A, The number of point-of-care glucometer readings for 10 random continuity patients by month in 2015. B, The total number of point-of-care glucometer readings performed for all clinic patients overall during the same time period. The black line represents the policy change to eliminate routine glucometry on March 15, 2015.
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Wofford JL, Martin MJ, Campos CL. Eliminating Routine Glucometer Readings in the Office Setting: Correcting a Foolish Consistency. JAMA Intern Med. 2016;176(11):1721–1722. doi:10.1001/jamainternmed.2016.5769
Although new, expensive diagnostic tests are attractive targets for critics of runaway health care costs, overall health care costs may be driven more by a high volume of more routine, less costly tests.1 Estimating blood glucose with a glucometer in patients with diabetes is a standard procedure in most primary care clinical settings.2 Routinely providing the busy clinician with a glucometer reading seems an efficient way of preparing for informed clinical decision making about diabetic management in the ambulatory setting. However, the routine tasks that are components of rooming the clinic patient are increasing in number.3 In the process of exploring how to make the rooming process more efficient, we examined the value of the glucometer test as a routine maneuver in the clinic.
The Downtown Health Plaza Adult Medicine Clinic of Wake Forest Baptist Health typically logs more than 60 000 primary care clinic visits each year. Approximately one-third of clinic patients have diabetes, and the average glycated hemoglobin (hemoglobin A1C) level has long been approximately 9.1% (reference range, 4.5%-6.4%).
Increasing delays from accumulating tasks assigned to the nurse and/or assistant rooming the patient (vital signs measurement, screening for clinical conditions; alcohol abuse, depression, falls; medication reconciliation, and health maintenance update) led us to scrutinize the value of a routine glucometer reading on every patient with diabetes. After a 1-week trial without routine clinic glucometry, we subsequently made glucometer readings optional with the understanding that the nurse or patient could request a glucometer reading at any time.
The 3-month period before the policy change (January 1, 2015, to March 15, 2015) was compared with the 3-month period after the change date (March 16, 2015, to June 30, 2015). For each month, a random sample of 10 patients with both an established diagnosis of diabetes and a documented continuity clinic visit were chosen for medical chart review. In addition to the random sample of patients with diabetes, a download of all glucometer readings conducted in the clinic was available. The cost of a glucometer reading was estimated to be approximately $7 for glucometer supplies and 5 minutes of nursing time.4 An institutional review board waiver was obtained from the Wake Forest University School of Medicine.
The Figure shows a marked decrease in number of glucometer readings that coincides with the change in clinic policy. A conservative estimate of the decrease from an average of 400 to 100 glucometer readings per month resulted in an estimated cost savings over $2000 per month and 25 hours of nursing time.
A 1-week trial without routine glucometer readings during which no adverse events occurred was sufficient to convince clinicians to change the long-standing practice of routine glucometry. Despite the fear of missing an occasional markedly elevated glucose level, clinicians gradually grew comfortable and never reconsidered reinstitution of routine glucometer readings. While the savings in glucometer supplies and nursing staff time were substantial, these outcomes went largely unnoticed, and nurses remained busy with other responsibilities.
The routine use of glucometers in the office setting is an excellent example of how the growing clutter of seemingly good ideas for improving efficiency deserves continued scrutiny. The foolish consistency of routine office glucometry was expensive, not just in terms of time and money spent but also in cognitive burden for clinicians. Stopping this routine procedure required patient education because some patients were disappointed that the glucometer test was no longer being performed.
Challenging the value of routine glucometer readings in the clinic is consistent with recent recommendations to discourage routine home glucometer readings for patients who are not taking insulin,5 a policy reversal that also requires much patient education. As important as the lesson that routine glucometer readings in the clinic is a wasteful practice, the more important lesson is that examining office routines for foolish consistencies should be a regular component of making primary care more efficient.6
Corresponding Author: James L. Wofford, MD, MS, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27157 (email@example.com).
Published Online: September 26, 2016. doi:10.1001/jamainternmed.2016.5769
Author Contributions: Dr Wofford had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Wofford, Martin.
Acquisition, analysis, or interpretation of data: Wofford, Campos.
Drafting of the manuscript: Wofford.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Wofford.
Study supervision: Wofford.
Conflict of Interest Disclosures: Dr Wofford, the clinic director, led the staff meeting discussions where the policy decisions were made, initiated the study design and data analysis, and drafted the first version of the manuscript. Drs Martin and Campos were the key participants in the staff meeting discussions after the policy changes were made, and both reviewed the final manuscript. No other conflicts are reported.
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