Comparative study of blood glucose levels using glucometer and laboratory glucose

hexokinase method among diabetic suspected patients in Ethiopia public health Institute
(EPHI).
Introduction

Diabetes is a disease that occurs when your blood glucose ( blood sugar) is too high due to  lack
of enough insulin or doesn’t use insulin well. Glucose then stays in your blood and doesn’t reach
your cells. Over time, having too much glucose in your blood can cause health problems called
diabetes mellitus [1]. Measurement of glucose in the blood or circulation is the basic mechanism
for controlling and preventing of the disorder diabetes. As we know currently there are many
different methods of blood glucose concentration measurement techniques. Each techniques have
their own principles and the difference in their principle leads to variation of glucose results from
method to method as many studies indicate. Alteration in blood glucose levels in patients is
difficult to detect clinically. Hence a reliable “point of care” device (glucometer) for early
detection and treatment is needed [2]. A point-of-care glucometer (POCG) testing have an
advantage like reduced turnaround time of blood sugar diagnostic testing, reduced pre analytic
and post analytic testing errors, rapid data availability, self-contained and user-friendly
instruments, shorter patient length of stay, and use of small sample volume for a given test. The
majority of POCG devices utilize glucose oxidase method, based on advanced electromechanical
technology that is specific for β-D glucose measurement specifically catalyzes glucose and
reduces interferences. In addition, POCG devices measure blood glucose level within a range of
20-600 mg/dl, and work at an optimum temperature of 10-40°C [4].

Where as the test principle of , hexokinase method which is consideredas a gold standard
method, and considered as a referencemethod for most glucose measurement evolution tests; is
the enzyme hexokinase catalyzes the phosphorylation of glucose to glucose-6-phosphate by
ATP, and rate of phosphorylation is directlyproportional with the concentration of glucose in the
sample.The absorbance of thereaction read at sub and main wavelength ranges of 700 and340
nm. The concentration of glucose is expressed in mg/dl [4, 5].

Changes in medical practice have intensified institutional pressures to achieve clinical efficacy.
Thus hospitals are decreasing the admission of patients with non-acute conditions and increasing
the proportion of patients admitted for major therapeutic interventions [5].

Most of the benefits for the physicians, nurses, patients and administration are based on the
belief that “faster is better” but accuracy of the result must get greater consideration beside its
turnaround time(TAT). The dynamic equilibrium between medical utility, technological
capabilities and cost determines whether laboratory testing is conducted in central laboratories or
at distributed sites. Accuracy is the ability of a test to produce results close to the best available
measure . TAT is a complex process that begins with the physician’s initiation of a laboratory
order, continues with the acquisition of the appropriate specimen, proceeds with the actual
analysis time, and concludes with the transmission of the results to the physician[5].

Glucometer may not be very accurate across the full range of glucose values, especially lower
values, its utility however, as a screening tool cannot be underestimated. Point of care testing is
not widely used in hospitals; there are only few places like intensive care units, emergency
departments where arterial blood gases and glucose testing is performed to know the current
status and to provide immediate care to the patient. In various hospitals and outpatient clinics,
glucometers are widely used as a first line tool to get an idea about the current blood glucose
levels. Recent advances in technology have made available a number of systems that allow near-
patient testing. Results are produced within minutes which compare favorably to the much longer
time experienced with centralized testing [5].

Literature review

Study done in Iraq in 2017 on admitting female patients at Rezgary and howler teaching
hospitals Erbil-Iraq by cross sectional method shows that 94% of the samples measured by point
of care method were within ± 20% of the laboratory values of the value determined with the
hexo Kinase method, 2 subjects discovered to be diabetic by both methods but there was
significant difference between both methodologies. So that they decided that Point of care
glucose testing can be used as a part of diagnostic process of diabetes; even if; there was a
significant difference between both methodology [6].

Study done in Croatia in 2013 on patients referred to the Vuk Vrhovac University Clinic from
April 2012 till April 2013; done by undergoing venous and capillary blood sampling for the
reference laboratory procedure (RLP) and POC-glucose measurement on a total of 237 patients,
137 were diagnosed with diabetes with reference laboratory procedure (RLP), and only 6 of them
were reclassified as having glucose intolerance with POC; was not differ from POC-fasting
glucose result and the results of that study indicate that Stat Strip POC glucose meter could serve
as a reliable tool for the diabetes diagnosis, particularly in primary healthcare facilities with
dispersed blood sampling services [7].

As a study done in Aga Khan University and Hospital Karachi, Pakistan,from April 2005 to
March 2006 on a total of 110 patients ware included and blood glucose levels were analyzed on
glucometer by finger stick and at the same time venous blood glucose analyzed by automated
analyzer (SYNCHRON CX7) by glucose oxidase method. And they reported that there is agood
correlation between bed side glucometer and laboratory automated analyzer for glucose values
between 3.3 mmol/L (60 mg/dl) and 16.7 (300 mg/dl). A significant difference was observed for
glucose values less than 3.3 mmol/L (p=0.002) and glucose values more than 16.67 mmol/l (p=
0.049). Mean Turnaround time for glucometer and automated analyzer were 0.08 hours and 2.49
hours respectively. The cost of glucose testing with glucometer was 48.8% lower than
centralized lab based testing. And depends on their finding they concluded that, Bedside
glucometer testing, though less expensive does not have good accuracy in acutely ill patient with
either very high or very low blood glucose levels[8].

Study done in university of lagos, nigeria, in 2017, to analysis of glucose oxidase method and
three point-of-care measuring devices for glucose determination; which is carried out by
laboratory glucose determination was carried out on plasma samples using glucose oxidase
method while finger prick whole blood was used for point-of-care testing methods. Out of a total
of 150 confirmed diabetic patients; there were significant differences in the mean value of
glucose using glucose oxidase method when compared with the point-of-care testing devices
(p<0.05). On the other hand, analysis of variance showed a significant difference (p<0.05)
between the glucose values from laboratory method and point of-care testing devices used for
this study. The significant difference between glucose oxidase and point-of-care testing noted in
this study may suggest the importance of laboratory evaluation of plasma glucose in proper
evaluation and effective management of patients with diabetes mellitus. While home monitoring
with point-of-care testing should be encouraged, it should not be absolutely relied upon as this
may occasionally lead to erroneous result [9].

A study conducted in 2017, in Ethiopia, Tikur Anbessa Specialized Hospital (TASH), College
of Health Sciences, Addis Ababa University at the Department of Medical Laboratory Sciences
(DMLS), to evaluate blood glucose test results performed with four randomly selected
glucometers on diabetes and control subjects versus standard wet chemistry (hexokinase)
methods; indicates that the minimum and maximum blood sugar values were recorded by
CareSens N (21 mg/dl) and hexokinase method (498.8 mg/dl), respectively and the mean sugar
values of all POCG devices except On Call Extra showed significant differences compared with
the reference hexokinase method; even if; all four PoCG devices had strong positive relationship
(>80%)with the reference method (hexokinase). On the other hand, none of the four PoCG
devices fulfilled the minimum accuracy measurement set by ISO 15197:2003 and ISO
15197:2013 standards. And the study conclude that the overall evaluation of the selected four
PoCG measurements were poorly correlated with standard reference method. The study also
recommended that better there should be a standardized evaluation platform for validation before
introducing POCG devices to the market[4].

Significance of the study

Diabetes is a chronic, metabolic disease characterized by elevated levels of blood glucose (or
blood sugar), which leads over time to serious damage to the heart, blood vessels, eyes, kidneys,
and nerves. The prevalence of diabetes is steadily increasing everywhere, most markedly in the
world’s middle-income countries. As WHO 2018 report around 422 Million adults have
diabetes, 1.6 million deaths are directly attributed to diabetes each year. The most common is
type 2 diabetes, usually in adults, which occurs when the body becomes resistant to insulin or
doesn't make enough insulin. In the past three decades the prevalence of type 2 diabetes has risen
dramatically in countries of all income levels. Type 1 diabetes, once known as juvenile diabetes
or insulin-dependent diabetes, is a chronic condition in which the pancreas produces little or no
insulin by itself. For people living with diabetes, access to affordable treatment, including
insulin, is critical to their survival. There is a globally agreed target to halt the rise in diabetes
and obesity by 2025.The mission of the WHO Diabetes Program is to prevent type 2 diabetes
and to minimize complications and maximize quality of life for all people with diabetes. Our
 core functions are to set norms and standards, promote surveillance, encourage prevention, raise
awareness and strengthen prevention and control[10].

In general the lack of effective policies to create supportive environments for healthy lifestyles
and the lack of access to quality health care means that the prevention and treatment of diabetes,
particularly for people of modest means, are not being pursued. When diabetes is uncontrolled, it
has dire consequences for health and well-being. In addition, diabetes and its complications
impact harshly on the finances of individuals and their families, and the economies of nations
[10].

SO the main aim of this study is to compare the accuracy, turnaround time, accessibility and
cost of point of care device which are mainly and easily accessible with low cost and simple
procedure in developing countries like Ethiopia with the hexo Kinase method on fully
automated machine which is gold standard method for the measurement of glucose
measurement.

Objective

To compare blood glucose levels using glucometer and laboratory glucose hexokinase method
among diabetic suspected patients in Ethiopia public health institute (EPHI)

METHODS FOR MEASURING BLOOD/PLASMA GLUCOSE CONCENTRATION:

1. REDUCTIOMETRIC METHODS: Traditional methods for measurement of blood glucose

depend on the reducing property of glucose. An example is the ferricyanide method. These
methods measure total reducing sugar concentrations.
2. GLUCOSE OXIDASE METHOD: Glucose oxidase catalyses the oxidation of glucose to yield
glucoronic acid and hydrogen peroxide. The concentration of hydrogen peroxide liberated is
measured using a peroxidase step coupled to a colored oxygen acceptor or an electrode. These
reactions form the basis of both reagent strips and bench top glucose electrode methods [12 ].
3. HEXOKINASE METHOD: Hexokinase catalyses the phosphorylation of glucose by ATP.
Glucose-6-phosphate is then reduced by glucose dehydrogenase yielding NADPH/ H + which can
be measured using a suitable spectrophotometric indicator system. This method is precise and
highly specific for glucose but the main drawback is its cost[13]
4. REAGENT STRIPS: These were initially developed for monitoring blood glucose
concentration in diabetics and not intended for detection of hypoglycemia. Care must be taken to
avoid contamination by alcohol skin-cleansers, to cover the whole surface of the test pad and to
time the reaction precisely before wiping the strip. Even when all these precautions are taken,
they tend to under-estimate systematically the mean of a series of measurements in the range of
glucose concentrations relevant to the diagnosis of neonatal hypoglycemia [12].
Several commercially available Reagent strips systems are available and have been evaluated
for neonatal use including: Dextrostix, BM-test-glycemie, Chemstrip bG, Glucostix. Reagent
strips are subject to false positive and false negative results.
In glucose strip method of analysisfalse positive result happened during low hematocrit values
(<35%). and contamination with iso propoyl alcohol. false negative is caused by different factors
like; high hematocrit values (>55%), glucose values > 200mg/dl, hyperglycemic- hyperosmolar
states with or without ketosis, delay in lab analysis.

VARIATIONS AND ERRORS IN MEASUREMENTS:

Arterial blood has a slightly higher glucose concentration than venous. The magnitude of this
difference varies with tissue glucose demands and will be greatest under anaerobic conditions.
Capillary sampling is unreliable if peripheral blood flow is reduced. Samples must be always be
free-flowing as squeezing the heel causes hemolysis which interferes with the assay unless
deproteinisation is performed. The sample should either be analyzed immediately or
deproteinised (for example using perchloric acid) and chilled. Glycolysis otherwise continues [14
COMPARATIVE STUDY OF GLUCOMETER AND LABORATORY GLUCOSE
OXIDASE METHOD FOR THE ESTIMATION OF BLOOD GLUCOSE LEVELS IN
NEONATESHarish J1, Srinivas H. A2, Soumya A3].
Contamination by alcohol used for skin preparation leads to erroneously high values. One of
the problems with neonatal samples is that haematocrit may vary from <40 to>70%. Red cells
contain less water than an equivalent volume of plasma though the glucose concentration in red
cell water is the same as that in the plasma. Plasma glucose concentration is therefore higher than
that of whole blood, on average by about 18% [14].

All methods employing paper reagent strips are subject to an intrinsic haematocrit bias; the
higher the haematocrit value, the lower the result. Possible reasons include discoloration of the
test-pad and resistance to wiping or washing before reading. Also the higher sample viscosity
impedes diffusion of plasma into the test-pad of the strip. Bilirubin also interferes with glucose
oxidase-peroxidase based strip methods. Bilirubin inhibits both steps of the assay leading to
falsely low values. Haemolysis also produces falsely low values. This may be attributable to
presence of hemoglobin or to release of reduced glutathione which competes with the chromogen
for hydrogen peroxide released in the assay [14].
Material and Methods
The study was conducted in April 2019 in the Department of Medical Laboratory Sciences,
Clinical chemistry MSC students, Addis Ababa University. The study protocol was approved by
DMLS. About 50 diabetic voluntary individuals and 50 non diabetic voluntary individuals in
Ethiopia public health institute, Addis Abeba, Ethiopia, during the study period were included
in the study.

Blood glucose levels was measured by using glucometer from finger prick whole blood and at
the same time serum glucose level which is collected by SST tube was measured by using
hexokinase method by fully automated machine (Cobas 600; roche product). A drop of blood
was applied to the electrode/strip (provided by the manufacturer, having lot number and expiry
date) and the reading was noted on digital window of glucometer. The glucose in the blood
combines with the chemicals on the electrodes to produce very small electrical currents. The
sensor measures these currents and displays results in digits. Simultaneously 2 ml of blood
drawn from peripheral vein was collected in to SST tube. The tube was marked for identification
and transported to clinical laboratory, section of clinical chemistry. Plasma was separated by
centrifugation, at a speed of three thousand rounds per minutes for a period of five minutes with
a relative centrifugal force of 1400 (RCF) and was analyzed on automated analyzer (Cobas 6000)
by glucose hexokinase method. Then capillary blood glucometer values were compared with
hexokinase method (reference laboratory values) which is the gold standard one.

Statistical analysis was done using SPSS (version 21.0) software. Simple Correlation
Coefficient and Simple Linear Regression was used to see the association and relation between
the two methods. Data was analyzed by dividing patients into three groups based upon their
blood glucose values (Less than 70mg/dl, 70 -120 mg/dl and more 120 mg/dl obtained by
standardized automated testing in the e laboratory. Hypoglycemia was defined as blood glucose
levels less than 70 mg/dl (3.88 mmol/L) and hyperglycemia was defined as blood glucose level
greater than 126 mg/dl (7 mmol/L).

RESULTS choose 2

A total of 100 patients ( 50 diabetic and 50 non diabetic patients) were enrolled in the study.
More than half (57.3%) of them were males. The average age of patients was 56.85 years
(ranged between 18 to 93 years; Median age = 58.5 years) (Table 1).

A significant difference was observed between the two glucose testing methods for patients
whose blood glucose values were less than 3.88 mmol/L (Mean difference = -0.60; 95% C.I. for
the difference = -0.86, -0.34; p-value=0.002) or above 7 mmol/L. (Mean difference = 3.09; 95%
C.I. for the difference = 0+, 6.19; p-value = 0.049). It was observed that glucometer readings
were higher as compared to centralized glucose readings for centralized glucose levels below
3.33 mmol/L and lower for centralized glucose readings above 16.67 mmol/L.

No significant difference was observed between centralized glucose reading and glucose testing
using glucometer for centralized glucose levels in the range of 3.33 to 16.67 mmol/L. (Mean
difference = -0.02; 95% C.I. for the difference = - 0.32,0.28, ; p value =0.893) Table 2. Linear
regression analysis showed good correlation between the two methods ((r2 = 0.82) as shown in
Figure 1. The model is: Glucose Centralized reading (estimated) = 1.01 + (0.88) (Glucometer
reading). It means that one mmol/L change in Glucometer reading will result in 0.88 mmol/L
changes in Glucose Centralized reading.

Only for observations, where centralized glucose test readings were between 3.3 and 16.6 mmol/L
Average TAT for centralized glucose testing was 2.49 hours (Table I). Mean time for glucose testing with
glucometer was 0.08 hours (5 minutes). The cost of supplies for glucometer was 57% higher than reagent cost for
laboratory based testing. However, the total cost glucometer test was 48.8 % lower than lab based test owing to the
additional cost incurred by the lab such as space, manpower and utilities

DISCUSSION choose 2
Bedside blood glucose testing using reagentimpregnated strips and simple reflectance meters has been
enthusiastically accepted as quick and simple means to monitor blood glucose levels 9. The importance of the self-
monitoring of blood glucose using home blood glucose meters has prompted numerous reports in scientific literature
regarding the statistical and clinical accuracy of these devices 10. The availability of sophisticated dry and wet
chemistry systems that offer a sizeable menu of laboratory tests has made it possible for laboratory tests to be done
out side the central clinical laboratory 4. The electro-chemical based glucometer systems have glucose catalytic
enzymes, electronmediators and electrodes in strip. During glucose oxidation, the electrochemical system measures
the current, the magnitude of which correlates with glucose concentration in the sample11.

Studies have been done to compare results between glucometer of different manufacturers but we are not aware of
any study which compared glucometer and laboratory based automated testing over a large range of glucose levels
that evaluated the accuracy, turn around time and cost effectiveness of these devices. Studies in physician’s office
laboratories in the United States have shown a large variability in results obtained with physician office analyzers 4.
choose 2

There was good correlation between two methods in the range between 3.3mmol/L and 16.67 mmol/L, which
suggests that glucose values falling in non-critical range can be safely used when making decisions only by
glucometers (Fig1). This also highlights that technique used by non-laboratory health care workers was satisfactory.
It has been shown that most glucometers are inaccurate at very high or very low glucose concentrations and certain
variables like haematocrit, altitude, environmental temperature or humidity and hypoxia may affect the result with
bedside testing12. Finger stick glucose testing does not accurately represent venous glucose............choose 2

Reference

1. DeFronzo RA, Ferrannini E, Groop L, Henry RR, Herman WH, Holst JJ, Hu FB, Kahn CR,
Raz I, Shulman GI, Simonson DC. Type 2 diabetes mellitus. Nature reviews Disease
primers. 2015 Jul 23;1:15019.
2. Villena Gonzales W, Mobashsher AT, Abbosh A. The Progress of Glucose Monitoring—A
Review of Invasive to Minimally and Non-Invasive Techniques, Devices and Sensors.
Sensors. 2019 Jan;19(4):800.
3. Raizman JE, Shea J, Daly CH, Karbasy K, Ariadne P, Chen Y, Henderson T, Redmond S,
Silverman S, Moore AM, Adeli K. Clinical impact of improved point-of-care glucose
monitoring in neonatal intensive care using Nova StatStrip: Evidence for improved
accuracy, better sensitivity, and reduced test utilization. Clinical biochemistry. 2016 Aug
1;49(12):879-84.
4. Wolde M, Tarekegn G, Kebede T. Comparative Evaluations of Randomly Selected Four
Point-of-Care Glucometer Devices in Addis Ababa, Ethiopia. Journal of diabetes science
and technology. 2018 May;12(3):673-9.
5. Liesirova K, Abela E, Pilgrim T, Bickel L, Meinel T, Meisterernst J, Rajeev V, Sarikaya H,
Heldner MR, Dobrocky T, Siqueira E. Baseline Troponin T level in stroke and its
association with stress cardiomyopathy. PloS one. 2018 Dec 31;13(12):e0209764.
6. Ahmed YB. Comparison Between Point of Care Glucose Measurement and Laboratory Measurement
in Diagnosis of Diabetes Mellitus. Diyala Journal of Medicine. 2017;12(1):54-7.

7. Vučić Lovrenčić M, Radišić Biljak V, Božičević S, Pape-Medvidović E, Ljubić S.

Validation of point-of-care glucose testing for diagnosis of type 2 diabetes. International
journal of endocrinology. 2013;2013.
8. Baig A, Siddiqui I, Jabbar A, Azam SI, Sabir S, Alam S, Ghani F. Comparision between bed
side testing of blood glucose by glucometer vs centralized testing in a tertiary care hospital.
Journal of Ayub Medical College Abbottabad. 2007;19(3):25-9.
9. Ekun OA, Ogunyemi GA, Azenabor A, Akinloye O. A comparative analysis of glucose
oxidase method and three point-of-care measuring devices for glucose determination. Ife
Journal of Science. 2018;20(1):43-9.
10. Yue P, Lamb KV, Chen X, Wang Y, Xiao S, Feng X, Wu Y. Identification of Family
Factors That Affect Self-Management Behaviors Among Patients With Type 2 Diabetes: A
Qualitative Descriptive Study in Chinese Communities. Journal of Transcultural Nursing.
2018 Aug 22:1043659618793713.
11. Kiechle FL, Main RI. Blood glucose: measurement in the point-of-care setting. Laboratory
Medicine. 2000 May 1;31(5):276-82.
12. A. F. Williams. Hypoglycemia in newborns: a review. BULL WHO 1997; 75: 261-90.
13. Gregory A. Threatte, John Bernard henry: Carbohydrates. In: Clinical Diagnosis and
management by laboratory methods. JB Henry. 19th ed. Noida: Harcourt Asia PTE Ltd,
1999; 194-207.