Abstract
The value of self-monitoring blood glucose (SMBG) in patients with non–insulin-treated type 2 diabetes (NITT2DM) has been debated; however, the practice remains common. Patient perception of SMBG has been documented in several qualitative studies. However, the literature is lacking on the perceived value of SMBG by providers. This study used a structured questionnaire to evaluate and compare the perceived value, recommended frequency, and utility of SMBG in patients with NITT2DM by primary care providers (PCPs) and endocrinologists. A total of 70 PCPs and 14 endocrinologists completed the questionnaire. The results suggest that PCPs and endocrinologists find the practice of SMBG valuable in NITT2DM and believe it promotes behavioral changes in their patients. However, endocrinologists tend to recommend more frequent SMBG and find SMBG values more useful in making medication decisions. Conversely, PCPs tend to find the hemoglobin A1c more valuable than SMBG in making medication adjustments.
Keywords: Provider perception, self-monitoring blood glucose, type 2 diabetes
The value of self-monitoring blood glucose (SMBG) has been debated in patients with non–insulin-treated type 2 diabetes mellitus (NITT2DM). While studies evaluating SMBG have not consistently demonstrated a meaningful reduction in hemoglobin A1c in this population,1–4 SMBG remains a common practice.5 As such, the SMBG market was estimated at $6 billion in 2019.5 Patient perception of SMBG has been documented in several qualitative studies.6,7 However, the literature is lacking on the perceived value of SMBG by care providers. To date, only one qualitative study has been published assessing perception of SMBG in patients with NITT2DM by a small group of primary care physicians (PCPs). This study suggested that most PCPs continue to recommend SMBG in patients with NITT2DM due to the belief that it promotes behavioral changes in their patients.8 The perceived value of SMBG in patients with NITT2DM by endocrinologists, who play an integral role in diabetes management, has not been studied. Understanding provider beliefs will help explain SMBG recommendations and prescribing patterns. Our study aimed to evaluate and compare the perceived value, recommended frequency, and utility of SMBG in patients with NITT2DM by PCPs and endocrinologists.
METHODS
This study used a descriptive cross-sectional design. A 14-item structured questionnaire was administered using Qualtrics XM software to a convenience sample of practicing PCPs and endocrinologists in the state of Texas through institution-specific listservs. Information on gender, years practicing medicine, percentage of their patients with T2DM, and level of familiarity with the American Diabetes Association (ADA) position on the practice of SMBG in patients with NITT2DM was collected from each provider. Additionally, nine 5-point Likert-scale questions were used to evaluate the perceived value of SMBG, the recommended frequency of SMBG, the utility of SMBG values, and the perceived impact of SMBG on behavioral changes in patients with NITT2DM. These questions also assessed differences in the perceived value of SMBG in patients who take noninsulin antidiabetic medications vs those who manage T2DM with diet and exercise alone. Frequency distributions for each question were tabulated and stratified by provider type (i.e., PCP or endocrinologist). Chi-square tests were used to establish statistically significant differences when comparing responses for different groups.
RESULTS
A total of 84 providers completed the 14-item survey; in the first question, 70 identified themselves as PCPs and 14 as endocrinologists. Results are shown in Table 1. More endocrinologists reported that at least 50% of their patients have T2DM (71.42% vs. 17.14%, P < 0.0001). All endocrinologists reported being at least somewhat familiar with the ADA position on the practice of SMBG in NITT2DM, while 25% of PCPs were only slightly familiar or not familiar at all. Most PCPs and endocrinologists agreed that SMBG was more valuable in patients who take noninsulin antidiabetic medications compared to those who treat their diabetes with diet and exercise alone. Endocrinologists were more likely to recommend SMBG at least once per day in patients who take noninsulin antidiabetic medications compared to PCPs (71.43% vs 45.71%). However, the difference was not statistically significant (P = 0.079). Most PCPs and endocrinologists agreed that SMBG values were useful in making medication adjustments in patients taking noninsulin antidiabetic medications; however, endocrinologists were more likely to utilize SMBG values to initiate medications in patients who managed their T2DM with diet and exercise alone (71.43% vs. 40.0%, P = 0.031). Most PCPs agreed that hemoglobin A1c is more valuable than SMBG in adjusting diabetes medications, while most endocrinologists disagreed with this statement. Most PCPs and endocrinologists agreed that patients are more likely to change diet and exercise patterns if they use SMBG.
Table 1.
Frequency distribution for questionnaire items
| Question | Options | PCP (n = 70) | Endocrinologists (n = 14) | Total (n = 84) |
|---|---|---|---|---|
| 2. Gender | Female | 28 (40.0%) | 5 (35.7%) | 33 (39.3%) |
| Male | 41 (58.6%) | 9 (64.3%) | 50 (59.5%) | |
| Prefer not to answer | 1 (1.4%) | 0 | 1 (1.2%) | |
| 3. Approximately how many years have you been in practice? | <5 | 10 (14.3%) | 4 (28.6%) | 14 (16.7%) |
| 5–10 | 13 (18.6%) | 4 (28.6%) | 17 (20.2%) | |
| 11–15 | 11 (15.7%) | 3 (21.4%) | 14 (16.7%) | |
| 16–20 | 6 (8.6%) | 0 | 6 (7.1%) | |
| >20 | 30 (42.9%) | 3 (21.4%) | 33 (39.3%) | |
| 4. Approximately what percentage of your patients have T2DM? | <25% | 19 (27.1%) | 1 (7.1%) | 20 (23.8%) |
| 25–49% | 39 (55.7%) | 3 (21.4%) | 42 (50.0%) | |
| 50–75% | 11 (15.7%) | 8 (57.1%) | 19 (22.6%) | |
| >75% | 1 (1.4%) | 2 (14.3%) | 3 (3.6%) | |
| 5. How familiar are you with the ADA’s position on the practice of SMBG in patients with T2DM who do not use insulin? | Extremely familiar | 8 (11.4%) | 5 (35.7%) | 13 (15.5%) |
| Moderately familiar | 21 (30.0%) | 7 (50.0%) | 28 (33.3%) | |
| Somewhat familiar | 23 (32.9%) | 2 (14.3%) | 25 (29.8%) | |
| Slightly familiar | 6 (8.6%) | 0 | 6 (7.1%) | |
| Not familiar at all | 12 (17.1%) | 0 | 12 (14.3%) | |
| 6. SMBG is valuable for the majority of patients managing their T2DM with oral agents and noninsulin injectables. | Strongly agree | 21 (30.0%) | 9 (64.3%) | 30 (35.7%) |
| Agree | 30 (42.9%) | 4 (28.6%) | 34 (40.5%) | |
| Neither agree nor disagree | 10 (14.3%) | 1 (7.1%) | 11 (13.1%) | |
| Disagree | 8 (11.4%) | 0 | 8 (9.5%) | |
| Strongly disagree | 1 (1.4%) | 0 | 1 (1.2%) | |
| 7. SMBG is valuable for the majority of patients managing their T2DM with diet and exercise alone. | Strongly agree | 13 (18.6%) | 2 (14.3%) | 15 (17.9%) |
| Agree | 25 (35.7%) | 6 (42.8%) | 31 (36.9%) | |
| Neither agree nor disagree | 6 (8.6%) | 3 (21.4%) | 9 (10.7%) | |
| Disagree | 19 (27.1%) | 3 (21.4%) | 22 (26.2%) | |
| Strongly disagree | 7 (10.0%) | 0 | 7 (8.3%) | |
| 8. For patients managing their T2DM with oral agents and noninsulin injectables, I typically recommend SMBG: | >1× per day | 8 (11.4%) | 5 (35.7%) | 13 (15.5%) |
| 1× per day | 24 (34.3%) | 5 (35.7%) | 29 (34.5%) | |
| <1× per day but >1× per week | 20 (28.6%) | 4 (28.6%) | 24 (28.6%) | |
| 1× per week | 12 (17.1%) | 0 | 12 (14.3%) | |
| Never | 6 (8.6%) | 0 | 6 (7.1%) | |
| 9. For patients managing their T2DM with diet and exercise alone, I typically recommend SMBG: | >1× per day | 2 (2.9%) | 0 | 2 (2.4%) |
| 1× per day | 9 (12.9%) | 3 (21.4%) | 12 (14.3%) | |
| <1× per day but >1× per week | 19 (27.1%) | 2 (14.3%) | 21 (25.0%) | |
| 1× per week | 21 (30.0%) | 6 (42.9%) | 27 (32.1%) | |
| Never | 19 (27.1%) | 3 (21.4%) | 22 (26.2%) | |
| 10. In general, SMBG values are useful in making medication changes for patients managing their T2DM with oral agents and noninsulin injectables. | Strongly agree | 17 (24.3%) | 8 (57.1%) | 25 (29.8%) |
| Agree | 28 (40.0%) | 4 (28.6%) | 32 (38.1%) | |
| Neither agree nor disagree | 7 (10.0%) | 2 (14.3%) | 9 (10.7%) | |
| Disagree | 15 (21.4%) | 0 | 15 (17.9%) | |
| Strongly disagree | 3 (4.3%) | 0 | 3 (3.6%) | |
| 11. In general, SMBG values are useful in deciding to initiate medication for patients managing their T2DM with diet and exercise alone. | Strongly agree | 11 (15.7%) | 3 (21.4%) | 14 (16.7%) |
| Agree | 17 (24.3%) | 7 (50.0%) | 24 (28.6%) | |
| Neither agree nor disagree | 12 (17.1%) | 3 (21.4%) | 15 (17.9%) | |
| Disagree | 21 (30.0%) | 0 | 21 (25.0%) | |
| Strongly disagree | 9 (12.9%) | 1 (7.1%) | 10 (11.9%) | |
| 12. In general, hemoglobin A1c is more useful than SMBG readings in making changes to a patient’s T2DM regimen. | Strongly agree | 26 (37.1%) | 1 (7.1%) | 27 (32.1%) |
| Agree | 23 (32.9%) | 0 | 23 (27.4%) | |
| Neither agree nor disagree | 12 (17.1%) | 5 (35.7%) | 17 (20.2%) | |
| Disagree | 7 (10.0%) | 6 (42.9%) | 13 (15.5%) | |
| Strongly disagree | 2 (2.9%) | 2 (14.3%) | 4 (4.8%) | |
| 13. Patients managing their T2DM with oral medications and noninsulin injectables are more likely to change their diet and exercise patterns if they use SMBG. | Strongly agree | 27 (38.6%) | 6 (42.9%) | 33 (39.3%) |
| Agree | 25 (35.7%) | 8 (57.1%) | 33 (39.3%) | |
| Neither agree nor disagree | 12 (17.1%) | 0 | 12 (14.3%) | |
| Disagree | 4 (5.7%) | 0 | 4 (4.8%) | |
| Strongly disagree | 2 (2.9%) | 0 | 2 (2.4%) | |
| 14. Patients managing their T2DM with diet and exercise alone are more likely to change their diet and exercise patterns if they use SMBG. | Strongly agree | 22 (31.4%) | 6 (42.9%) | 28 (33.3%) |
| Agree | 22 (31.4%) | 4 (28.6%) | 26 (31.0%) | |
| Neither agree nor disagree | 13 (18.6%) | 3 (21.4%) | 16 (19.1%) | |
| Disagree | 8 (11.4%) | 0 | 8 (9.5%) | |
| Strongly disagree | 5 (7.1%) | 1 (7.1%) | 6 (7.1%) |
ADA indicates American Diabetes Association; PCP, primary care provider; SMBG, self-monitoring blood glucose; T2DM, type 2 diabetes.
DISCUSSION
This study suggests that most PCPs and endocrinologists find the practice of SMBG valuable in the management of NITT2DM and believe it promotes behavioral changes in their patients. Endocrinologists appear to find SMBG values more useful in making medication decisions and thus tend to recommend more frequent SMBG compared to PCPs. Conversely, PCPs tend to find the hemoglobin A1c more valuable than SMBG in making medication decisions. The ADA states that routine glucose monitoring may be of limited clinical benefit in patients with T2DM who do not use insulin. To be useful, the information gathered from glucose monitoring should be integrated into clinical and self-management plans.9 Since endocrinologists tend to be more familiar with the ADA’s position, they are likely more aware of the importance of utilizing SMBG values to derive a clinical benefit.
Studies assessing patient perception of SMBG have documented perceived advantages and disadvantages. Perceived benefits of SMBG include having a heightened sense of awareness of how their behavior impacts glucose control and a sense of success or reassurance when glucose values are in range.6,7 Drawbacks to SMBG include amplified feelings of failure, anxiety, and self-blame when glucose values are not in range, difficulty interpreting results and uncertainty of how to respond, and the financial cost of supplies.6,7 Third-party payers often only partially cover diabetes testing supplies or limit the number of times a patient with NITT2DM can use SMBG. Given that endocrinologists often recommend SMBG multiple times daily in this population and utilize these values to make clinical decisions, perhaps coverage limitations imposed by third-party payers should be reconsidered.
This study has several limitations. There was a relatively small sample size limited to providers in Central and South Texas. The questionnaire in this study did not allow for comments to expand on or explain the answer selections. Lastly, SMBG was not defined to include or exclude continuous glucose monitoring; therefore, we are unable to differentiate the perceived value of traditional SMBG vs continuous glucose monitoring in this study.
In summary, PCPs and endocrinologists find SMBG valuable in NITT2DM; however, endocrinologists tend to recommend and utilize the values more in this patient population.
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