Title: Effectiveness of BRIGHT guidelines in self-monitoring of blood glucose among people with type 1 and type 2 diabetes.

Background
The burden of Diabetes is continuously increasing rapidly due to lack of healthcare infrastructure, insurance policies and coverage, the high cost of health care and non-existence of locally affordable guidelines. 'Advisory Board for the Care of Diabetes (ABCD) of Pakistan” has taken the initiative and established BRIGHT guidelines for the self-monitoring of blood glucose levels for people with Diabetes. These guidelines recommend four patterns of SMBGs in form of tables (Low- intensity, moderate intensity, medium intensity and high intensity). Each table recommends the different frequency of self-monitoring of blood glucose as per individual’s specific educational, behavioral or clinical requirements in order to identify, prevent and manage acute hyper- and hypoglycemia.

Aims:
- To evaluate the efficacy of bright guidelines in the monitoring of blood glucose levels among people with type1 and type 2 Diabetes at Karachi, Pakistan.

- To access the overall impact of structured monitoring of Blood glucose on metabolic control in people with type1 and type 2 Diabetes

Method
People with Diabetes who were registered Baqai Institute of Diabetology and Endocrinology and had been given direction to use specific SMBG protocols from Bright guidelines at least 3 months back were invited to participate in this study. A pre-designed questionnaire was administered after three months on the follow-up visit to collect the data regarding the self-report of the implementation of suggested SMBG protocols from Bright guidelines and patients written records were collected to assess the degree of implementation in terms of percentage of suggested tests done. Clinical Data and HbA1c values were retrieved from hospital records and also collected on the follow-up visit to compare the metabolic status. Subjects were categorized Good fair and poor followers of Bright guidelines on the basis of their verbal reports and submitted SMBG records. The difference in HBA1c on the day of data collection and 3-5 months before the data collection was calculated. Association between the implementation of bright guidelines and improvement in glycemic control was explored by comparing mean difference in hba1c in good and poor followers. Data was recorded and analyzed in SPSS version 19.0.

Results
Percentage of compliance to Bright Guidelines ranged from 20 to 100 %. Subjects’ self-reports had the significant positive association with diabetes educator’s records based assessment of implementation. Out of those who claimed implementation only 7.1% were categorized as poor followers while among those who did not claim implementation 87% categorized as poor followers. For good followers mean HbA1C had declined by 1.4% whereas it was raised by .6% for poor followers and this difference was statistically significant (P=0.004).

There was no significant difference between type 1 and type 2 diabetics in terms of degree of implementation of Bright Guidelines. Fear (45%) was the most frequently mentioned reason for not following the guidelines followed by lack of time (36%), cost (11%) and forgetting (4%).


Discussion
Bright guidelines have potential to have a positive impact on glycemic control of both type 1 and type 2 people with Diabetes. Strategies to increase subjects’ motivation are required to improve the degree of implementation.

Effectiveness of Bright guidelines in self-monitoring of blood glucose among people with type 1 and type 2 diabetes