Video A Step-by-Step Approach for Launching and Maintaining a CGM/AGP-Based Management Program in the Physician Associate Setting Play Pause Volume Quality 1080P 720P 576P Fullscreen Captions Transcript Chapters Slides A Step-by-Step Approach for Launching and Maintaining a CGM/AGP-Based Management Program in the Physician Associate Setting Overview Continue To Test Back to Symposium Hello and welcome to this part of the program called strategies for incorporating see GM into practice. We've already heard from Dr Unger who really set the foundational stage for C. G. M. And now I'm going to really talk about how we bring it to practice. My name is Diana Isaacs. I'm an endocrine clinical pharmacist. I also am the C G. M. And remote monitoring program coordinator at Cleveland clinic. And I get the pleasure of starting tons and tons of patients on C. G. M. And following up with them. What I want to go through today are really to describe the barriers to incorporating see GM into practice and then discussing some real world strategies to overcome those barriers. And then we're going to outline how to use the I. C. C. Framework which stands for identify configure, collaborate and how this framework can really be used to address many of the common barriers. Whenever I give a presentation on C. G. M. I love to show this visual to really illustrate how C. G. M helps us overcome many of the barriers to just traditional blood glucose monitoring and what you're seeing here is a 24 hour period and the zero represents 12 a.m. 24 represents midnight. The green represents what we call the target glucose range of 70-180. And these black marks represent glucose meter readings. So first of all I'm really lucky if I have a patient come in with their meter and they're checking four times a day but when I do have that and if I had data like this, it appears that all of these readings are in the target range and most likely I continue present management, right? But when you put C G. M. On a person, you see everything that happens in between those dots. And in this situation we're actually seeing undetected hyperglycemia. That's happening postprandial lee after breakfast and looks like what's probably after dinner. But what's really alarming here is that we're seeing undetected hypoglycemia uh and that's occurring overnight and this situation is actually really, really common In our efforts to help people get to a one C target. We often as a team, we may escalate therapy, increase their long acting insulin. Not realizing we're causing this to happen, which leads to more glucose variability and actually leads to worse outcomes. And C. G. M. Really helps us to uncover this this pattern. But in addition to that, C G. M also provides us with real time data and this allows the person with diabetes to take action if for example, someone is getting ready to drive home from work and uh it has to make sure it's safe. So we have them check their glucose. Well let's say the person checked with their meter and it was was 108. Well they'd probably say okay, it's safe for me to drive home. But what see GM provides is that one oh eight, but also that arrow letting them know the direction. And so if a person had like we see on the left A 108 with an arrow going straight down. That indicates in the next 15 to 30 minutes as they're driving home, they very likely could experience alone. But on top of that let's say a person just doesn't check. They don't look at their glucose that's okay too because these systems also offer real time alarms. And so even if a person didn't check, hopefully if they get to their low threshold often set maybe for 70 then that alarm will go off and the person can take action and really prevent a potentially catastrophic accident. And we know from CG on that from our studies, several randomized controlled trials and prospective observational studies that overall C. G. M. Really shows that it's able to reduce episodes of hypo and hyperglycemia which leads to reductions of emergency department visits and hospitalizations and also that it across the board is able to increase the time spent in target glucose range as well as reduce a one C levels. So that all sounds great right? But we also know that there are some barriers to see GM use. And I split these up really into three main categories where we have the healthcare professional barriers, the patient barriers and then health system barriers when it comes to health system barriers. Just anytime you're incorporating a new technology or anything new, you have to think about the logistics. Well who is starting the person who is facilitating the prescription, Who's doing the education and training. You have to come up with a plan for that. One of the biggest barriers though that we do face since there are different see gm systems available that have different data platforms is how do we easily access that data And ultimately what we're all striving for. And some systems have already successfully done this is the integration into the electronic medical record where it all seamlessly goes there. So we don't have to log into a different system. We don't have to retrieve data remember our user name, password at additional team members. But we're not we're not quite there yet. But that's the hope also just therapeutic inertia. So it's in some ways when we saw that example in the beginning when all you have is an A. One C. Or all you have some finger sticks. It's you don't have much data to work with. Right? But now all of a sudden we have a lot more data to work with. And so we want to take action instead of just bringing someone back at three months when we would normally recheck in a one C. Now we have this extra data. And so we want to think about, well when do we want to see the person back again and how frequently can we change medications or make lifestyle recommendations to really optimize care when it comes to the HCP and the patient barriers for the HCP. There can be for both http and patients. There can be tech aversions. Right. Just it can be hard trying something new on the patient's side sometimes wearing a device so I don't want to wear my diabetes or I don't want people to see that I have diabetes once an HCP is on board then it's you've got to communicate the benefits to the patient right and convey why it would be a good option. And then figure out that process for prescribing education and training. And then of course fitting in that data interpretation into those usual office visits and on the patient's side we no cost access can be a consideration also making sure that they get that appropriate education and training and then understanding what the data means so the person can take action on it and we're going to talk through many of these in a little bit more depth. I want to first talk about though, overcoming some disparities in C. G. M. Use because we do see health disparities all across healthcare especially in diabetes and then also related to C. G. M. So 65% of black and Hispanic patients compared with 79% of white knew that Medicare helps pay for diabetes testing supplies and self management education. So we have to ask ourselves why is the difference why do some people know why do more white people know than black and hispanic patients. A retrospective chart review showed that 30.5% of black and 32.5% of Hispanic patients initiated see GM compared with 54.3% of white patients. So why is there that difference? And then the third bullet among Medicare beneficiaries who acquired a C. G. M. Device. There was a significantly lower proportion of C. G. M. Use by black and hispanic beneficiaries only 0.5 and 2.9% respectively compared to 91% that were white and 5.6% other. And so we just want to make sure we're not we're we're recognizing these potential biases and we're not making assumptions about people's knowledge about things or people's insurance coverage just based on their color or their background. So now I want to introduce this I. C. C. Framework which is a great framework that can help us to overcome some of these barriers to technology use and also address some of these health disparities. So it starts off with identify and identify is identifying the right technology for the right person at the right time. Really taking into consideration these individualized factors and making sure people are aware of their technology options once that has been done and the device has been selected. Configuring that device based on user characteristics, user preferences, what the treatment plan is what type of support the person has and then collaborating with the person with diabetes. Having shared decision making through data driven conversations about the data and the reports and what it all means. So let's first talk about some of that identifying and with identifying. There's a lot of considerations when choosing a glucose monitoring device. One of those might be the frequency of sensor change. So we know some devices need to be changed every seven days. Uh and then we have an implantable that can be changed every 180 days. So there's definitely very variances there. Of course cost and access is a consideration what people can afford and what their insurance will actually cover compatibility with other devices. So if someone is thinking about using a connected smart pen or in a certain insulin pump or wants to use certain mobile apps. Thinking about which types of C. G. M. Will integrate with those devices. For some people the size of the sensor is a big consideration or where on their body they can wear it. Some people really want it to be more discreet and others are are very proud to show their diabetes Of course the accuracy of the sensor. Unfortunately with all of our FDA approved devices the accuracy has really improved dramatically over the years and then the ability for the real time or predictive alerts. Some just have alerts at high and low some devices have rise rates and full rates and additional alert options. So some things to think about when you're having that conversation with a person with diabetes, does a person want to have anything attached to them? Uh That's an important consideration And or if they wanted to be more discreet picking a sensor maybe that goes uh that can be worn on the stomach or in other places where it may be less likely to be seen by others or an implantable option where it's easy to kind of disconnect the transmitter if they want to and then um this person in the second quote, if I could see more information I think I'd feel more motivated to take my meds and eat healthier so often that can be a great impetus to using C. G. M. Over traditional blood glucose monitoring is just that desire to have more of that data and everything. So once we've identified the right technology for the right person at the right time and I am a big fan of making sure our patients know about all of the available options so that they can make an informed choice and that we don't assume based on their background that they may not have coverage. Um we should make those assumptions but once we've done that, let's help them configure this and this step is really important to ensure success with the device. Otherwise you can run into the situation where someone is prescribed it, they get it and they stop it after seven or 14 days because they didn't feel like they were benefiting from it or they felt like they were getting alarm overload from it. So here we've got different options. They've shown one of the systems where you can see, there's a lot of things you can adjust in terms of what you set your low and your higher high alert for if you want to have a rise rate or a fall rate on if you want to have a different alerts for bedtime versus daytime. If you want to signal loss alert, many will allow you to set reminders to take insulin doses or medications and these are all great in everything. But what I can tell you is if you put all the alerts on and especially if you make them really aggressive like setting that high alert for like 1 50. That is a recipe for disaster. That is going to be so frustrating to the person and the thing is going to beep all the time and then those beeps aren't even going to be meaningful. So having a conversation and determining what will work best for these alerts really goes a long way. And here's just some examples in thinking about when it comes to sharing data. So many, all the systems have some data sharing features where you can share the data with the clinic and you can share the data with loved ones or friends or caregivers and so asking the person what they feel most comfortable with. And here we've got a quote at the top. I want my wife and kids to see if I'm having a higher low blood sugar so they can help me if I if needed. So in that case we would probably really want to set up a lot of those sharing features right? In the second example about alarms the person says well sleep is really important to me. And I heard C. G. M. Beeps and buzzes all night. I do not want beeping during my sleep. I've always been able to feel my lows. So in that case we might we might still keep a low alarm. I'm Many systems if you're using the smartphone have an alert of 55 that you cannot shut off. But maybe in this case that's the only alert we have and we don't have other low alerts. And then for reminders this last person says well you know I get so wrapped up in what I'm doing I forget to check my glucose or take my insulin. I could really use those reminders So great for him we would turn them on. But there's other people that do not want reminders that have a very variable schedule and don't want anything beeping and buzzing and telling them what to do. This quote comes from the A. D. A. Standards of care and it says that no device used in diabetes management works optimally without education training and follow up. And this could not be more true and to really illustrate this, I want to share an example of a patient that I saw this is Camille, she was given a C. G. M. But she was not educated on her glucose targets and she had been wearing it for three months. So even if you know nothing about C. G. M. Interpretation, hopefully you can see here her average glucose is 368. She's only 2% in target and her her G. M. I, which is her basically an estimated at a one C. Is 12.1. And the The tragedy here is that she had been wearing it for three months and had no insight into the fact that she wasn't meeting her goals. She was actually very engaged with the device, 74% of the data has been captured but she didn't know she wasn't meeting her targets because she wasn't educated on what her glucose targets were. And so when we start someone on a device on a C. G. M, we want to make sure that they understand what their glucose targets are. It's also a great time to introduce the concept of time and range That we're aiming for that 70-180 and for most people were aiming to spend 70% or more in that range. If Camille had gotten that education, she could have at least reached out to the team to be seen sooner so we could address this and really be able to help her. So there's actually 42 factors that have been described to affect glucose levels. And when we often when we think about this we often think about the common things right? Like carbohydrates will raise glucose levels and insulin will lower glucose levels. But it's actually much more nuanced than this and that is where having the data is so powerful Because a person can see how they are uniquely affected by these 42 factors. And you will notice on here that some of these arrows go up and down or up and sideways, meaning people have variable responses. So for example with coffee with caffeine we see that some people are unaffected by a cup of black coffee because it doesn't have carbohydrates in it. But others will spike up and actually may need to take insulin or do something with that. And we also see similar things for example with activity levels depending on someone's fitness. Um sometimes activity intense activity might drop them for other people that initially spikes up. And the point of all this is when you have real time data, a person can address this. I recently had a patient who's wearing C. G. M. And she was able to figure out how a certain type of apple raises her glucose more than another. So that's where wow. Having this data is really powerful. But the data itself is is it's just data, it's having that collaboration and following up on it. And then some some patients are really insightful and they figure out a lot of things on their own. But meeting with the care team and reviewing the data together can really address some of the challenges and can help facilitate lifestyle changes as well as when medication adjustments are needed. And this is just highlighting here how technology itself does not necessarily fix things. Uh It's through that collaboration and doing something with the data. And so this brings us to well who on the care team will review and respond to the data. And this can be individualized based on the clinic based on the health system. And so thinking about this there are many different options for who can be involved in my system. It's often we've got pharmacists and diabetes care and education specialists that review the data with patients because we understand typical office visits uh sometimes are they can only occur based on availability every three months or every four months or six months. And we know with having this much data we can take action more quickly, especially in the beginning when we first obtain the data and we want to make more changes often over time it can be less frequent when someone becomes more stable but really think who on your team can you utilize either to train on C. G. M. To start it. Uh And then to follow up on it. And speaking of following up it really helps to have a systematic process for reviewing the data because it's easy to get lost in the weeds and just say oh my goodness there's so much information here. I don't know where to start. Fortunately we have what's called the ambulatory glucose profile report which is a one pager and really includes all the information. So we don't have to sift through multiple pages if we don't want to. But this five step process is a way to systematically go through the data where you start off and you download the data or you obtain that data right in this step. I also like to orient the person with diabetes to just make sure they understand what their glucose targets are and often make sure they understand this concept of time and range or introduce it if they have not heard about it before. I also like to ask what's going well with diabetes self management in this step the next is assessing safety and that is looking for hypoglycemia and trying to address it because we know that that is a safety concern. It often leads to rebound hyperglycemia and just more overall glucose variability after that. We focus on time and range. We focus on what is working well and trying to replicate it and sometimes this is counterintuitive because I know as a clinician I have I don't know I've been trained to want to fix things and so I am easily drawn to the areas the spikes where there's tons of hyperglycemia but this is kind of reach. Reframing it and focusing on what is working well which can be more motivating for the person with diabetes. And we can learn a lot from that and then trying to replicate that. Then in the next step we still we do look at potential areas to improve and then we take all of that information together and come up with an action plan collaboratively with a person with diabetes. And I like to emphasize that each step that this is information. This is not inherently good or bad. Even in ca meals case where her timing range was 2%. That's not bad. It just means it's information that we're going to use to help her increase for time and range and optimize her care. And I'm not gonna go too in depth on this. But I did want to show an example where this is a patient that I saw. This was his initial C. G. M. Report. And this is that A G. P. That really has all the information on the one page. So at the top we have those C. G. M. Key metrics. Then in the middle we have that ambulatory glucose profile which is the visualization of the data. And at the bottom we have those last 14 days of data. And so what you're seeing here is this patient actually spends 85% in target which is a goal. However he is spending 7% of the time below 70 which is much more than we'd like to see. That's too much hypoglycemia. And this is a good example of a case where kind of like that example I showed in the beginning where we see those lows are actually happening between 12 and eight a.m. Overnight. And so this is an example of someone who really is over basil ized who's on too much long acting insulin. And so our goal would be to decrease it and then figuring out how maybe we could optimize some of the Brandel the glucose elevations that occur postprandial lee. And so what we did in this situation and this did occur over a few visits. It wasn't necessarily just in one visit but work towards decreasing that long acting insulin. And in this case we actually added a GLP one agonist which we know can help with the postprandial glucose elevations. And you can see here we really maintain that time and range. This person is still 80. He's 86% in target but now only 1% of the time below 70. And still in terms of that glucose management indicator at 6.7% which is the FX goal under 7%. In addition to reviewing data on a case by case basis. R. C. G. M. Also really facilitates remote monitoring as well as population health and this is an example of one of the portals. The C G. M. Portals where I can look at my patients And actually organize them by different characteristics such as the percentage of time they're below target below 70 or the coefficient of variation which is the glucose variability or the percentage of time there in target. And the advantage of this is you could actually focus in on, you could say well I am going to we're going to proactively reach out to our patients who are spending greater than 5% of the time below 70 because we're concerned about their safety. Uh and because a lot of people now are using their devices on their smartphone, this data updates constantly to the cloud. So you always have the most current information. I want to spend the rest of the time just addressing some additional barriers and solutions to address those barriers. So we know patients may call and say oh gosh my sensor fell off early and that's a problem because you can't just put it right back on u need a hole insert or to do that. So we want to help people to have it stay on the whole wear time. And fortunately there's tons of products that really help this to occur. So in terms of options to help tape over the sensor, there's a lot of beautiful products out there that can be taped on that have different colors and different designs which can be really fun for kids or just people that like colors or you can use clear options. But many things that can go over the sensor as well as there are products that can go under the sensor as well. Uh Products like skin tags or master Cell can go underneath provide a tacky layer. You wait about 30 seconds and then you place the sensor on over it. So for people like when you think about people that sweat a lot or hot humid summers I may recommend both types of products and that generally works very well to make sure it stays on the entire time. Also advising people to make sure the area is very clean and dry before placing it. You want to avoid lotions or anything and you can always call the companies for replacements. They are great about that. So if it does fall off early I always encourage patients to call now. What about coverage? So a common mistake I see happen is that it's not the script is not sent to the right place. So many times the prescriptions can be sent to the pharmacy. Certainly for people with commercial insurance. However, Medicare generally goes through the durable medical equipment route. And so a common mistake I see happen is that the prescription actually gets sent to the pharmacy and then it's assumed it well it's not covered right it's not covered through the pharmacy. So it's assumed the person just doesn't have coverage for it. They end up not starting on the C. G. M. Because they're quoted a high price because it's not going through their insurance and sometimes it will ask for a prior authorization which inevitably gets rejected because it was supposed to go through D. M. E. And so knowing upfront that it's supposed to go through D. M. E. And then you can work with certain companies to process your DME. There's also systems like parachute that can connect you to multiple DME companies and really facilitate that process and the paperwork and that prescription as well. What about when to check blood glucose with a finger stick? See GM is amazing but we are not quite ready yet to throw away the meters. And in fact there is guidance from the A. D. A. Standards of care that says every person using C. G. M. Should have access to a meter and test strips. So when should a person check well with some devices, a calibration or a drop of blood may may occur on the device. And that lets the person know that like for example with the library in the 1st 12 hours of use it's recommended to confirm with the finger stick of making a dozing decision other times for any device if symptoms do not match expectations meaning someone's feeling low but they're devices not saying they're lower vice versa saying they're low and they feel fine. That would be a time to confirm with a finger stick. Also there are certain indications that are not FDA approved with the devices and one of those is pregnancy also in dialysis or in critically ill. And so those would be times where we still have patients where C. G. M. With these conditions but we would want them to confirm more with finger sticks to ensure the accuracy of the device and with some devices that have the non that do not have the non injunctive indication. So an example is the Guardian. It's recommended to always confirm with a finger stick if you are making a dozing decision off of that reading and then also with interfering substances. So we know some devices are affected by vitamin C. Or acetaminophen or hydroxyurea. So if using one of those substances then you'd want to confirm to ensure the accuracy of the device. And then there are some that do require calibrations like Guardian in ever since. And those will need some regular finger sticks for you. So we talked about a lot of information today overall See GM has really demonstrated many improved outcomes but to experience maximum benefit. People with diabetes need education and training on the devices and we also want the health care team to be trained and how to use the data. The identify configure, collaborate that I. C. C. Framework is a tool that can address many of the common barriers to see GM use and there are many ways that the health care team can help with c g. M. Access initiation, education and collaboration of data to ensure optimal use and maximal benefit. And I just want to leave you with some resources that I have personally found helpful through many of these various diabetes related organizations, and I want to thank you so much for attending today. Published May 19, 2022 Created by Related Presenters Diana Isaacs, PharmD, BCPS, BCACP, CDCES, BC-ADM, FADCES, FCCP Endocrine Clinical Pharmacy SpecialistCGM and Remote Monitoring Program CoordinatorCleveland Clinic Endocrinology and Metabolist Institute
