{"markup":"\u003C?xml version=\u00221.0\u0022 encoding=\u0022UTF-8\u0022 ?\u003E\n    \u003Chtml version=\u0022HTML+RDFa+MathML 1.1\u0022\n    xmlns:content=\u0022http:\/\/purl.org\/rss\/1.0\/modules\/content\/\u0022\n    xmlns:dc=\u0022http:\/\/purl.org\/dc\/terms\/\u0022\n    xmlns:foaf=\u0022http:\/\/xmlns.com\/foaf\/0.1\/\u0022\n    xmlns:og=\u0022http:\/\/ogp.me\/ns#\u0022\n    xmlns:rdfs=\u0022http:\/\/www.w3.org\/2000\/01\/rdf-schema#\u0022\n    xmlns:sioc=\u0022http:\/\/rdfs.org\/sioc\/ns#\u0022\n    xmlns:sioct=\u0022http:\/\/rdfs.org\/sioc\/types#\u0022\n    xmlns:skos=\u0022http:\/\/www.w3.org\/2004\/02\/skos\/core#\u0022\n    xmlns:xsd=\u0022http:\/\/www.w3.org\/2001\/XMLSchema#\u0022\n    xmlns:mml=\u0022http:\/\/www.w3.org\/1998\/Math\/MathML\u0022\u003E\n  \u003Chead\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/js\/js_itu2PgFdrjV-docKmLK8Jn5oXe_05RgvQh73eOhI_mE.js\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_at_symbol.js?nzmrld\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_article_reference_popup.js?nzmrld\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/js\/js_I8yX6RYPZb7AtMcDUA3QKDZqVkvEn35ED11_1i7vVpc.js\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022\u003E\n\u003C!--\/\/--\u003E\u003C![CDATA[\/\/\u003E\u003C!--\n(function(i,s,o,g,r,a,m){i[\u0022GoogleAnalyticsObject\u0022]=r;i[r]=i[r]||function(){(i[r].q=i[r].q||[]).push(arguments)},i[r].l=1*new Date();a=s.createElement(o),m=s.getElementsByTagName(o)[0];a.async=1;a.src=g;m.parentNode.insertBefore(a,m)})(window,document,\u0022script\u0022,\u0022\/\/www.google-analytics.com\/analytics.js\u0022,\u0022ga\u0022);ga(\u0022create\u0022, \u0022UA-15605596-27\u0022, {\u0022cookieDomain\u0022:\u0022auto\u0022});ga(\u0022set\u0022, \u0022page\u0022, location.pathname + location.search + location.hash);ga(\u0022send\u0022, \u0022pageview\u0022);ga(\u0027create\u0027, \u0027UA-189672-26\u0027, \u0027auto\u0027, {\u0027name\u0027: \u0027hwTracker\u0027});\r\nga(\u0027hwTracker.send\u0027, \u0027pageview\u0027);\n\/\/--\u003E\u003C!]]\u003E\n\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022\u003E\n\u003C!--\/\/--\u003E\u003C![CDATA[\/\/\u003E\u003C!--\njQuery.extend(Drupal.settings, {\u0022basePath\u0022:\u0022\\\/\u0022,\u0022pathPrefix\u0022:\u0022\u0022,\u0022highwire\u0022:{\u0022markup\u0022:[{\u0022requested\u0022:\u0022full-text\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;10\\\/6\\\/30\u0022},{\u0022requested\u0022:\u0022long\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;10\\\/6\\\/30\u0022}],\u0022ac\u0022:{\u0022spmdc;10\\\/6\\\/30\u0022:{\u0022access\u0022:{\u0022reprint\u0022:true,\u0022full\u0022:true},\u0022pisa_id\u0022:\u0022spmdc;10\\\/6\\\/30\u0022,\u0022atom_uri\u0022:\u0022\u0022,\u0022jcode\u0022:\u0022spmdc\u0022}}},\u0022googleanalytics\u0022:{\u0022trackOutbound\u0022:1,\u0022trackMailto\u0022:1,\u0022trackDownload\u0022:1,\u0022trackDownloadExtensions\u0022:\u00227z|aac|arc|arj|asf|asx|avi|bin|csv|doc(x|m)?|dot(x|m)?|exe|flv|gif|gz|gzip|hqx|jar|jpe?g|js|mp(2|3|4|e?g)|mov(ie)?|msi|msp|pdf|phps|png|ppt(x|m)?|pot(x|m)?|pps(x|m)?|ppam|sld(x|m)?|thmx|qtm?|ra(m|r)?|sea|sit|tar|tgz|torrent|txt|wav|wma|wmv|wpd|xls(x|m|b)?|xlt(x|m)|xlam|xml|z|zip\u0022,\u0022trackUrlFragments\u0022:1},\u0022ajaxPageState\u0022:{\u0022js\u0022:{\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/jquery.cluetip.js\u0022:1,\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/lib\\\/jquery.hoverIntent.js\u0022:1,\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/lib\\\/jquery.bgiframe.min.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/highwire\\\/highwire\\\/plugins\\\/highwire_markup_process\\\/js\\\/highwire_at_symbol.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/highwire\\\/highwire\\\/plugins\\\/highwire_markup_process\\\/js\\\/highwire_article_reference_popup.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/contrib\\\/google_analytics\\\/googleanalytics.js\u0022:1,\u00220\u0022:1}}});\n\/\/--\u003E\u003C!]]\u003E\n\u003C\/script\u003E\n\u003Clink type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EIt is increasingly an open question as to when and where point-of-care (POC) glucose meters should be used and what clinical decisions should be made based on POC readings. This article discusses related issues in a dedicated lecture on the subject, as well as implications for for tight glucose control, currently the standard of care in intensive care units.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EHyperglycemia\/Hypoglycemia\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EInsulin\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EIt is increasingly an open question as to when and where point-of-care (POC) glucose meters should be used and what clinical decisions should be made based on POC readings. In one recent study, five of the most commonly used POC devices were compared and found to have an average percentage difference between monitor pairs that was statistically significant in more than half of the paired comparisons (p\u0026lt;0.05), with significant differences ranging from 5.7% to 32.0% [Kimberly MM et al. \u003Cem\u003EClin Chim Acta\u003C\/em\u003E 2006]. Such broad variability is of greatest concern in the hospital setting, where patients, particularly those who are critically ill, will exhibit those confounders, such as anemia, that further skew the accuracy of a given POC device measure. As reviewed by Dungan et al., the observed error rates are high enough to lead to missed or overreaching medical interventions that may result in patient suffering and possibly death [Dungan K et al. \u003Cem\u003EDiabetes Care\u003C\/em\u003E 2007].\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EMitchell Scott, PhD, Washington University School of Medicine, St. Louis, MO, and Richard Hellman, MD, FACP, FACE, University of Missouri-Kansas City School of Medicine, Kansas City, MO, both addressed this issue in a dedicated lecture on the subject. Dr. Scott explained the implications for for tight glucose control (TGC), currently the standard of care in intensive care units.\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EDr. Scott noted that, as of 2008, there were at least 30 POC meters on the market, representing a $6 billion-a-year health care investment. Recent innovations have brought so-called \u201cno wipe\u201d strips, sample volume detection, smaller sample sizes, faster analysis, and data storage and capture. However, in contrast to these advances, and despite doctor\/patient enthusiasm regarding the availability of simple-to-use, portable meters, significant errors occur due to user error or as a result of the intrinsic nature of the device.\u003C\/p\u003E\u003Cp id=\u0022p-5\u0022\u003EFor many devices, common interferences include the effect of aberrant hematocrit levels. Anemic patients may register higher blood glucose values than actual, or polycythemia may result in measures that are lower than actual values. Meter readings may also be skewed by reducing agents, such as ascorbate or acetaminophen. Problems are also common with test strips that rely on some glucose dehydrogenase detection methods (GDH-PQQ) [Dungan KM et al. \u003Cem\u003EDiabetes Care\u003C\/em\u003E. 2007]. This last issue was serious enough to prompt the FDA to advise the avoidance of GDH-PQQ glucose test strip use in health care facilities in August of 2009.\u003C\/p\u003E\u003Cp id=\u0022p-6\u0022\u003EInterferences that are problematic in homecare may be life-threatening in the critical care setting. Anemic hematocrit levels \u0026lt;30 are not unusual in the ICU, nor is the administration of intravenous immunoglobulin (IVIG), which contains a maltose component, or icodextrin, which is present in peritoneal dialysis solution. Both compounds would be read as glucose by GDH-PQQ strip POC meters.\u003C\/p\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EPOC in the ICU\u003C\/h2\u003E\n         \u003Cp id=\u0022p-7\u0022\u003EIn a landmark paper in 2001, van den Berghe and colleagues established that tight glycemic control (TGC; \u0026lt;130 mg\/dL) in critically ill patients saves lives [van den Berghe G et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2001]. This conclusion led to the adoption of TGC in medical institutions all over the world and a subsequent increase in critical care POC meter testing. At Dr. Scott\u0027s institution, the Barnes-Jewish Hospital, the use of test strips grew from a quarter of a million strips in 2000 to over half a million strips by 2009. A central lab can not process samples fast enough for the real-time insulin adjustments of TGC. Therefore, POC must be used.\u003C\/p\u003E\n         \u003Cp id=\u0022p-8\u0022\u003EThe health benefits of the TGC protocol in practice were evaluated in many small studies, but not until 2008 did a meta-analysis of 27 studies of TGC determine that not only was there no benefit in morbidity and mortality for critically ill patients but a 3\u20135-fold increased risk of hypoglycemia had been introduced to study subjects [Wiener RS et al. \u003Cem\u003EJAMA\u003C\/em\u003E 2008]. One year later, results from the randomized NICE-SUGAR trial (n=6104) found a decreased rate of survival and an increased incidence of hypoglycemia in patients who were undergoing TGC (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E) [NICE-SUGAR Study Investigators. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2009].\u003C\/p\u003E\n         \u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/6\/30\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022NICE-SUGAR. One-Year Survival Rates.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-182867285\u0022 data-figure-caption=\u0022NICE-SUGAR. One-Year Survival Rates.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/6\/30\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/6\/30\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/6\/30\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11379\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-9\u0022 class=\u0022first-child\u0022\u003ENICE-SUGAR. One-Year Survival Rates.\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003ECopyright \u00a9 2009 Massachusetts Medical Society. All rights reserved.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-10\u0022\u003EWhy were so many patients not seeing the benefits of van den Berghe\u0027s protocol? The answer, Dr. Scott proposed, may lie in part in the methods of glucose testing. Van den Berghe and colleagues used arterial gas analyzers. Of the 27 studies in the meta-analysis, only 10 actually reported the method of testing, and of those, 8 used POC meters. In the NICE-SUGAR study, the method of glucose testing varied by participating institution and POC meters were allowed. These combined results led Dr. Scott to suggest in his published commentary that currently available POC glucose meters may not be adequate for TCG protocols until measuring standards can be improved. \u201cIf it\u0027s a given that meters are not used for diagnosis, should they really be used for dosing intravenous insulin [in critical care]?\u201d [Scott MG et al. \u003Cem\u003EClin Chem\u003C\/em\u003E 2009].\u003C\/p\u003E\n         \u003Cp id=\u0022p-11\u0022\u003EDr. Scott reviewed the allowable error rates for meters and those being commonly observed in practice. The Clinical Laboratory Improvement Act allows for an error rate of 10% or 6 mg\/d, whichever is greater. The ADA suggests \u0026lt;5% while the FDA allows for a 20% error rate at values of \u0026gt;100 mg\/dL or 12 mg\/dL at \u0026lt;100 mg\/dL [Chen E et al. \u003Cem\u003EDiab Tech Ther\u003C\/em\u003E 2003]. The ADA criteria seem most ideal; however, Dr. Scott acknowledged that no currently available meter can achieve such accuracy.\u003C\/p\u003E\n         \u003Cp id=\u0022p-12\u0022\u003EInvestigations that have compared metered values to the central laboratory or to the reading of other meters indicate a broad range of accuracy. A study by the Center for Disease Control (CDC), evaluating 5 commonly used meters, in which a single technician tested 93 subjects at 12 samples each, showed an error rate of 11% relative to laboratory values and a difference as high as a 32% in values recorded between meters [Kimberly MM et al. \u003Cem\u003EClin Chim Acta\u003C\/em\u003E 2006]. A study from Johns Hopkins showed error rates as high as 8.7% [Chen E et al\u003Cem\u003E. Diab Tech Ther\u003C\/em\u003E 2003].\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EClinical Dilemma\u003C\/h2\u003E\n         \u003Cp id=\u0022p-13\u0022\u003EDr. Hellman pointed out that rapid testing time and convenience of POC meters have greatly enhanced the clinician\u0027s ability to adjust insulin levels for patients whose need is urgent. However, though results within allowable rates of error are considered a reasonable tradeoff by some, Dr. Hellman sees considerable danger in statistical outliers (those glucose results that deviate by relatively large values from the true reference glucose value).\u003C\/p\u003E\n         \u003Cp id=\u0022p-14\u0022\u003EConsider a recent case in which a 71-year-old man, with a diabetes duration of 24 years, currently on insulin infusion, presented with fever, chills, a blood pressure of 74\/40 mm Hg, and glucose measure of 51 mg\/dL by POC meter. The patient was admitted to the ICU, insulin infusion was discontinued, and IV glucose was initiated. Central lab measures subsequently revealed a glucose level of 144 mg\/dL. \u201cThe patient had been improperly treated,\u201d said Dr. Hellman. POC meters are known to give false readings in patients who are hypotensive, a statistical outlier, resulting in inadequate treatment, such as that found in this case (\u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E). It is also common to have falsely low POC glucose meter readings in patients with diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic nonketotic (HHNK) states.\u003C\/p\u003E\n         \u003Cdiv id=\u0022F2\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/6\/30\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Why Outliers Are Dangerous.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-182867285\u0022 data-figure-caption=\u0022Why Outliers Are Dangerous.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 2.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/6\/30\/F2.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/6\/30\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 2.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/6\/30\/F2.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11384\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 2.\u003C\/span\u003E \n               \u003Cp id=\u0022p-15\u0022 class=\u0022first-child\u0022\u003EWhy Outliers Are Dangerous.\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EReproduced with permission from R. Hellman, MD.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-16\u0022\u003EMany POC glucose meters have greater accuracy and precision at only one portion of the glucose measurement range, and if their greatest inaccuracy or imprecision is in the hypoglycemic range, the use of the meter will result in a disproportionate risk for hypoglycemia. A study on 27 glucose meters showed that 41% of the meters did not fulfill even the minimal accuracy requirements under DIN EN ISO 15197 standards [Freckmann et al. \u003Cem\u003EDiabetes Technol Ther\u003C\/em\u003E 2010].\u003C\/p\u003E\n         \u003Cp id=\u0022p-17\u0022\u003EIn addition, published data on accuracy and precision of a meter, typically performed in clinical trials by highly trained technicians with new strips, properly stored, with well-cared-for meters, properly calibrated, may not be indicative of results that are obtained in usual patient care. Studies have shown that results are often poorer in less controlled settings [Kristensen et al. \u003Cem\u003EClin Chem\u003C\/em\u003E 2004; Skeie et al. \u003Cem\u003EClin Chem\u003C\/em\u003E 2002]. Furthermore, the quality of strip manufacturing may be very variable. A 2008 study showed lot-to-lot variations by several manufacturers, with 5 of 9 instruments showed excessive error in glucose levels due to variation in the hematocrit [Kristensen et al. \u003Cem\u003EDiabetes Technol Ther\u003C\/em\u003E 2008].\u003C\/p\u003E\n         \u003Cp id=\u0022p-18\u0022\u003ECiting this and other examples of the nuanced capabilities of POC meters, Dr. Hellman emphasized that until meter standards improve, the responsibility is on the provider to familiarize itself with the characteristics of each type of meter that its patients and staff may be using. That knowledge must be complemented by patient-specific information (awareness of dietary items\/supplements containing interfering compounds, ability of patient to comprehend the meter\u0027s instructions, etc.), comprehensive staff training, regularly scheduled quality control, reagent storage (strips are temperature-sensitive), and other pertinent factors.\u003C\/p\u003E\n         \u003Cp id=\u0022p-19\u0022\u003EGiven all the potential confounders to POC meter accuracy, it might be argued that they should not be used in hospitals. However, despite the risk of significant error, greater harm has resulted from infrequent or ignored glucose testing, which has led to what Medicare has classified as \u201cnever events.\u201d They are medical crises that never should have happened. In 2007, Medicare noted nearly 15,000 such episodes, 76% of which were patients who developed diabetic ketoacidosis after being hospitalized.\u003C\/p\u003E\n         \u003Cp\u003ETo achieve a balance between convenience and clinical utility, Dr. Hellman recommends:\n\u003C\/p\u003E\u003Cul class=\u0022list-unord \u0022 id=\u0022list-1\u0022\u003E\u003Cli id=\u0022list-item-1\u0022\u003E\n                  \u003Cp id=\u0022p-21\u0022\u003EThe widespread use of POC blood gas multichannel analyzers in critical care\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-2\u0022\u003E\n                  \u003Cp id=\u0022p-22\u0022\u003EFDA requirements for the testing of all POC glucose meters and strips postapproval for accuracy and precision by an independent center; These results should be available to the public\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-3\u0022\u003E\n                  \u003Cp id=\u0022p-23\u0022\u003EAll meters should be required to achieve a standard, with a set allowable error (\u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E):\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-4\u0022\u003E\n                  \u003Cp id=\u0022p-24\u0022\u003EIntegrated quality assessment programs for POC glucose meters within hospitals and clinics\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-5\u0022\u003E\n                  \u003Cp id=\u0022p-25\u0022\u003EFunding (public or private) for patient education programs, refresher courses, and proficiency testing regarding meter use and maintenance\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-6\u0022\u003E\n                  \u003Cp id=\u0022p-26\u0022\u003EIndustry standard interfaces for securely downloading information that is available to the patient and provider without charge\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-7\u0022\u003E\n                  \u003Cp id=\u0022p-27\u0022\u003ERequirements that POC meters that are offered by payers or pharmacy benefit managers be equivalent in accuracy, precision, and ease of learning\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-8\u0022\u003E\n                  \u003Cp id=\u0022p-28\u0022\u003EStudies to determine if meter accuracy standards can be achieved with patients in ordinary, everyday settings\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-9\u0022\u003E\n                  \u003Cp id=\u0022p-29\u0022\u003EInformation on the useful life expectancy of the meter to be made available at time of purchase and evaluated by independent nongovernmental agency\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-10\u0022\u003E\n                  \u003Cp id=\u0022p-30\u0022\u003EPatient-oriented information and recommendations for optimal use of each meter system, with online availability\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-11\u0022\u003E\n                  \u003Cp id=\u0022p-31\u0022\u003EHealth care providers should be knowledgeable about the meters their patients are using\u003C\/p\u003E\n               \u003C\/li\u003E\u003Cli id=\u0022list-item-12\u0022\u003E\n                  \u003Cp id=\u0022p-32\u0022\u003EHealth care providers should not use POC meters uncritically, especially when the clinical setting makes these values suspect \u2014 \u201ctrust but verify\u201d\u003C\/p\u003E\n               \u003C\/li\u003E\u003C\/ul\u003E\u003Cp\u003E\n         \u003C\/p\u003E\n         \u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/11385\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/11385\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11385\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1:\u003C\/span\u003E \n               \u003Cp id=\u0022p-33\u0022 class=\u0022first-child\u0022\u003EProposed Standards for Total Allowable Error.\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2010 MD Conference Express\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/10\/6\/30.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzmrld\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzmrld\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzmrld\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}