Video Fundamentals of Sensor-Based CGM: The Family Physician’s Perspective Play Pause Volume Quality 720P 720P 576P Fullscreen Captions Transcript Chapters Slides Fundamentals of Sensor-Based CGM: The Family Physician’s Perspective Overview Continue To Test Back to Symposium Welcome to F M X 2022 sensor based C. G. M. How to optimize diabetes care in the family medical setting and incorporating technology. I'm joined today by Diana Isaacs from the Cleveland clinic dr Eugene right from Duke University and I am dr Eden Miller and it's just a pleasure to be presenting this very important, highly beneficial approach to integrating C. G. M. We're glad to be supported by an educational grant from Abbott diabetes care and I'm going to start by discussing this step by step approach for launching and maintaining C. G. M. As well as the A. G. P. Based management program in the primary care setting. It really is my passion. I really want you to get a feel for how do I work into my clinical day and how do I take those available resources that I need to get started to overcome that barrier to integrate and you see GM in an effective manner uh in our practice. So we're gonna definitely try and answer that question for you today. As I mentioned, I'm dr Eden Miller, I'm the director of diabetes and obesity care. I'm a board certified family medicine specialist but I'm also a diabetic ologists. Then I have my diplomat status in obesity medicine. Here are my disclosures. So let's start by talking about C. G. M. Systems as a 30,000 ft view. They are really more than just new monitors. Right? They're not just a new way to check your blood sugar. A step beyond finger stick. They really do move us beyond that point in time care, which we are familiar with but never quite fully gave us that direction they provide for us predictive glucose management directional glycemic journeys. They give us retrospective and real time data that will provide both patient utilizing insight and prescribing insight as well for diabetes management. But you need to remember that just monitoring doesn't mean you automatically manage. You have to understand what the data gives. You. You have to orient the patient to that data and you have to give that data meaning and context of the person in front of you and you as the prescriber, the therapy that you have for intervention. It's also beyond that it's lifestyle intervention. It's engagement, it's social determinants of health and stress. You can see that this is really the personalized GPS, you know of systems of that glucose pattern system for this individual and we want you to get familiar with this piece of technology. It's going to help you and your persons with diabetes immensely. So I want you to think of C. G. M. As beyond just a real time glucose meter. Okay. It's a predictive tool. It's a retrospective tool and an interventional therapeutic tool for both you as a prescriber and the person who utilizes that. It really is a way to help them engage in their disease and it's a way to turn them into their own expert and utilizing a tool that remembers they have diabetes when you as the person and the prescriber. Don't always remember that right? But it really needs that high level of monitoring without all of the distress associated with it. So I often ask this question over and over again to see GM or not. To see GM. We I think at this point in time I understand the utility of C. G. M. But we'll review it again to really set it on a firm foundation. First of all, the A. One C is an average. It's a metric that we've used for quite a while. We understand its utility. We have a lot of clinical research based on it. But knowing your average speed doesn't help you from speeding, it allows you limited information and it's always retrospectively you never can prospectively use an A. One C. We also know that the A. One C. Doesn't tell the whole story. We're gonna talk about people who have different ones who have the same A one CS but different patterns and different risks. And Eugene is going to talk about that too as well of you. I know we're pushing the A. One C. For control but really we need to validate the A. One C by time and range because you could have an A. One C. That's maybe not a goal maybe higher than you want but they're hypoglycemia is significant and we want to de intense by therapy. But Eugene I know is going to talk about that as I like to say. See GM brings diabetes out of the past into the present, gives them that real time experience and predicts the future. We also want to consider C. G. M. When things just don't make sense. The patient comes in their testing once a day. They their a one C you know is seven or 7.5 or eight and they say they're fasting, blood sugar is great and that's where you need more data to figure out what the patterns and the insight is and is to their glycemic journey. I also utilize C. G. M. To engage and include the patient and the management of their own disease. You guys get frustrated with adherence and engagement and C. G. M. Allows for that because a lot of people who really don't engage in their disease are just highly distressed and they don't know how to engage in it. So this is an opportunity for patients to manage their own disease with a tool that helps them participate. And then finally we don't want to put C. G. M. Into a silo of just a hypoglycemic detection tool. But it does have a safety feature associated with it. It does an amazing job of identifying predicting and preventing hypoglycemia as well as helping with that whole psychological burden that many family members or loved ones have to shoulder when a person and their family has diabetes and so it equips them to watch over to engage as well with the person and the disease and empower them to prevent you know, some of the side effects and dangers that can happen. So let's unpack a little bit more about what we talked about equal A one CS. They don't equal time and range. And this is why I'm really trying to pass on this new concept that we need to validate a particular A one C by its time and range or it's time and range targets. And you're gonna hear about a lot of that during this presentation, we can't assume that a person who is on target with an A. One C. Of seven patient A on the left hand side has 100% their time and target range between 70 to 1 80. That T. IR target in range or target time and range. In fact, a person with an A. One C. Of seven couldn't have 100% of those levels in time and range. It would be pretty hard to do based on the ebb and flow. And I see mia if we look at patient bu as the identical A once you're the identical metric that we're used to look at this particular persons. How shall I say time and range targets or hours compared to those individuals who are like patients see? So patient B has 63% of their time in the green. Which is that 70 to 1 80 but 29% it's above 1 88% is below 70 which is outside the acceptable range for hypoglycemia and it's not on target, right? But if we look at patients see who also has the same name and see as patient B. We have a very serious hypoglycemic risk 18% is below the recommended threshold of less than 4%, less than 70. And only time and range is 24% and the time of beverages 58%. That's what we call variability. That's the person that's really really high highs and really really low lows. And so we want to expand upon your knowledge of what the A. One C. Tells and validated or to conceptualize it based on time and range. So that's why I keep mentioning about these two men that we think we need because you might in patients see when jean starts talking about his risk calculator, we might actually want to de intensify treatment with patients. See even though the agency is not a target because of their unexplained or unacceptable I should say hypoglycemic risk. So one of the challenges I think we have is identifying the right person for C. G. M. Now I'm gonna try to break the mold a little bit and that is you know of course we want to use the C. G. M's on label and we have limited I say we have some specific indications for C. G. M. In the U. S. But we also don't want to just say that C. G. M. Is used for particular persons based on their coverage. Right. Yes. We all live in that world and I get it. You know, there's acquisition approval and then there's acquisition but it's challenging so far in the U. S. Persons is greater than or equal to two years of age depending on the C. G. M. Who need or want more engagement with their diabetes. Irrespective of the diagnosis can obtain or utilize C. G. M. Outside the US if you have type two diabetes or gestational diabetes that is covered. Which is different when you're pregnant versus the United States. We do not have that approval. Neither do we have a contra indication that I'm not trying to promote it necessarily. But rather we do not have an indication for those pregnant if you are pregnant and type one. Yes, we do have that indication but not gestational or type two diabetes. We also identify persons at risk for hypoglycemia who may not need alarms or need alarms. Those individuals who are on cell phones areas, they have an inherent risk of hypoglycemia. We are now seeing quite a bit of emerging data and I will review some of that today using basil insulin beyond just mealtime insulin which I believe any person on a pump or any person on multiple daily injections irrespective of either Type one or type two should be on C. G. M. But those utilizing basil insulin also can benefit greatly from clinical data as well as personal. Um how shall I say a quality improvement of life? Those with advanced age inability to determine if they're hypoglycemic complex patients or those with chronic diseases including cardiovascular disease and um renal problems. The these individuals may not be able to detect hypoglycemia and in addition hypoglycemia has an inherent risk factor. And then finally my this clinicians favorite any person with poorly managed diabetes who can benefit from the understanding or the influence of diet and activity and medication and glycemic management or that therapeutic insight. So you can see how really all persons potentially could benefit from C. G. M. Depending on how you look at it and how you incorporate it in their personalized care. We have challenges in outpatient management of Type two diabetes. I'm gonna go from kind of the overall realm of diabetes to specifically Type two. Like I said this clinician as well as the A. D. A. Recommend all persons with Type one be offered and utilize C. G. M. Due to its safety and its engagement and its potential. But when we talk about the vast majority of persons with diabetes in the Type two room we have some challenges. We do need a progressive plan of treatment, intensification with engaged patients. These are we call therapeutic inertia. Right I sit on the committee for the A. D. A. For overcoming therapeutic inertia. And even though we have all these great tools and all these great technology and different therapies for intervention. We're still really not keeping pace with those persons with diabetes and it is very prevalent in the management of Type two diabetes. We have about 50% of those that are not on target and there's a reason for that and we're not getting any more time to manage diabetes. That's why I think C. G. M. Actually is a time saver. It allows the patient to manage their disease that allows you to have insight that would have take immense amount of work and time to get. We also have this barrier of providers as well as patients who fear hypoglycemia. They fear that if they intensify that they want to distance themselves from hypoglycemia so they raise the blood sugar which really in some cases can actually increase the rate of hypoglycemia because we think that it's the destination a onesie that confers the risk not how you get there and it's how you get there and the tools that allow you to get to your A. One C or your your glycemic control that really minimizes hyperglycemia. We know diabetes distress. Remember how I mentioned that unengaged or lack adherent individual they really have a high level of diabetes distress and they really don't know what to do and they don't know how to communicate and they don't know what the monitoring means and see GM allows for a bridge for that. It allows them to identify the areas empower them for intervention, illuminate those things for you as a prescriber to help with ongoing treatment and it can help with treatment persistence right? When you have this little alarm that says hey if you don't take your Metformin or if you don't take your basal insulin, this is what happens. It's not meant to be ashamed. It's meant to be a tool that can alert you and can allow you to get feedback on your lifestyle and how it impacts. We also know that there's so much mortality and morbidity. I hate to say it but we have 90 million prediabetes individuals in the US now and at 8% they're going to go to diabetes. And in 10 years we're gonna have 60 million individuals. I don't know that we can afford the current way of treating them and all the morbidity mortality or what I call metastatic diabetes that goes around it. And then finally there is quite a bit of silent hypoglycemia or what we call asymptomatic are unaware. I I'd be willing to suggest that a lot of falls as well as orthopedic injuries are different cognitive issues are related to the silent hypoglycemia or the middle of the night hypoglycemia and we can't just assume that they're a type two person. They don't get this. In fact they get it quite a bit uh and so illuminating that risk and being able to detect it is paramount. So what is a, let's talk a little bit about professional C g M versus personal. Many of you are very familiar with personal, you see them on the backs of these individuals, arms on their bellies, you see them on television, you're aware of it. But if you are somebody that's new to the C G M and you just want to wade into the pool and you are concerned about coverage or all of that thing, I would urge you to look at Professional C G M. It is probably the low hanging fruit. It's something that you can orient yourself. You purchase these devices through McKesson or different suppliers. You apply, I'm in the office, you can build for every segment and you don't have to get authorization ahead of time for them. They're all covered under Medicare and Medicaid and they're different time intervals, we can say at least every three months to be safe but you can do them technically every month. And this allows you the illumination of the person's bisi mia. But in many cases are blinded. There is one of them that is blinded option but Professional C G M is kind of on the provider side, let's let's think of it as the holter monitor of, of glycemic control. It will allow you to see where those issues are as as indicated on the left hand side, it's owned by the healthcare professional loan to the patient build to the patient Always reimbursed uh approved for multiple use. The reader is often times um if you have a transmitter that can be returned by the patient, many of them are disposable as well. It collects that real time data can be displayed. They can be generally worn up to 10 to 14 days. But Medicare requires 72 hours of data for it to be interpreted and and to be how shall I say build for it? And so if you have it fall off less than three days, you really want to reapply it and start again. And so that's why I want to make sure that they stay on and that the person either saves the the data either through the receiver, I'm sorry through the sensor based or where they acquire the data from. So let's transition a personal C. G. M. This is where you illuminate the data to the person. That's opened up. A lot of these systems look identical on body format but the patient owns it. They get it either through cash pay through their insurance company and they wear it as an ongoing part of their daily lives. It's open. They can see the data then you can intervene or link with it through downloading it in person by plugging it in or through the cloud based system. If they have a cell phone technology compatible, their view, the values are visible and actionable by the person with diabetes and then they can be retrospectively looked at generally for the most part, your sensors are 10 to 14 days that there is one version. It's only seven and then there's implantable ones that are 90 and 100 and 80 days here in the US we either have a real time or a flash version available but all of them now have real time options or streaming options And we will go through those in just a moment. So when we talk about the benefits, we get two sided benefits. It's not a lot of things in in diabetes management and technology that benefits the patient and benefits the health care provider is a time saver for the patient and the time saver for the person with diabetes. I've been talking with some of the payers as well as the accountable care organizations saying, you know, your healthcare providers Pretty burned out if you help them incorporate. See GM It's actually gonna lessen their burnout. I know that sounds like it's not possible. But you know, I specialize in burn out with physicians that I've been there. I've done it and utilizing things that help the patient manage your own disease will help us as well. The hard part is is carving out that about 1-2 hours in your clinic where you have to orient you have to create a workflow. But once you do that, you're not going to have the issues. And if you don't create that that work flow, you're going to need it time and time again. And so you just really have to pause it and take a moment to incorporate it. So the person that utilizes that has an increased individual engagement with their own the disease that illuminates their own unique disease experience because it is individualized, right? It is that individually driven, they'd be able to see trend arrows on the device itself up down flat. They noticed these right away. I just had a patient yesterday saying you're good euros flat. It's amazing how they can intuitively see that if you inter gauge with your patients using C. G. M. To create a log or just even a mark on many of the C. G. M. S to see how food stress activity, physical activity, sleep engagement illness, all those things are gonna start to see patterns and an insight many of the patients I've had one time I gave him the C. G. M. And I said, hey, write down just a brief what you eat. And he came back and I said, what did you learn from that continuous glucose monitoring? He said, oatmeal hates me and I love that. It just makes me laugh because he said, I thought I was doing something healthy. I was told it was healthy but for his individual glycemic needs it was creating a high glucose spike. And so he made a change on his own and did greek yogurt and fruit and he did fine with it. So this is where you allow the patient to to learn their own for their disease. And then finally it allows the loved ones and the caregivers to have an ease of mind for for control and hypoglycemic risk. So on the provider's side we see that opportunity for increased engagement. We're all looking for that right away is to make it easier for the patient. So they engage in their own disease. Take a little bit of our burden off. Of course we have that protection for hypoglycemia both through illumination and predictive and prevention. And so it allows us as prescribers to maybe push the envelope a little bit with our therapy. Uh and also re how should I say reassure us that certain interventions don't increase hypoglycemia. You know as we get Lauren Laurie one sees if the time in range is good and the hypoglycemic risk is low. Then we we feel confident that we're not putting them in danger. It also for the first time eliminates to you as the prescriber that each tool that you use each therapy. Each medication has its own C. G. M. Signature and its own unique whether you want to know it or not that its own unique imprint on the patient. And so you can look at the Mick needs and prescribe agents that impact that particular guy see mia you actually want to know that and that might seem like it's daunting But what if I tell you you can look at ambulatory glucose profile or the report of the heads up and say hey you have a postprandial problem here, the postprandial agents and then of course you can get this data compile a ble. I think that's the biggest thing as prescribers. They don't really download it. They don't engage in that data. They don't print it out, they don't talk to the patient and I don't have time. Well trust me I live in the world same world you do. And I managed to find that 3 to 5 minutes to sit there and say hey listen because then I know a directional way to improve their glucose. It saves me tons of time by spending a few minutes with them. And it allows me to see the effect to have that bridge right? We have the patient, the provider or the person and we have the bridge of the C. G. M. And I go hey I'm glad that you learned about lifestyle. Tell me about those foods that do better with your glucose. Tell me how exercise impacts that. Let's talk about when you missed your particular medication or can you see that your blood sugars are great in the morning but they rise at night. I need to add a postprandial asian. So these are all those conversations we want you to start to become familiar with and also don't understand you're not being graded either If you and the patient sit there and look at the A. G. P. And start writing on it and where do we know that kind of thing? You guys will discover this together. Don't don't feel intimidated by it. It's it's in a little map and sit down and have a meaningful discussion with it and remember it's a marathon not a sprint. You don't have to solve it all in a day. So how do you identify that person again? I think we hear that all the time over and over again. And why did I put this in here? All of your persons can benefit from C. G. M. You just have to identify one in this group. You need to start by choosing one that's fine. Get your feet wet, identify somebody who you think might be a candidate. You think they might be covered fine and make sure there are multiple daily injections. But then as you get more familiar with it you can expand out into the periphery to all of those people who can benefit from it. So let's talk a moment about the available devices. They're not massive. In fact we really have the freestyle family. The decks come the medtronic and the sensi onyx. We have different versions within that group and you can see that we have the original freestyle 14 and then it graduated to the two and now we have the most innovative which is the freestyle libre three. I'll be presenting a little later on during our F. M. X. 2022. Regarding this very familiar with the decks. Com G six and how it has its different pastors. You see the pastors are the other wearable technology that displays the data. That's what they call them. They called pastors and the FDA has certain ways in which they approve those pastors. Uh Some of the freestyle library families aren't what we call I C. G. M. Capable but the freestyle two and three are both I C. G. M. That means they can be integrated with insulin delivery devices. But many of you who are quite intelligent are saying but they're not integrated. Yeah not right now but in the future they can be because they've met those standards for accuracy and they do not require calibrations. None of the freestyle family nor the decks com require calibrations. Now if we go to the right hand side of the screen we have the Medtronic Guardian connect. And it is the system that is as a stand alone. It's not used as often as a state but it is connected to their 7 70 pumps. And so it tends to be one that's paired with the pump. Currently it does require calibration so it doesn't have that status and then we have the implantable Cynthia nix ever since. Which goes in the upper outer arm here it's an 80 and 90 day. I I have placed several of them in the state of Oregon and the transmitter or the receiver transmitters were on the outside of the body uses kind of an E K G sticky and then it goes to the phone. And that also requires calibration. So you can see that we have different varying devices and they have different kinds of benefits. And so if you see here, these are all the CGM devices I just mentioned to you. But if you look top down, we see the labeling from left to right, we see some require calibrations, Some do not. We see the ages from left to right as I've told you to and above is in the US and that's the G six born above is the freestyle libre two and three version. Any of the implantable is going to be 18 and above. And the Guardian ever since sensor is for 14 above. If you use it with the pump, they usually kind of look the other way based on its utility. If we go left to right with Medicare coverage, the only thing to mention is that the Guardian sensor three this last couple of years have not been supported by Medicare. I think it's because they're coming out with a new concept in the future. So you can see the day where 14 day for the freestyle family, 10 day for the mexican family and seven for the Guardian. Then of course, 90 to 80 day insertion application for ever since now the warm ups are a little different um in the future we may see the decks come with a quicker warm up we'll see as the G seven comes out it's not out yet and I would have told you if it's available hasn't been approved. So we're not gonna discuss it today but you can see the different warm up periods and then all of them have alarms summer optional in the library two and three. But the old the older version library 14 doesn't have alarms but the only system that has optional arms is a free slightly break two and three. Many of them as you can see our data display capable with android and IOS or iphone some have pastors, the decks six as pastors and then the pump integration for the decks com G six um is both the tandem T slim and now the 25 which just came out a few weeks ago which is compatible at G six and then the 6 37 6 77 70 pumps through the guardian sensor. We don't have any I. C. G. M. Or uh pump connection with either freestyle or ever since at this point in time. So they're pretty much disposable in the freestyle family, halfway disposable in the decks com G six and Guardian but the transmitter which is the battery portion needs to be reused and then the ever since again is that external transmitter which is rechargeable. So you can see there's a few just differences with that. So now let's go to Okay you've been introduced to the systems. You introduced their indications and approval. Now how do we get the data, display the data, read the data. So everything in the freestyle libre Abbott family, everything 14 2 and three are all under liberal view all of them. But each phone based app is separate. So the 14 day has its own application. The two has its own application and the three has its own application. And we now have those open based apps for all of them and the link up which is what the loved ones see is unique for each sensor which means it's still the same application but they accept the invitation from the person who wears it. They accept it and then they can link up and see their data. The liberal link is the phone based app. So I'm gonna give you a hack which you can tell if a person's phone is compatible with a particular sensor and that is you go into the app store, you put the sensor, you want either the 14 the two or the three. And if it doesn't show up in the app store it won't work with their phone. You need to get a reader. Now they all have readers except the library three. Right now it's in the process of development. Uh And so there is that how should I say work around or secondary data acquisition if you cannot utilize your phone but understand if you utilize the phone, that's when you can use the library link view the app based the link up for the family members and you can do cloud based data transmission to the library view, desktop app for the clinician. But if you have a reader you gotta plug it in so in the middle you can see the reader And again there's readers for 14 and two, not three yet and that's where it has to be plugged in but it's not hard to do and then you still get the same data through the review. So as clinicians you've got to put the liberal view on a desktop and if you've got issues with administration you've got to work around it because sometimes these things need updated. If you're in an absolute firewall, find it an old laptop, put it on there, you know, download it and send it as a pdf through whatever secure basis to the chart that's a workaround. Now, if you're looking at decks com, it's system is through clarity. So all the Decks com technology is going to go through clarity, clarity needs to be on the patient's phone. If you're going to acquire the data, the patient needs to have the app. So the decks. Com IOS and android app and the clarity on their phone as well in order to share that data that we pull off of the decks. Com computer based viewing platform in order to get the data if you're using a phone, you can download it through the cloud. But if you're using a reader which you can see anything in the center, it also gets plugged in identical to other systems and you can acquire the data. Uh And then of course if you want to share the data to the loved ones that's the application share and so the person with diabetes sends them the invite through email that's considered the compliance or the invitation. And then once they accept that you can then share that data then the purse or then the prescriber needs to either give that clinic code that you generate through your desktop acquisition account or you invite them by email and they confirm just because you're somebody's prescriber doesn't mean you can see their data. You have to go through one step of approval in all of those systems because of hipAA and compliance. You only do that once, once you invite through both platforms. I don't care if you're the freestyle libre or the decks come once you invite them once you can share that data and then incorporate it into your clinical note through pds and discuss it and print it off and do all those things. So Medtronic has a similar, you can acquire the data only through a phone based system or it connects to a pump and you have to upload the care link software in order to acquire that data and the connect is for loved ones who want to also follow along now ever since only has a phone based system it doesn't have a reader based system. And in order to get that data you have to go to the pro ever since D. M. Dot com website in order to acquire that cloud based data so you can see there a little bit different But none of them are too hard in terms of to to download. Put on your as your workflow again I would suggest you do one system at a time, choose a system that works for you explore it from book and the book and and then as you get familiarity you can go to some of the systems. So let's talk a little bit about some of the data you want to make sure you get comfortable to. Are you really sure that C. G. M really helps in terms of a real world setting. So this is a lovely study that in my opinion actually changed the way that we looked at diabetes because it really talked about how increased monitoring actually lowers the A. One C. Increases the time in range and lowers the hypoglycemic risk you might say Really? Yeah. Do you remember a few years ago the court trial said a low a one C will kill you. Well again it's not the destination. It's how you get there and we want to get to a normalization of blood glucose. I'm not saying remission but target in some cases in early persons with diabetes we want normalization to prevent progression. But we want to get there. Not at the expense of hypoglycemia. So I love this trial because it shows using the freestyle libre system by Abbott looking at scans and so we have the we have the A. One C. On the left and we have the scans on the right and it shows that the more you scan the better your A. One C. Is okay. That that's not surprising because you enable them with the data there comes a point where you get a sweet spot and that sweet spot. You know they have the dotted there at eight which is you know you need to do it every eight hours in order to get all the data. But but this provider thinks about 8 to 13 times a day of looking at your phone or looking at your scan after that. When you get to 40 times you're just a little neurotic. You you don't have improvement of the A. One C. So then let's translate that into hyperglycemia. The more you scan, the less hyperglycemia you get, the lower your A one C. Is and then you look at your time and range right? Of course your time and range is related. As you scan more you get a better time in range. You get a better A one C. But what's most important in this graphic is the first one, The more you scan, the less hypoglycemia you get even though your A. One C. Is tight controlled. So it's not the destination A one C. It's how you get there and whether you're a one C. Is validated by time and range. If you have a low A one C. And you're blinded to the data, who knows what that A one C. Is composed of. So I'm here to change the way you look at it that the A. One C. With the highest rate of hypoglycemia was 82. And so all of you that are distancing yourself from an A. With an A. One C. To prevent hypoglycemia. You're not really enabling that. And so what you really need to do is to give that patient that individual the real time glitchy me of where they're at. So this was a great little trial that gene. Right? My buddy who was presenting as well. He and I with laura Bradner did this and it was a couple of years ago we did it at the A. D. A. It was looking at the A. One C reduction after initiation of freestyle system. It was a real world trial looking retrospectively at the data at six months and 12 months baseline and start before starting the freestyle libre in type two persons whether they were on non insulin therapy, that could have been an injectable GLP went non insulin therapy and then on long acting or basil insulin. And we looked at Liberty view and we looked at quest diagnostics with A one C. And we reconciled their medications through DRG And we compiled all of this data. We wanted to make sure that the A one C. Was greater than 65 before the six months prior, we looked at 100 and 80 days and 360 days of their A one C. And this is what we found. So on the left hand side is the pooled data. All persons whether you are on basal insulin or just on non insulin agents, oral anti diabetics and injectable GLP ones. You saw a .8% reduction in the first six months. It was statistically significant. And we saw that still maintained at .6. But here's the part that really surprised us. So if you look at the right hand side data, that's the greatest reduction in A one C. Was seen in the type two non insulin group of 20.9 and that maintained at 0.7 these were people who are not on insulin. Why did they do so well? Because they're always blinded nobody ever has them test if you do you only have a test once a day, which means absolutely nothing. And so this a one C reduction was patient engagement. It was probably provider engagement for therapies as well. But but look at that. That great? S A one C reduction was seen in the non insulin group. And so this is one proof of concept to say, hey listen, a lot of people can benefit from real time monitoring. Now. You're going to be going through the ambulatory glucose profile a little bit with me in the cases and you'll go more from my colleagues as well. But we wanted you to be familiar with the nomenclature. This is called the A G P A G P ambulatory glucose profile or what some of my colleagues called the actionable glucose plan because it really is an individualized report card, not a grading system to tell you where you're at. And so you can see this is a 12 am to 12 PM. You can see the gray lines of the time and target the dark blue is the line of congruity or the medium. In other words, their average the cloud is the 25 to 75% and the 10th to 90th percentile. Okay, which is that around their mean that's the variability variability is how high to low and the trends are where they're going the time of day. So if we just look at this right now, just for fun, when does their blood sugar start rising? I can sit here and say, hey, it looks like you start eating breakfast around 6 30. How do you know that? I see the glycemic deflect, wow your highest glucose is with breakfast and wonder if it's something you eat. Your greatest risk for low, not really bad in this individual is in the middle of the night and maybe possibly on a basal insulin or so funny area. But your highest variability with dinner. I bet you eat dinner at different times in different amounts and so you can see by just looking at this, you don't have to be an expert. Just start writing. Put their meds on there, look at their profile, ask the patient what they see, right? This is something that you can learn with them. You don't have to be a master on this. Just start just start writing and start asking if they have noticed these trends as well. Now if we go one step further, when we look at the A. G. P. We also get the written data. So on the left hand side of this particular report we see how long they wore. The sensor. We see the time it was active. And then we see the target ranges. The targets are the international time and range consensus for the vast majority of type one and type two it's this amount. If your d intensified treatment due to advanced disease or risk of low the time and target is going to be different. But what we're looking for is 70% between 71 80 less than 4% below 70 less than 1% below 54 less than 5% of up to 50. Then we see the average glucose. Some of you are still in the average glucose realm. That's like average speed. I don't look at it a lot, but it's there. And you see something called the glucose management indicator. Gmi, That's my favorite thing. That looks very much like an A. One C. Well it's not, but it is meant to be that in this two weeks of data, if all things stay the same going forward for three months, this is probably what your A one C would be. Now, why do we do that? It's not meant to be exact. It's meant to be hopeful. Hey, look at the intervention. You've done, look at what this might do or inspiring. And this is cool data right now. We also look at variability, variability is another step, jeans gonna walk you through that. It's your, it's your around the mean high and low. And what we want is tight data. Not as much variability in range. With minimized hyperglycemia. That's what we want. That's the Holy Grail right now, if you look at the right hand side, the graphic, that's this person. That's this individuals. A one C. I'm sorry, A G P. The left hand side of the target. This is the person and this is their time in target range. You see their 47% above range. Okay. 40 I'm sorry. You see 47% time in range. Target range 47% time above range is 43. Really, really high is 20. But look at their hypoglycemia there at 10% And they're very low as 66%. We got to intervene and we might actually need to de intensify at first, which is really you guys are always plowing forward, but we need to de intensify to reduce the hypoglycemia and shift our intensification to a different area. You see, you got to be able to treat the appropriate glitchy mia and know what this contributors are. So this is the time and range. International consensus. Just briefly show it to you. The majority is going to be on the left hand side. The type one and type two intense control 70 and above time. And target less intense older high risk individuals cardiovascular disease don't put 40 year olds in this in this position. Uh If you have individuals who aren't getting hypoglycemia and they have different risk factors, keep them at that level. But we do say you can be less intense less time and target, especially if the risk for hippo is high and that's that second cohort. So pregnancy. Type one, nice and tight pregnancy. Type two, man, they can't even go above 1, 40 really hardly at all. Uh And those are what the international consensus is that we're really trying to target. So these are Diana Isaac's nine steps interpreting A. G. P. Um We have kind of utilized them all as a group and I give her credit for these because I think there are ways to look at it and we start by checking for adequate data. That's important. If you don't have adequate data, if you don't have enough to make determinations then you're not really gonna get a good uh generalization. We want to make sure that from Medicare at 72 hours or three days or above to really build for it. Please download it, print it off, put it P. D. M. Send it to your secure portal however you want to engage with it. But your first thing you're going to look for is low because you gotta d intensified treatment not looking at, you gotta de intensify and minimize the hypoglycemic risk. Then we want to look for patterns of high, where do you get high is it breakfast? Can we look at diet? Can we look at medication intervention? What are the areas of variability, variability is called inconsistencies, inconsistencies or variability or variable timings of food types of food types of medication types of intervention stress job that kind of thing. Not saying that you have to be perfect. But when you look at variability, can you bring some normalization to that? We want the appropriate time range and we want to improve that time and range and buy in intervening with those numbers 34 and five. you will improve time and range. So we gotta make sure we have that target as I'm printing these off and I'm showing the patient. I asked them what do you see here? What do you see in here? What do you notice And I allow them to engage in their own disease. Is there anything you think we can do? I have my ideas looking at patterns and some of the things you're telling me. But what do you think would be a good way to intervene with this? Let's write in the chart. Let's bring you back in another time interval and see if we've made some improvement again. I'm going to re emphasize print it out, Mark it up. Do what you want. Use your international pointer that engaged with it. Even if you don't know exactly what to do. Have that discovery. Hey let's look at this. Oh boy. What do you see? Oh I got really high after breakfast. Why do you think that is? I don't take my shots. I don't take my meds so it's okay. You don't have to know all the solutions. Start asking questions so the two of you can discover what to do. So again to remember these are how we engage in it and there's different ways to engage with it. I like Diana Isaac's top things but this is another way of engaging with the data again. You've got to make sure it's adequate. Make sure you're marking it up. I like to print them out. You don't have to have a color printer. I like to write this is where you take them and this is where you do that again. Look for the hypoglycemia. Talk to them about that. Ask them if they've made any journaling of their food because that's where their engagement on their lifestyle can help again. It's not a shame or blame. And we want to choose that therapy. And and what are we gonna do? Are we going to change an interventional therapy? Are we going to keep a hypoglycemic drug? Are we what are we gonna do? Right. What's our next step in prescribing for them And again short interval follow up. Can you can build for a monthly you don't have to do it two weeks. Sometimes they do that in particular individuals. But short interval follow up haven't come back in a month. Look at it again. Check your your work. Well I I can't have them come back in a month. I'm too busy. Well that's what's challenging right? We might be a little too busy with all the people were seeing rather than the depth of what we're seeing but that's for another discussion in primary care. So now let's talk about workflow. I mentioned it again. I'm gonna hammer it again create a workflow that works for you and your staff. I don't know your need positions. I've already created my workflow. You want to see my workflow? Go on the american diabetes association website. I filmed my office. You can see it everything from the beginning person to the end. But I urge you if you want to incorporate technology, don't keep having this time sucker of not having a workflow. You need to pause. You can do it in about an hour, maybe two. But for sure in an hour. So this is what the front office staff has their responsibility. Bring them in. You need to have diabetes only appointments. This is paramount for the overcoming therapeutic inertia. I know you're in primary care. I'm a primary care provider but they still have diabetes only appointments because they're going to have diabetes the rest of their life. They may not have hemorrhoids the rest of their lives, but we've got to prioritize diabetes. So in my template I have diabetes only follow ups. It shows it and then I say if I get done with it, I'll go to some of the other things or we might have to come back. I don't want to come back. I know, but it's important. We prioritize your diabetes. I have reminder calls to the patients. You guys have it emails, reminder calls to bring their diabetes technology there. Medallists, their connected devices to the appointment at the check in part when my staff is there. I noticed you're here for your diabetes appointment. Do you have your diabetes related technology? I actually sent the patient home the other day. I know you guys don't do that but that's how I do it. I had a guy come in to adjust his palm and he didn't have any of the C. G. M. Data and I'm like go home and come right back. I went on with my day and sure enough they came back. Now that's not every person. I know you all are cringing and rolling your eyes but it's a wasted appointment. So you gotta have ways to remind your patients to do that now. Ap computer data platforms. You've got to do this work flow. It's not that hard. You want to do the C. G. M. Pick one. Put it on a desktop computer orient your staff at the front and back office of how to access this. Make sure you stay updated with the software now in my staff. My front office staff knows how to download them back off the staff now is how to download them. That's up to you and your workflow. You may have to pass that necessary task on the other team members. Right. Might be um A well I don't have enough time. Guess what? I have one M. A. And she does it because we've created a workflow that works for her and my um a knows how to do this. She is familiar or he we actually had a male as well who was quite familiar with the C. G. I'm quite familiar with the past or the platform. She actually created user name and password. I'd ask her the other day what's my user name and password because it's her workflow. In fact she knows the components of the sensors. She knows how to set up and initiate. I know that might seem daunting to you but they're at 1/5 grade level. If the patient can apply it at home your EMA can apply it in the office. Again I got one M. A. I walk out and I tell her a particular C. G. M. And to apply it. No she's not doing the Cynthia nix Medtronic. Maybe not so much but the decks come in the library are in your wheelhouse you can do that, you apply it you download the app, you get them on their way you send the invite again. Overcoming barriers. I don't want to spend a lot of time doing this So I do it right the first time in a very concise manner and it's challenging. But we can do it in 3 to 5 minutes and get it going. Then when they come back in fact I can already pull up my schedule for tomorrow and the A. G. P. S. Already downloaded. My staff knows patients coming in for diabetes only appointment. She goes into the things she sees their name and sure enough they got the data she pulls it off at a PDM and it's already ready to do it's already there. What did it take her a minute and a half of how to do that. So then when I go to the appointment I'm ready it's there it's ready to go. I do this telemedicine to virtual medicine. It's already there so you can see how you really need to identify diabetes Champion. And I know some of you are thinking oh my gosh this is so much it's not it's just a pause and dedicating that hour to getting it done. So what are the basics of building? It all depends on who owns the equipment. Remember I told you Professional C. G. M. That's owned by the provider. Okay That's a unique building. They're not there's only three codes and I'll show you what they are. But you have to ask yourself who owns it, the patient or the provider. Did it occur over a day minimum 72 hours where that's what I'm going to tell you Three days. If it fell off under three days you can't build you can't build for the interpretation. You need to download the downloading of the receiver or the cloud based printed out or electronic transfer. You can't just say you looked at it. You either have to have a copy of it or a pdf archived in there to say yep. Here it is. You can charge the day of the download the day of the visit the E. N. M. Code or if you looked at home after seven o'clock at night and you communicated with the patient you can still build that cpt as a modifier. I usually do it at the time of the visit but occasionally I'll get a call. Hey so and so is having severe hyperglycemia. I want you to look at this, tell me if we need to tell appointment I look at it and then I bring him in. Okay? You have to have again a 72 hour minimum where face to face is not required. You can either stand alone or as an E. N. M. Code who can build for interpretation. Anybody who can prescribe. You can't prescribe. You can't bill. So an M. A. Cannot build for interpretation. We have a physician an N. P. R. P. O. P. A. Those are the ones who can prescribe and those are the ones who can build these are your codes. You might go I don't know that's fine. Call your bill or you have three codes. 952499525095251. What are you going to use? Over and over again. The 95251. That's the interpretation. I don't care if your professional or personal. You're going to use that code depending on application if you apply it in the in the office and you download the app and you show them how to do it. You can build for that you're gonna do for the professional because you own it. You have to go on kissing or something and by that sensor so you better get reimbursed for it because it's a different reimbursement when you do a 9 to 5 to 50 you talk to your bill or how much this sensor costs. What are our current charges for that? What do you build for for applying? Remember? Medicare covers 100%. So it's Medicaid right? Your low hanging fruit when you do a personal application, the person has the sensor. They don't know how to do it. They haven't done it at home. You can bring them in and put it in there. Okay. Bill for that. And some one time I had this great conversation with a person from the V. A. They said I feel guilty for building for C. G. M. I'm like why? Like it's your time, it's your expertise like. Oh I don't know I just I work for the V. A. And I just don't know if they should do it? I said do you do an E. K. G. Well yes. Do you bill for the nurse to put the E. K. G. On or the, mm. Well yes. Do you build for the machine or the paper and stuff? You buy that that kind of thing? Well yeah. Do you interpret the E. K. G. And and you cited in your note and you put it in the note right? You gotta do that and then you build for the E. K. G. Because it's your expertise? Well, yes. Why is C. G. M. Different? Why is it different? It's no different. So I like to use that analogy. So you're comfortable with that. So here's my closing remark before I turn it over to my colleagues and you can see I have zero passion in this realm. Now I really want to encourage you. This is amazing. This amazing technology that well, that benefits everyone. It's not very often we see that, but here's what you have to do. You have to take the time now to establish a clinic workflow. And for you, familiarize yourself with that diabetes technology. You'll save countless hours and you will maximize your patient interactions as well as your outcomes. Thank you very much for allowing this opportunity to review this data with you and I hope that you have found it quite beneficial. Published September 12, 2022 Created by Related Presenters Eden Miller, DO FounderDiabetes and Obesity Care LLCSt. Charles Hospital Bend, OR
