Test Strip Use Research Articles

Prevalence and correlates of fentanyl test strip use among people who use drugs in Rhode Island

BackgroundIllicitly manufactured fentanyl accounts for a majority of overdose fatalities in the US. Research has demonstrated that fentanyl test strips (FTS) help people who use drugs (PWUD) avoid unintended exposure to fentanyl and overdose. This study assesses characteristics associated with FTS use among PWUD in Rhode Island. Such findings may shed light on whether there are subgroups of PWUD who are less likely to be using FTS and therefore may benefit from their use. MethodsFrom September 2020 - February 2023, participants were recruited to participate in RAPIDS, a clinical trial assessing whether FTS provision can reduce overdose rates. Baseline data were used to assess correlates of lifetime FTS use through bivariable and multivariable analyses. We also examined drug testing patterns relating to FTS use in the past month. ResultsOf 509 people enrolled, 376 (73.9 %) had heard of FTS before enrollment. Among this group, 189 (50.3 %) reported lifetime FTS use and 98 (26.1 %) reported use in the last month. In bivariable analyses, lifetime injection drug use, responding to an overdose, and drug selling were associated with FTS use. Solitary drug use was not associated with FTS uptake. In the multivariable analysis, gender and lifetime naloxone administration were associated with FTS use. Of those who used FTS in the past month, 76.5 % had at least one test that was positive for fentanyl. ConclusionsWe found high uptake of FTS use among PWUD in Rhode Island. Our results also suggest a need for targeted outreach to increase FTS uptake among sub-groups of PWUD. Clinical trial registrationThe Rhode Island Prescription and Illicit Drug Study is a registered clinical trial, NCT043722838

Evaluating fentanyl test strips as a harm reduction strategy in rural and urban counties: study protocol for a randomized controlled trial

BackgroundOpioid-related fatalities are a leading cause of death in Ohio and nationally, with an increasing number of overdoses attributable to fentanyl. Rapid fentanyl test strips can identify fentanyl and some fentanyl analogs in urine samples and are increasingly being used to check illicit drugs for fentanyl before they are used. Fentanyl test strips are a promising harm reduction strategy; however, little is known about the real-world acceptability and impact of fentanyl test strip use. This study investigates fentanyl test strip distribution and education as a harm reduction strategy to prevent overdoses among people who use drugs.MethodsThe research team will recruit 2400 individuals ≥ 18 years with self-reported use of illicit drugs or drugs purchased on the street within the past 6 months. Recruitment will occur at opioid overdose education and naloxone distribution programs in 16 urban and 12 rural Ohio counties. Participating sites will be randomized at the county level to the intervention or non-intervention study arm. A brief fentanyl test strip educational intervention and fentanyl test strips will be provided to participants recruited from sites in the intervention arm. These participants will be eligible to receive additional fentanyl test strips for 2 years post-enrollment. Participants recruited from sites in the non-intervention arm will not receive fentanyl test strip education or fentanyl test strips. All participants will be followed for 2 years post-enrollment using biweekly, quarterly, and 6-month surveys. Primary outcomes include (1) identification of perceived barriers and facilitating factors associated with incorporating fentanyl test strip education and distribution into opioid overdose education and naloxone distribution programs; (2) differences in knowledge and self-efficacy regarding how to test drugs for fentanyl and strategies for reducing overdose risk between the intervention and non-intervention groups; and (3) differences in non-fatal and fatal overdose rates between the intervention and non-intervention groups.DiscussionFindings from this cluster randomized controlled trial will contribute valuable information about the feasibility, acceptability, and impact of integrating fentanyl test strip drug checking in rural and urban communities in Ohio and help guide future overdose prevention interventions.Trial registrationClinicalTrials.gov NCT05463341. Registered on July 19, 2022. https://clinicaltrials.gov/study/NCT05463341

FRI653 Hemoglobin A1C-testing Inertia: A Barrier Observed In A Digital Diabetes Ecosystem Study

Abstract Disclosure: N. Thingalaya: Employee; Self; Sanofi. D. Kerr: Advisory Board Member; Self; Sanofi, Novo Nordisk, Abbott Diabetes Care. Research Investigator; Self; Novo Nordisk, Abbott Diabetes Care. Other; Self; Glooko, Hi.Health, SNAQ. F. Lee: Employee; Self; Sanofi. K.M. Pantalone: Consulting Fee; Self; AstraZeneca, Bayer, Inc., Corcept Therapeutics, Diasome, Eli Lilly & Company, Merck, Novo Nordisk, Sanofi. Research Investigator; Self; Bayer, Inc., Merck, Novo Nordisk, Twin Health. Speaker; Self; AstraZeneca, Corcept Therapeutics, Merck, Novo Nordisk. P. Potukuchi: Employee; Self; Sanofi. J. Unger: None. G. Grunberger: Speaker; Self; Eli Lilly & Company, Abbott Diabetes. Introduction: For people living with type 2 diabetes (T2D), digital health interventions show promise in improving clinical outcomes. Dario Diabetes Solution (DDS) is an application that combines remote self-blood-glucose monitoring, data visualization, and disease education to facilitate behavior change. We designed a retrospective study (RS) to assess clinical effectiveness of DDS on patients with uncontrolled T2D. As clinicians continue to rely on monitoring hemoglobin A1C (A1C) to assess disease progression, this study design gave us insights into the prevalence of A1C-testing inertia in T2D. Methods: Data from DDS users, their A1C and electronic medical records (EMR) were analyzed. Adults with T2D receiving ≥1 diabetes medication, with A1C ≥7.0%, and not using a continuous glucose monitor between 01/01/2017 and 10/31/2021, were eligible for inclusion. Baseline (BL) period was 1 year before the index date, defined as first registration for DDS users or first claim date in the quarter for nonusers. The follow-up period was index date +180 days. Severity of illness was compared using Charlson Comorbidity Index (CCI) score, diabetes medication use, and other comorbidities, including mental health burden such as depression and antidepressant use. We identified test-strip use as a proxy for degree of self-care. By applying sequential 1:3 exact and propensity-score (PS) match methods, we identified 1,005 users and 1,160,825 nonusers at BL from a database linked to claims and EMR. Results: The exact and PS match methods used in the RS generated a well-matched external cohort, with CCI scores of 1.5, 51% of oral antidiabetic-only users, and 6% insulin-only users. There was a well-matched distribution of payer mix, depression, and use of antidepressants. There were 7% more users of test-strips in the nonuser groups (p=0.0026) compared with DDS users at BL. 43.3% of users (n=570) and 45.9% of nonusers (n=628,167; p=0.098) did not have A1C results at 6 months. Conclusion: These findings suggest that the frequency of A1C testing remains sub-standard in the United States. Over 40% of a population with uncontrolled T2D did not have A1C values at 6 months, regardless of their degree of self-care behavior. While not all sources of A1C values were captured, this study ensured comparable disease severity and access to care. A1C was not performed to clinical guideline recommendations in either group. Testing inertia should be further studied to improve implementation of routine A1C testing. Despite use of glycemic targets as measures by payers, frequency of A1C testing remains sub-standard, even among digital health users. Identifying specific barriers to A1C testing could help inform future strategies for digital health solutions, which may help to reduce the existing therapeutic inertia. Presentation: Friday, June 16, 2023

Association of Fentanyl Test Strip Use, Perceived Overdose Risk, and Naloxone Possession among People Who Use Drugs

Background: As opioid overdoses continue rising, interventions are needed to expand naloxone carriage, an opioid overdose reversal agent. Use of fentanyl test strips (FTS) might promote naloxone carriage. This study examines the relationship between FTS use, perceived overdose risk, and naloxone carriage in Wisconsin, United States. Methods: In a survey of people who use drugs (n = 341) in southern Wisconsin, respondents were asked about FTS use, perceived overdose risk, and how often they (1) have naloxone, (2) have more than one dose of naloxone, and (3) the number of naloxone doses possessed currently. Likert responses were mapped to an integer scale. Ordinal and linear multivariable regression examined the relationship between FTS use and study outcomes while adjusting for respondent characteristics. Results: Most respondents were male (59.6%), identified heroin as their drug of choice (70.7%) and reported intravenous use (87.9%). In unadjusted models, FTS use was associated with more often having naloxone (OR: 2.10; p = 0.005), more often having multiple naloxone doses (OR: 2.98; p < 0.001), and possessing a greater number of naloxone doses (dose count difference: 2.85; p = 0.001). In adjusted models, FTS use was associated with more often having multiple naloxone doses (OR: 2.29; p = 0.005) and possessing a greater number of naloxone doses (dose count difference: 2.25, p = 0.020). Conclusions: Individuals who use FTS more often carry multiple doses relative to individuals who do not use FTS. Given that naloxone carriage is critical for reducing opioid overdose risk, expanding FTS use may offer a strategy to reduce opioid overdose rates via improved naloxone carriage.

Feasibility study of using mobile phone-based experience sampling to assess drug checking by opioid street drug users

BackgroundTo date, evaluations of take-home fentanyl (and/or benzodiazepine) test strip use — the most common form of drug checking services — and potential effects on overdose risk have relied on retrospective accounts for some preceding time period, usually a week to several months. Such accounts, however, are subject to recall and memory biases. This pilot study assessed the feasibility of using experiential sampling to collect daily information in situ on drug checking and associated overdose risk reduction — the primary outcomes — among a sample of street opioid users and compared the results to retrospective reports.MethodsWe recruited 12 participants from a Chicago-based syringe services program. Participants were 18 years of age or older, reported using opioids purchased on the street 3 + times per week in the past month, and had an available Android mobile phone. A phone-based app was programmed to collect daily drug checking information and provided to each participant along with a supply of fentanyl and benzodiazepine test strips and instructions for use over 21 days. Comparable retrospective data were collected via follow-up in-person surveys at the conclusion of daily report collection.ResultsWe found a reasonably high rate of daily reporting (63.5%) with participants submitting reports on 160 “person-days” out of 252 possible days. Participants submitted daily reports an average of 13 of 21 days. Reports of test strip use frequency varied between the retrospective and daily reports with a relatively higher percentage of days/time using test strips obtained from the daily reports. We also found higher proportions reporting overdose risk reduction behaviors on the daily reports compared with the retrospective reviews.ConclusionsWe believe the results support using daily experience sampling to collect information on drug checking behaviors among street drug users. Although resource intensive in comparison to retrospective reports, daily reporting potentially provides more detailed information on test strip use and its association with overdose risk reduction and, ultimately, fewer overdoses. Needed are larger trials and validation studies of daily experience sampling to identify the optimum protocol for collecting accurate information on drug checking and overdose risk reduction behavior.

Differences in drug use behaviors that impact overdose risk among individuals who do and do not use fentanyl test strips for drug checking

BackgroundOpioid-involved overdose continues to rise, largely explained by fentanyl adulteration of the illicit opioid supply. Fentanyl test strips are a novel drug checking tool that can be used by people who use drugs to detect the presence of fentanyl in drug products. However, it is unclear whether fentanyl test strip use can prompt behavior changes that impact risk of overdose.MethodsIn this mixed-methods study involving a structured survey (n = 341) of syringe service program clients in southern Wisconsin, we examined the association between fentanyl test strip use and overdose risk behaviors in scenarios where the presence of fentanyl is confirmed and unknown. Individual items were transformed into summary scales representing the performance of riskier and safer behaviors. Linear regression examined the association of behaviors with FTS use. Models are adjusted for study site, race/ethnicity, age, gender, drug of choice, indicator of polysubstance use, times used per day, and lifetime overdose count.ResultsIn response to survey questions before prompting about fentanyl risk, people who used fentanyl test strips reported an increased number of safer (p = 0.001) as well as riskier behaviors (p = 0.018) relative to people who did not use fentanyl test strips. The same held true in situations when fentanyl adulteration was suspected, though fentanyl test strip use lost significance in the fully adjusted model examining safer behaviors (safer: p = 0.143; riskier: p = 0.004). Among people who use fentanyl test strips, in unadjusted models, a positive test result was associated with more safer behaviors and fewer riskier behaviors, but these associations became nonsignificant in fully adjusted models (safer: p = 0.998; riskier: p = 0.171). Loss of significance was largely due to the addition of either polysubstance use or age to the model.ConclusionsFentanyl test strip use is associated with behaviors that may impact overdose risk, including safer and riskier behaviors. Specifically, a positive test result may promote more risk reducing behaviors and fewer risk enhancing behaviors than a negative test result. Results suggest that while FTS may promote safer drug use behaviors, outreach and education should emphasize the need for multiple harm reduction techniques in all scenarios.

I Don't Believe a Person Has to Die When Trying to Get High: Overdose Prevention and Response Strategies in Rural Illinois.

Overdose is a leading cause of morbidity and mortality among people who inject drugs. Illicitly manufactured fentanyl is now a major driver of opioid overdose deaths. Semi-structured interviews were conducted with 23 participants (19 persons who inject drugs and 4 service providers) from rural southern Illinois. Data were analyzed using constant comparison and theoretical sampling methods. Participants were concerned about the growing presence of fentanyl in both opioids and stimulants, and many disclosed overdose experiences. Strategies participants reported using to lower overdose risk included purchasing drugs from trusted sellers and modifying drug use practices by partially injecting and/or changing the route of transmission. Approximately half of persons who inject drugs sampled had heard of fentanyl test strips, however fentanyl test strip use was low. To reverse overdoses, participants reported using cold water baths. Use of naloxone to reverse overdose was low. Barriers to naloxone access and use included fear of arrest and opioid withdrawal. People who inject drugs understood fentanyl to be a potential contaminant in their drug supply and actively engaged in harm reduction techniques to try to prevent overdose. Interventions to increase harm reduction education and information about and access to fentanyl test strips and naloxone would be beneficial.

Characteristics and context of fentanyl test strip use among syringe service clients in southern Wisconsin

BackgroundFentanyl adulteration of illicit drugs is a major driver of opioid-involved overdose in the USA. Fentanyl test strips are increasingly used by people who use drugs to check for fentanyl. However, little is known about factors that influence test strip use in this population.MethodsIn this mixed-methods study employing semi-structured open-ended interviews (n = 29) and a structured survey (n = 341), we examined characteristics associated with test strip use, characteristics of test strip use, and situational, logistical and psychosocial factors influencing test strip use. Respondents were recruited from a syringe service program in southern Wisconsin. Bivariate tests of association and multivariable logistic regression examined the relationship between respondent characteristics and test strip use. Summary statistics were used to describe how situational, logistical and psychosocial factors impact test strip use.ResultsMost respondents were male (59.6%), non-Hispanic white (77.4%), young (mean 35.7 years), reported heroin as their primary drug (70.7%), injection as their primary route (87.9%), and use ≥ 3 times daily (78.6%). In multivariable models, site, race and ethnicity, drug of choice, and seeking fentanyl were associated with test strip use. Among test strip users, 36.5% use them most of the time or more and 80.6% get positive results half the time or more. Among individuals reporting heroin, fentanyl, methamphetamine, or cocaine or crack cocaine at least once per month, 99.1%, 56.8%, 42.2%, and 55.7% reported testing these drugs, respectively. Test strip use is supported by information from suppliers, regular transportation, diverse distribution locations, recommendations from harm reduction staff, and having a safe or private place to use.ConclusionsWe found that individuals who use fentanyl test strips are more often non-Hispanic white, use heroin, and seek drugs with fentanyl relative to individuals without test strip use. Findings confirm high fentanyl penetration in the Wisconsin drug supply. Low rates of stimulant testing suggest inadequate awareness of fentanyl penetration. Findings support outreach to key populations, increased diversity of distributing locations, efforts to correct misperceptions about drug wasting, emphasis on pre-consumption testing, and the importance of adjunct behaviors to prevent overdose given high rates of intentional fentanyl use.

The Economic Evaluation of Team Clinic-Group Approach to a Care Model of Early Adolescents With Type 1 Diabetes.

Glycemic control is challenging for adolescents with type 1 diabetes (T1D). Team Clinic, a shared medical appointment model, has improved psychosocial outcomes in middle school patients with T1D. We aimed to evaluate the costs of delivering Team Clinic. Participants were randomized into Team Clinic (n=44) or usual care (n=42) groups. We found no significant difference in 6-month total costs per subject ($3,204 [intervention] vs. $3,476 [control]. No significant differences were found in health care use, test strip use, or continuous glucose monitoring and/or pump. The intervention had more clinic visits (2.41 vs. 1.52 times) and a longer length of visit (2.34 vs. 0.74 hr, but no difference in provider time per patient per visit (median, 0.67 vs. 0.68 hr). The Team Clinic care model may help young adolescents with T1D improve psychosocial outcomes and increase completion of clinical visits without increasing costs.

“If I had them, I would use them every time”: Perspectives on fentanyl test strip use from people who use drugs

IntroductionFentanyl contamination in the illicit drug supply has contributed to a significant increase in overdose deaths in the United States. Fentanyl test strips (FTS), which can detect the presence of fentanyl in drugs, are increasingly given to people who use drugs (PWUD) as an overdose prevention intervention. No studies to date have described PWUD's perspectives from a real-world setting about ideal FTS program characteristics. These perspectives, specifically any identified facilitators, barriers, and suggestions for use, are crucial to informing scalability and implementation of FTS. MethodsThe study team conducted qualitative interviews between January and May 2021 with PWUD in Philadelphia, PA, who had used FTS on a variety of substances. The study recruited participants outside of a harm reduction agency and provided informed consent. The team conducted interviews utilizing a semi-structured interview guide, and audio-recorded and transcribed them. The research team analyzed interviews with a conventional content analysis approach. ResultsA total of 29 PWUD participated in an interview. Participants were predominantly cisgender male (n = 21, 72.4%) and White (n = 18, 62.1%). Participants reported previously using FTS on heroin (65.5%), crack cocaine (55.2%), powder cocaine (48.3%), synthetic cannabinoids (31.0%), and benzodiazepines (24.1%). Eighty-six percent of participants learned about FTS through harm reduction or other social service organizations. Most participants incorporated FTS into their daily lives and found them easy to use. Participants identified key barriers, including lack of necessary supplies needed to test, not having an ideal testing location, and confusion reading test results. Suggestions included adding supplies needed for using FTS to distribution packets, ensuring that each PWUD receives enough FTS per distribution, and expanding the types of programs distributing FTS. ConclusionsWhile most participants reported FTS as practical and easy to use, participants identified a few key barriers to use that should be addressed to optimize FTS use across a broader population. These barriers include expanding training materials and distributing additional testing materials (e.g., water, cookers) with FTS. Findings can inform sustainable and effective FTS distribution practices, such as distributing FTS in packs of 20 and distributing at other locations that regularly interact with PWUD (e.g., emergency departments, housing shelters, and food banks).

"You can't go wrong being safe": Motivations, patterns, and context surrounding use of fentanyl test strips for heroin and other drugs.

Unintentional drug overdose fatalities due to fentanyl contamination continue to increase. Fentanyl test strip (FTS) use has emerged as a valuable harm reduction strategy to detect the presence of fentanyl in drugs. However, motivation for FTS uptake and context surrounding use have not been well characterized in the literature. This study aimed to capture people who use drugs' (PWUD) lived experiences to understand motivations underlying FTS uptake, ongoing use, and actions after testing. We conducted qualitative interviews with PWUD at a harm reduction organization in Philadelphia, PA. Interviews asked about experiences with using FTS. Interviews were audio-recorded, professionally transcribed, and reviewed. Data were analyzed through a conventional content analysis approach and organized into broader categories via team consensus. Twenty-nine PWUD with experience using FTS were interviewed between January and May 2021. Interviews were organized into three thematic categories: first time use of FTS, patterns of FTS use, and contextual factors of FTS use. Motivations to use FTS among PWUD varied, but were largely driven by factors related to knowledge, access, neighborhood, and drug market trends. Frequency of use was characterized by number of FTS, ongoing FTS access, and drug purchasing location and amount. Participants reported few logistical barriers to testing. This research supports the current literature that states FTS are an accepted and effective harm reduction strategy for the PWUD community. To support increased use of FTS, distribution campaigns should be widespread geographically and provide enough strips to ensure availability for PWUD to test more frequently.

“I probably got a minute”: Perceptions of fentanyl test strip use among people who use stimulants

BackgroundFentanyl dominates the heroin supply in many regions of the United States. One harm reduction response has been the distribution of fentanyl test strips to people who use heroin to test for the presence of fentanyl. Reports increasingly indicate that fentanyl contamination is occurring in the illicit stimulant market, but whether people who use stimulants would use fentanyl test strips is unknown. MethodsBetween January 2019 and January 2020, fifteen people in Philadelphia, PA who reported stimulant use completed a semi-structured interview with questions about their perceptions of fentanyl and willingness to use fentanyl test strips. Data were coded and analyzed for thematic content using constructs from the Health Belief Model and risk environment theory. ResultsParticipants primarily reported using crack cocaine or crack cocaine/heroin, while some used methamphetamine, powder cocaine, or prescription opioids. All were aware of fentanyl and believed they were susceptible to a fentanyl overdose as stimulant users. Participants perceived benefits of using test strips but reported barriers, such as the unpredictable nature of buying or using drugs and not wanting to delay drug use to test. Structural conditions impeded participant actions to reduce overdose risk if their drugs tested positive for fentanyl. ConclusionFentanyl test strips were a desired harm reduction tool by many participants who used stimulants. In addition to providing access to the strips, programs should tailor overdose prevention education to these clients by acknowledging susceptibility, amplifying benefits, and addressing drug-specific barriers to use of fentanyl test strips.

A randomized clinical trial of a theory-based fentanyl overdose education and fentanyl test strip distribution intervention to reduce rates of opioid overdose: study protocol for a randomized controlled trial

BackgroundOpioid overdose deaths involving synthetic opioids, particularly illicitly manufactured fentanyl, remain a substantial public health concern in North America. Responses to overdose events (e.g., administration of naloxone and rescue breathing) are effective at reducing mortality; however, more interventions are needed to prevent overdoses involving illicitly manufactured fentanyl. This study protocol aims to evaluate the effectiveness of a behavior change intervention that incorporates individual counseling, practical training in fentanyl test strip use, and distribution of fentanyl test strips for take-home use among people who use drugs.MethodsResidents of Rhode Island aged 18–65 years who report recent substance use (including prescription pills obtained from the street; heroin, powder cocaine, crack cocaine, methamphetamine; or any drug by injection) (n = 500) will be recruited through advertisements and targeted street-based outreach into a two-arm randomized clinical trial with 12 months of post-randomization follow-up. Eligible participants will be randomized (1:1) to receive either the RAPIDS intervention (i.e., fentanyl-specific overdose education, behavior change motivational interviewing (MI) sessions focused on using fentanyl test strips to reduce overdose risk, fentanyl test strip training, and distribution of fentanyl test strips for personal use) or standard overdose education as control. Participants will attend MI booster sessions (intervention) or attention-matched control sessions at 1, 2, and 3 months post-randomization. All participants will be offered naloxone at enrolment. The primary outcome is a composite measure of self-reported overdose in the previous month at 6- and/or 12-month follow-up visit. Secondary outcome measures include administratively linked data regarding fatal (post-mortem investigation) and non-fatal (hospitalization or emergency medical service utilization) overdoses.DiscussionIf the RAPIDS intervention is found to be effective, its brief MI and fentanyl test strip training components could be easily incorporated into existing community-based overdose prevention programming to help reduce the rates of fentanyl-related opioid overdose.Trial registrationClinicalTrials.gov NCT04372238. Registered on 01 May 2020

Perspectives on Fentanyl Test Strip Use among People Who Inject Drugs in Rural Appalachia

Background: Fentanyl-associated overdose fatalities have increased dramatically throughout the United States. Fentanyl test strips (FTS) may be used by people who inject drugs (PWID) to lower overdose risks; however, virtually no research has been conducted to understand the perspectives of rural PWID in Appalachia on FTS utilization. Objectives: We aim to explore FTS awareness and potential use among PWID in two rural counties in West Virginia (WV). Methods: Semi-structured interviews with PWID (n = 48) in two rural counties in WV were conducted to explore FTS awareness, potential use, and possible behavioral changes following FTS utilization. Participants were recruited in areas where PWID congregate in each county. With participants’ permission, interviews were audio recorded and transcribed verbatim. Transcripts were analyzed using an iterative, constant comparative approach. Results: Very few participants had heard of FTS prior to the interview. Upon learning about FTS, PWID who reported frequently injecting heroin expressed high willingness to use FTS. Participants explained that learning their drugs contained fentanyl may make them more likely to engage in overdose risk reduction behaviors, such as: using less, doing tester shots, and not using the drugs entirely. Conclusion: Among our sample of rural PWID in Appalachia, most were unaware of FTS but expressed high willingness to utilize the technology. Participants described how receiving a positive FTS result may lead them to engage in overdose risk reduction behaviors. Augmenting existing overdose prevention initiatives in rural Appalachia such that rural PWID have access to FTS may result in reductions in overdose fatalities.

Self-Monitoring of Blood Glucose and Hypoglycemia-Related Hospitalization in a Population-Based Cohort of Canadian Patients With Type 1 or Type 2 Diabetes

ObjectivesThe aim of this work was to determine whether: 1) blood glucose test strip use in the population is associated with hypoglycemia hospitalization rates, and 2) blood glucose test strip use among individuals is associated with a reduced risk of hypoglycemia hospitalization. MethodsAdministrative databases from Saskatchewan, Canada, were used to ascertain population-level hypoglycemia hospitalizations and test strip utilization over the period from 1996 to 2014. For objective 1, a generalized linear model with generalized estimating equations was fit to provincial data stratified by age group, sex and year. For objective 2, a nested case-control study was conducted for a cohort of insulin users with diagnosed diabetes. Multivariable conditional logistic regression was used to test the association of test strip use with hospitalization, after adjusting for clinical and demographic factors and health services use. Odds ratios (ORs) and 95% confidence intervals (95% CIs) are reported. ResultsA total of 5,166 hospitalizations for hypoglycemia were identified in the observation period. Annual glucose test strip use increased by over 350%; however, no association was found with provincial hypoglycemia hospitalization rate during the same period, even after controlling for all-cause hospitalizations and population demographics. In the case-control analysis, test strip use was not associated with hospitalization for hypoglycemia among insulin users (n=10,617; adjusted OR, 1.08; 95% CI, 0.88 to 1.31). A sensitivity analysis in an independent cohort of noninsulin users produced a similar finding (n=47,501; adjusted OR, 1.04; 95% CI, 0.55 to 1.94). ConclusionOur findings add to the body of evidence against a protective effect of blood glucose test strip use for serious hypoglycemia.

Marked improvement in HbA1c following commencement of flash glucose monitoring in people with type 1 diabetes

Aims/hypothesisMinimal evidence supports the efficacy of flash monitoring in lowering HbA1c. We sought to assess the impact of introducing flash monitoring in our centre.MethodsWe undertook a prospective observational study to assess change in HbA1c in 900 individuals with type 1 diabetes following flash monitoring (comparator group of 518 with no flash monitoring). Secondary outcomes included changes in hypoglycaemia, quality of life, flash monitoring data and hospital admissions.ResultsThose with baseline HbA1c ≥58 mmol/mol (7.5%) achieved a median −7 mmol/mol (interquartile range [IQR] −13 to −1) (0.6% [−1.2 to −0.1]%) change in HbA1c (p < 0.001). The percentage achieving HbA1c <58 mmol/mol rose from 34.2% to 50.9% (p < 0.001). Median follow-up was 245 days (IQR 182 to 330). Individuals not using flash monitoring experienced no change in HbA1c across a similar timescale (p = 0.508). Higher HbA1c (p < 0.001), younger age at diagnosis (p = 0.003) and lower social deprivation (p = 0.024) were independently associated with an HbA1c fall of ≥5 mmol/mol (0.5%). More symptomatic (OR 1.9, p < 0.001) and asymptomatic (OR 1.4, p < 0.001) hypoglycaemia was reported after flash monitoring. Following flash monitoring, regimen-related and emotional components of the diabetes distress scale improved although the proportion with elevated anxiety (OR 1.2, p = 0.028) and depression (OR 2.0, p < 0.001) scores increased. Blood glucose test strip use fell from 3.8 to 0.6 per day (p < 0.001). Diabetic ketoacidosis admissions fell significantly following flash monitoring (p = 0.043).Conclusions/interpretationFlash monitoring is associated with significant improvements in HbA1c and fewer diabetic ketoacidosis admissions. Higher rates of hypoglycaemia may relate to greater recognition of hitherto unrecognised events. Impact upon quality of life parameters was mixed but overall treatment satisfaction was overwhelmingly positive.

Patterns, Policy and Appropriateness: A 12-Year Utilization Review of Blood Glucose Test Strip Use in Insulin Users.

Considerable attention has been paid to the rising costs of the use of blood glucose test strips (BGTS). Insulin users have generally been treated as a single homogeneous group, resulting in policies that cap usage (8.2 strips/day) in provincial drug insurance programs. The objective of this study was to conduct a utilization review of BGTS by insulin users and to evaluate use patterns against current insulin use patterns and BGTS policy. BGTS usage was examined in a cohort of insulin users with type 1 and type 2 diabetes over a 12-year period (2001 to 2013) using the population-based administrative data in Manitoba, Canada. Total BGTS strip use increased by 121%, from $4.3 to $9.5 million. However, the number of insulin users also increased by 115%. Use has been stable at 1.5 strips per day per person since 2004 by insulin users with type 2 diabetes but has risen from 1.9 to 3.0 strips per day per person in those with type 1 diabetes. Mean daily test strip use was below the number of daily tests recommended for patients using insulin as per the current Canadian guidelines, with 11% and 15% of insulin users with type 1 and type 2 diabetes not claiming any BGTS use and a further 15% (type 1) and 28% (type 2) using fewer than 1 strip per day. BGTS use per insulin user has been stable for most of the past decade, and the vast majority of use falls well below provincial insurance caps. The amount of low-level testing (0 to <1 strip/day) suggests that greater attention should be directed to ensuring a safe level of testing by all insulin users.

Self-Monitoring of Blood Glucose Levels: Evaluating the Impact of a Policy of Quantity Limits on Test-Strip Use and Costs.

To evaluate the impact of new quantity limits for blood glucose test strips (BGTS) in August 2013 on utilization patterns and costs in the elderly population of Ontario, Canada. We conducted a population-based, cross-sectional time series analysis of all individuals 65 years of age and older who received publically funded BGTSs between August 1, 2010, and July 31, 2015, in Ontario, Canada. The number of BGTSs dispensed and the associated costs were measured for 4 diabetes therapy subgroups-insulin, hypoglycemia-inducing oral agents, non-hypoglycemia-inducing oral agents, and no drug therapy-each month during the study period. We used interventional autoregressive integrated moving average (ARIMA) models to assess the impact of Ontario's policy change on test strip use and costs. In the course of the study period, 657,338,177 test strips were dispensed to elderly patients in Ontario, at a total cost of CAN$482.3 million. Introduction of quantity limits was associated with significant reductions in the number of monthly strips dispensed and the associated costs (p<0.0001). In the year following the policy's implementation, test strip use decreased by 22.2% compared with the prior year (from 145,232,024 test strips to 113,007,795 test strips, a net decrease of 32,224,229 strips), resulting in a 22.5% reduction in costs (from $106.5 million to $82.6 million, a net cost reduction of approximately $24 million). The introduction of quantity limits, aligned with guidance from the Canadian Diabetes Association, led to immediate significant reductions in BGTS dispensing and costs. More research is needed to assess the impact of this policy on patient outcomes.

Opportunity Cost and Policy: A Utilization Review of Self-monitoring of Blood Glucose in Manitoba, Canada

PurposeRecently, there has been a re-evaluation of the frequency, benefits, and costs associated with self-monitoring of blood glucose (SMBG). Based on little evidence of the benefit of frequent SMBG in patients with diabetes not using insulin, new guidelines and test strip limit policies have been suggested and implemented in various Canadian jurisdictions to promote a more selective practice of SMBG. The objective of this study was to assess the overall utilization and cost associated with test strips and lancets for SMBG in Manitoba from 2000 to 2013 as well as to explore the policy implications of the implementation of test strip quantity limits and its impact on overall and government costs. MethodsAn analysis of prescription claims for blood glucose test strips (BGTSs) and lancets for all patients with diabetes in Manitoba from 2000 to 2013 was conducted. In each year, patients were stratified into 4 mutually exclusive hierarchical groups according to most intensive diabetes treatment. Test strip and lancet utilization and cost were assessed for each group in each year, and the potential cost savings associated with implementation of a BGTS limit policy was projected using autoregressive integrated moving average models. FindingsIn the year 2000, 8 million test strips were dispensed in Manitoba, increasing by 170% to 21.7 million test strips in 2013. Insulin users accounted for the majority of test strip use. However, based on potential implementation of test strip limit policies, 95% of the reduction of test strip use is predicted to occur in the groups not using insulin. Based on current trends, the 5-year predicted additional cost associated with not implementing a test strip limit policy similar to that implemented in other Canadian provinces was estimated to be a total of $12.35 million. ImplicationsImplementation of the guideline-based policy limits is predicted to produce considerable savings, with 95% of potential savings occurring in patients not using insulin. There is, therefore, a significant opportunity cost associated with not implementing a policy to reduce BGTS utilization by patients with diabetes in Manitoba. Based on the lack of evidence to suggest significant outcome improvements with long-term frequent SMBG by patients not using insulin, more selective use of test strips for SMBG could allow for significant cost savings that could be redirected to other programs and interventions for the growing population of patients with diabetes in Manitoba.

Frequency of self-monitoring blood glucose and attainment of HbA1c target values.

Test strips for self-monitoring of blood glucose (SMBG) represent in Argentina, around 50% of diabetes treatment cost; the frequency of their use is closely associated with hyperglycemia treatment. However, the favorable impact of SMBG on attainment of HbA1c goal in different treatment conditions remains controversial. We therefore attempted to estimate the relationship between use of SMBG test strips and degree of attainment of metabolic control in an institution of our social security subsector (SSS) in which provision is fully covered and submitted to a regular audit system. Observational retrospective study using information of 657 patients with T2DM (period 2009-2010) from the database of the Diabetes and Other Cardiovascular Risk Factors Program (DICARO) of one institution of our SSS. DICARO provides-with an audit system-100% coverage for all drugs and keeps records of clinical, metabolic and treatment data from every patient. The average monthly test strips/patient used for SMBG increased as a function of treatment intensification: Monotherapy with oral antidiabetic drugs (OAD)<combined OAD therapy<insulin treatment. In every condition, the number was larger in people with target HbA1c levels. Test strips represented the larger percentage of total prescription cost. In our population, the type of hyperglycemia treatment was the main driver of test strip use for SMBG; in every condition tested, targeted HbA1c values were associated with greater strip use. Patient education and prescription audit may optimize its use and treatment outcomes.