British Columbia Pharmacy Association (BCPhA) Clinical Service Proposal Self-Monitoring of Blood Glucose in Type 2 Diabetes

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1 British Columbia Pharmacy Association (BCPhA) Clinical Service Proposal Self-Monitoring of Blood Glucose in Type 2 Diabetes

2 Introduction Self-monitoring of blood glucose (SMBG) is in widespread use among both patients with type 1 and type 2 diabetes. A recent (2010) systematic review by the Canadian Agency for Drugs and Therapeutics in Health (CADTH) 1 provides evidence that most patients with type 2 diabetes who are not on insulin can reduce the amount of testing they do without negative health effects. Evidence shows that in this group, routine self-monitoring of blood glucose will not result in any clinically significant improvement in glycemic control. The Canadian Diabetes Association (CDA) has also revised its guidelines and moved away from recommending daily testing to establishing protocols on an individual basis. What Is the Scope of the Problem? In 2011, blood glucose test strips were the third-highest BC PharmaCare expenditure, accounting for $52.5 million of which $22.8 million was spent on testing among patients with non-insulin-dependent type 2 diabetes. As a result, the Pharmaceutical Services Division launched a campaign to encourage patients to test with purpose ; 2 that is, to test only when there is a reason to. Guidelines for testing with purpose include: The patient is taking medications that increase his/her risk of hypoglycemia The patient has a history of very low hypoglycemic episodes when he/she engages in unplanned physical activity The patient has a change in his/her regular eating patterns The patient s diabetes is not controlled to the degree that the care provider and patient would like The patient s diabetes medications have been changed recently The patient is sick The patient is pregnant or planning a pregnancy It is well known that management of diabetes involves much more than glucose testing, and patients require education about the essential elements of self-management: Eating a healthy, nutritious diet Exercising regularly Maintaining a healthy weight Taking all prescribed medications as directed Monitoring blood pressure Managing cholesterol Maintaining good foot care

3 What Role Can Pharmacists Play? For people with diabetes, information on their disease comes from a variety of health providers, including pharmacists. Patients purchase blood glucose test strips from pharmacists. Pharmacists then are well-positioned to inform and educate patients with non-insulin-dependent type 2 diabetes about testing with purpose and other important self-management activities. Using educational tools developed by the CADTH and CDA, pharmacists can promote the message that most of these patients can test their blood glucose less frequently with no negative effects on their health. Such a clinical intervention could significantly reduce the $22.8 million spent on blood glucose test strips for this patient group. Community pharmacists are committed to the role they can play in diabetes care, with a growing number of pharmacists becoming certified diabetes educators. How Can This Benefit the Patient? The burden of SMBG on patients with type 2 diabetes who are not on insulin has been associated with higher scores on depression scales, and yet SMBG has no clinically significant effect on glycemic control. 3 Pharmacists are ideally positioned to advise patients about individualized glucose testing as recommended in the accepted guidelines. Having easy access to this advice will help to ensure that patients are testing only when they need to. Furthermore, having access to a pharmacist to help with diabetes management is convenient for patients. How Can This Benefit the Health Care System? Having pharmacists influence the level of testing in this patient population will have an immediate impact on the use of blood glucose test strips and has the potential to save a significant portion of the $52.5 million spent on blood glucose test strips in 2011 that is projected to grow to $60 million by Unlike other health care professionals involved in providing diabetes education (physicians, care providers in hospital-based clinics), pharmacists interact with patients when they are purchasing test strips. This provides them with a unique opportunity to influence patients future testing patterns.

4 BCPhA s Proposal The BCPhA recommends using community pharmacists to educate and support patients with diabetes to follow the principles of testing with purpose. This proposal anticipates that over the next three years, pharmacist intervention will be provided to at least half of patients with non-insulin-dependent diabetes and will reduce their testing frequency by 50 per cent, resulting in a cost savings of approximately $5.7 million (50% x 50% x $22.8 million) annually or $17.1 million over three years. Pharmacists will provide a standardized consultation with non-insulin-dependent diabetes patients. Each patient intervention will include a review of the patient s current testing patterns and will create a testing protocol that is appropriate for that patient. The consultation will include the provision of other self-management information. A report will be generated for the patient and for his or her physician. For planning purposes and to estimate savings potential, we propose setting the service at $50 per pharmacist consultation. The cost for providing this service to 50,000 patients (approximately half of patients in BC with diabetes, not using insulin 5 ) over the three years will be up to $7.5 million, resulting in a net saving of $9.6 million. The savings are ongoing beyond the first three years and will increase with the rising number of people diagnosed with diabetes. It is anticipated that the prevalence of diabetes will grow by 10 per cent by 2020 from 338,000 to more than 548,000 people. 6 Conclusion Governments have a significant opportunity to utilize pharmacists to control drug costs. Pharmacists have a role in non-insulin-dependent type 2 diabetes management. By implementing a SMBG consultation service focused on educating patients about purposeful testing, pharmacists will reduce the burden of testing on these patients, while equipping them with tools to better manage their disease. This service has the potential to avoid unnecessary blood glucose testing costs of $17.1 million over three years, with a net saving to government of at least $9.6 million. 1 Canadian Agency for Drugs and Technologies in Health (CADTH). Systematic Review of Use of Blood Glucose Test Strips for the Management of Diabetes Mellitus. CADTH Technology Reviews, Vol. 1 Issue 2, June British Columbia. Ministry of Health. Self-Monitoring of Blood Glucose (SMBG). 3 Efficacy of self monitoring of blood glucose in patients with newly diagnosed type 2 diabetes (ESMON study): randomised controlled trial. BMJ 2008;336: Canadian Agency for Drugs and Technologies in Health (CADTH). Self-Monitoring of Blood Glucose Prescribing Aid Card.

5 5 Johnson, J. Presentation: The Reality: Economics of SMBG. Institute of Health Economics and School of Public Health, University of Alberta. October 12, The Canadian Press. Diabetes time bomb ticking in BC October 27, Retrieved from:

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