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