Case Scenario

A.F., a 71-year-old with a history of non–insulin-dependent type 2 diabetes mellitus, presents as a new patient to my family medicine clinic. A.F.’s most recent A1C level is 8.0, and they take metformin, 500 mg twice daily, and atorvastatin, 40 mg daily. A.F. reports that they check their blood glucose one to three times daily using a home glucose monitor, as recommended by their previous physician. I recommend discontinuing self-monitoring of their blood glucose because its effectiveness in achieving glycemic control is limited in patients who are not taking insulin. A.F. becomes upset by my suggestion, wondering how they can keep their diabetes under control without checking their glucose levels at home. How do I respond to my new patient?

Commentary

This case addresses a common situation in primary care that can occur when new evidence changes practices that were once taken for granted by physicians and patients as contributing to quality care. Discontinuing low-value interventions can be challenging for patients and physicians.

Until recently, self-monitoring of blood glucose was a routine recommendation for all patients with diabetes, including those not taking insulin. Among patients who do not use insulin, a growing body of evidence validates that self-monitoring of blood glucose is not effective in achieving long-term glycemic control. A 2012 Cochrane review, which compiled data from 12 randomized controlled trials, showed that patients with non–insulin-dependent diabetes who self-monitored their blood glucose levels did not have clinically significant improvements in glycemic control after one year.¹ More recently, a 2017 study assigned patients with non–insulin-dependent diabetes to one of three groups: no self-monitoring, once-daily self-monitoring, and once-daily self-monitoring with enhanced patient feedback, including automatic messages about the results delivered via the glucose meter. This trial found no notable differences in A1C levels across all groups at one year and no differences in health-related quality of life.²

Routine self-monitoring of blood glucose also has potential harms. Although the exact costs are difficult to quantify, one 2012 study estimated that self-monitoring costs more than $700 annually per patient.³ In addition to cost, patients may find using a lancet painful,⁴ and studies indicate that stress, worry, distress, and depressive symptoms may increase with the frequency of self-monitoring.⁵

As a result, multiple professional societies have recommended against prescribing self-monitoring for patients with non–insulin-dependent type 2 diabetes. As part of the Choosing Wisely campaign, the American Academy of Family Physicians and the Society of General Internal Medicine have recommended against physicians prescribing self-monitoring for these patients.^6,7

Nevertheless, routine self-monitoring of blood glucose in patients with non–insulin-dependent diabetes persists. The current prevalence of the practice is difficult to estimate, but in a 2012 study, approximately 75% of patients with non–insulin-dependent diabetes reported self-monitoring at least once daily.⁸

Barriers to Evidence-based Care

Why does this low-value practice continue? In this case scenario, both physician and patient factors influenced the situation, including a previous physician’s recommendation to self-monitor and the patient’s concerns that discontinuing the practice could cause harm.

Multiple barriers may prevent physicians from finding, interpreting, and implementing the most updated evidence-based practices.⁹ Although physicians have widespread online access to clinical practice guidelines, including the Choosing Wisely campaign, research demonstrates that some physicians are skeptical of clinical guidelines. One systematic review of physicians’ attitudes toward clinical practice guidelines showed that only 75% of physicians believe them to be helpful and up to 30% of physicians consider guidelines to be impractical and too rigid to apply to individual patients.¹⁰

Concerns about adapting guidelines to individual patients may explain much of the continued self-monitoring in those with non–insulin-dependent diabetes. For example, in a 2018 qualitative study based on structured interviews with 17 physicians, participants emphasized the role of self-monitoring of blood glucose in supporting patient commitment to the lifestyle changes needed for improved diabetes outcomes.¹¹