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Meta-analysis of diabetes care in general practice

Editor—A meta-analysis of diabetes care in the community concluded that unstructured care is associated with poorer follow up, worse glycaemic control, and greater morbidity than is in-hospital care.1 The article emphasised that the transfer of responsibility for diabetes to general practice without adequate support is associated with adverse patient outcomes. Such support is essential in the monitoring of the quality of community based glucose assays, although this was not specifically referred to in the article. 
 
In 1987, as a consequence of a patient’s death, the Scottish Health Service issued a safety hazard notice relating to the incorrect use of glucose meters.2 Key messages in the notice include ensuring that staff using the meters are fully trained and that quality control procedures are adopted. In response to this our laboratory developed a quality control scheme to monitor the performance of meters and users across our two hospital sites. The scheme entails distributing, fortnightly, sterile horse blood supplemented with glucose, and it has been effective in identifying poor user technique and malfunctioning meters, thereby helping to assure the quality of bedside glucose assays. 
 
Recognising that glucose meters in use in general practice surgeries were not subject to formal quality control measures, which potentially puts patients in the community at risk, we decided to pilot our scheme to a general practice that was routinely using six glucose meters. Shortly after initiating the pilot scheme we identified a malfunctioning meter, which was giving an average systematic positive bias of 15% (table), and we arranged for its replacement. Internal quality control performance, for which the aqueous material supplied by the manufacturer was used, was within acceptable ranges throughout this period. 
 
Two important issues emerge from this work. Firstly, all glucose meters, irrespective of their location, must be subject to formal quality control measures. Secondly, the quality of results cannot be assured by sole reliance on analysis of the manufacturer’s aqueous quality control material. All laboratories involved in the quality control of glucose meters should consider extending such schemes into the community.