In Depth

Is the NHS right to cut costs in blood testing for type 2 patients?

The cost-cutting battle to scale back self monitoring of blood glucose (SMBG) testing in type 2 diabetes patients is under way. While the plan may seem fiscally necessary for the NHS, will the health of those affected suffer as a result?

In the UK, only insulin-treated patients with type 2 have access to prescription test strips by the NHS. Access is otherwise granted on a case-by-case basis providing a doctor states a legitimate need for SMBG in a patient.

In April, a study published by the British Journal of General Practice reported an increase of nearly £20m spent on diabetes self-monitoring between 2009 and 2012.

The NHS is therefore looking to cut back. This intervention in Tower Hamlets, London was used to demonstrate how much could be saved by the NHS by restricting SMBG in people with type 2 diabetes who are not on insulin.

The study, however, did not evaluate the impact on the health of the people involved. So is SMBG actually useful or even valuable for people with type 2 who are not on insulin?

The issue is divisive and vast.

Only insulin-treated type 2 patients have access to prescription test strips by the NHS

The NHS recently demonstrated they could save £20m on SMBG in type 2 patients

In 2013, Leon Litwak et al concluded there was a “worldwide failure” among patients with type 2 diabetes to achieve glycemic targets. By hitting these targets, the risk of vascular complications and further burden on healthcare systems could be reduced.

To hit these targets, SMBG could be extremely useful. A study by Eleni I. Boutati, MD in 2009, published in Diabetes Care, reported a number of benefits that structured SMBG could have for people with type 2.

These included improved blood glucose levels, reduced HbA1c and subsequent chances of developing diabetes-related complications, all serving to improve patients’ quality of life.

But the context of this debate is important. Patients with type 2 on insulin require SMBG to identify, manage and prevent low blood glucose levels. This is also the case for those on sulphonylureas or prandial glucose regulators who are also at risk of hypoglycemia.

When studies have examined the need for SMBG in people with type 2 diabetes that are not susceptible to hypos, the evidence has been scattered.

When studies have examined the need for SMBG in people with type 2 diabetes that are not susceptible to hypos, the evidence has been scattered.

But why is this data so varied?

There is no shortage of research into the issue. B. McIntosh et al reported a “modest, statistically significant reduction” in HbA1c levels of non-insulin treated type 2s through SMBG. Structured SMBG was also found to significantly improve glycemic control in type 2s not on insulin by WH Polonsky et al.

Conversely, an International Diabetes Federation (IDF) Clinical Guidelines Task Force observed the SMBG “data are less clear for people who are not being treated with insulin.”

A Canadian study concluded that: “Most non-insulin treated patients with type 2 diabetes do not require routine SMBG” and that “using SMBG in non-insulin treated patients with type 2 diabetes is very costly and has not been shown to improve outcomes that matter to patients: mortality, morbidity or quality of life.”

Research into the medical benefits is certainly wide ranging, but offers no substantial counter-argument to those who say too much money is being spent on SMBG in type 2 diabetes.

An NHS case study into SMBG in type 2 diabetes in 2010 reported: “The prevalence and costs of T2DM are rising steadily at a time when NHS development funds are going to be very scarce. Funding an increase in SMBG will divert money from other aspects of care. The study found that there is little, if any, overall benefit in investing in SMBG for patients with T2DM not treated with insulin.”

This manufacturing cost was detailed as £14.57 for a 50-strip pack – which costs around £25 in pharmacies – but this case study bought up another issue, which is that “every test requires a finger prick to obtain blood, which some people find distressing.”

A 50-test strip pack costs around £25 in pharmacies, but is cheaper to manafacture

A 50-test strip pack costs around £25 in pharmacies, but is cheaper to manafacture

The issue of people requiring willingness to test is a key factor of SMBG. This was highlighted by S. F. Clarke and J. R. Foster, who wrote: “Patients may be stressed by the responsibility of self-care and the demands of regular and possibly repeated painful finger prick, or lack the motivation and discipline required.”

Those prescribed SMBG equipment who are not interested in testing, or afraid to prick their finger every day, are unlikely to see any gain.

However, prescribing SMBG supplies to people that are actively interested in testing is more likely to produce significant benefits in terms of improved blood glucose levels and better diet composition.

Some non-insulin treated type 2s may be happy to focus on healthy diet, exercise and lifestyle in managing their condition. In these cases, a doctor may not prescribe SMBG.

Willingness aside, there are other barriers people face which may limit the success of SMB. Alan M. Delamater concluded: “Compliance or adherence problems are common in diabetes management. Many factors are potentially related to these problems, including demographic, psychological, social, health care provider and medical system, and disease- and treatment-related factors.”

Certain socioeconomic factors may affect the compliance and adherence of some patients to SMBG. A lack of available education to help explain test readings and how to make lifestyle changes will hinder the success of regular blood testing.

Certain socioeconomic factors may affect the compliance and adherence of some patients to SMBG. A lack of available education to help explain test readings and how to make lifestyle changes will hinder the success of regular blood testing.

Without education, the efficacy of SMBG is greatly reduced.

Then there are those that likely want SMBG equipment to assess the numerous lifestyle changes they are making, but if SMBG is not deemed necessary in these patients, they will not be able to find out their daily results.

How can this apparent impasse be resolved?

If you side with the view that SMBG in non insulin-treated type 2 patients is too expensive, doesn’t provide clinically proven benefits and could be hindered by barriers such as socioeconomic factors, or a lack of education, then there isn’t a problem.

The current system of individual assessment, rather than policies, in assigning SMB for patients may be seen to work perfectly well and prevent money being wasted due to a generalised approach.

“Ultimately, the lack of clinical evidence does not mean there is no evidence but that it has not been possible to gather and interpret it,” a Diabetes UK statement from 2013 read.

Theoretically, should clinical evidence on SMBG categorically prove medical benefits, such as a reduced risk of complications, this policy will come under distinct scrutiny.

The necessity for comprehensive studies is immediate, especially as the NHS has already instigated their plan to reduce expenditure. If there are health benefits to be had for non-insulin treated type 2s, and some evidence says there is, limiting SMBG could lead to further costs later on treating medical complications which could have been avoided.

SMBG can be beneficial for those willing to test and provided with the education to understand their results. If these are benefits are not stressed, and resources continue to be scant for somen, people actively looking to make changes will be denied the tools to do so.

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