diabetes (Pickup, 2003). The UKPDS showed clearly that type 2 diabetes is a progressive condition with a gradual and almost inevitable deterioration in glycaemic control over time. In people with type 2 diabetes, commonly used anti-diabetic agents have been shown to not affect progression of the condition (UKPDS Group, 1998).

SMBG allows people with diabetes to recognise the impact that lifestyle factors that they can control – such as diet and exercise – have on their condition. It may, therefore, have an important role to play as part of an integrated self-care package for people with type 2 diabetes.

While the consensus cannot change the lack of explicit guidelines on SMBG within the nGMS contract, it can help healthcare professionals to see the context in which SMBG may be beneficial to the range of people with diabetes.

Encouraging active participation of people with diabetes
A central point of the consensus is that individuals with diabetes should be able to understand the reasons why they are using SMBG. When people with diabetes are fully aware of the reasons behind the testing process and the significance of results, successful self-management is encouraged. It is crucial that individuals understand why they are testing and know the target range of blood glucose levels they are aiming for. Understanding these points will mean that the individual is more likely to carry out the test.

On a day-to-day basis, people with diabetes need to understand what the results mean in terms of lifestyle and treatment and to know that they have the ability to adjust some factors accordingly. By monitoring changes in blood glucose, people with diabetes can actively see how factors such as diet, exercise, stress levels, other illnesses and the weather have an impact on their condition. The influence of external factors on blood glucose can be demonstrated through changes in the test results and the healthcare professional can educate the person with diabetes on how to manage such changes. Where appropriate, people with diabetes can be taught to adjust treatment according to their test results and to change lifestyle factors that are directly influencing their blood glucose levels.

When a person with diabetes is involved in the education process about the benefits of regular SMBG, effective self-management can then help to reduce complications and long-term risk (Hampson et al, 2001). SMBG is an effective tool through which healthcare professionals can teach people with diabetes about managing their condition and its treatment. Empowered and educated people with diabetes can achieve improved outcomes for themselves.

Conclusion
The new consensus document represents the only SMBG guidelines currently available for the primary care sector. The document expresses clearly the importance of SMBG and states that there should be no restrictions placed on it. The consensus strives to place the needs of the individual with diabetes at the centre of treatment, and to educate the individual on the importance of achieving good glycaemic control through SMBG. It potentially allows the primary care team to see how targets set by the nGMS contract may be achieved, and one of its aims is achieving standardised care based on clinical need.

Without this document, and a standard consensus of what constitutes good clinical practice, people with diabetes are subject to inequalities through lack of knowledge, lack of education or PCO restrictions. Universal adoption of this consensus would mean an end to the patient inequality that has increased in the absence of clinical guidelines.