The Diabetic Test Strip Story
…Nova Scotia’s Version
2013 CEO Forum
February 6th, 2013
Peggy Dunbar
Diabetes Care Program of Nova Scotia
Alan Cassels
Drug policy researcher, University of Victoria
Diabetes: Profits Before Evidence
Posted: 06/11/11 09:47 AM ET
The Huffington Post
A year ago, Nova Scotia decided it was going to try to put a
stop to the waste and harm caused by the overuse of diabetes
test strips and capped the number of strips it would cover for
non-insulin-dependent diabetics. This sounded like a
reasonable thing to do and I admired their pluck.
This is our story…
Setting the Stage
• Diabetes is a significant and growing concern
– 10-12% in the 20+ population; 25-30% in the 75+
– ~ 20-25% with prediabetes in the 45-75 yr. age
• Approaches to management vary by diabetes type and treatment
– Insulin/pumps to lifestyle only
• Some approaches are more efficacious than others
• The management demands placed on people with diabetes are
overwhelming
• Diabetes management should focus on patient self-care and those
aspects of care that have proven efficacy
Ours is not the only story….
SMBG Café Scientifique events
hosted in 12 cities
SMBG presented as
topic during hospital
rounds at Whitehorse
General
CME session through
Wednesday @ Noon webinar
program hosted by Memorial
University
SMBG presentations and
workshops at conferences
throughout Canada
Guidebook for DM
Management in LTC to
be released in 2013.
Launched “Test
With Purpose” – a
knowledge
translation
campaign to
educate providers
and patients.
RxFiles (academic
detailing program)
disseminating SMBG
information
NB Diabetes Strategy Bulletin,
distributed to more than 1,200
physicians, highlights CADTH’s
work on SMBG
Academic detailing service in 2010
(though Dalhousie University) and
ongoing CM&PE through Deans.
Nine nursing homes
adjusted SMBG
schedules to monthly
testing.
DCPNS LTC
Guidelines
address SMBG
CADTH Key Messages
People with T1DM using
basal-bolus (long- and
short-acting) insulin
regimens
Self-monitoring of blood
glucose (SMBG) should
be individualized.
Adults with T2DM using
insulin
SMBG should be
individualized, up to
14x per week is
sufficient for most of
these patients.
Adults with T2DM
managed on oral antidiabetes drugs
CADTH. Optimal Therapy Report – COMPUS. 2009;3(7).
Adults with T2DM
controlled by diet alone
*For most patients
Routine selfmonitoring of blood
glucose is not
required.*
Cost Considerations—Individual and System…
Canada public and private drug plans, 2006
•
BG test strips > $330 Million
•
BG test strips in top 5 classes of total expenditures
•
Costs exceed all oral antidiabetes drugs combined
Nova Scotia Pharmacare program, 2008:
•
Diabetes medications $8,532,000
•
Glucose test strips
$8,522,200
o
> $4,000,000 (oral antidiabetes drugs or no drugs)
o
$870,000 no diabetes drugs on file
Ref. CADTH. Optimal Therapy Report – COMPUS. 2009;3(4). CADTH. Optimal Therapy Report – COMPUS.
2009;3(2).
PHAC. Diabetes in Canada – Facts and Figures. 2008. CDA. The prevalence and cost of diabetes. 2008. NS
Pharmacare Program
Provider Approaches…variability between and within
provider groups
Self-Monitoring of Blood Glucose (SMBG):
What are Healthcare Professionals Recommending?*
Faculty of Medicine, Dalhousie University – Family Medicine
Qualitative Study:
Interviews of Physicians, Pharmacists, Diabetes Educators to determine:
1.
Recommendations for SMBG in well-controlled adults (A1c ≤ 7.0%) with T2DM
(lifestyle only and oral agents)
2.
Use of SMBG results
3. Sources of information for SMBG recommendations
Findings:
Variable results between and within provider groups—for frequency (< 1 to 4 x/day) and timing
(ac/pc/random)
*Latter C., McLean-Veysey P, Dunbar P, Frail D, Sketris I, Putnam W. Self-Monitoring of Blood Glucose:
What Are Healthcare Professionals Recommending? Can J Diabetes 2011;35(1):31-38
Summary Messages
• Most adults not using insulin don’t have to test as much as they
currently do
– Lack of high quality evidence in Type 2 DM not using insulin
– No clinically relevant improvement in BG control or patient well-being
– Lack of hard outcomes; i.e., mortality
– Insufficient evidence to determine optimal frequency of SMBG
• SMBG should be used when linked to specific patient actions such as:
–
Treatment of hypoglycemia and/or self-directed medication dosage adjustment
• Substantial spending
• Inconsistency among and between health care providers
• Focus on collaborative efforts and educational initiatives to modify
approach to SMBG in Nova Scotia across settings & provider groups
Nova Scotia Partnership Activities
DCPNS SMBG Working Group (07/2009)
CADTH:
COMPUS Report
Released
(06/09)
DCPNS SMBG Working Group/Workshop
• Consensus Development (01/2010)
Provider Decision Tool Development
Café Scientifique:
• Public
• Providers
(02/10)
DCPNS Provincial Workshop—DEs)
Academic Detailing—MDs & DEs
DEANS
Nova Scotia Policy
• Feb. 26 2010,
100 strips/yr (Non-In)
• Early March, 2010
recalled
• ? 1212 policy
Academic Detailing Rx—Pharmacists)
Videos Development (1 & 2)
Inter-professional Workshops
(Community-based) 02/2011….
Other
efforts
Features of the Decision Tool
Can be used to guide, and focus, group
discussion and individual decision.
Provides:
•indications for testing (who should test—safety issues).
• required conditions for testing (use of results by provider/pt).
•examples of low and high intensity testing and reinforces the need for “time limited” testing.
And, addresses the role of self-management education (if you feel
someone just needs to test).
Supported by two videos (YouTube link):
1. Background rationale (clinical champions)
2. “How to use” with applied case studies
What We’ve Learned
• A multipronged approach, continuing over time, and Clinical champions
are essential
• Providers are making changes
–
–
–
–
Fewer patients are coming in with meters
Doctors are suggesting testing less
Letters from Diabetes Educators indicate less testing
We ask “how are you today”, rather than “show me your book/meter results”
• Patients welcome the change
– “My fingers will thank you”
– Those choosing to test, are testing less
“We need to do a better job earlier with physicians and others--“how to say no” to unfounded
practice and to play more of an advocacy role in the change process.”
Kevin McNamara, Deputy Minister of NS DHW
In Closing
… are we guilty of “treatment creep” in teaching people
with type 2 diabetes who do not require insulin about
SMBG?
– We must convince leaders in healthcare settings to abandon the
use of SMBG as a measure of quality in clinical care
– Savings in public funding for strips can be diverted to human
resources to encourage behaviour modification to achieve
optimum glycemic control.
Editorial commentary by Dr. Heather J. Dean Can J Diabetes 2011;35:19-20
Acknowledgments & Special Thanks
Partners/collaborators
• Dalhousie University:
- Divisions of Continuing Medical and Pharmacy Education
- Academic Detailing
• The Drug Evaluation Unit, Capital Health
• Nova Scotia DHW/DEANS (The Drug Evaluation Alliance of NS)
• The Diabetes Care Program of Nova Scotia:
- “Champions for Change”- participants and attending observers of the DCPNS SMBG
Workshop and reviewers of the “decision-tool”
• CADTH (national and local representatives)
• Nova Scotia PATH Program (focus on the frail elderly)