Pharmacy & Therapeutics - March 2008 - (Page 165) Compliance and Self-Monitoring of Blood Glucose continued from page 160 providers who wanted their patients to check their blood glucose levels often and disagreed with the recommendations, or some sites might have encouraged their pharmacists to change the prescription to follow the recommendation. Table 3 depicts the potential cost savings based on the findings of the August 2006 and January 2007 MUEs. DISCUSSION To increase compliance with VHA/DoD recommendations, the VISN 3 medical centers implemented a new computer software package. The package allowed patients who were not using insulin to receive 50 blood glucose test strips for 180 days unless the health care provider considered it necessary to prescribe more. The new recommendation was implemented on November 1, 2006. Our pilot review revealed a reduction in excess strips prescribed in January 2007 (12%), compared with the number for August 2006 (17%). The new package has thus far improved compliance with VHA/DoD recommendations and has had a positive impact in decreasing the number of strips prescribed for diabetic non-insulin patients. In addition to implementing software changes, the network P&T committee informed health care providers about the guidelines limiting the number of strips for patients not using insulin. Although the providers were informed both before and after the software change, they received more instruction after the change; network management concentrated on disseminating this information more aggressively because of the potential cost savings involved. The outcome of our pilot review should result in significant cost savings—almost $250,000—to VA medical centers (see Table 3). A larger sample size is needed to determine the actual statistical significance of compliance and the new computer software. excess blood glucose test strips used by diabetic patients not needing insulin and has led to cost savings for VISN 3. We conducted the January 2007 review only two months after the new package was implemented. With more time and attention to the prescribing of test strips, this initiative should help to reduce the number of excess strips to a greater extent than that shown in the January 2007 findings. This improvement has the potential to lead to even greater cost savings than those identified in this article. To increase compliance with the new guidelines and to decrease costs for medical centers, the new recommendation of 50 blood glucose test strips for 180 days needs to be re-emphasized for prescribers and pharmacists. Because this was a preliminary pilot review with a small sample size, we recommend that a larger number of prescriptions be examined and that statistical analyses performed in order to determine the differences realized with the new software. Improved monitoring of HbA1c levels should also be conducted to assess the potential impact on quality of health care. REFERENCES 1. Centers for Disease Control and Prevention. National Diabetes Fact Sheet, United States 2005. Available at www.cdc. gov/diabetes/pubs/pdf/ndfs_2005.pdf. Accessed May 8, 2007. 2. American Diabetes Association. Direct and Indirect Costs of Diabetes in the United States. Available at: www.diabetes. org/diabetes-statistics/cost-of-diabetes-in-us.jsp. Accessed May 8, 2007. 3. Management of Diabetes Mellitus. VHA/DoD Clinical Practice Guideline Working Group. Veterans Health Administration, Department of Veterans Affairs and Health Affairs/Department of Defense. No.10Q-CPG/DM-03. Washington, DC: Office of Quality and Performance; December 1999 (Update 2003). 4. American Diabetes Association. Tests of glycemia in diabetes [position statement]. Diabetes Care 2004;27(Supp 1):S91–S92. 5. Oki JC, Flora DL, Isley WL. Frequency and impact of SMBG on glycemic control in patients with NIDDM in an urban teaching hospital. Diabetes Educ 1997;23:419–424. 6. Meier JL, Swislocki AL, Lopez JR, et al. Reduction in the selfmonitoring of blood glucose in persons with type 2 diabetes results in cost savings and no change in glycemic control. Am J Manag Care 2002;8(6):557–565. 7. Harris M. Frequency of blood glucose monitoring in relation to glycemic control. Diabetes Care 2001;24:979–982. 8. Rindone JP, Austin M, Luchesi J. Effect of home blood glucose monitoring on the management of patients with non–insulin dependent diabetes mellitus in the primary care setting. Am J Manag Care 1997;3:1335–1338. 9. Faas A, Schellevis FT, Van Eijk JTM. The efficacy of self-monitoring of blood glucose in NIDDM subjects: A criteria based literature review. Diabetes Care 1997;20:1482–1486. 10. Coster S, Gulliford MC, Seed PT, et al. Self-monitoring in type 2 diabetes mellitus: A meta-analysis. Diabet Med 2000;17:755–761. 11. Holmes V, Griffiths P. Self-monitoring of glucose levels for people with type 2 diabetes. Br J Commun Nurs 2002;7:41–46. 12. Farmer A, Wade A, Goyder E, et al. Impact of self-monitoring of blood glucose in the management of patients with non–insulin treated diabetes: Open parallel group randomized trial. BMJ 2007;335(7611):132. 13. Wieland LD, Vigil JM, Hoffman RM, et al. Relationship between home glucose testing and hemoglobin A1c in type II diabetes patients. Am J Health Syst Pharm 1997;54(9):1062–1065. I STUDY LIMITATIONS Our evaluation was associated with several potential limitations:7–11 • We reviewed only 100 prescriptions, a relatively small number. • We analyzed data in August 2006, one month before the implementation of the new software package, and in January 2007, two months after the guidelines were implemented. Six-month data would have yielded a better representation of compliance. • We examined the number of test strips per prescription, not the number of prescriptions per patient. • We did not evaluate overall test strip use to include insulinusing patients as well as non–insulin-using patients. • The overall impact on patient outcomes, such as analyzing HbA1c for glycemic control, had not yet been assessed. In several studies, however, similar limitations in SMBG by diabetic patients not using insulin did not affect overall HbA1c values and did not compromise patient care. CONCLUSION Implementing a new computer software package at our VA network in November 2006 helped reduce the number of Vol. 33 No. 3 • March 2008 • P&T® 165
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