Self monitoring of type 2 diabetes more expensive and less effective
18 April 2008
The National Health Service (NHS) in the UK is spending £100 million
a year to help people with non-insulin treated type 2 diabetes monitor
their own blood sugar levels, but the process is more likely to make
them depressed than provide any long-term health benefits, according to
a series of articles published in bmj.com.
Globally one in twenty people have diabetes. The majority (85–95%)
have type 2 diabetes, in which the body has either stopped making
insulin or has difficulty making enough to convert blood sugar into the
fuel our bodies need. Cases of type 2 diabetes are on the increase in
It has been generally acknowledged that self monitoring of blood
glucose levels is beneficial for patients who have type 1 diabetes and
those with type 2 diabetes who use insulin to treat their condition.
However, the majority of people with type 2 diabetes do not use
insulin, and it is for this group of people that there has been debate
over the effectiveness of self monitoring. Yet, despite a lack of
evidence, self monitoring has been widely promoted for this group in
Dr Maurice O’Kane and colleagues from the University of Ulster,
report on a randomised controlled trial to assess whether self
monitoring has an effect on blood glucose levels and the incidence of
hypoglycaemia in people with newly diagnosed type 2 diabetes.
The researchers found no significant effect of self monitoring on
blood sugar levels or cases of hypoglycaemia after a year. However, the
patients in the self-monitoring group reported higher levels of
depression and anxiety.
Evidence suggests that some patients find self monitoring
“uncomfortable, intrusive and unpleasant”. And the researchers suggest
that the negative feelings reported in the study might be due to the
enforced discipline of regular monitoring without any obvious benefit,
rather than due to “feelings of powerlessness in the face of high blood
Self monitoring of blood glucose is the largest single management
cost associated with implementing more intensive blood glucose control
in the UK, with costs of providing test strips increasing from £85m to
£118m between 2001 and 2003. Thus, it is important to establish if self
monitoring represents a cost effective use of resources that could
otherwise be used to finance other aspects of diabetes care.
In a separate study, Dr Judit Simon and colleagues from the
University of Oxford, analysed the cost-effectiveness of helping
patients with non-insulin treated type 2 diabetes self monitor their
blood glucose levels in addition to standardised usual care, using data
from the diabetes glycaemic education and monitoring (DiGEM) trial.
Their analysis confirms that self monitoring of blood glucose is
significantly more expensive than the standardised usual care. They
found that the additional healthcare costs of self monitoring were about
£90 per patient each year. Furthermore, people who self monitored
reported a lower quality of life probably owing to significant increases
in their levels of anxiety and depression.
The authors say that self monitoring in addition to standardised
usual care is unlikely to provide this group of patients with
significant lifetime health benefits or be cost effective for the NHS.
They conclude: “This study therefore provides no convincing evidence for
routinely recommending self monitoring to patients with non-insulin
treated type 2 diabetes.”
In an accompanying editorial, Professor Martin Gulliford argues that
the £100 million that is spent each year on self monitoring for this
group of patients: “Represents a substantial opportunity cost in terms
of alternative interventions that might have improved the health of
people with diabetes…[such as] more effective disease control measures
aimed not at blood glucose but also at blood pressure, cholesterol,
smoking, body weight, and physical activity.”