Video A Step-by-Step Approach to Launching and Maintaining a CGM/AGP-Based Management Program in the Primary Care Setting Play Pause Volume Quality 1080P 720P 576P Fullscreen Captions Transcript Chapters Slides A Step-by-Step Approach to Launching and Maintaining a CGM/AGP-Based Management Program in the Primary Care Setting Overview thanks so much for joining me for a step by step approach for launching and maintaining a C G M A G. P. Based management program in the primary care setting. How do I work with my available resources and what do I need to know to incorporate C. G. M. A G P. Into my primary care practice. I am Dr Eden Miller. I'm the director of diabetes and obesity care in bend Oregon. I am a board certified family medicine specialist but I'm also a diabetes ologists. I'm a diplomat of obesity medicine. I received my fellowship in obesity a couple of years ago to bring really high level care for my persons in my practice who suffer from diabetes and have weight related challenges. I'm happy to present to you today on behalf of Abbott which gave us an unrestricted grant for this particular program. Here are my disclosures. So, CGM systems are more than new monitors. They really move us beyond what we call that point in care time for blood sugar, self monitoring blood glucose testing and they really are the predictive glucose measurements. We have more data and more insight. Another analogy would be taking diabetes out of the past, putting it into the present and predicting the future. I also like to describe to my colleagues as well as my persons with diabetes that I'm going to take off the blindfold. That self monitoring blood glucose all all all sometimes causes us to be blinded to all of the data. Yeah, I indicate to them that C. G. M. Is like your own personal gps of all the different glucose is that you visit when you have diabetes. In addition it can give you that heads up of where you're going with your glycerine, me a high or low staying stable. And then on the provider side we can but get this data download and interface with it with the patient and have a shared decision about so many things that go into having diabetes and we're going to explore that today. But monitoring is not necessarily managing just because you wear a C. G. M. Doesn't mean that you're automatically engaged in your ongoing care. So we need to fully utilize what C. G. M. Has to offer for the person as well as the prescriber. We really ought to think of it as beyond real time metering and use it as that predictive as well as retrospective and therapeutic tool that it is. You can sense that I have excitement with this because I'm empowering you and empowering the patient. This is one of those devices where there isn't any person in the whole continuum who isn't going to benefit from it and it's an immensely empowering and engaging tool that I want you to become familiar with because you will look back as a health care prescriber and your patients will look back and you'll say how did we ever manage without this because you cannot control what you do not monitor. It's exceedingly hard and so you're going to find that this is gonna open up a new pathway, an easier pathway for you to engage and assist your persons with diabetes in reclaiming a bit of what diabetes is taken away from their life. So the question is to see GM or to not see GM First of All, A one C is an average. I like to sometimes talk about a one CS like an average speed. Imagine if you were driving and you got pulled over by a law enforcement person and they said, Hey, you're going 35 in a 25. And you said, Well put my average speed is 25. They would say, I don't care what your average speed is. Yes. They want to see as a metric and I don't see us ditching that anytime soon. But it's a limited metric. It's an average and patients can have the same a one C but vastly different contributing glucose ranges. As I mentioned. See GM takes diabetes out of the past in a three month retrospective metric of diabetes management and places it in the present and helps anticipate the future. We also want to see GM when things just don't make sense when a person is telling us a fasting plasma glucose that is normal range or in target yet their A one C does not demonstrate that or they are talking about other feelings throughout the day. It's also an engagement tool when persons with diabetes are not tracking their own disease. I often utilize it for those who are highly distressed with their diabetes, I think very few people have a personal harm wish to themselves and those that are not engaged, just don't know what to do. And so if you empower them by revealing or exposing what their glucose is, our to them, they will have more tools for empowerment. Now. Somebody right now are saying oh if my patient knows what their blood sugars are, they're going to get depressed. That's when I say don't ever emotional eyes, your numbers, you don't emotional eyes, your gas gauge, you don't emotional eyes, your speed. And so this is information and I say it's to learn you because you're unique in how you have diabetes. There are many factors that affect your glucose that we're not even aware of. This is an opportunity to discover who you are. I want you to journal what you eat, your stress, your engagement and your medications, your sleep, your physical activity. I want to learn you and I want you to come along for this journey. Of course see GM prevents against hypoglycemia. But to just think C. G. M. Is a hypoglycemic identification and prevention tool is too highly limit the benefits that C. G. M. Can provide. So here's an example about how the same an A one C. Doesn't equal what we call time and range Time and range being 70- 180. We erroneously assume that patient a with an a. one c. of seven has 100% of their time and range. No. In addition if we look at patient B. Who has an A. One C. Of seven we can see that their time in target range 70 to 1 80 is about 63% And their time above range is 29 and below is 8%. But another individual with the same a. one c. Only has 24% of their time in range because they have split their glycerine mia amongst the time above range and time below range. So the A. One CS don't really tell the story. I've often said you can know the A. One C. But not know the time and range. But if you know the time and range you can know the A. One C. Or if you increase that time and range you will know what the A. One C. Is. So how do we identify the right person for C. G. M. This provider would tell you that there isn't a single person with diabetes who couldn't benefit from C. G. M. But let's take a deeper dive in those that we want to make sure that you understand. So persons greater than or equal to two years of age depending on the device would qualify for C. G. M. Who need or want more engagement in their diabetes. It doesn't matter whether a type one or type two outside the U. S. We have the opportunity to use C. G. M. Beyond type one diabetes who are pregnant and they use them and those individuals with Type two, we do not have that really endorsed here in the US but understand it's not contra indicated that's the difference. But we hope that that will occur here in the United States very soon because the utility of C. G. M. For those controlling their glycerine miA during pregnancy, irrespective of which type is imperative. Now, we know that we want to identify at the very minimum all persons who are at risk for hypoglycemia but they may or may not need alarms depending on the system. And those would be persons that utilize symphony areas, basil, insulin, multiple, daily insulin dosage or those on insulin delivery pumps. That should be your very minimum. Every person if you approach see gm from a hypoglycemic standpoint should be offered or utilize this particular technology. Now, I would also encourage you for those with advanced age or complex disease, congestive heart failure, kidney disease. Those are approved if an individual has kidney disease because of the risks associated with it. Now, what about persons with poorly managed or engaged diabetes who could benefit from understanding their personal influence that diet activity medication. Glycemic management could benefit from illumination of what their personal glucose history is. Now there are current challenges that we have and especially management of type two diabetes we really need to have a progressive plan that intensifies or what I like to say, keeps pace with the person's progression but also encourages individual engagement of the patient. Clinical inertia is vast. In fact, it's one of the roles that I play beyond here. And many of the articles you can see below. I have co authored for overcoming therapeutic inertia. It's so prevalent in the United States, especially in type two diabetes and the longest delays we see for insulin initiation and titrate ation are in the years before this is accomplished and we got to move that needle. We also have this under recognized or under equipping fear of hypoglycemia. What do I mean by that? We're afraid of it, but we don't know how to manage or mitigate those symptoms as a result of that. When a provider is uncomfortable or unequipped, we see a transferring of that diabetes distress to the person because they don't feel confident or they don't feel like they're provider knows how to direct them and we'll get ongoing treatment and lifestyle not adherence and poor treatment, persistence and therapy. As a result, we see increased healthcare utilization costs. If we don't manage it, we pay for it later and it might be the largest costs associated with diabetes. We allow it to metastasize to other organs. We allow it to go unchecked and we think that it's expensive to treat diabetes, it's more expensive to have the consequences of diabetes. There's often this unawareness or what we call a symptomatic or silent hypoglycemia in the type two population. And I'm going to demonstrate that a little bit later by a discussion of a particular case. So let's distill down how a person may benefit either from professional or personal. C. G. M. Now understand professional. C. G. M. Is owned by the healthcare provider. It can be billed as a CPT code. It's purchased by the provider. They're very affordable because they're reusable and depending on the type of C. G. M. That's in professional it can either be blinded. In other words the person who is wearing it does not see the data and in many cases it can also be illuminated or opened up for them to see it. So it depends on the device it is placed in the office, it is reviewed in the office, it is built for in the office. We can be multiple uses in terms of either the transmitter battery or the receiver or in some cases there are disposable which are individual to the person. But the sensor itself generally is a disposable system. It collects the real time data and it can either be worn for 367 or 14 days depending on the type of C. G. M. Professional that's utilized. All of these can be downloaded and I can tell you that they're highly reimbursed which means we don't have to get authorization. I would encourage you to document in the chart while you're doing it. Treatment, intensification, illumination of hypoglycemic risk, you know subtraction or D into intensification of insulin revealing the glycemic pattern for personal engagement. The Medicare and Medicaid will cover them and cover them quite frequently. So be familiar with what interval whether it's three months or six months. But this is not something that is hard to navigate. Now if we transition to personal CGM that's owned by the person, the sensors, the transmitter, batteries, the receivers or the phone based application, it's owned by the person. It can be standalone. It can be linked to other family members that can actually be linked to. I had a patient come in yesterday who had their Apple watch and they were looking at there glue glycemic levels visibly whether through a reader, which the FDA requires for all C. G. M. S to be provided on the personal basis which has its own unique NDC code or a reader that is through the phone based application. Either IOS or android and that is looking at it through an app which are all free. And so you can see that there are different ways to engage in it. In addition there are certain pumps that pair or link with I see GM systems and I will mention that a little bit later. Most sensors on a personal level are either worn seven or 10 days. There are often summer 14 days and now we actually have implantable sensors in the US at 90 days And those have just been advanced to 100 and 80 days and I will review them as well. They are either a real time pushed data or they are a flash version. What's flash flash is where you can engage and pull the data or swipe or what we call activate the transference of data and I will also identify which ones fall in those different categories. So what does the person and the provider get with CG? And let's talk about that. So let's talk about the benefit to the person who's wearing it. They really do get that opportunity for increased individual engagement with their own disease. It really is a barrier buster. It's an engagement tool that you will be amazed when you apply it for the first time to a person and they come back and I start out by saying, what did you learn about yourself? It is very individually driven and so you have to say, hey, you may not be used to monitoring your blood sugars very often. You might just look at it once a day according to self monitoring. So I need to engage with this quite a bit. And that engagement is always before and after meals bedtime, that kind of thing or or when things are different when they exercise their high stress. And I said this is for you and it's where if you don't engage in that data. How are you going to learn anything right. In addition you want to orient them to trend arrows on the receiver where directional arrow, their blood sugars going. That's empowering to prevent hypoglycemia, hyperglycemia to talk about stability. It's very good for family members who are concerned and worried about their caregiver. You've given them a tool for safety. And then of course if you have the person utilizing see GM effectively log kind of journal, don't make it too complex. Food, time of day activity levels, illness, stress, sleep mm hmm. After all, you want to know what happens with their glucose with their activities of daily living. What a great opportunity. And and I would say that both persons and providers benefit as well. And this ease to apply it. Often times I'll get questions. It's complex. It's that 1/5 grade level. And so that's understandable for people who wear it for caregivers or those who interface with it so they can share, they all have sharing data capabilities through phones. And this is not hard to do. I don't, I want to encourage you as prescribers but if a person can do it at 1/5 grade level, you can do it with advanced degrees. So don't shy away from that. Now let's transition to the healthcare provider and the benefits that they get. Of course we benefit when a person owns their own disease. After all, my job is to turn them into an expert on their own disease. I can't be with them all the time. I want them to shoulder the burden of the work of their disease but with the greatest of ease. So this is often one of in my opinion, one of the greatest benefits we do get increased awareness and protection against hypoglycemia prevention. Now, here's the part that we're going to break through a little bit in our subsequent slides. You may be blinded to the fact that your therapeutic management, your prescriptions, your directional changes in medication has a therapeutic signature. Each drug, each therapy has a particular way in which it interacts with the person and you may be totally unaware of this by downloading a person, see gm whether it's um how shall we say personal or professional, you're going to start revealing these profiles. It's going to take some time to learn them. It's kind of like that name. That tune. You hear a few couple of notes and you go, I know what that is, because you're gonna have to be exposed to these. And you're going to be able to say with a glance, I know what they need. I know what the medication is and how it's impacting their glycerine mia. So, as you embark on this adventure, take those reports and I will show you in a moment and right on them put where their medications are put where their activity is because you now have a compiler herbal principal data set that reveals all of these things we talked about and then to cap it all off, you can build for it and you should build for it and you can build for it every single month for that time, whether it's virtual or in person. So again, it's very hard to identify where a person or a provider with diabetes wouldn't benefit from incorporating and utilizing C. G. M. So we've talked a little bit about that person with C. G. M. And it's important that you know this because it's going to give you the greatest direction and it's going to give you the greatest approval. So we will go through which ones and how that they are FDA approved But keep these in mind so that you can choose the right one. So let's talk a little bit about the commercially available ones and I'm also going to talk about the ones that are upcoming. But my disclaimer is is that they're not necessarily approved yet but you will get a feel. And as you can see here it's not a massive list. This is a group that you can become familiar with and you can find one or two that you can incorporate into your practice for first we have on the left hand side, the Abbott freestyle libre system. We have the traditional 14 day which you can see on the left upper hand corner has a phone app has a reader. It's very unique. The sensor and the reader in the app are very encased in other words you can't be switching between sensors and apps. You need to stay with that family now. They do not have alarms but they're non calibrated, which means you don't have to poke your finger. But then we have the freestyle libre two which also has a very similar look and feel. You can see the readers of different color. The application is a different color but the sensors look the same but they are different. They're both worn for 14 days. They both don't require calibration and they are not currently linked. There is a pen that's linked out there but they're not currently linked to any pumps but they may be in the future in addition what's in development but again, not approved, we're not saying it's out there, don't go try to look for it. But in development is the library three. It's going to look different and it's going to have different what we call interaction or linking capabilities. So stay tuned, we have the decks com G six family and you can see it's little portfolio here with the sensor that's applied on the left, the transmitter battery, which is the gray one and then we have the different phone applications transition to different fitness or wearable related devices and the G seven is going to be coming out but again, not necessarily approved, but I heard that it's already in review at the time of this taping, Medtronic has the Guardian connect which interfaces with its pump. It also has a stand alone. They also have a pro the decks com also has a pro system as well as the library and the decks com does interface with the tandem pump and it is going to interface with the omni pod soup and then finally we have the implantable sensi onyx ever since which is in the right hand corner and that's what it looks like in an uncased kind of version And it is currently 90 days but the 180 day has been approved and I would anticipate its utilization in the U. S. Shortly it's applied in the upper outer arm area and the receivers worn on the outside. Now here is those cleared by the FDA and you'll be able to look at these in a more in depth. You can see the sensors that we've just reviewed from left to right and you can see that there are different age approvals as we look at the 14 day in the library to which is four and above and the G six is which is two and above the Guardian which is 14 and above and the ever since 18 and above. We can see the Medicare coverage with that the only one to know that isn't covered by Medicare is the Guardian sensor three. And we can see the wear length depending on which one, the freestyle are generally 14, the decks come is going to be 10, the Guardian is seven and now the ever since is 90 to 100 and 80 days, the warm ups are a little different between them. And I've even heard that it's possible that some of the newer versions of the freestyle libre three in the decks, com G seven may have a different warm up, but we will wait for those to be published. Now the alarms are not hard to remember because all of the systems have high and low alarm, some are optional, some are not the freestyle libre 14 does not have an optional alarm, but you still can't tell if you're trending down and such to prevent hypoglycemia. Now, what's unique probably about the freestyle libre two is the alarms are Optional. That means you can turn them on and off. You can just do a low, you can just do a high, but I will tell you going from the freestyle libre rate to over all of them have a non optional alarm. In other words of less than 55, it's going to alarm even if you turn those alarms down or augment them. And so depending on the type of person, this is where you might want to customize particular. See GM for a person personal, where and if you look at, you know, persons on pumps, you know, even though you can effectively manage a person's diabetes with a sensor that's non integrated with the pump. If you're looking for certain pumps such as the tandem right now, That is going to be paired with the G six. So some of its control like features can be utilized. The Guardian three sensor of course is with the 7 70 medtronic pump and it allows its interfacing. But in the future some of the pumps, some of the options including the omni pod coming out and other versions may have different compatibility with different sensors. You're going to have to see the ever since is not currently linked to any pumps, but it still allows individuals to create the data and to make meaningful decisions. So both freestyle families are all disposable. In other words, there is no transmitter battery that's required to retain both the decks calm and the Guardian required the transmitter battery to be retained to the next sensor and the ever sense that overlaying receiver or transmitter of the data rather, I should say, transmitter requires charging of that battery to occur. Now if we go very specific into the freestyle libre, you can see here, this is kind of the ways in which to engage. It doesn't matter if you're the 14 day or the two you're going to use the library app for the corresponding sensor to achieve to get the data or the reader. Then if a person wants to share that data, they will take their app, which is the liberal link that's the individual person that downloads that app to receive their personal CGM data and they're going to send an invite through their email and the loved one or family member is going to have the library link up app on their phone and they will approve the invite because of privacy things and they will now be able to follow along the participant. Can you follow along the library link up with the reader? No you can't because it's not a phone. So in orderly utilize that you're going to have to be through the phone app based system. Now the Liberal view on the left hand side is your health care provider desktop. I don't care what it is. It's a laptop, it's a desktop. You need to download that in your office in order to interface with the data. I urge you to do it, do a workflow, take a few minutes, do it at lunch, have a particular representative come from library to download this library view, create an account. It's not hard to do. It's not rocket science and you will either receive the data if they're on a phone based system through a cloud after approval or sending your code or approving an email. But if you have a reader you gotta plug it in. Okay now if we go to dex calm we have both phone based applications which is the app which is the looking of the data. So what's called the decks calm app for IOS and android. Now you can share same kind of way the person who's the family member puts decks com share on their phone and then they get an email and now they can see that person's real time data. Now clarity is something that's important that the healthcare provider has to put on their desktop in their office in order to engage with the data. But the person with diabetes also has to have clarity on their phone as well to take that data and transmit it. And you can share that data or get approval through hipAA and privacy by either you as a clinic sharing your decks com code or you also approving an email and so you may receive that data through a cloud based system. But if you're utilizing a reader for the decks. Com you have to plug it in to the desktop at the office in order to download that Donna Now same thing for Medtronic. You have a phone based app, you can connect through the connect app similar process through uh email and code approval. And it's the care link software that is on your desktop as a health care provider. And then you can take that information either through a reader or through the phone and interact with that data in the office ever since also has a similar thing. However their reader is the phone and the only way to engage in that is through the ever since mobile app IOS or android. And you can get that through the cloud based system. But you need to have an account with ever since M S D M S dot calm and create that link through your desktop. So let's transition a bit to some data. So we've gone from the utility the you know the boots on the ground kind of utilization of C. G. M. And now we're gonna talk about data. There is real world data. This particular study is using the freestyle flash glucose monitoring system and it really for the first time opened our eyes to how increased monitoring, knowing what your glycerin mix is and how it affects A one C also decreases hypoglycemia and increases time in range. So I'm going to orient you because this to me is one of the pivotal data that really changed the way we looked at glucose is because for a long time we thought if you rose in a one C. If you had to hire a one C, you would have less hypoglycemia. So let me show you that first one on the left On the one axis, you see a one c. Then on the right access you see minutes or time in hypoglycemia on the bottom. It's the daily scans of the freestyle glucose monitoring system where you could also say if you looked at a C. G. M. And what we found is that you had less hypoglycemia when you engaged in your data, right? When you saw your data you had less hypoglycemia As your a one c. dropped. And what we found is that the A. One C. Of 8.2% had the highest rate of hypoglycemia. So if all of you are out there saying you're going to raise an A. One C to try and prevent hypoglycemia, I'm going to tell you it's not going to work. It's not the destination A one C. That confers hypoglycemia. It's glucose variability and unawareness. So if you have people more aware of their hypoglycemia they'll get it less. Not because something magically happens with their body but they'll be able to prevent it. And so as a result of that, we came up with the sweet spot. For scans, it's about 8 to 12 times through today. Yes you can scan more but that didn't really necessarily improve. It got into the neurotic standpoint. But you can see that effect. The same thing occurred with hyperglycemia. The more you knew, the less hypoglycemia you had and the better A one C. Was. And then we saw that inverse relationship. The more you scan the less hypo the less hyper the more time and range. So this proves it not only that this data set really established the fact That the a. one c. doesn't confer protection against hypoglycemia, it's knowing what your sugar is that confers the protection. So here is an additional presentation that I actually authored presented at the A. D. A. In 2020 and it was looking at a one C reduction after initiation of the freestyle libre system. And persons who were on long acting insulin, basil or NPH or no insulin therapy at all not mealtime insulin. We're talking long acting insulin. And so the aim was to evaluate the change in A one C from baseline to six months and 12 months after we started the freestyle libre system. In persons with type two diabetes who are on long acting insulin or non insulin agents but they were including GLP one therapy. They retrospectively looked at it, you can see where the data was sourced. You can see the time that we did it index period, you have to have an A one C. Higher than target prior to the initiation. And then we followed it with an A. One C closest to the 183 160 day time. And this is what we saw. We were astounded. What we saw is there was a reduction in A one C. After freestyle libre initiation and all persons with type two diabetes. Right so the whole cohort reduced by 20.8 And then at the 12 months was a .6 but look at the right hand side, the greatest A one C reduction was seen in the type two diabetes group that was not on insulin. What do you mean how can you improve glycerine mia. Now that doesn't mean that their medications were tight traded. This is the a. one C reduction by engagement. It was at .9 and these were people on non insulin agents, oral agents, GOP one's And that maintained pretty much still a bit quite a bit of reduction at the 12-month period. And so this was presented as a poster by myself a couple of years ago. Really is a testimony to to say you guys are putting a onesie in a box for who's going to benefit from it. Because I just demonstrated to you that those on basil insulin are going to benefit but you don't even have to be on insulin to benefit. And so this is why I say to you all persons with diabetes can benefit in some way by illumination of what their glycemic numbers are. They just benefit in different ways but it all comes down to their glycemic control. So we've talked about see GM talked about the data associated with it. Now let's defined the reports. Now there are forward facing reports on all of the readers and all of the apps for patients that they can see this data but I'm going to define it for you as the prescriber. So when you take a C. G. M. System and you download it you get what's called an A. G. P. Okay remember that Vocab? It's gonna be good to know it going forward. So the A. G. P. Stands for ambulatory glucose profile or you could coin it the actionable glucose plan because that's what you're going to do with it. And you can see that it gives you a 24 hour amalgamated data for A two week or seven day or 30 or 90. But let's say for now a two week timeframe because two weeks is the what I call the ideal time to analyze. Seven might be a little less than a pattern. 30 and 90 kind of gets a little too wide. And so let's assume that this is a two week compiled data of what the person is overlaid on the time of day. So I can orient you to six a.m. Where they wake up we assume that they eat breakfast because of the excursion of the glycerin mia. You can see the hyperglycemia by the width of the curve. You can see the trend which is called the line of Congruity which is that darker blue line. And the variability is the thickness Of the high and low glucose. Right? And then of course we can see the hypoglycemia as defined by the below 80 or time and range that set from 80-180. But earlier I told you it's 70-180. So this old document even though it's so good at describing it it's really 70-180 by the International Consensus for time and range. So this is meant to be a snapshot for you to look at the A. G. P. And make determinations recommendations. And when you get this ambulatory glucose profile which is fairly standardized amongst all of them. They look similar they're not identical but they're similar nomenclature. This is what I want you to write on. I want you to print it out. I want you to say you know from midnight to six. What happens? Are you on insulin or you're on oral agents do you fast? What happens when you eat? I see you eat here write it up. Put the meds start to understand how the meds work and how the meds not work and what the person needs and what you have to intensify and de intensify. Now another portion of the ADP report we talked about that was the graphic or what we call the map. We also have these heads up display in terms of the written or the kind of chart form or scaled data. This is common language amongst all a Gps. This was established by the international consensus on C. G. M. We see the statistics of the date and the time of where how much it's active whether they you know took it off for that kind of thing or weren't engaging in it. We see the glucose ranges which is 70-180. That's why I mentioned a second ago about time and range we see below 70 which is considered kind of Stage one hypoglycemia below 54, which is severe and above to 50, which is that time above range and to the right is our targets. So we have the glucose ranges on that left, just immediately to the right of the targets. It's what we want to get the person. We want them 70% or greater at between 70 and 180. We want them less than 4%, less than 70. And in my book we don't want anything less than 54 because that's severe Correspondingly we want to minimize the time above target or above to 50 to less than 5%. And so as a result of that, we can tolerate a little bit from 182-50, but we really are shooting for these targets. So then let's transition to the right side of the slide. The right side of the side is the patient's data. Left side is the goals definition of time arranged by the international consensus panel right side is this person's glycerine mia. So you got to see the previous graphic is kind of like that picture and this one is more of a table. This individual is only in target range 47%. This individual has unacceptable severe hypoglycemia at 6%. You get the drift of how to read these. Now let's go to the bottom, lower corner because here are metrics that can be helpful but they have limitations. The average glucose is there because it takes all the data high. The low and that gives you the average. Now if you want to know the scope around the average, that's your variability. So you take your average glucose and then your scope. So it's high and low 49% around the meat. Now it's not a great benefit to know average glucose. Right? Going back to, you know, that whole average, they wouldn't see that kind of thing. But you can see how it still tells the picture to still tells the story. Now there's a metric called the glucose management indicated that looks awfully suspicious like an A one C. It is a representation of what the a one c technically would be if everything stayed the same for a full 2-3 months. So you might say, well why do we have that number actually. It's a very good number. I use it a lot. I use it for encouragement. Hey, by the way, look at how your numbers have been the last two weeks. If we keep them that way based on your diet and your engagement and your therapy, this is what your A one C. Is going to be. and in fact you can see these numbers if somebody maybe was a 12 the last time they had an A one C. Right? And so this is a big motivator. Not only that. I often use it in my practice to clear people for surgery. What do you mean? Maybe they have an A. One C. Very very high. They need an emergent surgery and they're not urgent but but it needs to be scheduled and we need to get them to an appropriate level in order to safely do surgery. You could do this for two or three weeks rather than wait months and months and months until the A. One C. Gets to target. Now glucose variability is something that you were kind of emerging this term glucose variability. Maybe a bigger predictor of hypoglycemia than actual a one C. Glucose management indicator or average glucose because it's those peaks and valleys, the ski lifts the ski jumps and it's why people feel so lousy, we're really trying to get them into the low thirties, percent of glucose variability. In other words, more flatter glycerine mia. Which often doesn't show up in A one C. And so I urge you to be familiar with this glucose variability. So here's the international consensus statement for the most part, you're gonna look to the left hand side on all the A. G. P. S. This is what's going to show up on the left hand side. This is the consensus for target time and range for persons with diabetes type one and type two. If you're a higher risk person you can stretch it out a little bit. In other words, no lows at all Or not nothing less than 70 target range shrinks a bit and time above range expands but we still don't want an exceedingly high really really hyperglycemia. Now this is somebody who's at the end stage of their diabetes who has other comorbidities. But please don't put this on the average person with diabetes. This should be the exception. Now pregnancy type one is very tight control, pregnancy. Type two has even tighter control. And so we have this international consensus statement yes we can utilize C. G. M. On persons who are pregnant with Type one. You don't have to take it off. But right now we don't have approval for those with Type two diabetes. But you can see how this this presenter kind of wonders why we don't because there's nothing magical about a person that is pregnant and why is it that we can utilize it in type one diabetes in pregnancy but not type two. Even though they're actually our consensus and other countries outside the U. S. Are doing this. I hope it is ruled on student in this country. So we need to interpret an A. G. P. With steps and and I'm gonna show you with some of these steps and I just actually met with dr berg install the other day. Very nice acquaintance of mine. We've done some presentations together. Uh This is his interpretation of an A. G. P. Many of us have taken it and adapted it but I just want to give him credit because this is how he first approached it and he didn't want to minimize it. He didn't want to make it to expanded. But there really is a way for you to think about how to look at the data. So the first is make sure we have adequate data. 14 days is kind of the holy grail to really make good interpretations. But Medicare requires 72 hours. But I would urge you to do at least 7 to 14 days. Okay. Make sure that there's not a lack of data and you're going to try to make meaningful information regarding them. Show I first download and print off that A G. P. After I checked for adequate data, then I look for patterns of low glucose levels. That's what you want to look at. First safety. First safety first. And I sometimes ask the patient, hey, have you noticed any of these hypoglycemic events? You're gonna look where they occur. You're gonna look what they're associated with. Then you look for patterns of highs, tell me what happened on this day. That was my birthday. I just did it yesterday, patients said, what did she say? That was nachos? That's what she said. That was nachos and none of the nachos are bad per se. But maybe I say to them, is that a card worthy food for you, Can you afford it? What do you want to do? How do you want to incorporate this? It's a conversation. Then we look for variability, right? The highs and lows are the range because variability is definitely correlated to high and low and hypoglycemia. It's important then we want to say, okay what's your time and range? How close are you in your time in range and how can we help improve this now? Throughout this whole thing? You're not going to wait till the end. You're gonna ask the person what they see. What did you see? What did you learn? You know, you printed out, you write on it, you hand it to them, you just do that one page if you want with the time and range in the in the graphic you have to do the whole thing. You don't have to do reams of paper with these people. I even send it to their own patient accounts. Sometimes I'm gonna give it to you at home so later on. Or I'm gonna print it off for you. So we take this a G. P. And make it an action plan, do something with it, change it overcome barriers. Talk about it. Try to do a meaningful impact, empower them, teach them, Mark it up, put the meds, put the insulin, put this, put that I had one the other day where the sugars were high throughout the week and I go what is this? And he goes it's when I go to work. Whoa he would have totally missed that. He gets stressed. And so we're talking about how to mitigate that. And then at the very end bill for it, it's your time, it will be covered. You don't need it authorized. I promise you this is in the CPT codes, you need to be compensated for your time. And everybody is going to benefit from downloading, printing, engaging and interacting with the A G. P. Cat. This is another way to look at that. It's another way to consider to overcome and have interventions. What are you gonna do? Do you need to engage more by swiping? Do you need to look at when you miss meds right on there? Oh I forgot to take my med here. Okay so take what the report shows you and see if you can intervene. It's a unique conversation every time. It's not always the same. You know, sometimes I see it always on the weekend hyperglycemia. So I go out to dinner, can you make different choices, see this is a actionable plan and you're going to agree upon an intervention, You're going to take this document and it's going to be imaged or uploaded in your chart. Now, some of you are asking right now, does it interface directly with my HR system. It interfaces as so much as it's a pdf and you put it in there and you make a macro and you do time and range and you populate it. But no it doesn't interface where each line is queria ble by your thr first of all this provider doesn't think you need that. It's exceedingly expensive. It's really only for research driven purposes. If you want to query time and range or different people, then you make a macro and that's queria ble. But to put every line in aquarium ble thr format, uh I don't think you need that. I do research utilizing C. G. M. And I can obtain the data through the back end in the actual HCP desktop thing. So if you're doing research data fine. But if you're sitting here just wanting this to occur, that is a massive file to have each line credible pdf label it, print it off, share it with your patient, discuss it in the note, put a macro, you're done, that's good enough for engagement with that. Okay let's talk some cases let's put this into action. Now we dissected the A. G. P. Here is what the A. G. P. Looks like in in kind of a complete format. There's also a portion on the on the bottom as a two week review. So just take a moment and see the time utilize the date the average glucose. The consensus on the left and the data on the right. This is the person's data. Look at the graph. What do you see by just looking at it, go through those things in the head, adequate data. Risk of hypoglycemia risk of hyperglycemia variability. Okay so that's what I want you to start doing every time. Now. Let's talk about a case. So this is a 63 year old female. Oh, by the way, these are all my cases, there are real people as I'm giving them to, I can actually see the person pop up it in my head. Female type two for 3.5 years has a consultative appoint with me. Typical history, class two, obesity, hypertension, Hyperloop anemia. Here's your current related diabetes medications. Met foreman with four adherence due to gi related side effects. I asked her, I don't say, how many times do you take your Metformin? I say, how many times do you miss your Metformin? So this is a two week follow up of her glucose management indicator is a two week follow up. I gave it to her. I talked with her about engagement and she follows up with me. My first question I asked her is what did you learn? She said, I realized the effects of my glucose when I didn't take my Metformin. Okay, very good. That's amazing that you saw it firsthand. In addition, I really felt like I had awareness of the food and my medications without affecting my glitzy mia. That's awesome. I'm glad that you received that I could talk with her about rates of blood glucose is and ranges and highs. I can talk about how breakfast goes up, lunch gets better. Dinner is always above target and then our own native insulin kicks in. Right? That's what I can get from this particular encounter. Now I gave her an assignment I printed it off, we reviewed through what the data showed us. We make connections with that. And I said what do you want to do? What do you want to do? You either need to adhere to your Metformin or we need to make a directional change. And she said you know I don't want to take the metformin, I just have trouble remembering it and I really don't like the G. I related side effects. And now that I know how food and stress and activities affect me, I'm gonna learn a lot. So I decided to get rid of the Metformin and add and titrate. A GLP one receptor agonist. I added it I titrate did it. We did all these things she did find and this is her follow up appointment to look at her age. Look at her a one c. Now let's go back for just a second. Her a one c. Prior to that was not that bad. It was 74 and many of you might have gone. She's good enough but look at her glucose ranges and how different it looked Between the 7 4 a. g. p. And the 68 A. G. P. What do you see variability? Boom, narrowness. Right. It's nice and tight. So not only is there a one c better but it's tighter. We know that variability might actually affect heart disease and risk of hyper we know that just feeling overall yucky. Right? She still had a few times where it popped up with lunch but it wasn't the issue with dinner. Who knows what lunch was. I actually think it was stress. I remember her reporting that right. She's not having hypoglycemia. What's interesting is she was actually at a higher rate of hypoglycemia in her previous ag how was that? She was on matt foreman. Don't neglect endogenous native insulin persons who have why glaciers variability can dump their own sugar and then have reactive hypoglycemia even when you're not on hypoglycemic agents. So look at her time and range. It was 90. Now hurry when she was 68 but her G. M. I was 66 because for the last two weeks that was what her control was. She said I never want to get rid of the C. G. M. It's my accountability partner. I love it. So you can see how this was a non insulin agent person. This was a this was a an example of engagement adherence and illumination of lifestyle. It it this is why I get excited about this. I want you to see this and utilize this in your practice as well. Okay let's go to a different case A. G. P. After applying it to a person that came in 72 year old male type two diabetes for nine years heart disease neuropathy stage three kidney disease. Gloomy pure ID. Daily Staten and an ace. That's what he was on. First of all really crappy meds for his heart disease and his kidney disease. Right? A. One C. Is nine B. M. I. S. 27 blood pressure G. Fr no glucose management indicator to the right. Why doesn't have enough data? So you see his time activist 47. Why is it active because he worked for 14 days? Well this is a freestyle libre A. G. P. And he did not swipe it. See those data gaps on either end. Data gaps are where you have to swipe at least every eight hours to hand off the data. That's why the battery small that's why it's disposable. So his engagement in the sensor didn't give us enough data to give us an average. It does paint a picture of high glucose all the time and I can fill in the blanks. He goes even higher after dinner and then finally comes down to his baseline. Okay so we made an intervention. What did we do? We said you have to engage in your diabetes better in your C. G. M. Better. We are going to remove the cell phone area and we changed to an S. G. L. T. To why his heart disease for goodness sakes the salt makes it worse. Right? It does and he still needs to engage in a sensor more. His A. One C. Has dropped to 77 From 9- 7. 7. He has better data. We still don't have a glucose management indicator because his time active is not high enough and he still has data gaps. Anybody know why those particular data gaps. Those are the bedtime data gaps. You gotta swipe right before you go to bed, right when you get up and I suggest the middle of the night party swipe when you go to the bathroom and you engage the data if you do it at eight hours right? When you go to bed, right when you get up. But if you can see if a person is not used to that they're going to miss some of that data but you can still see the utility of it. But you can't get all the metrics because the A. G. P. Report will not say we need more data to make recommendations. Are there other options for therapy for this individual? Yeah. What could you do? Look at it you could add a GLP one. Now why are they drifting to hypoglycemia? Here is a case of native endogenous insulin overproduction. I look because I need more postprandial coverage. Are you going to use a basil insulin on this person? You're gonna make him go hypo look at the glucose. They need treated and add an agent that covers it. Run out of new GOP. Wasn't only that he has heart disease. So we're going to add that additional protective benefit. Okay Here are the CPT codes for reimbursement. There are three you guys can remember three. Talk to your biller. (952) 499 525095251. You're going to use the 95251 the most it is interpreting the A. G. P. I just told you about it's what you add on to your E. N. M. Quote. Right? You're 99 to 14 to 13 whatever you have, you add on the 95251 because you interpret an A. G. P. Of at least 72 hours and you can build this every month. Published March 16, 2022 Created by
