The Diabetic Test Strip Story…Nova Scotia’s Version

2013 CEO ForumFebruary 6th, 2013

Peggy DunbarDiabetes Care Program of Nova Scotia

Alan CasselsDrug policy researcher, University of Victoria 

Diabetes: Profits Before EvidencePosted: 06/11/11 09:47 AM ETThe 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….

Launched “Test With Purpose” – a knowledge translation campaign to educate providers and patients.

Guidebook for DM Management in LTC to be released in 2013.

RxFiles (academic detailing program) disseminating SMBG information

Nine nursing homes adjusted SMBG schedules to monthly testing.

CME session through Wednesday @ Noon webinar program hosted by Memorial University

Academic detailing service in 2010 (though Dalhousie University) and ongoing CM&PE through Deans.

NB Diabetes Strategy Bulletin, distributed to more than 1,200 physicians, highlights CADTH’s work on SMBG

SMBG presented as topic during hospital rounds at Whitehorse General

SMBG Café Scientifique events hosted in 12 cities

SMBG presentations and workshops at conferences throughout Canada

DCPNS LTC Guidelines address SMBG

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 anti-diabetes drugs

Routine self-monitoring of blood glucose is not required.*

Adults with T2DM controlled by diet alone

CADTH Key Messages

*For most patients

CADTH. Optimal Therapy Report – COMPUS. 2009;3(7).

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

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

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

Provider Approaches…variability between and within provider groupsSelf-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

*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

Findings:Variable results between and within provider groups—for frequency (< 1 to 4 x/day) and timing (ac/pc/random)

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/Workshop• Consensus Development (01/2010)

Café Scientifique:• Public• Providers(02/10)

Academic Detailing—MDs & DEs

DCPNS Provincial Workshop—DEs)

Academic Detailing Rx—Pharmacists)

Inter-professional Workshops(Community-based) 02/2011….

CADTH:COMPUS Report

Released (06/09)

Provider Decision Tool Development

DCPNS SMBG Working Group (07/2009)

Videos Development (1 & 2)

Nova Scotia Policy• Feb. 26 2010, 100 strips/yr (Non-In)

• Early March, 2010 recalled

• ? 1212 policy

DEANS

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

… 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

In Closing

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)

Acknowledgments & Special Thanks