Establishing Expert, Multi-Disciplinary, Peer-Reviewed Consensus to Lead a Paradigm Shift in Optimal Blood Glucose Management

Diabetes is a widely prevalent long-term condition in which raised blood glucose levels over time contribute to complications that are costly in terms of healthcare use and impact adversely on quality of life. Blood glucose monitoring (BGM) has an important part to play in the management of blood glucose in diabetes and the reduction of risk of serious secondary complications [1]. The first BGM meter was introduced in 1970 [1], and available technology has evolved markedly since then. In today’s technology-rich environment, self-monitoring of blood glucose is an integral part of effective diabetes management [2], allowing patients to monitor their glycemic status and adjust their therapy accordingly.

Modern healthcare requires that long-term conditions are managed in a shared and collaborative way between the patient and all stakeholders involved in their care, rather than solely by the patient or healthcare professionals (HCPs). Despite clear demonstrations of the benefits of BGM meters that provide feedback to patients [2], and diabetes being almost universally managed in the UK by NHS professionals, there is an apparent lack of clarity within the NHS regarding emerging BGM technologies and their potential to positively impact service delivery and increase resource efficiency while supporting patient empowerment. This was demonstrated in a survey of over 1000 BGM users carried out by Diabetes UK [3], with the responses suggesting that NICE (National Institute for Health and Care Excellence) guidance is not always implemented as recommended for type 1 [4] and type 2 [5] diabetes.

This consensus steering group (all members are co-authors to this paper) has sought the real-life perspectives of NHS staff involved in diabetes care to gain an understanding of their attitudes to BGM technology and its value for people with diabetes who require intensive BG monitoring. This was felt necessary because the speed of introduction of technology was perceived to move more quickly even than centralized expert guidance. In order to fulfil the requirements for fully collaborative shared care, it is important that optimum technology is utilized and a ‘big data’ approach is adopted, in order to increase resource efficiency.

This article does not contain any studies with human participants or animals performed by any of the authors.

The group used the Delphi [6] methodology to validate the views of a large number of peers regarding BGM in the current UK National Health Service (NHS) setting, with the goal of better understanding their views regarding changing demographics and BGM technology. The recommendations derived from the responses seek to support HCPs in assessing new technologies available to them and provide decision-support for choice of technology. As such, these consensus views and recommendations which the group felt were justifiable from the responses are offered in order to provide a reference point for the use of BGM for both commissioners and providers. In addition, the consensus process aimed to identify regional variation in the responses to statements and is intended to inform the paradigm shift required to adopt new technologies for BGM.

A group of clinicians and payers involved in diabetes care met to review the current adoption of BGM systems in the UK and determine a framework for consensus. Seven key topics were initially identified, and consensus statements developed for each (Table 1). These statements were collated into a questionnaire, which was circulated widely over a 3-month period to clinicians involved in diabetes management by in-person cascade and by e-mail from group members and with the help of LifeScan, Inc. (London, UK) representatives. Responses were collated and analyzed in confidence by Triducive Ltd (St Albans, UK). Respondents were required to use a 4-point Likert scale to rate their agreement with each statement. Responses were: ‘strongly disagree’; ‘tend to disagree’; ‘tend to agree’; and ‘strongly agree.’ The questionnaire also asked respondents for their locality, their speciality, and the department in which they work. While personal details were not used for reporting results, clinical background and locality were used to assess potential differences in responses between professions and across the UK.

Completed questionnaires were then collated, and the individual scores for each statement analyzed in order to produce a full arithmetic agreement score for each statement. The responses were then sub-grouped by locality and specialty to identify variances in the respondent’s agreement scores by either geography or role.

The steering group had predefined the threshold of agreement for consensus at ≥ 66%. Consensus was defined as ‘high’ at ≥ 66% and ‘very high’ at ≥ 90%.

Due to the high levels of agreement with all but three of the statements, demonstrating very strong consensus views, the group elected to avoid a further round of questionnaires to generate a larger number of responses, and instead chose to work with the responses to the original statements.

Completed questionnaires were returned by 222 respondents. The questionnaires were analyzed to score the total level of agreement with each of the 38 statements. Of the 38 statements, 35 (92%) achieved an agreement score exceeding the 66% threshold, and 26 of these (68%) exceeded 90% agreement (Table 2, Fig. 1).

Only three of the statements achieved an agreement score of < 66% or > 33% and thus were defined as not achieving consensus (Table 3).

Respondents were analyzed by region. The number of respondents from each region is shown in Table 4. The sample was dominated by respondents from England (n = 136) while only four respondents were from Wales. Eighteen respondents did not indicate their region.

While the majority of statements were scored similarly, irrespective of the respondent’s region (Fig. 2), nine statements showed larger regional variation in score (Table 5).

Responses were also analyzed according to the respondent’s role (Table 6).

While the largest single respondent groups by role were diabetologists and diabetes specialist nurses (DSNs), 39 respondents did not share their role on the questionnaire and thus remain unknown and 19 had other roles. Comparison between the responses of diabetologists, DSNs and the group overall is shown in Fig. 3.

With the exception of statements 3, 4, 5, 16, 17, 27, 30, and 37, the views of DSNs were well aligned with those of the wider group. The variation in agreement scores for these statements according to role is shown in Table 7.

In this paper we describe the consensus views of a large group of clinicians working the UK NHS, a government-funded, cost-limited healthcare system that is substantially free at the point of use. As such, the recommendations and views presented here may not reflect the views of HCPs in other healthcare systems.

For patients with a need to optimize their glycemic control, many factors may influence their choice of BGM system. Understanding the value of a system to a patient may be a more important measure than simply looking at the acquisition cost of that device. In light of this, sharing the acquisition cost with the patient may be a valid option, as patients have demonstrated that when a device is recognized as offering important advantages, they may be willing to contribute to the cost [7].

Effective BGM is recognized by 99.1% of respondents as having the potential to reduce hypoglycemia and ketoacidosis in patients with type 1 diabetes. Effective BGM may be regarded as achieving tight glycemic control (according to the type of diabetes) in line with personalized goals.

Respondents strongly agree with the assertion that flash glucose monitoring has the potential to improve the use of NHS resources (88.9% agreement) and should be considered as an investment rather than a cost (96.3% agreement).

The conclusions drawn by the consensus group after consideration of the questionnaire responses are as follows: