Now we're gonna move to the next session. Talking about sensor based C. G. M. To optimize diabetes care in a family medicine setting. We're going to focus on which patients, why, how and with which technology. My name is Eugene. Right. I'm a consulting associate in the department of medicine at Duke University Medical Center and I currently serve as the medical director for performance improvement at the charlotte area Health education Center. Today's topic will be incorporating C. G. M based google's patterns, insight report and treatment prompts in type two diabetes with a focus on refining and simplifying clinical decision making based on C G. M data. Let's start off with the ambulatory glucose profile report or the A. G. P. The ambulatory glucose profile report or the A. G. P. Is a standardized report developed by endocrinologist and specialist at the International diabetes center that shows a standard set of information and graphs. You can see on the slide that you have in the upper left, the glucose statistics, which are the time and range target values. You have the subject right next to it the time and range values you have in the middle section here, what's called the A. G. P. Figure or the ambulatory glucose profile. And at the bottom you'll have the daily glucose profiles. This is the report as it was in 2021 in 2022. There's been a slight update to this report that colour cause it to look more like the glucose patterns insight report and I'm going to discuss with you subsequently. Why do we need a glucose patterns insight. report. Primary care physicians may not be diabetes specialists but treat a number a lot of patients with diabetes. We also know that primary care physicians are very busy and have limited time to address the other healthcare needs apart from the diabetes. And in fact, one study would suggest that and you look at the reasons for a visit, diabetes is number five on the list. We've also noticed that there's a discordance between the quantity and kinds of new therapies for type two diabetes and improved outcomes. That highlights an unmet need for tools to help primary care providers make appropriate therapeutic adjustments and decisions. Primary care physicians would benefit from a way to make it easier, faster and safer to make a better clinical decision for their patients living with diabetes. And finally a useful performance improvement tool would permit the non expert PCP to make a better clinical decision with minimal disruption to the workflow, easier, taking no more time or hopefully less time being faster and without adding additional risk for adverse events such as hypoglycemia or safer. Now we talked about the glucose patterns insight report. I will refer to it as the G. P. I. Report and you can see here that again, it is intended for non diabetes specialists but people who treat patients with diabetes. The care strategy is very simple to identify and work on one pattern at a time to do this. We simplify the assessment and therapy change process by focusing on what we call the most important pattern hierarchically looking at low patterns first, then high patterns with some lows then high patterns. The strategy is to address the low patterns first. And if a low pattern is mitigated at the next visit, you can address the other patterns. You only address the high patterns when the low patterns have been mitigated, taking care not to make clothes worse when addressing the high patterns. Now high variability that may prevent addressing highs without making lows worse. We want to discuss with patient lifestyle behaviors that may be contributing to variability such as alcohol intake activity levels, varying times of when they take their medications. Now we're gonna look at the old A. G. P. Report, putting next to the glucose patterns insight report and there are a couple of things that are quite obvious as you put them side by side the glucose patterns insight report updates from the A. G. P. And you can see that the removed the time and range consensus target that were in the upper left hand corner of the old A. G. P report. There's a different A G. P figure down at the bottom. Now that is color coordinated to match the G. P. I report. It shows the critical patterns that you also on this A G. P report. And you can see box here in the bottom and the red and over here to the right and these are the critical patterns. And in this section we in the middle section here we have a section that talks about what are some of the therapeutic considerations. Either medication or lifestyle to help the clinician make a better decision. We've removed the daily profiles, glucose profiles that at the bottom of the A. G. P. And we've removed some of the glucose variability targets. So as we look at this report, we developed a problem statement does the G. P. I improve primary care physician's decision making? In order to do that. We prepare to study, we took 10 cases from clinical data. We had three endocrinologists and diabetes specialists review these cases and generally generated reports. Both an A G. P. Report for these 10 cases and for the same 10 cases we generated 10 glucose patterns insight reports are G. P. I. Reports we randomized 35 clinical practitioners and you can see the subjects were 20 physicians, 15 non physician practitioners to include nurse practitioners, P. A. S. And clinical pharmacists. And you can see some of their breakdown here with years of practice greater than 10. Greater than equal to 10 and less than or equal to 10. We also asked in these that the clinicians would make their first best therapy change and excluding simultaneous changes in therapy. So how we did this is we took 17. We called group A. And 18 in group B. We gave the 17 in group A. They all got 10 A G. P. Profiles. To read the 18 in group B. All got to read 10 glucose patterns insight reports and then we cross them over. So if you got the A G. P in the first round you got a G. P. I. In the second round. If you got the G. P. I in the first round you got those same cases. But now with the A G. P in the second round in this way we did this so that each physician could be, each clinician could be compared to themselves in their interpretations. So let me give you an example of what an A G. P case might look like with an overnight lows we provided for the patients. Their labs the labs were okay the A. One C. Was 7.5% their medication the regimen was metformin maximum dose they were on a GLP one receptor and Agnes at maximum dose and blip aside for breakfast dose at five and dinner dose at five mg. They were given a card here as you can see and they could select what they wanted to do to address this pattern. And they got the A G. P. As you've seen here with the glucose statistics and targets here at the right time and range of the patient over here on the right and then the middle section had the ambulatory glucose profile and the daily profiles. So this is what each clinician got for the A. G. P. Same patient, same characteristics labs medication, same card. But now, given the glucose patterns, insight report or the G. P. I. And you can see right away that there's some striking differences. So how do we break this down of the 10 cases? We chose five cases that had a low glucose pattern is the most important pattern. We had three cases that were high glucose patterns. One with high with some lows and there was one that was good control. So there was no discernible pattern. The reason that we focused on the hypoglycemia is that it's hypoglycemic is see MIA is really prevalent in Type two diabetes with greater than 25% of insulin using patients with Type two showing severe hypoglycemia. There's also a growing link between hypoglycemia and cardiovascular disorders in type two diabetes. So what we wanted each of the practitioners to do in this case is to analyze each pattern subset separately and for each case they would classify their therapy decisions as address the most important pattern that meant they decreased insulin to address the lows or they were characterized as they worsen the most important pattern they added or increased insulin to address the glucose lows or they prolong the most important pattern. If they had low, it was the most important pattern, they change nothing that would prolong that pattern. And we also track their deliberation time for each case. So what did we learn? Go back again? The low patterns, they were heavily weighted toward the low patterns with the A. G. P versus the G. P. I. The patient. The clinicians improved their recognition and their therapy decisions with the glucose patterns insight report compared to the A. G. P. But in addition they improved the time that it took them to address that pattern. That most important pattern with the glucose patterns insight report. You can see for the high the high with lows and no pattern. There was really no discernible difference. So let's break that down a little further. With the glucose patterns insight report benefit. They were three times more likely to identify and treat hypoglycemia. They were 50% less likely to make a treatment decision that would worsen hypoglycemia. And there were about 50% less likely to make a treatment decision that would prolong hypoglycemia. And they did it faster. Healthcare professionals were faster to identify and treat hypoglycemia with the glucose patterns insight report versus the A. G. P. So we concluded that the G. P. I. Improved decision making in less time. Well how did the practitioners, how did the P. C. P. S. What was their perception and their perspectives of these reports? The glucose patterns insight report was preferred 2 to 1 over the A. G. P. With 23 or 35 practitioners. Well why it was less busy than the A G. P. Report. They felt it was cleaner and easier to interpret. They preferred the color coded A G. P. To match the time and range metrics. It really helped them capture what they were looking at and compare the statistics to what they could see on the graph. They like the boxes that highlighted the most important pattern with the A G. P. And in the limited time that you have you want to get to what do I need to do quickly and make sure that I can make a decision that will safely take care of the issue at hand. For those who prefer the A. G. P. Over the G. P. I. There were about 12 of the 35. What features did they like? They like the daily traces six of the 12 use those in clinical decision making. And some preferred the blue color palette verse for the A. G. P. So I think the take home lesson here is that it is not the glucose patterns insight report G. P. I. Or the A G. P. It is the G. P. I. And the A G. P. So you can get the benefits of both. So let's give you some examples of these individual case results and how this played out. If we looked at case too, which was clearly a case of overnight lows. You can see at the bottom here that patient had an A one C. Of 7.2% with normal labs. Metformin at max dose GLP one at max dose insulin, P. M. Gloria jean NovoLOG with breakfast, lunch and dinner. This is the A G. P. Report. This is the G. P. I. Report. When we looked at how the conditions did in the 60 seconds here With the AG. P. report, only three recognize and address the hypoglycemia. Whereas with the G. P. I report, that number jumped to 18 six times greater recognition and addressing hypoglycemia with the G. P. I versus the A. G. P. And similarly, if you look at the decisions that were made to worsen hypoglycemia, 17 made the decision that would have worsened hypoglycemia with the A. G. P. While only seven did that with the G. P. I. And for prolonging hypoglycemia. 15 with the A. G. P versus 10 with the G. P. I. So clear differences in the recognition and addressing the most important pattern. Let's look at another case. Case three overnight low glucose is again, you can see at the bottom the A. One C. The medications that the patient was on the A. G. P. Report over here on the left. The G. P. I. Here in the middle again, 17, address seven. Excuse me address the G. P. I. The the A G. P. Address hypoglycemia versus 19 with the G. P. I. 16 would have worsened hypoglycemia. Using the A G. P. While only seven would have worsened it using the G. P. I. And 12 prolonged hypoglycemia. While only nine prolonged hypoglycemia with the G. P. I. Versus the A G. P. So there's a clear distinction here that the G. P. I. Help clinicians make better decisions and remember they made it faster. So what are the effects of the report design on changes to primary care physicians decision making. This was a novel C. G. M. Based glucose patterns, insight report G. P. I. R. That identifies patterns of sub optimal glycemic control and highlights the clinically most important pattern and offers therapy considerations to address that pattern. To assess the utility of this report a clinical and clinical decision making a reading study. This reading study was conducted comparing it against the standardized A G. P. Report and the clinical data from 10 subjects were used to generate complementary G. P. I. Reports and a GPS and non specialist primary care clinicians Were asked to evaluate each case report design alongside the A. one c. and medication regimen to make a therapy change recommendation. The therapy change recommendations were categorized by whether they address the most important pattern present with a priority priority on treating hypoglycemia. If that occurs coincident with other patterns in a given case, what did we learn that the primary care clinicians addressed the most important pattern equally well in each report in the cases presenting with patterns other than hypoglycemia. The big change here was on hypoglycemia and this was really a significant because hypoglycemia can be a safety issue Across all cases and all subjects therapy change categorizations were different in 79 instances with 67 of these instances presenting his hypoglycemia. This meant that primary care physician's recommendation, using one report addressed hypoglycemia, while that using the other report did not within this subset in all but one instance or 99% primary care physicians correctly identified low glucose with the glucose patterns, insight report when they did not for the same case using the A. G. P. These findings indicate that the G. P. I. Report aids in identification and treatment of hypoglycemia that would otherwise be missed. Using the current standardized reports. Thank you very much for your time and attention and we'll be happy to take questions.
