Pharmacy & Therapeutics - March 2008 - (Page 158) Self-Monitoring of Blood Glucose: A Pilot Review Impact of Computer Software Modifications on Compliance Anita D. Patel, BA, PharmD; Viktoria Kharlamb, PharmD; Arthur P. Reiter, BS, MS; and Ron Lovly, MS, RPh INTRODUCTION Diabetes mellitus is a complicated disease that affects more than 20% of people aged 60 or older.1 According to the Centers for Disease Control and Prevention (CDC), 7% of the entire population in the U.S has diabetes.1 Health care costs associated with this disease, as well as its complications and treatments, are very high. According to data from 2002, 11% of federal health care funds were spent on diabetes alone, and the direct cost of diabetes was estimated to be $92 million for that year.2 Federal data from 2005 showed that this spending rate increased to 12%. This cost includes medications and testing supplies such as blood glucose test strips. Veterans Integrated System Network 3 (VISN 3) of the Department of Veterans Affairs dispensed approximately 4.7 million test strips with an estimated cost of $1.5 million for fiscal year 2006. Blood glucose test strips are prescribed for approximately 13,740 patients with stable type-2 diabetes who are not taking insulin in VISN 3. Clinical Practice Guidelines, developed jointly by the Veterans Health Administration and Department of Defense (VHA/DoD), recommend that (1) diabetic patients who are not using insulin limit blood glucose testing to twice weekly and use no more than 50 strips every 150 days, and (2) patients taking oral agents may be eligible for an increased number of strips for a limited time period for various indications (Table 1).3 According to the American Diabetes Association (ADA), the optimal frequency of self-monitoring of blood glucose (SMBG) is not known for patients with type-2 diabetes.4 Few data exist to support the routine use of SMBG for improving glycemic control in patients with diabetes who are not using insulin.5,6 Several review articles7–11 and a clinical trial, published in 2007,12 concluded that SMBG by patients who do not use insulin shows no clear effect on glycosylated hemoglobin (HbA1c) levels. The VHA/DoD guidelines were developed on At the time of this writing, Dr. Patel was a Pharmacy Practice Resident in the Department of Veterans Affairs at the New York Harbor Healthcare System in New York, New York. She is currently an Ambulatory Care Clinical Pharmacist at the VA Medical Center in Philadelphia, Pennsylvania. Dr. Kharlamb and Mr. Reiters are Clinical Assistant Professors at the Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, in New York. Dr. Kharlamb is also Senior Pharmacy Consultant, Mr. Reiter is Pharmacy Clinical Manager, and Mr. Lovly is Chief, all with the Veterans Integrated System Network 3 Pharmacy Benefit Management Program in the Department of Veterans Affairs at the New York Harbor Healthcare System. the basis of clinical evidence showing that periodic HbA1c testing was usually sufficient for monitoring glycemic control.3,5,9,13 The guidelines also provide recommendations for SMBG in patients who are using insulin.3 As a result of the VHA/DoD recommendations, VISN 3 implemented guidelines that allow two test strips per week (about 24 strips every 90 days) for diabetic patients not using insulin. However, prior to November 1, 2006, because of the limitations of the available computer software package that allowed for a maximum 90-day supply and the contracted test strip package size of 50, our local VISN 3 guidelines stated that patients who were not using insulin were limited to 50 test strips for a 90-day period unless the health care provider could document that the patient needed additional strips. After November 1, 2006, the medical centers in VISN 3 implemented a modification of the computer software package that allowed more precise compliance with the VHA/DoD guidelines. Patients who were not using insulin could receive 50 strips for 180 days (two strips per week) unless more strips were warranted. The VISN 3 network’s P&T committee advised health care providers about the new software and guidelines on the limited use of strips for patients not using insulin. OBJECTIVE Our primary objective in this pilot review was to evaluate adherence to VHA/DoD guidelines for SMBG by patients not using insulin therapy. We evaluated adherence both before and after the new computer software package was implemented. Our secondary objective was to determine the potential cost savings associated with the computer package, assuming a decreased use of blood glucose test strips for diabetic patients who were not using insulin. METHODS In August 2006, we used the medical center’s computerized patient record system to generate a report of patients who received blood glucose test strips. Because we conducted the pilot review to determine whether the new computer software might have been effective in decreasing the number of test strips prescribed, we set out to evaluate a total of 100 patients. This was a random, relatively small number of patients who were selected for the initial evaluation. Ultimately, a larger number of patients would need to be evaluated in order to obtain statistically significant data. We then conducted a retrospective manual chart review of 100 randomly selected patients. From the generated list, every 10th patient was randomly chosen. We reviewed the medical Disclosure: The authors have no commercial or financial relationships to disclose in regard to this article. Accepted for publication December 3, 2007. 158 P&T® • March 2008 • Vol. 33 No. 3
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