Video Clinical Conversations on the Use of Technology in the Primary Care Setting Play Pause Volume Quality 1080P 720P 576P Fullscreen Captions Transcript Chapters Slides Clinical Conversations on the Use of Technology in the Primary Care Setting Overview Hi my name is Dr Jeff Hunger. I am a family physician at a diabetes ologists located in southern California and my job is to take people with diabetes and make them perfectly well controlled. Thanks to the new technologies we have. I can usually do this within a period of 2-8 weeks and I'll show you during this slide presentation how much fun and easy it is to do. So let me tell you about one of my patients. His name is Henry. Henry is 70 years old, is a Vietnam war vet. I uh saw him as dr number nine on his list. He's never in the last 15 years been able to get his A one c less than 9%. So I asked Henry Why are you not able to get your a one c less than 9% of what the doctors said to you about this. And he got really upset with me actually pointed his finger at me and he said, you know what, I'm sick and tired of doctors and nurses and educators telling me that I needed to exercise more and eat less. I've done all that but I still am not successful in my diabetes management. I'm still the same drugs they put me on 15 years ago which is metformin and so far in your area and they expect me to do well. I can't do well. So I thought about this and I said you know what, this is terrible. We, as clinicians are supposed to get people to target. It's up to us to do this. It's not up to the patient. The only thing the patient has to do is understand what we're trying to accomplish and and make this happen. Along with us as a team venture. We're going to take a look at diabetes technologies, new technologies that are available now to help manage patients with diabetes. We'll talk about C. G. M. Continuous glucose monitors, connected pens, insulin pumps and even uh integrated and attached devices. We'll talk about how you can successfully use these diabetes technologies and devices for each patient. And we'll also talk about managing patients with special population needs. This is a video which I'm not going to play. It's a little bit too long. But this is one of my patients Roy, he's an amazing guy. He was diagnosed At age 15 way back in 1961 is having type one diabetes, He's now 77 years old. He was told by his doctor back in 1961 that you're not gonna live past 20 age of 20 enjoy life. Roy was initially placed on one or two shots of Pork insulin daily. He was doing his urine testing. Uh he had no idea really how to manage diabetes. In fact 1961. Nobody nobody else did either. So I started seeing about nine years ago and now he's on an integrated hybrid insulin pump and sensor that is the pump and the sensor are talking and Roy who really has no complications. At this point in time. we started this pump. He came back a month later and I asked him Roy, how do you like this pump? And the sensor? And he said, you know what I dreamed about this back in 1961? I never realized that this technology would be available here. It is and it's not only changed my life but saved my life. He was crying when he said this, This is technology. And you look here, he's 77 years old. If Roy can do this, anybody can do this. And it's an honor and a privilege to be able to successfully manage these types of diabetes for these patients. All right, why are we even considering using C. G. M. To use glucose sensors in our patients? Well, back in 1993 the diabetes control and complications trial suggests that the A. One C. Should be the gold standard for managing patients with diabetes. So wait a second. What is an A. One C. How do you explain this to patients Patients? We all know is clinicians that a patient has to have a targeted a one C. But the patient said, did they ever ask you? Well, why what is an A. One C. To begin with? Well, diabetes is a very sticky disease. As glucose levels rise, the glucose sticks to things. And one of the things that glucose sticks to is hemoglobin or blood cells. Now, once you stick glucose to a handle. Goldman, I don't have a crowbar, I can't pull it off so you're stuck. The normal hemoglobin lives in the body for three months. Then it's then it's destroyed that it's recycled. So a glide hated hemoglobin tells us essentially how the blood sugars have been doing over a three month period of time. The A. one c. is a surrogate measurement for predicting one's likelihood of developing long term complications. But there's a lot of gaps and they would see interpretation in a lot of patients that we put all these medicines give all these medicines to are still unable to achieve their goal. In fact, we've got 250 different ways that we can actually manage patients with type two diabetes different drugs. But only about 50% of them are able to achieve their target. Why is that? Well, they're not engaged fully in understanding all the different issues involved with diabetes care And there's a lot of problems associated with the a. one c. itself. So if you have iron deficiency anemia, if you've got a diabetic kidney disease, hemoglobin up these, you're not going to get an accurate level of a one C. For example, if you have sickle cell anemia, the hemoglobin doesn't have a C terminus and at that point you don't have a C terminus, you can't attach glucose to that C terminus. So the A one C. Is essentially nothing. You can't use it. We also have problems with pregnancy with your E. Meus played a medley. All of this can get all these different issues. Can give a false positive they would see. So if you have somebody that's on dialysis for example they can't have an A. One C. Of 5.2 but that's not an accurate level of glycemic control. They might really be in trouble. They may have a higher A. One C. As well. So it's very difficult to assess A one CS when you have diabetic candidacies. So this is your lucky day. Your medical assistant tells you've got three patients coming in all with the same. A. One C. Of 7%. Why is that a good thing Because now you collect your $5 performance bonus because you've got these patients their glycemic target however they're all wearing C. G. M. As well. So let's take a look at these three patients and see if they're all equal patient A. Comes in and he's got an A. One C. Of 7% good for you. If you look at their sensor, download 100% of their glucose values are in the range of 70- 180. That is your target range target range 70 280. If you get 100% of your numbers in that zone, good for you. You deserve that $5 bonus. Here comes patient B. Again 7% A. One C. You get you another $5 bonus up to $10 now. But if you look at the C. G. M. Readings you determine that 4% of the total readings are in the hypoglycemic zone. If you don't remember anything else about what I tell you today, remember this hyperglycemia doesn't kill. It just increases the risk of developing long term complications. Hypoglycemia kills. Here's patients. See Another a. one c. 7%. This one's a little bit different. This man is 68 years old. He's got coronary heart disease, got two steps. He's got type two diabetes for 15 years. Look at the percentage of the time that he's achieving hypoglycemic numbers, it's 18%. He's not even close to the range. The target range of 7200 2 72 180 at least 70% of the time. Only 24% of his numbers are in the zone. This patient is at risk for having an event. Why do I say that? Because with hypoglycemia, if you have coronary heart disease, when your glucose levels drop below 70, your heart rate goes up, your pulse goes up. You have inflammation inside the coronary arteries, the coronary arteries constrict and you can get fatal dysrhythmia. This is not the type of patient that you want to have driving in the freeway lane next to your daughter coming home from school for the weekend because this patient is likely to cause a car accident. So this is not acceptable. But if you look at the A. One C. Good for you? $5 bonus. Here's to patients again with a one CS A 7.8%. They're both the same. A one CS. However, because they're not a target of of 7%, you're going to use some basal insulin at 9:00 PM. Are these two patients equal in their safety evaluation? So let's take a look at patient one. This patient using sensors shows that overnight between the hours of midnight and six a.m. He is low. He's also low again after in the afternoon around four or five o'clock in the afternoon. So if you put this patient on guardian insulin that's just gonna push this patient's uh glucose values overnight. Even lower. This is not a safe thing. Here's patient to a one C. Again 7 20%. Look at the sensor data. This patient isn't going low. It's just not very well controlled. No problem. All you gotta do is put them on large in 10 units and he's gonna be just fine. You're going to achieve your goal targeted uh glycemic goal very quickly with this patient but they're not identical. They're not equally safe. What about this? I'm sure you're familiar with looking at blood glucose logs. Well the problem with this is what are you supposed to do now? You've got an a one c. At some .6. If you look at the glucose logs off to the right, they're all a little bit high. So what do you want to do? I mean he's already on metformin. He's on deck to deck uh insulin, he's only arrogant type. What do you think we ought to do based on one blog glucose reading a day? I don't know. I have no clue. I don't know what to do. Uh as far as changing his diabetes management. So I'm kind of a cheap guy. Uh and the last week I decided to take my wife to the movie. That's what I told. Let's go to the movies. So she she got excited. She got all dressed up and everything else. We drive to the movie theater, I take her to the theater. We walk out to the side of the movie theater and there we see the the the posters, we see the posters for frozen. And I said, look at this. This is this is really nice. This is nice. Let's get back into the car's weight again. This is this is just a poster. Aren't you gonna take me into the movie? I said, no, no, I don't want to spend money on a ticket for you and then you can have that big popcorn and a big diet coke. Uh No, I said I was going to take you the movie, I took you to the movie theater that counts. So when we look at some self management of diabetes using finger sticks, you can see in this chart A couple of things. First of all our target is 70 280 all of these glucose values. The figure sticks for in a day are in that range. This is cheap stuff. If you go to the movie you can actually see what's happening in between the little posters. So here's the posters, here's the movie. So what you see is even though the finger sticks show the glucose values are perfect. You can see significant hyperglycemia. In fact half the day this person is hypoglycemic. Is this the patients fault? No no it's your fault. It's your fault for putting on a therapy that is likely to cause hyperglycemia. This guy is so scared. In fact of getting low that around 2:00 AM he's going to eat some donuts just to get his blood sugars up high. This patient is basically on too much insulin. So you can see the difference between being cheap and being frugal by using C. G. M. And preventing disaster. So what's the value of using C. G. M. And patients with Type two diabetes, there are so many different things but you can detect hyperglycemia hyperglycemia that you were unaware of. You can determine if the patient does get hypoglycemia. How long does the hypoglycemia last last. You could look at something called male glycerin E. Mia or disk glycerine mia where you have glucose levels going up and down. We call that the diabetes rollercoaster. But I think my favorite thing to tell other clinicians is A couple weeks ago I had this patient coming. His name is Bob and Bob was started on a sensor about 10 days before he came in unannounced. He now who's knocking on the door? Now Bob has an interesting background. He actually is a real live rocket scientist and he works in Pasadena, which is about 25 minutes away from me. So bob knocks on the door says I gotta see dr Andrew, I gotta see him right now. I've got some important, incredible information for him. So I decided to see if Bob's a nice guy. So he comes in and he brings reams and reams of data. Remember he's only had this sense around for like 10 days and he brings me pie charts and bar graphs and uh and uh hazard ratios and all the p values and all these things. And it was a pile like this is what are you showing me bob just summarized the stuff. He said did you know he was serious. Did you know dr that when you exercise your blood sugar goes down? Oh no, I didn't know, he said you should publish this. I said already did. But that's okay. You see what I'm saying here patients, see what's going on with their life. They see what happens when they eat the cake when they eat pizza, when they eat chinese food when they exercise, when they sleep when they travel all this and this helps the patient get to their glycemic targets safely and effectively. So who benefits from the use of continuous C. G. M. Well I was one of the authors of the ace guidelines for use of technology and patients with type two diabetes actually with diabetes period. We published this uh last year and we had a lot of discussions about this over the course of our work of this manuscript and here's the bottom line who benefits from patients for that need to use CGM. And the answer is everybody everybody with diabetes doesn't matter Type one Type two prediabetes, even pregnancy gestational diabetes. All these all these patients should benefit for the use of CGM. Even Children can use this. So this is a much better way of determining what we need to do is to help these patients than using finger sticks. Did you know that the American Diabetes Association a couple of years ago was recommending that people with type one diabetes Should do finger sticks 10 times a day. Have you ever seen a patient want to do finger sticks? Have you ever seen a patient that was excited to do finger sticks? And most of the time when the patients brought in their results with their finger sticks. Did you ever really look at the data and try to figure out what's going on. So they were frustrated these patients would come in and not even bring their data with them because who looked at them. So now we've got a better way to go. We've got a couple of different things that we can do in the office. In regards to see Gm. We've got professional see jim We've got Personal CGM. So professional CGM basically means that you put this device on the patient wears it for anywhere between six days and 14 days. You download the data. You sit down with the patients. You know what this is what you ought to do based on this data. But a lot of these devices are blinded. In other words the patient has no clue what's going on. They just can see the download. So it's a retrospective analysis of their glycemic control. Uh This is a professional CGM can be used to patients of special population needs. So for example patients that have no financial ability to pay for these devices are not very expensive by the way but they can't do it. They won't do whatever you can use this intermittently. And guess what the A. One C. Actually goes down and you can also reduce their likelihood of developing treatment emergent hypoglycemia. But the more common way that we do this is with personal C. G. M. This is what the patient puts on themselves and the patient can make decisions on how to dose their insulin other therapeutic interventions and so forth. But it really increases engagement and people regarding diabetes self management. We also know that personal. See GM could do a lot of good things. We can lower a one c we can within anywhere between two months and six months. We there's a reduction in absenteeism at work. There's increase in productivity work. That's because we're reducing hypoglycemia. If you get hypoglycemic in the middle of the night then the patient is going to be exhausted the next day and really not going to be able to be very productive at work. There's a reduction in the cost of hospitalization For every time the patient is hyperbole. Scenic and go to the hospital. It's gonna cost somebody $5,000. So these are all good things that personal. See GM could allow you to use chuck is my next patient chuck is amazing what a story he's got. He came to see me the first time about six months ago And he's 62 years old. He's got type one diabetes has had type one diabetes for 20 years. Look at his face, see that round face there, keep that in the back of your mind. He was prescribed an insulin regimen consisting of 280 units of insulin per day. Now I can calculate out how much insulin this guy needs based on his body weight turns out it's like 74 units a day. That's all we need. So he's taking a lot of insulin. He's using NPH and regular insulin which I don't use anymore. I haven't used it in a long long time. And he was also told to use syringes and vials which is fine. But they never showed him how to do it. So he was administering two shots a day with all this insulin and he was having a lot of symptoms. So he's had a non stem BME two years ago requiring stenting. He doesn't bring his blood sugars into his doctor. He said why why do it? They don't look anyway In the last two months he was admitted 10 times to four different hospitals. The symptoms requiring hospitalization included confusing confusion, trouble walking, weakness, and chest pain. He was admitted. And fortunately All 10 of his memories of the brain are normal. I asked him Chuck, what did the doctors tell you about these admissions? He said you know what? I didn't say anything. They didn't tell me anything. Each hospitalization. three days. I've calculated out how much chuck cost this particular insurance in a period of two months and it was $240,000. It turns out he was having significant hypoglycemia. So here's chuck. Look again at his face. I'm gonna go back here, see this round face right over here That was chuck on day one and now here's chuck, 67 days later. We put them on a sensor and the sensor initially showed That none of his glucose values when the target range of 70- 180. He had something called the G. M. I. Of 11.7 G. M. I will talk to you about that in a second. That's poor man's a one C. It's a predictor of A one C. So despite being on all this insulin is a one C. Was close to 12%. His average blood sugar was 320 67 days later. After adjusting his therapy, he's got 79% of his numbers and target range. There is no hyperglycemia. Average blood sugar 1 65 and the A. One C. Is 7%. Look at his face, see how much weight he's lost. He was eating himself out of house and home just trying to manage hyperglycemia. These sensors have alarms. So when the alarms start go off it implies that the blood sugar is dropping and you could do something that time besides eating cake and ice cream. So there's a lot of different types of glucose sensors out there. You've got the desk calm and then you've got the Abbott, freestyle libre. Uh and you've got the Guardian Medtronic pump and sensor. Each one of these devices submit data to either a reader or to an app on a cellphone or to an insulin pump which allows the patient to do better with diabetes self management. You can also upload this data virtually and see exactly what's going on with patient fact. If you've got nothing to do and it's three in the morning and you're bored. You can actually log into your computer and determine what the patient's glucose levels are at that point in time. It's really good. These are the different types of sensors and I've just put it in a chart form here for you. You've got the freestyle library as well as the library to the Medtronic Enlightened Guardian three I pro sensor. This is real time. See GM and you've got dex calm as well. The library has to be scanned so it's not real time is called flash glucose censoring. You can see the cost of these sensors as well. The least expensive is the Abbott freestyle libra. And the most expensive is the decks. Com However, they all do different things. The decks com is designed to interact with insulin pumps and they communicate. So if you have somebody with an insulin pump maybe the decks calm would be the right thing to do as well as the Medtronic. But with the lead right, there's no connectivity, you can't connect this to different devices. So what do we do with this data? You know and a lot of times when people start interpreting this data, they get really nervous to see all these charts and graphs and colors. This is easy. This is real simple. This is called an A G. P. Report. So that's an ambulatory glucose profile three or four years ago a group of very smart clinicians got together I wasn't one of them but they got together and they asked the question how can we design a continuous glucose sensor report that is easy to interpret and actionable. So they came up with this one page summary. Let's take a look first at the right upper part of this. That's the target range. Again we want Glucose values on the sensor to be between the range of 70- 180. If you get 70% of your numbers in that range You will have a predicted a one c of 7% or less. You can see here it's only 47% on this patient. Is that bad? Well maybe not. Maybe you just put the patient on a sensor two weeks ago and he's at 47%. But then if you download the data again two weeks later it might be at 62% and then 89%. This happens all the time. What about the opposite? What happens if you have a patient that's under really really good control one month and then he could have an 87% of his numbers in target range And then three or four months later it goes from 87% down to 47%. Well we've got a problem that tells me he may not be using his medications properly. Or there could be something else going on. It also tells us this chart also tells us that time spent in hyperglycemia. We want less than 4% of the total values in the range of less than 4% left upper part of the part of the chart. We see the average glucose value, we see the G. M. I remember we're doing sensor data. Interstitial glucose values every minute to every five minutes of every day. And these are extremely accurate readings. So if you've got 20,000 readings in a period of two weeks, you can predict what the A. One C. Is going to be. In this case. The G. M. I. Is 7.6. It's very accurate. And then the glucose glucose variability glucose variability tells us about the roller coaster, the ups and downs of glycerine a control. Hey, we really want to strive for glycemic variability levels to be under 33. We want to flatten that line, that's what we want to do. And then we have the daily glucose profiles down below the daily glucose profiles allow us and the patient to see what's going on in relation to eating in relation to travel in relation to exercise and sleep. It's his summary. So you can see here that on Saturday the 15th, whatever that month was. This patient had a lot of yellow. So you ask him about this, What happened there. Gary gary says, you know what I had a little bit of cake before I went to bed and I said, no problem. If this happens again, watch the sensor data, you'll see it going up and just give a little bit more insulin for that. So he's fine with that. We don't yell at people. We we point this stuff out. This is teaching. This is allowing patients to achieve their targeted goal. This is the ambulatory glucose profile of the A. G. P. We want to flatten this curve when you see a curve like this, there are three things that need to be done. First of all, You need to eliminate the hyperglycemia. You can see here that this patient's glucose values overnight 10% of the time are dropping below 54 a lot. That's not a good thing we need to fix. That is just the patients fault. No, he may need to have an adjustment in his base Linssen they're also going low again in the afternoon. You know what if you have somebody that gets hypoglycemic once during the day, they're likely to go hyper glycemic again because they've lost their ability to counter regulate hyperglycemia. So thing number one we always do is fix the Hippos. Next, what we do is we fix the postprandial spikes. You see that there around 9:00 AM and after dinner as well. We want to adjust therapy to fix that. And the last thing we want to do is flatten that curve by adjusting therapy. So what do I mean by flattened curve. This is a perfect Normal curve and stumbling with type one diabetes, it is perfect. Now Diaw Atallah gist. Look a little bit differently at flatlines and cardiologists. We love flat cardiologist. When they see something like this, they're gonna shock, they're gonna shock the patient. Thank goodness. He's alive. What about a neurologist? The neurologist will look at this that there's nothing else I could do. This patient's dead and will walk away. But that's typically what neurologists do. Anyway, they do nothing. I'm sorry. I just had to say it. Uh This is another report. This is called an KGB report for a desktop And you can see on the right that this patient has 80% of his numbers on the target and they're spiking a little bit at dinner. See that yellow stuff there. No problem. When you do is give a little bit more insulin during dinner time and we should be fine. But there's no hypoglycemia. There's it's less than 1%. Very low. So you're doing really, really well. You can also see the G. M. I. is 6.7% and the standard deviation deviation is 41. So this means that there's a little bit of a roller coaster ride going on there, there was some adjustments, we can get things normalized. So again, how do you interpret this data? It's not hard, You do one or two of these and you're you're you're on the road, You're a professor already. First thing we wanna do is fix the lows. Next fix the highs. We want to make sure that the patient has 70% of his numbers in that target range. And then we want to look for any specific times during the day. But there may be problems associated with diabetes control. This is lee another one of my patients. He's an amazing guy. Uh and remember I'm a family doctor, I take care of all the stuff. He's got a lot of issues. He's 48 years old. He's got something called any card Olympian antibody syndrome, which means he's prone to clotting. In fact, he's completely included his inferior vena cava. He's opioid dependent. Used to use heroin clean and sober. Now he's got portal hypertension. He's got fatty liver and oh yeah, A couple of weeks ago he goes to the emergency room and is just feeling miserable and turns out he has newly diagnosed diabetes. He's got an a. one c. In the hospital of 10.2%. So they put him on that form and they sent him to me the next about three or four days later I saw him we put him on a sensor. You can see the ADP report on the right So this is nine days of glucose readings time and range 13%. Now all he's just an informant. Nothing else. You can see no lows he's not in range, you can see everything. All of his numbers are above that 180 mark. If you look at the daily glucose profiles, you can see that he's hypoglycemic all the time. Is this his fault? Is he doing something wrong? No, we just haven't intensified his diabetes management. So we decide to do something here. We're going to find out if leah's type one or type two, we have a target range that we want to assess eventually and we do it. We look at a GM I after just two weeks and his G. M. I. Is 9.6. Remember this is the poor man's A one C. And his actual a one c. is 10.2. So there's good correlation here. What are we going to do to get the under good control. Now in the old days, Back in 2006 it was really easy getting people under their under their control. The american diabetes association says start with metformin three months later if they're U. N. C. Isn't less than 7% as a cell fondiaria three months later. If not a target at a T. C. D. And a year later. If you're not a target. Oh we got insulin But now I don't have patience for this. I can get this guy better in just a period of maybe 6-8 weeks. So this is lee and we are now eight weeks after he went to the emergency room on the left. You see the initial sensors. This is a freestyle libre sensor Again, of its numbers are in target. But now he's on medication. He's on the ragged tied insulin degradation. You can see 98% of his values are in the target range. A. G. M. I. is 5.4 and the lion is flat. How long did that take? eight weeks? How's he feeling? Great. Look at the daily glucose profiles initially with very little pharmacology. He pharma co therapy. He was always high and now. Perfect. So how do you address problematic glycemic patterns? It's one thing to do with test or put the patient on a sensor. What are gonna do to fix this or if they're hypoglycemia is frequent. You gotta fix it. You have to adjust therapy. Sometimes patients give insulin but they don't eat or they're using mixed insulin or they're using stefania Rias or they're exercising the wrong time of the day. So all you gotta do is coach the patient on on fixing these issues and they'll be fine with this. Remember it's an interaction, it's a story between you and the patient. If the time and range is less than 70 you have to discuss medication adherence. We've got lots of different medicines that we can use. Maybe the patient can't afford it. Maybe the patient is using it improperly. I mean I've seen with GOP. Once I've seen people try to inject with the cap on. So there's there's things that need to be done if your time and range is less than 70% make it easy when you do this onboarding. This should be a fun thing. Now in my office when we onboard sensors, I do not give the patient an option when they come in the first time they're gonna get a sensor. I just don't even tell them they're going to get a sensor. So uh two weeks 2 3 weeks ago, I have a medical student, he's a first year student. He's really nervous and we're gonna put a sensor on this patient's arm and has to go in the back of the arm. So I said the medical student, you're going to do this? He said no no no I I don't know what you're gonna do this. So he took the sensor uh and his and his hands were shaking like this shaking, shaking, shaking. I put his shaking hand next to the patient's arm, I slapped the medical school students and he put the sensor in came up. Perfect. I said that is your first ever procedure. Remember this. So it's very simple. It takes two minutes to on board these sensors and when you do that you kind of explain to the patient how to scan how to use how to interpret and the patients love it. Have you ever seen a patient that really likes to in finger sticks. Oh no but they like using this and they will tell you that every time all the patient has to do is make sure that the center stays on that. They're scanning or looking at the data periodically and they bring the reader or their app in. That's all they gotta do. And we can do this remotely as well. We have smart pens. Now the smart pens allow communication between the actual pen and an app on the phone. I don't use a lot of smart pens. But it is one way that we can reduce the risk of insulin stacking, which means patients give an injection of insulin fast acting insulin in their blood sugar might be going up two hours later. Uh and so they give additional insulin and they stack the insulin, which means they are more likely to develop hyperglycemia. We've got these patch pumps to we've got the omni pod wireless pump. We've got something called a Vigo insulin pump. The Vigo is a disposable pump, you just take it off and you throw it away after 24 hours. The omni pod is also disposable. It comes with something called the PDM, which is kind of like a robot remote control so that you could bolus insulin using the remote control. The problem with this is if you leave you lose the PDM, you're in trouble, you gotta have that remote control. We've got connected pumps and centers as well. And this is this is really neat technology because you can connect the decks com G six with the tandem pump and you the pulpit sensors, they talk and they work together to get the patient's glucose levels under near perfect control. In fact, it's so easy that when you're on one of these automated instant delivery systems that patients wake up typically every day every day with the glucose of 1 10, 1 10, 1 10, 1 10. It gets boring, But it's safe when you wake up with the 110 then the rest of the day is very, very simple. You don't have to worry. However, you wake up with the 320, you're playing catch up all day long. You've got the Medtronic 6 70 G. And the Guardian. See GM sensor again, these two pumps and sensors, they communicate with each other with each other and they allow for automated insulin delivery. A lot of times patients, I show them this this chart here to show them how lucky they are to have this technology. If you just give somebody a large ng 10 units at bedtime, Then the patient really has to live with that. 10 units. They may get high. They may get low with this guardian. Once you give it it's in the skin, you can't suck it out. You can't do anything. So if you look at this chart over here on the left, this is the this green bar over here. This is time and range, But every. is a five minute interval when the glucose levels go up. This is insulin delivery. The insulin delivery goes up to when the insulin start, when the glucose levels start going down. So does the insulin delivery. So there's communication, this communication from the pump and sensor keeps everybody in the safe range Every five minutes of every day. So it's not like enlarging once you give it, you're done with the automated sensor and insulin delivery devices, you have adjustments going on throughout the day, including during exercise and after eating as well. What do we use connected pence for? Well, if you're on three shots state it might be a good idea to do this. If you're, if you have type one diabetes and you're prone to developing hypoglycemia, then using the automated pumping sensor is probably a good idea. You have less risk of hyperglycemia. It's really important to understand when patients are in the hospital, You do not want to stop their pumps and sensors. They will not like you patients that are using pumps and sensors. They are smart dudes and ladies do debts. So never take their pumps and sensors away unless they're unconscious because if the patient has has the ability to function, they know better than you know how to adjust their insulin doses don't touch the pump. So we also have what we call team pumpers. So I have patients that have Parkinson's disease. Uh, they have a hard time using the pumps sensors. But it's not a problem. Their, their significant other does this for them and they do a great job. Even with dementia we've got team pumping as well. This is chuck chuck comes in and he says you know what, six months down the road, I'm feeling great. No further hyperglycemia. So there are some codes that you need to remember as well because you can actually be compensated for putting a sensor on onboarding. That's 9525 oh I think Medicare pays $80 for this. You can only do it one time one sensor one time for on boarding but 95251. You could download this information on a monthly basis and you constant. I believe in between 36 $50 for this as well. And when you do this your your medical assistance can can do this to get the data to you or you can simply look at it on online and you can determine how best to manage the patients diabetes and please build for this. You should. So we've got this great technology now that can really improve and impact patients. Survivability and quality of life. I'm gonna go back here to Henry. Henry is my Vietnam war vet patient comes in with an A one c of 9.2. So I'm six months ago and this is a happy ending because we put him on a sensor and we adjusted his glucose values his pharmacology and you know what Henry is excited. His agency is now 7.2, but that's not the end of the story. It's the beginning of the story because Henry just got married. He married his high school sweetheart and the high school sweetheart told him before he came to see me, said Henry, if you can get your diabetes under control, I'm going to marry and they had a great wedding, it was lovely and he wore his sensor during the wedding as well. It changed his life. It's these sensors are changing the lives of all of our patients with diabetes. There really is no downside to these sensors. It's something that we as primary care clinicians should do. We should do this. It's inexpensive, it's safe and allows you to treat your patients successfully. Thank you very much for your time and I appreciate all you do for all of our patients with diabetes. Published March 31, 2022 Created by
