Patent Publication Number: US-8532933-B2

Title: Insulin optimization systems and testing methods with adjusted exit criterion accounting for system noise associated with biomarkers

Description:
TECHNICAL FIELD 
     Embodiments of the present disclosure relate generally to diabetes management, and particularly to methods and systems for diabetic patients to optimize their administered insulin dosage. 
     BACKGROUND 
     Diabetes mellitus is a collection of metabolic diseases characterized by hyperglycemia resulting from inadequate insulin secretion, insulin action, or both. Diabetes manifests itself differently in each person because of each person&#39;s unique physiology that interacts with variable health and lifestyle factors such as diet, weight, stress, illness, exercise, and medication intake. Biomarkers are patient biologically derived indicators of biological or pathogenic processes, pharmacologic responses, events or conditions (e.g., aging, disease or illness risk, presence or progression, etc.). For example, a biomarker can be an objective measurement of a variable related to a disease, which may serve as an indicator or predictor of that disease. In the case of diabetes mellitus, such biomarkers include measured values for glucose, lipids, triglycerides, and the like. A biomarker can also be a set of parameters from which to infer the presence or risk of a disease, rather than a measured value of the disease itself. When properly collected and evaluated, biomarkers can provide useful information related to a medical question about the patient, used as part of a medical assessment, as a medical control, and/or for medical optimization. 
     For diabetes, clinicians generally treat patients according to therapeutic guidelines such as Joslin Diabetes Center &amp; Joslin Clinic,  Clinical Guideline for Pharmacological Management of Type  2  Diabetes  (2007) and Joslin Diabetes Center &amp; Joslin Clinic,  Clinical Guideline for Adults with Diabetes  (2008). The guidelines may specify a desired biomarker value, e.g., a fasting blood glucose value of less than 100 mg/dl. 
     While guidelines and algorithms have been developed for insulin titration, the exit criterion for titration algorithms is often defined with the same threshold value applied to all patients. However, some biomarker levels (e.g. blood glucose measurements) have high variance, or noise associated with their measurements. Noise or variance may vary from patient to patient. The sources of variance, or noise, can be placed in two categories: system noise and protocol noise. In essence, system noise occurs when the amount of insulin delivered to the diabetic patient differs from the amount actually effective. System noise may be caused by insulin sensitivity i.e., variable physiological effects which vary the effectiveness of insulin from day to day. The protocol noise may result from patient error due to improper physical manipulation of the insulin delivery vehicle e.g., syringe or failure to measure blood glucose at the proper time. All sources of noise can lead to greater risk of adverse events (e.g., hyperglycemic and hypoglycemic events), and system noise in particular causes increased risk due to the difficulty in controlling the internal physiological effects. Consequently, patients with high system noise associated with their biomarker readings should not have the same exit criterion as patients with low levels of system noise 
     It is desirable to include an algorithm which accommodates for system noise in the exit criterion, thereby leading to fewer adverse events. 
     SUMMARY 
     It is against the above background that the present testing method embodiments suitable for diabetic patients to optimize their administered insulin dosage are provided. The present disclosure provides a structured approach to alter the exit criterion for insulin titration by quantifying the risk of adverse events (e.g., hyperglycemic and hypoglycemic events), and optimize the insulin titration by minimizing the risk. While in the current disclosure the procedure for altering the exit criterion is presented for fasting blood glucose values in insulin titration, the underlying methodology is broad enough to be applied to a variety of different algorithms and biomarkers. 
     Embodiments of the disclosure can be implemented, for example, as follows: a paper tool; diabetes software integrated into a collection device such as a blood glucose meter; diabetes software integrated into a personal digital assistant, handheld computer, or mobile phone; diabetes software integrated into a device reader coupled to a computer; diabetes software operating on a computer such as a personal computer; and diabetes software accessed remotely through the internet. 
     According to one embodiment, a testing method for optimizing an insulin dosage to a patient is provided. A testing method for optimizing an insulin dosage to a diabetic patient comprising collecting at least one sampling set of biomarker data, wherein each sampling set comprises one or more sampling instances recorded over a collection period and each sampling instances comprises one or more biomarker readings, computing a probability distribution function, a hazard function, a risk function, and a risk value for the sampling set of biomarker data wherein, the probability distribution function is calculated to approximate the probability distribution of the biomarker data, the hazard function is a function which yields higher hazard values for biomarker readings in the sampling set indicative of higher risk of complications, the risk function is the product of the probability distribution function and the hazard function, and the risk value is calculated by the integral of the risk function. The testing method further comprises minimizing the risk value by adjusting the diabetic patient&#39;s therapy, and exiting the testing method when the risk value for at least one sampling set is minimized to an optimal risk level. 
     According to another embodiment, a method for guiding a diabetic patient through a testing plan directed to optimizing an administration dosage of insulin is provided, wherein the method utilizes a data processing system. The method comprises instructing the diabetic patient via a display unit to collect one or more sampling sets of biomarker data. The method also comprises computing a probability distribution function, a hazard function, a risk function, and a risk value for the sampling set of biomarker data, and also comprises instructing the patient to adjust the patient&#39;s therapy, or exit the testing method if the risk value for at least one sampling set is minimized to an optimal risk level. 
     According to another embodiment, a collection device configured to guide a diabetic patient through a testing plan directed to optimizing the administration dosage of insulin is provided. The collection device comprises a meter configured to measure one or more selected biomarkers, a processor disposed inside the meter and coupled to memory, wherein the memory comprises collection procedures, and software having instructions that when executed by the processor causes the processor to instruct the diabetic patient to collect one or more sampling sets of biomarker data in accordance with the collection procedures. The software and associated collection procedures also causes the processor to instruct the diabetic patient, compute a probability distribution function, a hazard function, a risk function, and a risk value for the sampling set of biomarker data. The processor further instructs the patient to adjust the patient&#39;s therapy, or exit the testing method if the risk value for at least one sampling set is minimized to an optimal risk level. 
     These and other advantages and features of the invention disclosed herein, will be made more apparent from the description, drawings and claims that follow. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
       The following detailed description of the embodiments of the present invention can be best understood when read in conjunction with the following drawings, where like structure is indicated with like reference numerals. 
         FIG. 1  is a diagram showing a chronic care management system for a diabetic patient and a clinician along with others having an interest in the chronic care management of the patient according to an embodiment of the present invention. 
         FIGS. 2 and 2A  are diagrams showing embodiments of a system suitable for implementing a structured testing method according to an embodiment of the present invention. 
         FIG. 3  shows a block diagram of a collection device embodiment according to the present invention. 
         FIG. 4  shows a depiction in tabular format of a data record embodiment created from using a structured testing method on the collection device of  FIG. 3  according to the present invention. 
         FIG. 5  shows a flow chart depicting a testing method for optimizing the titration of insulin using risk minimization according to the present invention. 
         FIG. 6  is a histogram depicting a normal probability distribution of fasting blood glucose biomarker readings according to the present invention. 
         FIG. 7  is a graphical illustration of the hazard function according to the present invention. 
         FIGS. 8A-8D  are graphical views of exemplary embodiments depicting the relationship between the risk function and the hazard and probability functions according to the present invention. 
         FIG. 9  shows a risk surface according to the present invention. 
         FIG. 10  illustrates a therapy gradient according to the present invention. 
         FIGS. 11A and 11B  are graphical illustrations showing the adjustment of the target level and the adjustment of the insulin dosage associated with the testing methods for optimizing the titration of insulin using risk minimization according to the present invention. 
         FIGS. 12A and 12B  show the effect on the noise level for personalized and fixed targets when utilizing different insulin adjustment regimens according to the present invention. 
     
    
    
     DETAILED DESCRIPTION 
     The present invention will be described below relative to various illustrative embodiments. Those skilled in the art will appreciate that the present invention may be implemented in a number of different applications and embodiments and is not specifically limited in its application to the particular embodiments depicted herein. In particular, the present invention will be discussed below in connection with diabetes management via sampling blood, although those of ordinary skill will recognize that the present invention could be modified to be used with other types of fluids or analytes besides glucose, and/or useful in managing other chronic diseases besides diabetes. 
     As used herein with the various illustrated embodiments described below, the following terms include, but are not limited to, the following meanings. 
     The term “biomarker” can mean a physiological variable measured to provide data relevant to a patient such as for example, a blood glucose value, an interstitial glucose value, an HbA1c value, a heart rate measurement, a blood pressure measurement, lipids, triglycerides, cholesterol, and the like. 
     The term “contextualizing” can mean documenting and interrelating conditions that exist or will occur surrounding a collection of a specific biomarker measurement. Preferably, data about documenting and interrelating conditions that exist or will occur surrounding a collection of a specific biomarker are stored together with the collected biomarker data and are linked to it. In particular, a further assessment of the collected biomarker data takes into account the data about documenting and interrelating conditions so that not only the data as such are evaluated but also the link between data to which it is contextualized. The data about documenting and interrelating conditions can include for example information about the time, food and/or exercises which occurs surrounding a collection of a specific biomarker measurement and/or simultaneously thereto. For example, the context of a structured collection procedure according in an embodiment to the present invention can be documented by utilizing entry criterion for verifying a fasting state with the user before accepting a biomarker value during a Basal titration optimization focused testing procedure. 
     The term “contextualized biomarker data” can mean the information on the interrelated conditions in which a specific biomarker measurement was collected combined with the measured value for the specific biomarker. In particular, the biomarker data are stored together with the information on the interrelated conditions under which a specific biomarker measurement was collected and are linked thereto. 
     The term “criteria” can mean one or more criterions, and can be at least one or more of a guideline(s), rule(s), characteristic(s), and dimension(s) used to judge whether one or more conditions are satisfied or met to begin, accept, and/or end one or more procedural steps, actions, and/or values. 
     The term “adherence” can mean that a person following a structured collection procedure performs requested procedural steps appropriately. For example, the biomarker data should be measured under prescribed conditions of the structured collection procedure. If then the prescribed conditions are given for a biomarker measurement the adherence is defined as appropriate. For examples, the prescribed conditions are time related conditions and/or exemplarily can include eating of meals, taking a fasting sample, eating a type of meal with a requested window of time, taking a fasting sample at a requested time, sleeping a minimum amount of time, and the like. The adherence can be defined as appropriate or not appropriate for a structured collection procedure, a group of sample instances, or a single data point of a contextualized biomarker data. Preferably, the adherence can be defined as appropriate or not appropriate by a range of a prescribed condition(s) or by a selectively determined prescribed condition(s). Moreover the adherence can be calculated as a rate of adherence describing in which extent the adherence is given for a structured collection procedure or a single data point in particular of a contextualized biomarker data. 
     The term “adherence event” can mean when a person executing a structured collection procedure fails to perform a procedural step. For example, if a person did not collect data when requested by the collection device, the adherence is determined as not appropriate resulting in an adherence event. In another example, adherence criteria could be a first criterion for the patient to fast 6 hours and a second criterion for collecting a fasting bG value at a requested time. In this example, if the patient provides the bG sampling at the requested time but fasted only 3 hours before providing, then although the second adherence criterion is met, the first adherence criterion is not, and hence an adherence event for the first criterion would occur. 
     The term “violation event” is a form of an adherence event in which the person executing the structured collection (testing) procedure (protocol) does not administer a therapeutic at a recommended time, does not administer a recommended amount, or both. 
     The term “adherence criterion” can include adherence and can mean a basis for comparison (e.g., assessment) of a value/information related to a measured value and/or a calculated value with a defined value/information, or defined range of the values, wherein based on the comparison, data can be accepted with approval and positive reception. Adherence criterion can be applied to contextualized biomarker data so that a biomarker data can be accepted depending on a comparison of the contextualized data regarding the documentation and related conditions that exists or occur, during the collection of the specific biomarker. Adherence criterion can be akin to a sanity check for a given piece of information, or group of information. Preferably, the adherence criterion can be applied to group of data, or information, and can be rejected if the adherence criterion is not fulfilled. In particular, such rejected data are then not used for further calculations that provide a therapy recommendation. Mainly, the rejected data can only be used to assess the adherence and/or to automatically trigger at least one further action. For example, such a triggered action can prompt the user to follow a structured collection procedure, or a single requested action, so that the adherence criterion can be fulfilled. 
     As used herein, a biomarker, or event value, can be “acceptable” if the user follows the appropriate and recommended steps (i.e., adherence), and, in a preferred embodiment, the resulting data are within a predicted range. For example, before a sample is taken, the acceptance criteria can establish whether the steps leading up to taking of the sample were accomplished. For example, the processor in response to a request displays the question, “Have you been fasting for the last 8 hours?,” wherein a “Yes” response received by the processor via the user interface meets the acceptance criterion for this step. In another example, after the sample is taken, the processor can assess the received data for reasonableness using other acceptance criterion(s). For example, based on prior data, a fasting bG sample should be between 120-180 mg/dl, but the received value was of 340 mg/dl, and thus fails such acceptance criteria since it is outside the predefined range for an acceptable value. In such an example, the processor could prompt for an additional sample. If the re-sampling fails too (i.e., not between 120-180 mg/dl), the assessment provided by the processor can be that the patient has not fasted, and, thus, the processor, as instructed by the acceptance criterion upon a failing of the re-sampling, can automatically extend the events in the schedule of events accordingly. 
     The terms “software” and “program” may be used interchangeably herein. 
       FIG. 1  shows a chronic care management system  10  for a diabetes patient(s)  12  and a clinician(s)  14  along with others  16  having an interest in the chronic care management of the patient  12 . Patient  12 , having dysglycemia, may include persons with a metabolic syndrome, pre-diabetes, type 1 diabetes, type 2 diabetes, and gestational diabetes. The others  16  with an interest in the patient&#39;s care may include family members, friends, support groups, and religious organizations all of which can influence the patient&#39;s conformance with therapy. The patient  12  may have access to a patient computer  18 , such as a home computer, which can connect to a public network  50  (wired or wireless), such as the internet, cellular network, etc., and couple to a dongle, docking station, or device reader  22  for communicating with an external portable device, such as a portable collection device  24 . An example of a device reader is shown in the manual “Accu-Chek® Smart Pix Device Reader User&#39;s Manual” (2008) available from Roche Diagnostics. 
     The collection device  24  can be essentially any portable electronic device that can function as an acquisition mechanism for determining and storing digitally a biomarker value(s) according to a structured collection procedure, and which can function to run the structured collection procedure and the method of the present invention. Greater details regarding various illustrated embodiments of the structured collection procedure are provided hereafter in later sections. In a preferred embodiment, the collection device  24  can be a self-monitoring blood glucose meter  26  or a continuous glucose monitor  28 . An example of a blood glucose meter is the Accu-Chek® Active meter, and the Accu-Chek® Aviva meter described in the booklet “Accu-Chek® Aviva Blood Glucose Meter Owner&#39;s Booklet (2007), portions of which are disclosed in U.S. Pat. No. 6,645,368 B1 entitled “Meter and method of using the meter for determining the concentration of a component of a fluid” assigned to Roche Diagnostics Operations, Inc., which is hereby incorporated by reference. An example of a continuous glucose monitor is shown in U.S. Pat. No. 7,389,133 “Method and device for continuous monitoring of the concentration of an analyte” (Jun. 17, 2008) assigned to Roche Diagnostics Operations, Inc., which is hereby incorporated by reference. 
     In addition to the collection device  24 , the patient  12  can use a variety of products to manage his or her diabetes including: test strips  30  carried in a vial  32  for use in the collection device  24 ; software  34  which can operate on the patient computer  18 , the collection device  24 , a handheld computing device  36 , such as a laptop computer, a personal digital assistant, and/or a mobile phone; and paper tools  38 . Software  34  can be pre-loaded or provided either via a computer readable medium  40  or over the public network  50  and loaded for operation on the patient computer  18 , the collection device  24 , the clinician computer/office workstation  25 , and the handheld computing device  36 , if desired. In still other embodiments, the software  34  can also be integrated into the device reader  22  that is coupled to the computer (e.g., computers  18  or  25 ) for operation thereon, or accessed remotely through the public network  50 , such as from a server  52 . 
     The patient  12  can also use for certain diabetes therapies additional therapy devices  42  and other devices  44 . Additionally, therapy devices  42  can include devices such as an ambulatory infusion pump  46 , an insulin pen  48 , and a lancing device  51 . An example of an ambulatory insulin pump  46  include but not limited thereto the Accu-Chek® Spirit pump described in the manual “Accu-Chek® Spirit Insulin Pump System Pump User Guide” (2007) available from Disetronic Medical Systems AG. The other devices  44  can be medical devices that provide patient data such as blood pressure, fitness devices that provide patient data such as exercise information, and elder care device that provide notification to care givers. The other devices  44  can be configured to communicate with each other according to standards planned by Continua® Health Alliance. These therapy devices can be separate or integrated into the collection devices and data processing devices described herein. 
     The clinicians  14  for diabetes are diverse and can include e.g., nurses, nurse practitioners, physicians, endocrinologists, and other such health care providers. The clinician  14  typically has access to a clinician computer  25 , such as a clinician office computer, which can also be provided with the software  34 . A healthcare record system  27 , such as Microsoft® HealthVault™ and Google™ Health, may also be used by the patient  12  and the clinician  14  on computers  18 ,  25  to exchange information via the public network  50  or via other network means (LANs, WANs, VPNs, etc.), and to store information such as collection data from the collection device  24  to an electronic medical record of the patient e.g., EMR  53  ( FIG. 2A ) which can be provided to and from computer  18 ,  25  and/or server  52 . 
     Most patients  12  and clinicians  14  can interact over the public network  50  with each other and with others having computers/servers  52 . Such others can include the patient&#39;s employer  54 , a third party payer  56 , such as an insurance company who pays some or all of the patient&#39;s healthcare expenses, a pharmacy  58  that dispenses certain diabetic consumable items, a hospital  60 , a government agency  62 , which can also be a payer, and companies  64  providing healthcare products and services for detection, prevention, diagnosis and treatment of diseases. The patient  12  can also grant permissions to access the patient&#39;s electronic health record to others, such as the employer  54 , the payer  56 , the pharmacy  58 , the hospital  60 , and the government agencies  62  via the healthcare record system  27 , which can reside on the clinician computer  25  and/or one or more servers  52 . Reference hereafter is also made to  FIG. 2 . 
       FIG. 2  shows a system embodiment suitable for implementing a structured testing method according to an embodiment of the present invention, which in another embodiment can be a part of the chronic care management system  10  and communicate with such components, via conventional wired or wireless communication means. The system  41  can include the clinician computer  25  that is in communication with a server  52  as well as the collection device  24 . Communications between the clinician computer  25  and the server  52  can be facilitated via a communication link to the public network  50 , to a private network  66 , or combinations thereof. The private network  66  can be a local area network or a wide are network (wired or wireless) connecting to the public network  50  via a network device  68  such as a (web) server, router, modem, hub, and the likes. 
     In one embodiment, the server  52  can be a central repository for a plurality of structured collection procedures (or protocols)  70   a ,  70   b ,  70   c ,  70   d , in which the details of a few exemplary structured collection procedures are provided in later sections. The server  52 , as well as the network device  68 , can function also as a data aggregator for completed ones of the structured collection procedures  70   a ,  70   b ,  70   c ,  70   d . Accordingly, in such an embodiment, data of a completed collection procedure(s) from a collection device of the patient  12  can then be provided from the server  52  and/or network device  68  to the clinician computer  25  when requested in response to a retrieval for such patient data. 
     In one embodiment, one or more of the plurality of structured collection procedures  70   a ,  70   b ,  70   c ,  70   d  on the server  52  can be provided over the public network  50 , such as through a secure web interface  55  ( FIG. 2A , showing another embodiment of the system  41 ) implemented on the patient computer  18 , the clinician computer  25 , and/or the collection device  24 . In another embodiment, the clinician computer  25  can serve as the interface (wired or wireless)  72  between the server  52  and the collection device  24 . In still another embodiment, the structured collection procedures  70   a ,  70   b ,  70   c ,  70   d , as well as software  34 , may be provided on a computer readable medium  40  and loaded directed on the patient computer  18 , the clinician computer  25 , and/or the collection device  24 . In still another embodiment, the structured collection procedures  70   a ,  70   b ,  70   c ,  70   d  may be provided pre-loaded (embedded) in memory of the collection device  24 . In still other embodiments, new/updated/modified structured collection procedures  70   a ,  70   b ,  70   c ,  70   d  may be sent between the patient computer  18 , the clinician computer  25 , the server  52  and/or the collection device  24  via the public network  50 , the private network  66 , via a direct device connection (wired or wireless)  74 , or combinations thereof. Accordingly, in one embodiment the external devices e.g., computer  18  and  25 , can be used to establish a communication link  72 ,  74  between the collection device  24  and still further electronic devices such as other remote Personal Computer (PC), and/or servers such as through the public network  50 , such as the Internet and/or other communication networks (e.g., LANs, WANs, VPNs, etc.), such as private network  66 . 
     The clinician computer  25 , as a conventional personal computer/workstation, can include a processor  76  which executes programs, such as software  34 , and such as from memory  78  and/or computer readable medium  40 . Memory  78  can include system memory (RAM, ROM, EEPROM, etc.), and storage memory, such as hard drives and/or flash memory (internal or external). The clinician computer  25  can also include a display driver  80  to interface a display  82  with the processor  76 , input/output connections  84  for connecting user interface devices  86 , such as a keyboard and mouse (wired or wireless), and computer readable drives  88  for portable memory and discs, such as computer readable medium  40 . The clinician computer  25  can further include communication interfaces  90  for connections to the public network  50  and other devices, such as collection device  24  (wired or wireless), and a bus interface  92  for connecting the above mentioned electronic components to the processor  76 . Reference hereafter is now made to  FIG. 3 . 
       FIG. 3  is a block diagram conceptually illustrating the portable collection device  24  depicted in  FIG. 2 . In the illustrated embodiment, the collection device  24  can include one or more microprocessors, such as processor  102 , which may be a central processing unit comprising at least one more single or multi-core and cache memory, which can be connected to a bus  104 , which may include data, memory, control and/or address buses. The collection device  24  can include the software  34 , which provides instruction codes that causes a processor  102  of the device to implement the methods of the present invention that are discussed hereafter in later sections. The collection device  24  may include a display interface  106  providing graphics, text, and other data from the bus  104  (or from a frame buffer not shown) for display on a display  108 . The display interface  106  may be a display driver of an integrated graphics solution that utilizes a portion of main memory  110  of the collection device  24 , such as random access memory (RAM) and processing from the processor  102  or may be a dedicated graphic processing unit. In another embodiment, the display interface  106  and display  108  can additionally provide a touch screen interface for providing data to the collection device  24  in a well-known manner. 
     Main memory  110  in one embodiment can be random access memory (RAM), and in other embodiments may include other memory such as a ROM, PROM, EPROM or EEPROM, and combinations thereof. In one embodiment, the collection device  24  can include secondary memory  112 , which may include, for example, a hard disk drive  114  and/or a computer readable medium drive  116  for the computer readable medium  40 , representing for example, at least one of a floppy disk drive, a magnetic tape drive, an optical disk drive, a flash memory connector (e.g., USB connector, Firewire connector, PC card slot), etc. The drive  116  reads from and/or writes to the computer readable medium  40  in a well-known manner. Computer readable medium  40 , represents a floppy disk, magnetic tape, optical disk (CD or DVD), flash drive, PC card, etc. which is read by and written to by the drive  116 . As will be appreciated, the computer readable medium  40  can have stored therein the software  34  and/or structured collection procedures  70   a ,  70   b ,  70   c , and  70   d  as well as data resulting from completed collections performed according to one or more of the collection procedures  70   a ,  70   b ,  70   c , and  70   d.    
     In alternative embodiments, secondary memory  112  may include other means for allowing the software  34 , the collection procedures  70   a ,  70   b ,  70   c ,  70   d , other computer programs or other instructions to be loaded into the collection device  24 . Such means may include, for example, a removable storage unit  120  and an interface connector  122 . Examples of such removable storage units/interfaces can include a program cartridge and cartridge interface, a removable memory chip (e.g., ROM, PROM, EPROM, EEPROM, etc.) and associated socket, and other removable storage units  120  (e.g. hard drives) and interface connector  122  which allow software and data to be transferred from the removable storage unit  120  to the collection device  24 . 
     The collection device  24  in one embodiment can include a communication module  124 . The communication module  124  allows software (e.g., the software  34 , the collection procedures  70   a ,  70   b ,  70   c , and  70   d ) and data (e.g., data resulting from completed collections performed according to one or more of the collection procedures  70   a ,  70   b ,  70   c , and  70   d ) to be transferred between the collection device  24  and an external device(s)  126 . Examples of communication module  124  may include one or more of a modem, a network interface (such as an Ethernet card), a communications port (e.g., USB, Firewire, serial, parallel, etc.), a PC or PCMCIA slot and card, a wireless transceiver, and combinations thereof. The external device(s)  126  can be the patient computer  18 , the clinician computer  25 , the handheld computing devices  36 , such as a laptop computer, a personal digital assistance (PDA), a mobile (cellular) phone, and/or a dongle, a docking station, or device reader  22 . In such an embodiment, the external device  126  may provided and/or connect to one or more of a modem, a network interface (such as an Ethernet card), a communications port (e.g., USB, Firewire, serial, parallel, etc.), a PCMCIA slot and card, a wireless transceiver, and combinations thereof for providing communication over the public network  50  or private network  66 , such as with the clinician computer  25  or server  52 . Software and data transferred via communication module  124  can be in the form of wired or wireless signals  128 , which may be electronic, electromagnetic, optical, or other signals capable of being sent and received by communication module  124 . For example, as is known, signals  128  may be sent between communication module  124  and the external device(s)  126  using wire or cable, fiber optics, a phone line, a cellular phone link, an RF link, an infrared link, other communications channels, and combinations thereof. Specific techniques for connecting electronic devices through wired and/or wireless connections (e.g. USB and Bluetooth, respectively) are well known in the art. 
     In another embodiment, the collection device  24  can be used with the external device  132 , such as provided as a handheld computer or a mobile phone, to perform actions such as prompt a patient to take an action, acquire a data event, and perform calculations on information. An example of a collection device combined with such an external device  126  provided as a hand held computer is disclosed in U.S. patent application Ser. No. 11/424,757 filed Jun. 16, 2006 entitled “System and method for collecting patient information from which diabetes therapy may be determined,” assigned to Roche Diagnostics Operations, Inc., which is hereby incorporated by reference. Another example of a handheld computer is shown in the user guide entitled “Accu-Chek® Pocket Compass Software with Bolus Calculator User Guide” (2007) available from Roche Diagnostics. 
     In the illustrative embodiment, the collection device  24  can provide a measurement engine  138  for reading a biosensor  140 . The biosensor  140 , which in one embodiment is the disposable test strip  30  ( FIG. 1 ), is used with the collection device  24  to receive a sample such as for example, of capillary blood, which is exposed to an enzymatic reaction and measured by electrochemistry techniques, optical techniques, or both by the measurement engine  138  to measure and provide a biomarker value, such as for example, a blood glucose level. An example of a disposable test strip and measurement engine is disclosed in U.S. Patent Pub. No. 2005/0016844 A1 “Reagent stripe for test strip” (Jan. 27, 2005), and assigned to Roche Diagnostics Operations, Inc., which is hereby incorporated by reference. In other embodiments, the measurement engine  138  and biosensor  140  can be of a type used to provide a biomarker value for other types of sampled fluids or analytes besides or in addition to glucose, heart rate, blood pressure measurement, and combinations thereof. Such an alternative embodiment is useful in embodiments where values from more then one biomarker type are requested by a structured collection procedure according to the present invention. In still another embodiment, the biosensor  140  may be a sensor with an indwelling catheter(s) or being a subcutaneous tissue fluid sampling device(s), such as when the collection device  24  is implemented as a continuous glucose monitor (CGM) in communication with an infusion device, such as pump  46  ( FIG. 1 ). In still another embodiments, the collection device  24  can be a controller implementing the software  34  and communicating between the infusion device (e.g., ambulatory infusion pump  46  and electronic insulin pen  48 ) and the biosensor  140 . 
     Data, comprising at least the information collected by the biosensor  140 , is provided by the measurement engine  138  to the processor  102  which may execute a computer program stored in memory  110  to perform various calculations and processes using the data. For example, such a computer program is described by U.S. patent application Ser. No. 12/492,667, filed Jun. 26, 2009, titled “Method, System, and Computer Program Product for Providing Both an Estimated True Mean Blood Glucose Value and Estimated Glycated Hemoglobin (HbA1C) Value from Structured Spot Measurements Of Blood Glucose,” and assigned to Roche Diagnostics Operations, Inc., which is hereby incorporated by reference. The data from the measurement engine  138  and the results of the calculation and processes by the processor  102  using the data is herein referred to as self-monitored data. The self-monitored data may include, but not limited thereto, the glucose values of a patient  12 , the insulin dose values, the insulin types, and the parameter values used by processor  102  to calculate future glucose values, supplemental insulin doses, and carbohydrate supplement amounts as well as such values, doses, and amounts. Such data along with a date-time stamp  169  for each measured glucose value and administered insulin dose value is stored in a data file  145  of memory  110  and/or  112 . An internal clock  144  of the collection device  24  can supply the current date and time to processor  102  for such use. 
     The collection device  24  can further provide a user interface  146 , such as buttons, keys, a trackball, touchpad, touch screen, etc. for data entry, program control and navigation of selections, choices and data, making information requests, and the likes. In one embodiment, the user interface  146  can comprises one or more buttons  147 ,  149  for entry and navigation of the data provided in memory  110  and/or  112 . In one embodiment, the user can use one or more of buttons  147 ,  149  to enter (document) contextualizing information, such as data related to the everyday lifestyle of the patient  12  and to acknowledge that prescribed tasks are completed. Such lifestyle data may relate to food intake, medication use, energy levels, exercise, sleep, general health conditions and overall well-being sense of the patient  12  (e.g., happy, sad, rested, stressed, tired, etc.). Such lifestyle data can be recorded into memory  110  and/or  112  of the collection device  24  as part of the self-monitored data via navigating through a selection menu displayed on display  108  using buttons  147 ,  149  and/or via a touch screen user interface provided by the display  108 . It is to be appreciated that the user interface  146  can also be used to display on the display  108  the self monitored data or portions thereof, such as used by the processor  102  to display measured glucose levels as well as any entered data. 
     In one embodiment, the collection device  24  can be switched on by pressing any one of the buttons  147 ,  149  or any combination thereof. In another embodiment, in which the biosensor  140  is a test-strip, the collection device  24  can be automatically switched on when the test-strip is inserted into the collection device  24  for measurement by the measurement engine  138  of a glucose level in a sample of blood placed on the test-strip. In one embodiment, the collection device  24  can be switched off by holding down one of the buttons  147 ,  149  for a pre-defined period of time, or in another embodiment can be shut down automatically after a pre-defined period of non-use of the user interface  146 . 
     An indicator  148  can also be connected to processor  102 , and which can operate under the control of processor  102  to emit audible, tactile (vibrations), and/or visual alerts/reminders to the patient of daily times for bG measurements and events, such as for example, to take a meal, of possible future hypoglycemia, and the likes. A suitable power supply  150  is also provided to power the collection device  24  as is well known to make the device portable. 
     As mentioned above previously, the collection device  24  may be pre-loaded with the software  34  or by provided therewith via the computer readable medium  40  as well as received via the communication module  124  by signal  128  directly or indirectly though the external device  132  and/or network  50 . When provided in the latter matter, the software  34  when received by the processor  102  of the collection device  24  is stored in main memory  110  (as illustrated) and/or secondary memory  112 . The software  34  contains instructions, when executed by the processor  102 , enables the processor to perform the features/functions of the present invention as discussed herein in later sections. In another embodiment, the software  34  may be stored in the computer readable medium  40  and loaded by the processor  102  into cache memory to cause the processor  102  to perform the features/functions of the invention as described herein. In another embodiment, the software  34  is implemented primarily in hardware logic using, for example, hardware components such as application specific integrated circuits (ASICs). Implementation of the hardware state machine to perform the feature/functions described herein will be apparent to persons skilled in the relevant art(s). In yet another embodiment, the invention is implemented using a combination of both hardware and software. 
     In an example software embodiment of the invention, the methods described hereafter can be implemented in the C++ programming language, but could be implemented in other programs such as, but not limited to, Visual Basic, C, C++, Java or other programs available to those skilled in the art. In still other embodiment, the program  34  may be implemented using a script language or other proprietary interpretable language used in conjunction with an interpreter. Reference hereafter is also made to  FIG. 4 . 
       FIG. 4  depicts in tabular form a data file  145  containing data records  152  of self-monitored data  154  resulting from a structured collection procedure according to an embodiment of the present invention. The data records  152  (e.g., rows) along with the self-monitoring data  154  (e.g., various one of the columns) can also provide associated therewith contextual information  156  (e.g., other various ones of the columns as well as via row and column header information). Such contextual information  156  can be collected either automatically, such as for example via input received automatically from the measurement engine, the biosensor, and/or any one of the other devices, or via input received from the user interface which was manually enter by the patient in response to a collection request (e.g., a question displayed by the processor  102  on the display  108 ) during the structured collection procedure. Accordingly, as such contextual information  156  can be provided with each data record  152  in a preferred embodiment, such information is readily available to a physician and no further collection of such information is necessarily needed to be provided again by the patient either manually or orally after completing the structured collection procedure. In another embodiment, if such contextual information  156  and/or additional contextual information is collected after completion of a structured collection procedure according to the present invention, such information may be provided in the associated data file and/or record  145 ,  152  at a later time such as via one of the computers  18 ,  25 . Such information would then be associated with the self-monitored data in the data file  145 , and thus would not need to be provided again orally or manually. Such a process in the latter embodiment may be needed in the situation where the structured collection procedure is implemented as or partly as a paper tool  38  which is used with a collection device incapable of running the software  34  implementing such a structured collection procedure. 
     It is to be appreciated that the date file  145  (or portions thereof, such as only the self-monitored data  154 ) can be sent/downloaded (wired or wireless) from the collection device  24  via the communication module  124  to another electronic device, such the external device  132  (PC, PDA, or cellular telephone), or via the network  50  to the clinician computer  25 . Clinicians can use diabetes software provided on the clinician computer  25  to evaluate the received self-monitored data  154  as well as the contextual information  156  of the patient  12  for therapy results. An example of some of the functions which may be incorporated into the diabetes software and which is configured for a personal computer is the Accu-Chek® 360 Diabetes Management System available from Roche Diagnostics that is disclosed in U.S. patent application Ser. No. 11/999,968 filed Dec. 7, 2007, titled “METHOD AND SYSTEM FOR SETTING TIME BLOCK,” and assigned to Roche Diagnostics Operations, Inc., which is hereby incorporated by reference. 
     In a preferred embodiment, the collection device  24  can be provided as portable blood glucose meter, which is used by the patient  12  for recording self-monitored data comprising insulin dosage readings and spot measured glucose levels. Examples of such bG meters as mentioned above previously include but are not limited to, the Accu-Chek® Active meter and the Accu-Chek® Aviva system both by Roche Diagnostics, Inc. which are compatible with the Accu-Chek® 360° Diabetes management software to download test results to a personal computer or the Accu-Chek® Pocket Compass Software for downloading and communication with a PDA. Accordingly, it is to be appreciated that the collection device  24  can include the software and hardware necessary to process, analyze and interpret the self monitored data in accordance with predefined flow sequences (as described below in detail) and generate an appropriate data interpretation output. In one embodiment, the results of the data analysis and interpretation performed upon the stored patient data by the collection device  24  can be displayed in the form of a report, trend-monitoring graphs, and charts to help patients manage their physiological condition and support patient-doctor communications. In other embodiments, the bG data from the collection device  24  may be used to generated reports (hardcopy or electronic) via the external device  132  and/or the patient computer  18  and/or the clinician computer  25 . 
     The collection device  24  can further provide the user and/or his or her clinician with at least one or more of the possibilities comprising: a) editing data descriptions, e.g. the title and description of a record; b) saving records at a specified location, in particular in user-definable directories as described above; c) recalling records for display; d) searching records according to different criteria (date, time, title, description etc.); e) sorting records according to different criteria (e.g., values of the bG level, date, time, duration, title, description, etc.); f) deleting records; g) exporting records; and/or h) performing data comparisons, modifying records, excluding records as is well known. 
     As used herein, lifestyle can be described in general as a pattern in an individual&#39;s habits such as meals, exercise, and work schedule. The individual additionally may be on medications such as insulin therapy or orals that they are required to take in a periodic fashion. Influence of such action on glucose is implicitly considered by the present invention. 
     It is to be appreciated that the processor  102  of the collection device  24  can implement one or more structured collection procedures  70  provided in memory  110  and/or  112 . Each structured collection procedure  70  in one embodiment can be stand-alone software, thereby providing the necessary program instructions which when executed by the processor  102  causes the processor to perform the structured collection procedure  70  as well as other prescribed functions. In other embodiments, each structured collection procedure  70  can be part of the software  34 , and can be then be selectively executed by the processor  102  either via receiving a selection from a menu list provided in the display  108  from the user interface  146  in one embodiment or via activation of a particular user interface, such as a structured collection procedure run mode button (not shown) provided to the collection device  24  in another embodiment. It is to be appreciated that the software  34 , likewise, provides the necessary program instructions which when executed by the processor  102  causes the processor to perform the structured collection procedure  70  as well as other prescribed functions of the software  34  discussed herein. One suitable example of having a selectable structured collection procedure provided as a selectable mode of a collection meter is disclosed by in U.S. patent application Ser. No. 12/491,523, filed Jun. 25, 2009, titled “Episodic Blood Glucose Monitoring System With An Interactive Graphical User Interface And Methods Thereof,” assigned to Roche Diagnostics Operations, Inc., which is hereby incorporated by reference. 
     In still another embodiment, a command instruction can be sent from the clinician computer  25  and received by the processor  102  via the communication module  124 , which places the collection device  24  in a collection mode which runs automatically the structured collection procedure  70 . Such a command instruction may specify which of the one or more structured collection procedures to run and/or provide a structured collection procedure to run. In still another embodiment, a list of defined medical use cases or medical questions can be presented on the display  108  by the processor  102 , and a particular structured collection procedure  70  can be automatically chosen by the processor  102  from a plurality of structured collection procedures (e.g., procedures  70   a ,  70   b ,  70   c , and  70   d ) depending on the selection of the defined medical use cases or medical questions received by the processor  102  via the user interface  146 . 
     In still another embodiment, after selection, the structured collection procedure(s)  70  can be provided through the computer readable medium e.g.,  40  and loaded by the collection device  24 , downloaded from computer  18  or  25 , the other device(s)  132 , or server  52 . Server  52 , for example, may be a healthcare provider or company providing such pre-defined structured collection procedures  70  for downloading according to a selected defined medical use case or question. It is to be appreciated that the structured collection procedure(s)  70  may be developed by a healthcare company (e.g. company  64 ) and implemented via the public network  50  through a webpage and/or made available for downloading on server  52 , such as illustrated in  FIG. 2 . In still other embodiments, notices that a new structured collection procedure  70  is available for use on the collection device  24  to help address a particular use case/medical question that a user (e.g., healthcare provider and patient) may have can be provided in any standard fashion, such for via postal letters/cards, email, text messaging, tweets, and the likes. 
     In some embodiments, as mentioned above previously, a paper tool  38  can perform some of the functions provided by the diabetes software  34 . An example of some of the functions which may be incorporated into the diabetes software  34  and which is configured as a paper tool  38  is the Accu-Chek® 360 View Blood Glucose Analysis System paper form available from Roche Diagnostics also disclosed in U.S. patent application Ser. No. 12/040,458 filed Feb. 29, 2007 entitled “Device and method for assessing blood glucose control,” assigned to Roche Diagnostic Operations, Inc., which is hereby incorporated by reference. 
     In still another embodiment, the software  34  can be implemented on the continuous glucose monitor  28  ( FIG. 1 ). In this manner, the continuous glucose monitor  28  can be used to obtain time-resolved data. Such time-resolved data can be useful to identify fluctuations and trends that would otherwise go unnoticed with spot monitoring of blood glucose levels and standard HbA1c tests. Such as, for example, low overnight glucose levels, high blood glucose levels between meals, and early morning spikes in blood glucose levels as well as how diet and physical activity affect blood glucose along with the effect of therapy changes. 
     In addition to collection device  24  and software  34 , clinicians  14  can prescribe other diabetes therapy devices for patients  12  such as an ambulatory insulin pump  46  as well as electronically based insulin pen  48  ( FIG. 1 ). The insulin pump  46  typically includes configuration software such as that disclosed in the manual “Accu-Chek® Insulin Pump Configuration Software” also available from Disetronic Medical Systems AG. The insulin pump  46  can record and provide insulin dosage and other information, as well as the electronically based insulin pen  48 , to a computer, and thus can be used as another means for providing biomarker data as requested by the structured collection procedure  70  ( FIG. 2 ) according to the present invention. 
     It is to be appreciated that, and as mentioned above previously, one or more of the method steps discussed hereafter can be configured as a paper tool  38  ( FIG. 1 ), but preferably all the method steps are facilitated electronically on system  41  ( FIG. 2 ) or on any electronic device/computer, such as collection device  24 , having a processor and memory as a program(s) residing in memory. As is known, when a computer executes the program, instructions codes of the program cause the processor of the computer to perform the method steps associated therewith. In still other embodiments, some or all of the method steps discussed hereafter can be configured on computer readable medium  40  storing instruction codes of a program that, when executed by a computer, cause the processor of the computer to perform the method steps associated therewith. These method steps are now discussed in greater detail hereafter with reference made to  FIGS. 5-12B . 
     Testing Method Embodiments for Optimizing the Titration of Insulin 
       FIG. 5  is an exemplary testing method embodiment for optimizing the titration of insulin dosage, which thereby yields dosages of insulin which maintain biomarker levels within a desired range. The titrated insulin may be basal insulin. Upon starting the testing plan, the dosage of insulin is typically the initial prescribed dosage, for example, the initial prescribed dosage listed on the package. However, other dosages are contemplated depending on what stage of the testing plan, as the entry criteria may be considered before every biomarker reading. Consequently, the initial dosage may be an adjusted dosage above the initial prescribed dosage, the maximum allowable dosage, or even the optimized dosage. It is contemplated that the testing plan may be used to obtained the optimized insulin value, or may be used post-optimization to verify that the insulin dosage is still optimal. 
     Referring again to  FIG. 5 , the testing methods may optionally include the consideration of entry criteria  510  before beginning collection of the biomarker data. It is contemplated that the user, the healthcare provider, or both may determine whether the entry criteria are met. The entry criteria, which in some embodiments may be established by the healthcare provider, may relate to the age, weight, and medical history of the diabetic patient. Consequently, the testing method may require a diabetic patient to receive a check-up or physical to ensure the diabetic patient satisfies the entry criteria. For instance, the entry criteria may specify the fasting plasma glucose (FPG) level or glycolated hemoglobin level as determined by the HbA1c test. The normal range for the HbA1c test is between 4-6% for people without diabetes, so the entry criteria may require values above about 6%, or in an exemplary embodiment, between about 7.5% to about 10%. As an additional example of entry criteria, a fasting plasma glucose level of at least about 140 mg/dl is required. The entry criteria may also set requirements on weight or Body Mass Index (BMI). For example, the required BMI may be greater than about 25 kg/m2, or between about 26 kg/m2 to about 40 kg/m2. Additionally, the entry criteria may specify a desired age range (e.g., 30-70) or the number of years afflicted with diabetes (e.g., at least 2 years). Moreover, while it is contemplated that the testing method is applicable to persons afflicted all types of diabetes, the entry criteria may limit the testing method to type 2 diabetics. Furthermore, the entry criteria may center on the current diabetes treatment regimen of the diabetic patient. For example, the entry criteria may require that the treatment regimen for the diabetic patient be limited to oral anti-diabetes medication i.e., no injected insulin. Additionally, the entry criteria may require that the diabetic patient not be ill or under stress. 
     If the entry criteria are not met, the testing plan will not be initiated  515  in that optional embodiment. The diabetic patient or healthcare provider may determine whether the entry criteria have been met, or the data processor may determine whether criteria have been met. If the entry criteria are met  510 , then the diabetic patient may commence with the testing plan. However, in some embodiments, it may be required for the diabetic patient to satisfy adherence criterion before the collection of biomarkers or the administration of insulin. 
     Like other instructions provided to the user throughout the testing plan, the entry criteria may be provided to the diabetic patient via a paper instruction form, or a display unit on a data processing device or microprocessor  102  as shown in  FIG. 3 . The data processing devices may be any electronic device described above. In one or more embodiments, the data processing device may be a computer or a blood glucose meter with a data processor and memory units therein. The data processing device may prompt the diabetic patient to answer medical questions, wherein the answers to the medical questions are used by the device to determine compliance with the entry criteria or adherence criteria, and may inform the diabetic patient of the failure to comply with the entry criteria, or adherence criteria. For example, the data processing device may inform a diabetic patient if subsequent sampling instances are not taken around the same time as the first sampling instance, which is a failure to meet an adherence criterion. The patient can record sampling instances or answer medical questions by entering the data event directly into a device or computer, wherein the processor  102  can store the information and provide additional analysis depending on the parameters of the testing method. 
     Referring again to  FIG. 5 , the diabetic patient may begin collection of one or more sampling sets of biomarker data  530 . Each sampling set comprises one or more sampling instances recorded over a collection period. Each sampling instance comprises one or more biomarker readings. The collection period for the sampling set may be defined as multiple sampling instances within a day, multiple sampling instances within a week, multiple sampling instances within consecutive weeks, or multiple sampling instances on consecutive days within a week. The biomarker may relate to the levels of glucose, triglycerides, low density lipids, and high density lipids. In one exemplary embodiment, the biomarker reading is a blood glucose reading, specifically a fasting blood glucose reading. In addition to the biomarker reading, each sampling instance may comprise the biomarker reading and other contextual data associated with the biomarker reading, wherein the contextual data is selected from the group consisting of the time of collection, the date of collection, the time when the last meal was consumed, the recommended dose of insulin, and combinations thereof. 
     After the sampling set of biomarker data is obtained, the data is analyzed to determine if there are any adverse events or a risk of an adverse event. If the data indicates an adverse event  535 , then the healthcare provider may be notified, the insulin dosage may be reduced, or both  538 , and then the testing plan may be exited. Other patient actions are also contemplated. If there is no adverse event recorded, the probability distribution for the data is estimated. In alternative embodiments, adverse events may also be evaluated when any biomarker readings indicative of an adverse event are received, not just at the end of a sample set. In this embodiment, when an adverse event is detected, the healthcare provider may be notified immediately, not just after the entire sampling set is recorded. 
     In one embodiment as shown in  FIG. 5 , the mean and the standard deviation for the sampling set is computed  540  to obtain the probability distribution function; however, other methods (e.g., a kernel density estimator) may be used to calculate the probability distribution function. It is contemplated that the kernel density estimator could consider the current completed sampling set, a portion of the sampling set, or multiple sampling sets. By considering the standard deviation in addition to the mean, the probability distribution can at least in part account for the noise characteristics of the biomarker values during insulin titration. To produce the probability function, a normal distribution of the data is created as graphically depicted in the histogram of  FIG. 6 . 
     A normal distribution can be fitted to the data by calculating the current therapy mean and standard deviation for the sampling set of biomarker data over the collection period. The resulting probability distribution function p(B) for a normal distribution is defined in the following equation p(B)=N(  B , σ B ) wherein B is a biomarker reading or sampling instance,  B  is the mean of sampling set of biomarker data defined by the equation 
                 B   _     =       1   n     ⁢       ∑     i   =   1     n     ⁢     B   i           ,         
and σ B  is the standard deviation defined by the equation
 
     
       
         
           
             
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     The probability distribution of the biomarkers may also be calculated using kernel density estimators. These estimators can represent data that is not normally distributed such as bi-modal distributions. 
     
       
         
           
             
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     Referring again to  FIG. 5 , a hazard function for the sampling set of biomarker data is then calculated  560 . The conceptual basis for the hazard function lies in penalizing values that are associated with greater patient risk. The hazard function yields higher hazard values for biomarker readings in the sampling set indicative of complications (for example, hyperglycemia or hypoglycemia) and yields hazard values at or near zero at the target biomarker level. 
     In one embodiment, the hazard function H(B) is defined by the equation H(B)=(1.509(log(B) 1.0804 −5.381)) 2 , wherein B is a biomarker reading in the sampling set. This is a function proposed in the following paper: Kovatchev, B. P.; Cox, D. J.; Gonder-Frederick, L. A. &amp; Clarke, W.  Symmetrization of the blood glucose measurement scale and its applications . Diabetes Care, 1997, 20, 1655-1658. In view of the equation and the above conceptual basis for the hazard function, it is apparent that the hazard function is asymmetric as depicted in  FIG. 7 . 
     Other functions for the hazard function are contemplated herein. For example, the hazard function H(B) may be defined by the equation H(B)=H hypo (B)+H hyper (B), wherein B is a biomarker reading in the sampling set, H hypo (B) is the hazard value associated with hypoglycemic events, H hyper (B) is the hazard value associated with hyperglycemic events. In specific embodiments, H hypo (B) is 
                   H   hypo     ⁡     (   B   )       =       50   ⁢     (     1   -     1     1   +   e   -       (     B   -   55     )     /   5           )       +     50   ⁢     ⅇ       1     2   ·     30   2         ⁢     B   2               ,         
and H hyper (B) is
 
                 H   hyper     ⁡     (   B   )       =       ⅇ       1   100     ⁢   B       .           
These are exemplary hazard functions, and they may be adjusted to allow the physician to select the range of biomarker readings that result in a minimal risk. This is done by adjusting the patient&#39;s therapy to achieve the minimum of the hazard function.
 
     As graphically depicted in exemplary embodiments of  FIGS. 8A-8D , the risk value for the sampling set may be obtained  580  from the risk function  570 , which is the product of the probability distribution function and the hazard function as described above. The risk value is obtained from the integral of the risk function. As defined herein, the risk to a patient is the combination of the hazard associated with a biomarker reading and the probability that the patient will have that biomarker reading. 
     According to one embodiment, the risk value J is obtained by the following equation 
     
       
         
           
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                   . 
                 
               
             
           
         
       
     
     Referring to the embodiment of  FIG. 5 , the optimization of insulin titration in a patient is directed to minimizing the risk value J. In accordance with the present invention, the risk value may be minimized by adjusting the diabetic patient&#39;s therapy, wherein the therapy for minimizing the risk value is selected from the group consisting of adjusting the insulin dosage  630 , adjusting diabetic patient behaviors to reduce biomarker variability, adjusting a target biomarker level  640 , or combinations thereof. The insulin dosage parameter may comprise a basal dosage parameter, an insulin to carbohydrate parameter, an insulin sensitivity parameter, a meal rise parameter, a meal offset parameter, an insulin active parameter, and combinations thereof. While a risk value of zero is the goal of minimization, minimizing the risk value to zero may not be attainable for all diabetic patients, thus the risk value may, in some embodiments, be considered optimized if minimized to within a tolerable proximity to zero. In one embodiment, this tolerable proximity may be set by the healthcare provider. 
     Referring to  FIG. 5 , if the risk value is minimized to an optimal level  590 , then the user can exit the testing method  600 . As defined herein, the risk value is considered to be minimized to an optimal risk level, when the mean of the sampling set is at or substantially close to the adjusted target biomarker level or within the adjusted biomarker target range, and the current variance or noise is within a similar noise range of the variance used to define the adjusted target biomarker level or biomarker range. In addition to risk minimization via adjustment of insulin dosage and/or the target biomarker level, the optimization methods of the present invention may also consider other patient factors, such as health, diet, and exercise, to minimize that risk value. As used herein, “substantially close” refers to a mean value that deviates from the target level by less than a specified percentage of the target value (i.e. 10%), or less than a fixed value (i.e. 10 mg/dl). Also as used herein, a “similar noise range” refers to a variance or noise that deviates from the variance or noise used to define the biomarker target level or biomarker target range of values, which typically does not require the adjustment of the target biomarker level during insulin optimization. Moreover, the noise range may be characterized as a “similar noise range” because the variance is similar or the same as the most recently calculated noise. For example, the similar noise range may equal a percentage from a previous amount of noise calculated, for example, less than a 10% change or some other fixed change amount. If the variance does not fall within the “similar noise range”, it should be determined whether the variance falls within and acceptable noise range or level. Further as used herein, an “acceptable noise range” refers to a tolerable variance from the mean, which in one or more embodiments may include variance from the mean of up to about 20%, or up to about 10%, up to about 5% from the mean, or even greater variance or standard deviation from the mean. The acceptable noise range and or/the similar noise range may be estimated from the standard deviation, or it may be a value set by the healthcare provider. If the diabetic patient calculates a variance that falls outside of the similar noise range, but falls within the acceptable noise range, then the target biomarker level should be adjusted. If the variance falls outside of the acceptable noise level, the risk of a hypoglycemic event is increased, and in some embodiments, a health care provided may be notified. 
     This may be best viewed in light of the therapy gradient embodiment of  FIG. 10 . As shown in  FIG. 10 , the calculated mean  1002  and standard deviation  1003  for the current sampling set is shown at point  1001 . The target biomarker level for a given level of variance is located on the line of minimal risk  1007 , and for the specific noise defined by the standard deviation  1003  is located at point  1004 . The “substantially close” region  1005  to the mean and the “similar noise range”  1006  regions surround the target  1004 . If the variance extends beyond the similar noise range, then a new target should be calculated. The “similar noise range”  1006  may be updated after each sampling set of biomarker data is obtained. Upon optimization, the globally optimal risk region  1008  is obtained when both the variance  1003  and mean  1002  of the biomarker sampling set are successfully optimized to within the “substantially close” region  1005  and the “similar noise range”  1006  regions surround the target  1004  and the variance  1003  is within the “acceptable noise” region  1009   
     If the risk value is not within optimal levels, the risk may be minimized by altering the diabetic patient&#39;s therapy. Instructions to alter a patient&#39;s therapy may be provided by a healthcare provider, or by the system itself (i.e., the electronic device e.g., blood glucose meter or a paper instruction form). If the mean is not substantially close to the target biomarker level or within the biomarker value range, but the standard deviation is within a similar noise range as the target, then the insulin dosage level must be adjusted to achieve the target biomarker level  630 . If the mean is not substantially close to the target biomarker level and the standard deviation does not fall within a similar noise range, then the insulin dosage should be adjusted  630  and the biomarker target level (or setpoint) may be adjusted  640 . In addition to adjusting the insulin dosage and the biomarker target level, it is also contemplated that lifestyle changes, such as exercise and diet, may also be used to minimize the risk. 
     In cases where the mean deviates significantly from the target and the standard deviation is significantly above the similar noise range, then the healthcare provider or the system may consider adjusting the insulin dosage or the biomarker target level or range as stated above. Additionally, the sampling set data may also lead the healthcare provider to consider a therapy change, either by adding diet and exercise, and the like, or by changing to different insulin therapies or different insulin delivery vehicles, for example, multiple daily injections of basal-bolus insulin, or insulin pumps. The sampling set data may also help the healthcare provider to identify potential life changes in the diabetic person. 
     The minimization of the risk value to the optimal level may also require a predetermined acceptable level of risk for hyperglycemia or hypoglycemia. For cases where the hazard penalty values raise the risk value to a non-optimal level, the one or more biomarker readings indicative of such an adverse event should be ascertained. At which point, the next optional steps may be to exit the testing method and notify a healthcare provider. Alternatively, it is contemplated that the next steps may be adjusting the insulin dosage, the target level, or both to try to eliminate the risk of an adverse event in a subsequent sampling set of biomarker data. 
     In addition to the quantitative mathematical illustration of risk minimization provided above, it is also possible to illustrate risk minimization through a visual illustration such as a risk surface as shown in  FIG. 9 . When the hazard function is calculated over a range of probability distributions defined by a mean and standard deviation, it may create a risk surface as depicted in  FIG. 9 . Therapy can be selected to minimize the risk, or perform gradient descent on the risk surface as shown in  FIG. 10 . As shown in  FIGS. 9 and 10 , a range of plus or minus 10 mg/dl are placed around the minimum and this range defines the target criteria for titration. Other methods for setting the target range include using ±10% of the optimal BG or as the range within a specified tolerance of the minimal risk value. In practice, fasting BG measurements (biomarker readings) from a patient would be used to determine the patient&#39;s current location on the risk surface. As the patient&#39;s therapy continues, the evolution of the patient&#39;s location on the risk surface could be plotted over time to track patient compliance and improvement. This would provide a simple visual method for quickly evaluating the progress of a patient. 
     As shown above, the risk surface can also be viewed by plotting the gradient direction as shown in  FIG. 10 . In general, titration affects the biomarker readings (mean blood glucose), thus in regions where the gradient is vertical, the best therapy would be to further adjust the insulin dosage. When the biomarker reading is optimized, the gradient points toward reducing the variability of the biomarker reading, so the physician can then change therapy strategies. The patient can be continually evaluated to determine his location on the risk surface, and then determine best therapy or advice to minimize the risk toward a more optimal location. This same optimization procedure can be followed with other therapy adjustments as well by matching the gradient descent direction to the effect of the therapy adjustment. 
     In addition to determining that an adjustment to the target or insulin dosage is necessary, it is also necessary to determine a specific therapy, routine, or regimen to minimize the risk to optimal levels. The insulin dosage may be adjusted according to an insulin adjustment regimen. As used herein, the “insulin adjustment regimen” refers to the number of insulin dosage adjustments required to achieve a target insulin level and the amount of each adjusted insulin dosage, wherein target insulin level is amount required to achieve the target biomarker level. Many suitable regimens are contemplated to adjust the insulin dosage. 
     In accordance with the insulin adjustment regimen of the present invention, the maximum insulin dosage to achieve the target biomarker level should first be calculated. The maximum insulin dosage to achieve the desired target biomarker level D target  is calculated by the equation Error! Objects cannot be created from editing field codes., wherein m is the rate of change from a first mean of biomarker readings B k−1  to a subsequent second mean of biomarker readings B k  based on the adjustment of insulin from a first dosage D k−1  to a subsequent second dosage D k  as defined by the equation 
                 1   m     =           B   _     k     -       B   _       k   -   1             D   k     -     D     k   -   1             ,         
wherein B target  is the target biomarker level, and the subscript k refers to the k th  consecutive sampling set. Regardless of the calculations, the maximum insulin dosage to achieve the desired target biomarker level D target  cannot exceed a maximum insulin dosage set by a healthcare provider. Also, the calculated maximum dosage to achieve a target biomarker level D target  may be assessed by a healthcare provider in comparison to a calculated D target  for a prior sampling set.
 
     Next, the aggressiveness of the insulin adjustment regimen must be determined. As defined herein, an aggressive insulin adjustment regimen means that the insulin dosage will be adjusted to the maximum insulin dosage in the first adjustment. Additionally, other embodiments of the insulin adjustment regimen may utilize a more gradual adjustment approach wherein the insulin dosage is adjusted to the maximum level incrementally over at least two dosage adjustments. The adjusted insulin dosage D k+1  after adjustment by the insulin adjustment regimen may be defined by the equation D k+1 =D k +λ·m·(B target −B k ) wherein λ is a regimen tuning parameter which ranges from 0 to 1 and corresponds to an aggressiveness of the insulin adjustment regimen. For an aggressive insulin adjustment regimen, the λ value will equal 1, such that the adjusted insulin dosage D k+1  is the same as the maximum insulin dosage. For less aggressive insulin adjustment regimens, the λ value will be 0.5 or less, or about 0.2 to about 0.3, such that the dosage adjustment will gradually occur over at least two insulin adjustments. 
     In addition to the insulin adjustment regimen, the target biomarker level may also be adjusted using a biomarker adjustment regimen. The target biomarker level is set to biomarker level associated with the minimal risk for a given noise level. In one embodiment, when noise levels are high the target mean glucose level is increased to minimize the risk of hypoglycemia. 
       FIGS. 11A and 11B , which are graphical simulations of the risk minimization of the present invention, include an initial biomarker target level (fasting blood glucose) of 100 mg/dl, and a 10 unit initial dose of insulin (Lantus®) administered for the first seven days. During the first seven days of the test, the mean (shown with the dotted line) was significantly higher than the target, and there was significant variance from the mean. As a result, the target was raised (see setpoint as illustrated in  FIG. 11B ) and the insulin dosage was raised to 15 units. From day 8-14, the insulin dosage was maintained at 15 units; however, the mean blood glucose was still above the setpoint and the variance was still high, but it slightly decreased. Consequently, the setpoint was decreased to reduce the mean biomarker and the insulin dosage was increase to 25 units total. This adjustment combination, which was maintained for the remainder of the simulation, yielded a mean substantially close to the target, and a variance within similar noise ranges. 
     Referring to the graphical simulations of  FIGS. 12A and 12B , wherein hypoglycemic events for various subjects over 100 days were studied for 10 different patients using three different adjustment regiments, robust therapy (λ=0.25), middling (λ=0.50) and aggressive therapy (λ=1), it is shown that a more gradual insulin adjustment regime has less risk of adverse events than aggressive insulin adjustment regimens using fixed target setpoints ( FIG. 12A ) or personalized target setpoints ( FIG. 12B ). Consequently, a more gradual insulin adjustment regimen may minimize hypoglycemic events in diabetic patients. Further as shown in the simulation, it was found that the risk of hypoglycemic events are minimized significantly, even at more aggressive levels of optimization, when using adjustable personalized targets in comparison to fixed biomarker target setpoints. 
     Having described the invention in detail and by reference to specific embodiments thereof, it will be apparent that modifications and variations are possible without departing from the scope of the invention defined in the appended claims. More specifically, although some aspects of the present invention are identified herein as preferred or particularly advantageous, it is contemplated that the present invention is not necessarily limited to these preferred aspects of the invention. 
     All cited documents are, in relevant part, incorporated herein by reference; the citation of any document is not to be construed as an admission that it is prior art with respect to the present invention. To the extent that any meaning or definition of a term in this written document conflicts with any meaning or definition of the term in a document incorporated by reference, the meaning or definition assigned to the term in this written document shall govern. 
     While particular embodiments of the present invention have been illustrated and described, it would be obvious to those skilled in the art that various other changes and modifications can be made without departing from the spirit and scope of the invention. It is therefore intended to cover in the appended claims all such changes and modifications that are within the scope of this invention.