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1 Original Articles & Case Reports 전북대학교의학전문대학원내분비대사내과이경애, 전소연, 김웅지, 진흥용, 박지현, 백홍선, 박태선 The Education Effect of Glucometer Use on the Glucose Levels and the Glucose Value Comparison among Diverse Glucometers Kyung Ae Lee, Soyeon Jeon, Woong Ji Kim, Heung Yong Jin, Ji Hyun Park, Hong Sun Baek, Tae Sun Park Division of Endocrinology and Metabolism, Department of Internal Medicine, Research Institute of Clinical Medicine, Chonbuk National University Medical School, Jeonju, Korea Abstract Self-monitoring of blood glucose (SMBG) and point-of-care testing are widely used in the management of diabetic outpatients. However, SMBG records are sometimes inaccurate, and may differ from glucose values measured in the hospital. Therefore, the aim of our study was to evaluate the effects of patient education regarding glucometer use on blood glucose levels and to compare the glucose values obtained by six different types of glucometers currently used in Korea. Fifty-six diabetic patients participated in the present study. Each patient visited the hospital in a fasting state. Fasting plasma glucose (FPG) levels in capillary blood samples were measured by doctors and by the patients themselves before and after patient education sessions. Then, glucose levels were measured with each of the six glucometers by doctors and by the patients themselves. The differences between FPG and glucose values measured using glucometers were compared, and their relationships with HbA1c were also assessed. There were no significant differences between glucose levels measured by patients regardless of glucometer education. We obtained similar results for differences between glucose levels measured by patients and doctors. Patient HbA1c levels were not correlated with differences in measurements between glucometers and FPG. Measurements of glucose levels by the six different glucometers did not differ significantly. Our study indicates that education about SMBG, including glucometer handling, is important to increase SMBG accuracy, but that errors in SMBG records are trivial for glucometer users and that the different glucometers used in Korea demonstrate similar accuracy. (J Korean Diabetes 2011;12: ) 113 Keywords: Education, Glucometer, Self monitoring of blood glucose (SMBG) 서론 당뇨병환자에서혈당조절은가장근본적인치료이면서만성합병증예방에가장중요한치료이다. 따라서, 효과적인혈당조절을위해식이조절및운동을포함한생활습관개선등의비약물적인치료와경구혈당강하제또는인슐린과같은약물치료의병합의중요성이널리강조되어왔다. 혈당조절의목표에대해서미국당뇨병학회를포함한전문가단체에서는 가능한정상혈당에가깝게낮추는것을권고하였고이를위해자가혈당측정을통한혈당관리의중요성을강조하였다 [1]. 즉효과적인혈당조절을위하여환자가병원을방문했을때뿐만아니라집에서자가혈당측정을통하여스스로혈당변화에대응하여적절한행동을취할수있도록교육및관리가필요하다는것이다. 이에현재는의료진뿐만아니라당뇨병환자들에게있어서도자가혈당관리의중요성에대한인식은널리자리잡고있으며실제의료영역에서도폭넓게적용되고있다. 교신저자 : 박태선, 전라북도전주시덕진구금암동산 2-20 번지전북대학교의학전문대학원내분비대사내과, pts@jbnu.ac.kr

2 O r i g i n a l A r t i c l e s & C a s e R e p o r t s 114 이러한자가혈당관리를위한혈당측정기가 1970 년대초부터개발되기시작하였으며이후현재까지여러업체에서경쟁적으로개발되면서정확도와정밀도가개선되고사용편의성또한개선된혈당측정기들이다수개발되어사용되고있다 [2]. 그러나혈당측정기를사용하고있는당뇨병환자들중혈당측정방법을정확히숙지하지못한환자들이상당수있으며자가혈당측정값이병원에서측정한혈당값또는당화혈색소와차이를보이는경우가있고이는의료진의약물처방및혈당조절에상당한혼란을초래할수있다. 또한국내에서도여러종류의혈당측정기들이사용중이나혈당측정값의정확도에대한비교결과는보고된바없다. 따라서본연구의목적은자가혈당측정을하고있는당뇨병환자를대상으로혈당측정기사용법에대한교육전후의혈당측정을통해실제임상에서환자들의혈당측정방법이정확하게이뤄지고있는지를평가하고또한 교육이혈당측정의정확도에미치는영향에대해알아보고자하였으며, 현재국내에서사용되고있는 6 가지의혈당측정기를이용한혈당측정값의비교를통해기기들사이의정확도에대해비교분석하고자하였다. 1. 대상 대상및방법 1) 시험기간 : 2010 년 3 월 ~ 2010 년 6 월 2) 시험대상 : 제 1 형및제 2 형당뇨병진단후전북대학교병원외래추적관찰중인환자 3) 선정기준 만 18 세이상 75 세미만의당뇨병환자 Table 1. Baseline characteristics of patients Diabetes type Diabetes duration (yr) Sex Age (yr) FPG (mg/dl) HbA1C (%) Total cholesterol (mg/dl) TG (mg/dl) HDL (mg/dl) LDL (mg/dl) Creatinine (mg/dl) Type 1 diabetes: 5 (8.9) Type 2 diabetes: 21 (91.1) ± 8.35 Male: 28 (50) Female: 28 (50) ± ± ± ± ± ± ± ± 0.2 Values are presented as mean ± SD or number (%). FPG, fasting plasma glucose; TG, triglyceride; HDL, high density lipoprotein; LDL, low density lipoprotein. Table 2. The comparison of glucose values that measured before and after glucometer education Values are presented as mean ± SD. pt, patient; dr, doctor. a The absolute value of the difference between fasting plasma glucose and glucose value measured from glucometer (mg/dl). Comparison Glucose value a P value Patient (before/after) ± 8.25 / ± Doctor (before/after) ± 7.95 / ± Before education (pt/dr) ± 8.25 / ± After education (pt/dr) ± 7.73 / ±

3 자가혈당측정경험이있으면서본연구에자의로참여를결정하고서면동의한자 4) 제외기준 치매및뇌혈관질환등으로일정수준의교육이불가능한환자 기타시험책임자또는시험담당자에의해부적당하다고판단되는환자 2. 대상장비및검체 1) 교육전후혈당측정값의비교는환자가소유하고있는혈당측정기를이용하여시행하였다. 2) 국내에서이용중인혈당측정기를대상으로한비교분석에는다음의 6 종의혈당측정기가사용되었으며회사당한개의기기가사용되었다. Accu-Check Performa R (Roche, Germany) Onetouch lutra R (Lifescan, U.S.A) Glucocard X-meter R (Arkray, Japan) Caresens II R (i-sens, Korea) Cord Free R (SD, Korea) Glucodocter super II R (Allmedicus, Korea) 3. 평가방법 Table 3. The glucose value comparison among six glucometers 평가대상에포함된 56 명의환자들은검사당일공복상태로내원하였다. 연구에사용된모든혈당측정기는혈당측정전에대조용액을이용하여측정기의오류여부를확인하였다. 첫째로, 환자는내원하여교육을받기전평상시와같이혈당측정을하였고이때의료진이환자의혈당측정을한번더시행하였다. 이후혈당측정방법에대한의료진의교육을받은후에다시혈당측정을하였으며이때에도의사가환자의혈당을한번더측정하였다. 두번째는, 준비된 6 종의혈당측정기사용법을환자들에게교육을한후이를이용하여환자가혈당을측정하고각각의환자에대해의사가같은 Glucose value a Glucometer Measured by doctor Measured by patient ± ± ± ± ± ± ± ± ± ± ± ± Values are presented as mean ± SD. a The absolute value of the difference between fasting plasma glucose and glucose value measured from glucometer (mg/dl). 115 Table 4. Common errors in glucometer technique made by patients during self-monitoring of blood glucose Error in glucometer technique Patients (%) Inadequate blood drop obtained Blood incorrectly applied Used expired strips Alcohol not allowed to dry before testing, if used Target area not covered Glucometer appeared dirty Inserted strip incorrectly Glucometer coded incorrectly 48 (90.6) 18 (35.3) 10 (19.2) 88 (17) 85 (11.9) 84 (8) 84 (7.5) 81 (2)

4 O r i g i n a l A r t i c l e s & C a s e R e p o r t s 방법으로혈당을측정하였다. 혈당측정직후정맥혈채혈을통해당화혈색소및공복정맥혈당 ( 이하 FPG) 을측정하였다. 혈당측정기로측정한모든혈당값은 F P G 값을기준으로차이의절대값을계산하였고그값을통계학적인분석에사용하였으며당화혈색소와혈당값 (FPG 와혈당측정기측정값의차이의절대값 ) 사이의상관관계에대해서조사하였다. 또한환자들을대상으로혈당측정기사용및관리에대한지식및사용과정에범할수있는오류확인을위해설문조사를시행하였고이를분석하였다. 4. 교육방법 교육은경험이있는내분비내과의사에의해이뤄졌으며피부소독후채혈침으로찌르는방법, 정확히혈액을모으는방법, 혈액을시험지에적용하는방법등혈당측정기의올바른사용법에관해구두설명으로시행되었다. 5. 통계분석 통계분석에는 SPSS version 17.0 (SPSS Inc., Chicago, IL, USA) software 를사용하였으며교육전과 A B 116 C D Fig. 1. The difference between fasting plasma glucose and glucose value measured from glucometer. (A) Patient-before education. (B) Patient-after education. (C) Doctor-before education. (D) Doctor-after education. Before and after a patient education, glucose levels in capillary blood samples were measured by doctor and patients themselves. After that, the degree of glucose differences between fasting plasma glucose and glucose values measured form glucometers was compared. Fig. 2. The comparison of glucose values that measured before and after glucometer education. There was no remarkable difference between glucose levels measured by patients irrespective of glucometer education. And there was a similar result between glucose levels measured by patients and doctor. FPG, fasting plasma glucose.

5 후의혈당값비교에는 paired sample t-test 를이용하였고 6 가지혈당측정기들의혈당값비교는 one way ANOVA 를이용하였으며, P value < 0.05 를통계학적으로유의한것으로판단하였다. 결과 1. 대상환자의기본임상적특징 연구에참여한환자는총 56 명이었고, 제 1 형당뇨병환자 5 명 (8.9%), 제 2 형당뇨병환자 51 명 (91.1%) 이었으며남자와여자가각각 28 명씩 (50%) 이었다. 환자들의평균나이는 ± 13.8 세, 당뇨병유병기간은평균 ± 8.3 년, 평균당화혈색소 7.65 ± 1.5% 이었으며그외의인구통계학적인특성및기본검사결과는 Table 1 과같다. 56 명환자들의평균자가혈당측정경력은 6.79 ± 4.12 년이었고, 자가혈당측정시간은아침공복이가장많았다 (36 명, 64.3%). 측정횟수는하루 1 회측정이가장많았고 (23.2%), 하루 2~3 회측정도 (20%) 비슷한정도로조사되었다. 2. 환자교육전후의혈당값의비교 혈당측정기사용법에대한교육전후에측정한혈당값을 FPG 와의차이절대값을계산하여비교한결과교육에따른의미있는혈당값의차이는보이지않았다 (Table 2, Fig. 1, Fig. 2). 3. 혈당측정기로측정한혈당값과 FPG 값과의차이절대값과당화혈색소와의상관관계 혈당측정기로측정한혈당값과 FPG 값과의차이절대값과당화혈색소사이의상관관계에있어서도유의한상관관계는보이지않았다 (Fig. 3). 4. 혈당측정기 6 종간의혈당값의비교 6 종의혈당측정기를이용하여각각혈당측정을하고그값을비교한결과환자및의사가각각측정하였을때혈당값의의미있는차이는보이지않았다 (P = 0.251(by patients), P = (by doctor), respectively, Table 3, Fig. 4). 117 Fig. 3. Correlation between HbA1c and the absolute value of the difference between fasting plasma glucose (FPG) and glucose value measured form glucometer. Patient s HbA1C level was not correlated with the magnitude of the glucose difference between glucometer and FPG.

O r i g i n a l A r t i c l e s & C a s e R e p o r t s 118 5. 혈당측정기사용법및혈당측정방법에관한설문결과분석 자가혈당측정에대한설문조사에서측정방법의복잡성에관한문항에대해복잡하지않다는답변이 91.1% (51 명 ) 였고교육을받는장소는병원이 29 명 (51.8%), 혈당측정기판매점 13 명 (23.

6 O r i g i n a l A r t i c l e s & C a s e R e p o r t s 혈당측정기사용법및혈당측정방법에관한설문결과분석 자가혈당측정에대한설문조사에서측정방법의복잡성에관한문항에대해복잡하지않다는답변이 91.1% (51 명 ) 였고교육을받는장소는병원이 29 명 (51.8%), 혈당측정기판매점 13 명 (23.2%), 사용설명서를읽어서사용하는경우가 7 명 (12.5%), 가족들로부터교육을받는경우가 6 명 (10.7%) 이었다. 자가혈당측정후결과값에따른조절방법에관한질문에대해서는식사조절을하는환자가 31 명 (55.4%), 운동 15 명 (26.8%), 약물 ( 인슐린 ) 조절 4 명 (7.1%) 순으로나타났으며자가혈당측정이혈당조절에도움이되는지여부에관한질문에는 50 명 (89.3%) 의환자가도움이된다고대답하였다. 자가혈당측정을할때흔하게범하는측정법상의오류에관하여조사한결과를보면혈액을모으는방법상의오류 ( 쥐어짠다 ) 가 48 명 (90.6%) 으로가장많았으며, 혈액을시험지에적용하는방법의오류가 18 명 (35.3%) 으로두번째로많았다. 그외에유효기간이만료된시험지사용이 10 명 (19.2%), 측정전알코올을제대로건조하지않는환자가 8 명 (17%), 혈액양의부족이 5 명 (11.9%), 측정기청결도불량 4 명 (8%), 시험지의부정확한삽입 4 명 (7.5%) 순으로나타났다 (Table 4). 고찰 경제가발전하고생활양식이서구화되면서당뇨병의 유병률은지속적으로증가하고있다. 세계보건기구의통계자료에의하면전세계적으로당뇨병은 1994 년 1 억 1,040 만명에서 2003 년 1 억 9,400 만명으로증가하였고, 2025 년에는 3 억 3,300 만명으로 20 세이상성인의 6.3% 로증가할것으로예측하고있다 [3]. 우리나라는 2003 년 20 세이상성인의 6.4% ( 대략 219 만명 ) 가당뇨병을가지고있으며, 2025 년에는 8.3% (320 만명 ) 으로증가할것으로예상하는보고들이있다 [4]. 당뇨병유병률의증가는이와관련된만성합병증증가를동반하게된다. 과거에는사구체신염이만성신부전증의가장흔한원인이었지만현재는당뇨병에의한신부전이가장흔하다. 심혈관질환또한급속도로증가하고있으며이러한당뇨병의만성합병증으로인한사망률또한과거에비해매우증가되어있다. 당뇨병환자에서엄격한혈당조절이질병의악화와합병증발생지연에중요하다는사실은널리알려져있으며따라서당뇨병환자에서혈당조절은정상또는정상치에근접한혈당값을목표로낮추도록권고되고있다 [1]. 이러한적극적인혈당조절에있어서자가혈당측정및관리는가장임상적인요구도가높고시행빈도가많은현장검사종목중하나이다 [5]. 미국당뇨병학회를포함한여러단체의당뇨병전문가들은당뇨병관리에있어환자의자가혈당측정이식이및운동, 약물복용에대한유용한피드백을제공하며인슐린치료중인환자에서는저혈당확인을통해안전성을향상시킨다는측면에서자가혈당측정을권고하고있다 [6]. 또한실시간혈당상태에대한 A. Measured by doctor B. Measured by patients mg/dl mg/dl Fig. 4. The glucose value comparison among six glucometers. There were no statistically remarkable differences in glucose levels measured by six glucometers. X axis : six glucometers. Y axis : the absolute value of the difference between fasting plasma glucose and glucose value measured from glucometer.

7 피드백을통해부분적으로당화혈색소를대체할수있다는측면에서자가혈당측정은인슐린이발견된이래로당뇨병치료및관리에있어가장의미있는획기적약진으로여겨지고있다 [7]. 권고되는혈당측정횟수는환자마다차이가있지만인슐린치료를받고있는제 1 형당뇨병환자에서는공복및식전, 자기전적어도하루 4 회혈당측정을권고하고제 2 형당뇨병환자에서는치료제의종류및목표혈당에따라횟수를달리하도록하고있다 [8]. 자가혈당측정은특히인슐린치료중인당뇨병환자에서만성합병증발생위험감소에기여함이확인되었으며, 경구용혈당강하제를복용하는경우에는제한적인결과가있지만최근 2 개의메타분석에서혈당조절개선및합병증관련사고를감소시킴을발표하였다 [9,10]. 그러나이러한많은장점및권고에도불구하고실제임상에서자가혈당측정의시행및해석에는상당한제한이따른다. 혈당측정방법을정확히숙지하지못하거나혈당측정기및측정에사용되는시험지, 대조용액등에대한적절한관리가되지않는경우가있으며이로인해자가혈당측정값과병원에서측정한혈당값또는평균혈당정도를반영해주는당화혈색소와상당한차이를보이는경우가있어환자의측정값을임상에적용하는데어려움이있다. 따라서자가혈당값을가지고혈당조절정도를평가하거나혈당조절방법변경을고려하기전에개개의환자들의자가혈당측정및측정기관리가정확하게이뤄지고있는지평가가필요하다. 혈당측정기등의현장검사기기의평가에있어중요한사항은검체의특성, 검체량및검사수행과정상의문제점이나검사자의영향에대한항목이평가대상에포함되어야한다는것이다 [5]. 이와관련된흔한문제들로는부적절한손씻기, 적절한양의혈액채취의실패, 시험지에혈액을정확하기묻히지못하는경우, 측정기관리시대조용액을사용하지않는경우, 유효기간이지난대조용액의사용, 측정기의부적절한관리, 시험지의부적절한관리및보관등이있다 [6]. 또한최근사용되는혈당측정기가과거에비해정밀도와정확도가개선되긴하였지만모두표준화된방법으로수행능평가가시행된것이아니며국내사용중인여러가지혈당측정기들의정확도에대한비교결과는보고된바없다. 따라서, 본연구에서저자들은자가혈당측정및관리를하고있는당뇨병환자를대상으로하여이러한요소들을포함하여혈당측정법교육전후의혈당측정값의차이의통계적유의성여부와이와함께서로다른 6 가지혈당측정기를이용하여환자가동시에혈당측정을했을경우이들기기의차이에따른혈당값차이의통계적유의성에관해알아보고자하였다. 결과적으로 56 명의 환자를대상으로한분석에서교육에따른혈당값의의미있는차이는관찰되지않았다. 환자들에게시행한설문조사결과를요약해볼때대부분의환자들이혈액모으는방법 (48 명, 90.6%) 이나혈액을시험지에적용하는방법 (18 명, 35.3%) 등에서오류를범하는것으로나타났지만결과로나타난측정된혈당값들은교육여부에따른유의한차이가없었다. 또한의사가측정한혈당값과환자의혈당값사이에도유의한차이는없었다. 이는실제현장에서환자들이혈당측정과정에서오류를범하는것은사실이지만혈당측정값에의미있는변화를초래할만큼크지않음을의미하며적절한교육이정확한혈당관리에있어필수적이지만현장에서비교적정확하게이뤄지고있었다고추정해볼수있고또한환자의혈당관리에중요한정보를제공할수있음을확인하였다. 그러나, 결과를해석하는데있어다음과같은제한점도고려해야한다. 먼저대상환자모집과정에서의표본선택변의 (selection bias) 발생가능성이다. 본연구에참여한환자들은자발적인동의를통해참여한만큼평소자가혈당관리및혈당측정및관리에관한교육정도가높은환자들이선택적으로연구에참여되었을가능성이높다. 또한대상환자수가 56 명으로적기때문에통계결과를일반화해서적용할수는없는것도하나의제한점이라할수있다. 그리고교육전혈당측정시에오류가있었던환자와정확히측정한환자가구분되지않고모두함께통계적인분석을시행함으로써정확한평가가되지못한한계가있다. 다른제한점으로는본연구에서혈당값을비교시 FPG 와혈당측정기측정값의차이값을기준으로그차이의통계적유의성을비교하였는데, 좀더정확한비교를위해서는 FPG 가아닌모세혈관혈액으로측정한기준혈당값을사용해야했다는것이다. 추가적으로환자들의자가혈당측정및관리가혈당조절상태에어떠한영향을미치는지에대해알아보고자하였다. 즉, 당화혈색소가높은환자들에있어서자가혈당측정이정확하게이뤄지지않아정맥혈당값과차이가더큰지여부를확인하고교육이이러한상관관계에영향을미치는지에관해알아보고자하였으며결과적으로유의한상관관계는보이지않았다. 또한국내에서사용중인 6 가지혈당측정기들의측정값을비교시예상했던것처럼각각의혈당측정기는통계적으로유의한차이없이비교적일정한혈당측정값을보임을확인하여국내사용되고있는혈당측정기들사이의정확도및정밀도는우수함을확인하였다. 6 종의혈당측정기중에는국산혈당측정기 3 종이포함되어있었으며다른혈당측정기들과비교하여비슷한혈당값을나타내었다. 그러나, 혈당측정기간의 119

8 O r i g i n a l A r t i c l e s & C a s e R e p o r t s 120 정확도를비교하는데있어회사당한가지의기기만을사용하였기때문에, 한회사기기간의혈당차에대해서는검사를하지못한제한점이있으며, 혈당측정기의정확도를측정한혈당값과 FPG 값과의차이를비교하여결론을얻었지만, 실제로는좀더객관적인방법을이용한평가가필요하다. 즉, 비전문가인환자가사용하는혈당측정기의평가는검사실에서사용하는장비와다른표준화방법으로정확도및정밀도를평가할필요성이있다 [11]. 이에따라국제표준화기구 (International organization for standardization, ISO) 기술위원회 (ISO/TC 212) 에서는 당뇨병관리를위한자가시험용혈당측정기의요건 (ISO15197) 을발표하였고국내식품의약품안정청에서도 ISO 을기초로한 혈당측정기성능평가가이드라인 을 2007 년 11 월발표하여국내에서사용되는혈당측정기의수행능평가에필요한최소지침을규정하였다 [12]. 따라서, 혈당측정기들사이의정확도측면에서정확한비교를위해서는과학적인디자인의연구가추가적으로필요하겠다. 혈당측정기의정확도및정밀도에대해서는현재까지발표된다수의연구결과를살펴보면본연구의결과에서와마찬가지로정확도및정밀도측면에서대부분우수한것으로나타났다. 결론적으로, 본연구결과현재당뇨병환자에서시행되고있는자가혈당측정및관리는비교적정확하게시행이되고있으며여러종류의혈당측정기들의정확도또한유사한정도를나타내었다. 그러나본연구의제한점및앞서언급한현장검사종목으로써의발생가능한오류및문제점등을고려하여혈당측정기사용및관리에대해서는의료진의정확한교육및관리가필수적이라할수있겠다. 요약 자가혈당측정은당뇨병관리의귀중한도구로써인슐린용량에대한지침및식사에따른혈당변화에대한피드백및저혈당확인및대처에유용한정보를제공한다. 혈당측정기사용과관련되어오류가발생할수있는요인은앞서살펴본것과같이여러측면에서보고되고있고정확한사용법숙지가매우중요함은확실한사실이다. 그러나본연구결과환자들의혈당측정은비교적정확하게이뤄지고있으며혈당측정기사용및혈당측정과정의미미한문제들은실제혈당측정값에는큰오류를야기하는것같지는않다. 또한국내에서사용중인여러종류의혈당측정기들의정확도는신뢰할만한수준이며혈당측정기들사이의정확도의차이는비교적유사한것으로판단된다. 그러나 부정확한혈당측정및관리미숙은잘못된정보를제공하여치료에혼란을초래할수있으므로정확한사용방법및관리에대한교육을통한올바른혈당측정법을숙지하는것은매우중요하다고할수있겠다. 또한교육에따른혈당측정의정확도및차이에대한정확한결과분석을위해서는향후추가적인연구가고려되어야하겠다. 감사의글 This research was supported by the Chonbuk National University Hospital Medical Device Clinical Trial Center. 참고문헌 01. S Goldstein DE, Little RR, Lorenz RA, Malone JI, Nathan D, Peterson CM. Tests of glycemia in diabetes. Diabetes Care 1995;18: S Cohen M, Boyle E, Delaney C, Shaw J. A comparison of blood glucose meters in Australia. Diabetes Res Clin Pract 2006;71: S Gan D. International Diabetes Federation: Diabetes Atlas. 2nd ed. Brussels: IDF; p S Park IB, Baik SH. Epidemiologic characteristics of diabetes mellitus in Korea: current status of diabetic patients using Korean health insurance database. Korean Diabetes J 2009;33: S Lee SY, Lee NY, Kim JW. Evaluation of 6 glucose testing systems. Korean J Lab Med 2003;23: S Bergenstal RM. Evaluating the accuracy of modern glucose meters. Insulin 2008;3: S Bergenstal R, Pearson J, Cembrowski GS, Bina D, Davidson J, List S. Identifying variables associated with inaccurate self-monitoring of blood glucose: proposed guidelines to improve accuracy. Diabetes Educ 2000;26: S Benjamin EM. Self-monitoring of blood glucose: the basics. Clinical diabetes 2002;20: S Sarol JN Jr, Nicodemus NA Jr, Tan KM, Grava MB. Selfmonitoring of blood glucose as part of a multicomponent therapy among non-insulin requiring type 2 diabetes patients: a meta-analysis ( ). Curr Med Res Opin 2005;21: S Welschen LM, Bloemendal E, Nijpels G, Dekker JM, Heine RJ, Stalman WA, Bouter LM. Self-monitoring of blood glucose in patients with type 2 diabetes who are not using insulin: a systematic review. Diabetes Care 2005;28: S The International Organization for Standardization. In vitro diagnostic test systems-requirements for blood glucose monitoring systems for self-testing in

9 managing diabetes mellitus. ISO/TC 212/SC. International Standard ISO Geneva: ISO; S An D, Chung HJ, Lee HW, Lee W, Chun S, Min WK. Analytical performance evaluation of glucose monitoring system following ISO Korean J Lab Med 2009;29:

012임수진

012임수진 Received : 2012. 11. 27 Reviewed : 2012. 12. 10 Accepted : 2012. 12. 12 A Clinical Study on Effect of Electro-acupuncture Treatment for Low Back Pain and Radicular Pain in Patients Diagnosed with Lumbar