[shabbie6247]

my mum got a letter from her doctors surgery this morning, she says

Got a letter from my surgery, presumably to all diabetics. They have removed testing strips from my repeat prescriptions as they cost Cambridgeshire PCT £1.5 million per year. All diabetics are to test once per WEEK only from now on ! They didn't want me to have a flu jab this year, so how long before I have my Glucophage stopped too.

i wonder how far they are pushing this?

[REDLAN]

decisions quite often are made on cost, however ALL health authorities are required to follow the NICE guidelines (National Instituted for Health and Clinical excellence)

So I went through and read the detailed recommendations for type 1 and type 2 diabetes. The 2 need to be considered separately.

NICE use actual clinical data and studies to inform it's recommendations, and as such should be impartial (selection biases still apply) and this is what they concluded for type 2.

no evidence to show that self-monitoring of blood or urine glucose improves blood glucose control using HbA1c or fasting plasma glucose

and

no evidence that blood glucose monitoring is more effective than urine glucose monitoring in improving blood glucose control

they did go on to say that insulin therapy could only be performed in conjunction with self-monitoring.

I would suggest that this is the basis for the letter and that it only should apply to people controlling their diabetes with diet and lifestyle changes.

For type 1 NICE concluded that there was no evidence that BG monitoring in itself made any difference to HBA1C results. They concluded that self-monitoring was only effective if it was part of an overall education package, AND self-monitoring was used to inform the management of diabetes. They drew this conclusion from the DCCT (Diabetes Control and Complications Trial).

they then went on to say that modern regimes would not be possible without regular self-monitoring

they recommended the following for type 1

Adults with Type 1 diabetes should be advised that the optimal frequency of self-monitoring will depend on:
● the characteristics of their blood glucose control
● the insulin treatment regimen
● personal preference in using the results to achieve the desired lifestyle.

So...

Anyone on insulin therapy should be able to challenge this letter using the NICE guidelines (perhaps someone could write a letter). However if your diabetes is diet controlled then you might have a tougher time in persuading your practice to continue prescribing test strips, and you might have to use urine tests instead.

[JJM335]

This makes me really, really REALLY ***ANGRY***. This issue was raised in Diabetes UK Balance magazine about a year ago, when some GP's & PCT's started to restrict T2's to 50 tests per month. I was under the impression that even this had been nixed, so to reduce to 1 per week (and cut 'flu jabs) is totally unacceptable!!!!!!

The "no evidence that frequent monitoring makes any difference to A1c results" is also a statement that I would treat with suspicion. How was this established??? There is a huge amount of bad science out there, particularly when large statistical analyses are involved. Speaking personally, I was able to get my A1c down ONLY when I increased monitoring from 3-4 x daily to 12 x daily.

[REDLAN]

The link for the NICE document is here

Full guideline: Type 2 diabetes - Management of blood glucose

no evidence to show that self-monitoring of blood or urine glucose improves blood glucose control using HbA1c or fasting plasma glucose

they conducted a search of medical publications and pulled out 77 articles in the first search and 813 in the second. They rejected all of the second search articles, for failing to meet quality criteria. of the 77 only 12 met the relevant standards required - 6 of the 12 were Randomised Controlled Trials (they use RCT as an acronym) - RCT is considered the best available evidence. it is these 6 RCT's that they used to form the review.

3 of these trials showed that there was no difference between urine testing and BG monitoring. 1 trial showed that there was no difference between monitoring BG and not monitoring BG. And only 1 trial showed that there was a benefit to monitoring BG. One study perplexingly showed that monitoring led to greater compliance but not to improved glucose control.

if you wish you can read the article yourself - it starts on page 35 and is titled evidence.

[shockme]

and folks wonder why "free" health care here in the states scares the c*r*a*p* outta me....trish

[shabbie6247]

i guess a lot needs to be done on educating the masses too. i'm sure we've covered this before, its no good expecting Diabetics to test if they dont know what to do with the results.
i'll bet you experienced little or no education on how to manage your diabetes condition. i was just told to reduce my Bg's, not how to acheive this.

so while the nice guidelines are probably correct, it isnt taking into account that diabetics arent properly educated into the bargain.

is diabetes management another funding issue?

[JJM335]

A quick look at the NICE document reveals this GEM!

"Overall we would argue that we cannot give much credance to associations between blood glucose control and blood glucose self monitoring in observational studies as indeed it might be expected that patients and doctors who use and advocate self monitoring will be the same people who are motivated to achieve better control"

To counter this piece of sophistry I suppose you would need to identify a group of patients with no interest in achieving better control, make them test several times a day, and then compare A1c's with a non-testing control group to see whether there were any differences!!! Alternatively I suppose you could identify groups of patients who were very motivated to obtain good control, but not allow some of to test!

[Alice]

Are they including insulin-dependent diabetics in this limit? Although I managed to survive my first 20 years or so without a meter...I wouldn't go back to those days for anything.

Also, those were the days prior to A1C test on a regular basis. Ignorance is really bliss, isn't it? I'm sure there will be a correction in that policy.

[shabbie6247]

Originally Posted by Alice

Are they including insulin-dependent diabetics in this limit? Although I managed to survive my first 20 years or so without a meter...I wouldn't go back to those days for anything.

Also, those were the days prior to A1C test on a regular basis. Ignorance is really bliss, isn't it? I'm sure there will be a correction in that policy.

apparently the letter stated ALL diabetics! i would love to be a fly on the surgery wall when the insulin dependants get their letters!!!

[Gary_W]

I don't think I'm capable of writing a short post. Sorry for the eyestrain.

If you take 100 average T2's in the UK, I will bet you that half of them don't test from one week to the next. In our world of enlightenment here on the forum this is a shocker. For a lot of these guys it's everyday life.

A lot of these folks will be on free prescriptions. They'll be dished out 100 test strips every 6 months and they'll throw 99 of them away due to being out of date. They will still keep on collecting the test strips on prescription because they are 'entitled to them' or because they have a monthly repeat prescription set up which they can't be bothered to cancel. The cost of unused prescriptions to the NHS is terrifying. Have a look at this link in Northamptonshire earlier this year with a specific reference to test strips £2m is how much wasted prescriptions cost us - Northants ET This is just one small PCT....

With this in mind, a PCT has to come up with some kind of stratergy for dealing with the patients that just cannot be bothered to test but still collect the prescriptions. If they send out a letter like this, the folks that don't take care of themselves will not bat an eyelid and the PCT saves money. Anyone who feels BG monitoring is essential will kick up a stink and (as the PCT are saving a mint on the large numbers of people who don't care) will get the strips. It just needs the patient to go in to the doc and kick off and I bet they'll get the strips. The only losers will be the people who would like to test but who don't want to make a fuss. But if you don't want to challenge the healthcare system then you're living in the wrong country.

I don't like this situation, and the way the letter is worded is rotten. But part of me can see the PCT's reasoning. I believe your point about education is of key importance here, as not knowing what to do with the results of blood testing does indeed make it a pointless excercise. If they put some of the money they save at the PCT into buying in some more diabetes nurses to help out with education then it may turn into a good thing, but now I'm living in fairyland...

To show how much I agree with your point about education, consider the following...

This time last year, I was effectively out of control. The reasons for this were purely educational, as in I didn't get any education whatsoever from the local hospital and I always avoided Internet groups as I believed they were full of obsessive nutters. And then I found this place which has a refreshingly high 'sense to nutter' ratio and the rest is history.

These days I probably test between 6-8 times per day on average and this is essential to my wellbeing. I have a 5.5 HBA1c and feel terrific 95% of the time whilst eating and doing pretty much whatever I like. In my opinion, that's a pretty good way to manage diabetes. I have the knowledge now of what to actually DO with the blood test results. I can safely correct a high etc. so the testing is NOT a passive thing that is giving psychological reasurance only. It is an essential tool that allows me to safely use insulin to sail quite close to the wind for my long-term wellbeing.

Last year, I still used to blood test 6-8 times each day but I felt dreadful 95% of the time and had an HBA1c of 8+. I would blood test, find myself high, not have a clue how to treat it safely, test again later, be low, repeat to fade. For the most part, those tests did little but point out that I felt pants, and I already knew that. The lack of education meant that I had no clue of what to do with the results I got. The test strips did little for my control back then, and now they are essential. Education makes or breaks the usefulness of these things.

Any form of diagnostic test that you are not going to act upon is a pointless diagnostic test unless you are just wanting reassurance. Until you throw resources at teaching an out of control diabetic that a BG of 20+ is a good reason to lay off the pies (and the person listens and acts) then a blood test is an uncomfortable way to waste money.

Gary

[shabbie6247]

well said gary_w!!!

[JJM335]

Gary:

Good points on education. I was picking up some insulin from the pharmacist yesterday and the lady behind the counter asked me "do you inject?". It turns out she was T2, on medication, but was unaware of BG monitoring and had never heard of an A1c!

I realize many/most T2's don't test enough/at all, but do these people really pick up test strips that they don't use? My GP will prescribe me as many strips as I want, but I still have to request them, and they will only give me one month's supply.

Joel

[Gary_W]

Hi Joel,

I spend most of my working life in various UK hospitals, and there are always poster campaigns on about 'the most expensive drug is the one you don't use'. It is a real problem.

The biggest portion of the problem is with the elderly / infirm that do not organise and collect their own prescriptions. The doctors keep churning out the same old script again and again and a relative or friend picks it up. It's often the case that when someone dies they find cupboardfuls of out of date drugs that have been dished out... It is something that is easily done with meds that you are on for life, as the GP will literally dish out x amount each month. Prescription gets printed out and someone mindlessly signs it.

Gary