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The Pharmaceutical Journal Vol 265 No 7114 September 16, 2000
Pharmacy Practice Research
Papers presented at the British Pharmaceutical Conference, Birmingham, September 10 to 13, 2000 pR21

Can a community pharmacy influence the control of disease in people with diabetes through the use of a local quality control scheme?

By Noel Dixon, John Hall, Derek Knowles* and Eric Sanders*

Introduction Measurement of glucose in blood or urine employing a variety of methods, is used by patients to monitor their diabetes. Although use of quality assurance/ control procedures for these tests is regarded as essential in hospital practice,1 there seems little emphasis on their importance in domiciliary situations. Tighter glycaemic control has been shown to improve prognosis but increase the risk of hypoglycaemia.2 It is, therefore, now even more important that the accuracy of blood glucose meters, used in domiciliary situations, is checked regularly.

Method We contacted 390 people with diabetes, identified from our patient medication records and from sales records of blood glucose meters. Patients were interviewed at the beginning of the study and then every three months for a year using a standard, semi-structured interview form, incorporating demographic data, medication details and a scoring chart for estimating proficiency in testing technique and knowledge of diabetes.
At the first interview patients were alternatively assigned to a "quality control" (QC) or "no quality control" (NQC) group within their method of testing groups. The patients were interviewed and then asked to perform the glucose monitoring procedure they would use at home. Their technique was assessed and the result recorded. The pharmacist then measured blood glucose using an Accutrend (Roche Diagnostics) blood glucose meter. A third sample was sent to the local pathology laboratory for HbA1c estimation. All patients were given an information leaflet about diabetes, a fresh set of instructions about their meter and a diary to record their results. The patients in the QC group were also given a quality control solution and an instruction leaflet for this. A patient satisfaction survey was sent to each participant at the end of the study.
Statistical significance in improvement of technique was demonstrated using analysis of variance.

Focal points

  • Technique in home glucose monitoring is poor if the operator has had no training
  • Blood glucose meters should not be sold without training the operator
  • Significant improvements in the technique of home glucose monitoring can be made by educating the operator in a community pharmacy
  • With support from the pathology laboratory, a community pharmacy can be used for the implementation of a local quality control scheme

Results One-hundred-and-thirty people completed the study (58 QC), average age 62 years (SD 11.7), 47 per cent female; QC/NQC groups were well matched. During the course of the study the BMI of the QC group rose 0.3kg/m2 from 28.9kg/m2 and the NQC group increased 0.9kg/m2 from 28.7kg/m2.
The median HbA1c of the QC group rose 0.4 from 7.4 but the NQC group increased 1.1 from 7.1 (not significant). All QC subgroups by method of testing (visual and meter blood glucose estimation and urinalysis) and QC subgroups for treatment (metformin and sulphonylurea) showed smaller increases in HbA1c than their corresponding NQC subgroups. The QC insulin sub group (n=12) improved, median HbA1c decreased 0.3 from 8.7 and NQC group (n=11) deteriorated, increasing 0.9 from 8.4.
The average score for technique improved from 62.6 per cent (SD 23 per cent) to 82.2 per cent (SD 17 per cent), (P<0.001) with no difference between QC and NQC. The greatest improvement in technique was seen in the production of a hanging drop of blood where the score improved by 34 per cent.
Ninety-two per cent of participants replied to the patient questionnaire; of these 99 per cent were satisfied/very satisfied and 93 per cent had some gain from the study.

Discussion Attention to patients' home monitoring results can improve glycaemic control.3 Similarly, a Scottish study has found an association between HbA1c results and the number of testing strips dispensed, in people with type I diabetes.4 Our study also focused on this area of home testing and, although it was not powerful enough to demonstrate significant outcomes in the control of diabetes, people in the QC group did better. It is also important to remember that QC procedures are a necessary safety mechanism in any monitoring procedure.1
A community pharmacist can provide effective education in the use of domiciliary diabetes testing equipment and with help from the local pathology laboratory, the pharmacy is a suitable place for ongoing support using a local quality control scheme.

Dixon & Hall Ltd; *North Durham hospital trust

References

1. Blood glucose measurements: reliability of results produced in extra-laboratory areas. London: Department of Health and Social Security; 1987.
2. The diabetes control and complications trial research group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993;329:977-86.
3. Wredling R, Adamson U, Ericsson A, Larsson Y, Oestman J. Patients' opinions on diabetic care in relation to glycaemic control. Practical Diabetes International 1996;13:80-2.
4. Evans J, Newton R, Ruta A, MacDonald T, Stevenson R, Morris A. Frequency of blood glucose monitoring in relation to glycaemic control: observational study with diabetes database. BMJ 1999;319:83-6.