1. Explanations of SMBG Non-Adherence
Patient Reported Challenges of Self-Monitoring of Blood Glucose Require Patient Supportive Technology: Lessons from the ExAct Study
Fisher W.A.1; Fortwaengler, K.2; Maran, A.3; Tschoepe, D.4; Di Mauro, M5; Mast O.2, Moritz, A.2
Weissmann, J.2; Cranston, I.6; Kohut, T.1
1University of Western Ontario, Canada, 2Roche Diagnostics GmbH, Mannheim, Germany, 3University of Padua, Padua, Italy, 4Heart and Diabetes Center Nordrhein-Westfalen, Bad Oeynhausen, Germany, 5Department of Medical and Pediatric Sciences, Catania, Italy,6Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Cosham, UK.
Introduction
Recent research has established that the information, motivation, and skills demands of self-monitoring of blood glucose (SMBG) represent significant challenges to patient adherence and achievement of glycemic control1. Improved self-monitoring technology may be created and adopted to lessen the demands of SMBG and achieve optimal patient—technology “fit.” 2
Results cont.
Lack of self-management motivation was also associated with poorest glycemic control: Twice as many patients (32.4%) with the highest HbA1c levels (8.3% -14.0%) reported lack of motivation for self-management of diabetes compared to patients (15.3%) with lower HbA1c levels (7.0%-8.2%, p < .01).
Typically finding SMBG results to be discouraging was associated with poor glycemic control: 38.7% of those with the highest HbA1c levels compared to 26.3% of those with the lowest HbA1c levels reported that they typically found SMBG results to be discouraging.
Despite frequent reports that results of SMBG were confusing, such patients did not have lower frequencies of testing, or higher HbA1c.
Lack of confidence in self-management was significantly associated with infrequent testing: 13.5% of those practicing SMBG least frequently reported lack of confidence compared to only 4.7% of those practicing SMBG most frequently.
* Note: underlined values indicate significant contrasts
Materials and Methods
Insulin-using individuals with type 1 (N = 100) or type 2 (N = 254) diabetes who were non-adherent to recommended frequency of SMBG (≤ 3.25 tests per day) and who had suboptimal glycemic control (HbA1c ≥ 7.0%) were recruited and enrolled in the ExAct (Experience in Accu-Chek Integrated Strip-free System) study and completed assessments of a number of challenges to SMBG adherence at study baseline.
Results
Participants in this research were veteran diabetes patients with lengthy mean duration of insulin use who monitored their blood glucose infrequently and had high mean HbA1c levels. Participants often felt unmotivated, discouraged, or confused, and lacked confidence, with respect to SMBG (see Table 1).
Participant explanations for their lack of adherence to SMBG were diverse, ranging from forgetting SMBG to dislike of SMBG and SMBG-related pain (see Table 2).
Lack of motivation for diabetes self-management was associated with lowest SMBG frequency and poorest glycemic control. Twice as many patients (31.2%) with the lowest frequency of SMBG ( tests per week) reported that they lacked self-management motivation compared to patients (16.5%) who engaged in more frequent SMBG (11.5 – 22.5 tests per week; p < .001).
Table 3.
SMBG Challenges
SMBG Frequency*
Glycemic Control*
Low
High
SMBG unmotivated
31.2%
16.5%
32.4%
15.3%
SMBG discouraging
33.5%
31.5%
38.7%
26.3%
SMBG confusing
20.1%
23.5%
24.4%
19.2%
SMBG lack confidence
13.5%
4.7%
12.4%
5.9%
Table 1.
Sample Characteristics N
Mean / Percent
Std. Err.
Duration of Diabetes (yrs)
344
16.4
0.5
Duration of Insulin Use (yrs)
330
11.0
HbA1c (%)
354
8.5
0.07
SMBG unmotivated
340
23.8%
SMBG discouraging
335
32.5%
SMBG confusing
21.8%
SMBG lack confidence
9.1%
Conclusions
In this study, insulin using individuals with type 1 and type 2 diabetes who were non-adherent to SMBG reported multiple challenges to self-monitoring. Participants often lacked SMBG information (they failed to understand the benefits and risks of SMBG adherence and non-adherence), they often lacked SMBG motivation (they were unmotivated, discouraged, and lacked confidence), and they had SMBG skills limitations (considerable difficulty simply remembering to test). These challenges to SMBG adherence and glycemic control may be addressed via patient education and via the development of supportive technologies that are designed to minimize the demands of self-monitoring and specifically engineered to optimize “patient—technology” fit. For results of the ExAct study concerning the impact of supportive strip-free SMBG technology in improving SMBG adherence and glycemic control, compared to single strip systems, see ATTD Poster 0462
Table 2.
Explanations of SMBG Non-Adherence
Percent Reporting
I forget to self-monitor
55.5%
I do not see a risk in not following the recommended frequency of SMBG
18.3%
I do not see a benefit in the recommended frequency of SMBG
10.7%
I do not like SMBG
11.0%
Bothered by pain
4.4%
References
1Fisher, W. A., Kohut, T., Stegner, P., & Schachner, H. (2011). Understanding self-monitoring of blood glucose among individuals with type 1 and type 2 diabetes: An Information–Motivation–Behavioral Skills analysis. The Diabetes Educator 37,1:
2Orsama, A.L. et al. (2013) Active assistance technology reduces HbA1c and weight in individuals with type 2 diabetes: Results of a theory-based randomized trial. Diabetes Technology and Therapeutics,15(8):