Hello and welcome to this presentation called strategies for incorporating C. G. M. Into primary care practice. My name is Diana Isaacs. I'm an endocrine clinical pharmacy specialist and also the C. G. M. And remote monitoring program coordinator at the Cleveland clinic, endocrinology and metabolism institute. So there's a few objectives I want to go through today. We are going to describe the different barriers to incorporating C. G. M. Into primary care practice settings and also discuss real world strategies to overcome these barriers so that we can really optimize the use in primary care. And then we're also going to outline how the identify configure collaborate framework also called the I. C. C. Framework can be used to really address many of these common barriers. So I always like to have one of these diagrams anytime I do a C. G. M. Presentation to just really illustrate the power of C. G. M. And how it compares to our traditional blood glucose meter readings. Right? So what you are seeing here is a 24 hour time interval. The green represents what we call the target range which is described as 70 to 180. And what you see are four glue, commoner readings. And I know if I've got patients that check four times a day and bring in their log or their meter. I'm like over the moon because I don't usually have that much data. Right? But let's say we do we have that data and you might see something like this right? Where all those readings appear to be in range. Right. Well we're fortunate we we use a lot of C. G. M. In my practice. And so what happens when you put C. G. M. On a patient like this? Well suddenly you see everything that's happening in between the dots. Right? And so what we see here is actually undetected hyperglycemia. So likely some postprandial looks like maybe after breakfast after dinner. What's especially alarming though is the undetected hypoglycemia and this appears to be happening overnight and I wish I could tell you. Well this is just you know this is to make an example. This is an extreme but this is actually not. This situation happens all the time. Often in our attempts to help people get to their A one C target. We may intensify therapies. Often we increase long acting insulin and we don't realize that we're actually causing a situation like this to happen where maybe someone is over basil ized there actually going low which can be dangerous and also leads to worse outcomes. So that's where C. G. M. Really comes in handy. And of course the data can be very valuable for the healthcare team but also for the person living with diabetes in the moment having that real time data. And so with all of our devices whether it's real time C. G. M. Or it's intermittently scanned? C. G. M. Patients are able to see their glucose value. They are able to see their trend arrow and make an informed decision in the moment so someone can see oh it's it's 18 and it's dropping, well I better eat something before I go drive in this car or before I go and exercise. And not surprisingly because of all of these benefits. Right? We see that there's a lot of improved outcomes with C. G. M. Use that there's reduced episodes of severe hypoglycemia and also reduction in emergency department visits and hospital visits for extreme hypoglycemia or hyperglycemia. We also see increased time in that target range And reduction in a one c. levels. So certainly hopefully you can see there's a lot of benefits to C. G. M. Us. And so we want to be able to provide that for our practice for our patients. But we know that there are some barriers. So let's talk about those different barriers and how to address them. I have split it up into a few different buckets. We've got the healthcare professional barriers right? We've got patient barriers and then we have system barriers with the system barriers. There's definitely in terms of downloading data accessing data with multiple different systems. And then the dream would be that all the data seamlessly goes into the electronic medical record and we are making steps to get there. But that's definitely not the current state. The current state is that there are multiple systems, different user names, passwords, logging into those systems also just coming up with the logistics. Okay so we've decided we're gonna put a CGM on someone who's gonna do it, Who's going to download the data? Who's gonna look at it, Who's going to educate the patient, Right? And with multiple different team members and different specialties getting involved in diabetes. I mean now we've got drugs that are utilized by cardiology, by nephrology, right? Endocrinology and then they're definitely therapeutic. A nurse shot. Just when there are new things, new drugs, new technology, how do we seamlessly incorporate that into our practice Now within the healthcare professional and patient barriers. I've listed some of them out on here. And definitely there can be some tech versions anytime. There's something new. Um, it can be more challenging right to learn something new on the patient side of it. Sometimes patients may initially be concerned, well I don't want to wear my diabetes or I don't want people to know I have diabetes and if I'm wearing something, if it's on my arm and it's the summer, are they going to be able to see it? Once a healthcare professional has decided. Okay, well this is going to be good. Taking the time to communicate the benefits to convince the or you know, to help motivate the patient to be on board with it too and on the patient and we know there can be cost and access issues right with insurance and requiring prior authorizations and all of those things, figuring out how to prescribe it and then that path for providing education and training and then that data interpretation because the data is a little bit different compared to when all you have is an A. One C. Every three months. Or you just have those finger stick readings. And on the patient side also making sure that the patient gets enough education and training to understand what their glucose targets are, what trend arrows mean, how to set alerts and also so they can understand what their data means to be empowered. What we know unfortunately is that there are there's a lot of disparities in diabetes care but especially with technology and continuous glucose monitoring use. And I've listed some statistics here. So 65% of black and Hispanics compared to 79% of white beneficiaries knew that Medicare pays for diabetes testing supplies and self management education. So why is there gap? Why do less black and hispanic patients are aware of their benefits. A retrospective chart review showed that 30% of black and 32.5% of hispanic patients initiated C. G. M. Compared with 54.3% of white patients. So we have to ask ourselves why is the percentage so much lower. And then among Medicare beneficiaries who acquired a C. G. M. Device. This was over 3000 patients there was a significantly lower proportion of C. G. M. use by black and hispanic beneficiaries compared with white and others and it's quite a large difference here. You see black 0.5% hispanic 2.9 and then 91% white. So we have to ask ourselves why why are there all of these differences? And so a solution a potential solution to overcome all of these different barriers is called the I. C. C. Framework. And this stands for identify configure, collaborate and what it is is and it's really quite simple. So it's identifying the right technology for the right person at the right time. Then configuring that technology so based on the individual user preferences based on their treatment plan based on their support system and then collaborating on that data. So having data driven conversations reviewing the time and range reviewing the C. G. M. Download and through shared decision making. Coming up with strategies to optimize the treatment plan. What the key is with all of these is it's about individualization, it's not about, oh we take one type of device and we give it to everyone. We have different C. G. M. Options and it's all about really customizing it for the individual so that they can really make the most of it. Um And it's not enough just to give a person a C. G. M. But it's also really important to configure it and go through the data. So let's talk about these steps in a little bit more detail. So when when choosing a glucose monitoring device there's definitely different considerations and I love to sit down with patients and just explain what the different options are so that they can make an informed choice. So within our different types of C. G. M. Right, there's differences with the frequency of sensor change. Summer seven day wear. Summer 10, summer 14 we have an implantable option which can be worn up to 100 and 80 days. Right. There's certainly differences than cost in terms of how much you know, we we tend to see intimately scan. C G. M is a little bit lower costs compared to some of the other devices. Right? Although we definitely will vary based on a person's insurance plan, compatibility with other devices is a big one. So there's other systems out there now there are connected insulin pens or connected pen caps and each one may work with the respective see GM device, there's also insulin pumps and automated insulin delivery and each one may have a specific C. G. M. It works with and there's also mobile applications that can do some really cool things and sometimes they work with specific CGM devices. So knowing that and explaining that can help you select the best one size of the sensor is also a big one too, fortunately we're seeing how that is coming down and we see now with the library three that's the size of two stacked pennies. Right. For some people, the size is really important because they want something as discreet as possible for others. They don't care as much for some people, the site or location may matter where it's approved accuracy. So, fortunately all the devices now have improved so much with accuracy, but we know some still require finger stick calibrations that can certainly be a consideration. And the differences with alerts. All of our devices now have the ability to do alerts. Some have more options with predictive alerts than others. Also, some people, you know, when you ask about, well, how do you want to check your glucose? Some people may say, gosh, I don't want something attached to me. And then, you know, you have a conversation, sometimes people start off saying this, but you show them how small the sensor is and they say, oh, well that's really a lot smaller. Or you say let's try it out. Like let's just let's do a two week trial and then they're like, oh, I really didn't even notice that was there. So that's not always a deal breaker that you can't have a wearable device. So thinking about that. And then the second example we see if I could see more information, I think I'd feel motivated to take my meds and eat healthier and so sometimes I'll have patients that are on, you know, they're just on oral medications or just on Metformin. But they really feel like by being able to track their glucose levels all the time. It really motivates them to make healthy lifestyle choices and they really benefit from it. So once we've identified the right technology, right, we want to go ahead and configure it and there are so many options for configuration and often this is the step I see that just gets missed, you know, because yes, there's Startup videos, it's not so hard to start and educate a person on it, but if you spend a little bit of time configuring some of these, you can really help someone and um one of the most common things I see happen is someone will start wearing it and say I can't wear this anymore. There's an alert that's going off all night, it's waking up my spouse. I like this is too much for me. There are simple solutions to that. You could just turn off the high alert and in fact when I start someone on C G. M, I often Just turn I turn off the high alert or I set it for like 400 because we don't know if you go from finger sticks to see GM you really don't know how high the glucose levels are going to go between meals or overnight. And the idea is that there's not always so much you can do in the moment but we'll meet, we'll follow up on the data if we see it is going highlight that we will adjust. Therapy will do something about it. And I also stress to people, you can look at your device all you want but we don't necessarily need it beeping at you all the time. Right? That being said some people want to know, some people really want to stay on top of it. They want their alerts on, they want them aggressive. Some people for hypoglycemia, they want that low alert at 80 85 because they really want to catch it early. Others say oh leave it at 70 65 so we can really individualize it. And I've shown some examples on here of you know, additional alerts like full rates and rise rates which some people like but others may say gosh that's that's a little too much for me keeping in mind that while a full rate can be nice to have In our current systems, it's not differentiating are you falling from 300 to 200? Are you falling from 150? Right, so falling from 300 to 200 would be desirable. Falling from 150 with not so much. Right, so really going over this and coming up with a good options and then also sharing data. So data can be shared directly with the clinic which often we encourage our patients to do it also can be shared with caregivers and loved ones. And so some people really want their privacy, they don't want to share their data with everyone and others are happy for family members and friends to be able to see. And they feel like they've got some extra accountability or attention if something should if they should have a severe low. So here's some configuration examples, right? The top patient says I want my wife and kids to see if I'm having a higher low blood sugar so they can help me if I need it, especially when I'm out of town on business. Right? So here's the case where we would really work to set up those sharing features, make sure those family members have the sharing apps so they can see the person's data. Uh In the second example with alarms, sleep is really important to me. I heard C. G. M. Buzzes and beeps at night. I do not want anything beeping at me during my sleep. I've always been able to feel my loves so we take that into consideration and then we we may turn alerts off or set the low really really low so it's not going off, it's not as likely to go off and then reminders. So these devices also have reminders to check on glucose uh and other things so I get so wrapped up in what I'm doing that I forget to check my glucose or take my insulin. I could really use the reminders. So in that example we would put them on for another person, we might choose not to write. Uh Now let's go ahead and talk about the collaboration staff and here's where we can provide that education and training as well. And I've listed here a quote from the American diabetes Association standards of care that says no device used in diabetes management works optimally without education training and follow up and to provide an example of this. I want to show you Camille one of my patients and simply wearing the device may not automatically translate to health benefits. And poor Camille was given a C. G. M. But she was not educated on her glucose targets. And so she's been wearing it for three months and here's her C. G. M. Report. And even if you know nothing about interpreting reports, hopefully you can see that most of the data is not in the lines. Right. And so she's if we look she's spending 2% of the time in the target range, It's desirable to spend 70% or more. Um and that's okay, patients come from all different backgrounds and some of them are not near their targets. But what is the tragedy here is that this has been going on for three months and poor Camille did not know that this was not desirable that this was not normal that this is not what we're trying to get because when she was given the device, no one explained to her, what are your glucose targets, what are we aiming for? And Camille if you look at this, she actually she has 74% of data captured, meaning she was actively engaged with the device. She this is a scanning device. So she was scanning regularly just not understanding that these are not the target. So it is imperative that when someone start C. G. M. That we go through we review what are those glucose targets and I love to take this time to introduce the concept of time and range of maximizing that time span between 70 and 180. So it turns out there's actually a lot of factors that affect glucose levels. And that's another one of the reasons why C. G. M. Is so valuable and I love showing this to patients because sometimes people will be like well wait, I don't get it. Like I am eating similar meals each day. Like why are my numbers changing day to day? Why are they not the same? Well, it turns out it's more than just food that impacts glucose levels right? Even within food, you see all these different categories, right? How the quality of carbohydrate, the amount of fat and protein can impact the glucose levels. We also see it's fascinating how different people respond to caffeine. A cup of black coffee. I have got some patients that need to take insulin for black coffee and then others, you know, it doesn't have carbohydrate. So it doesn't really it doesn't cause them to rise and that's just that's just food. Right? So within other like activity is also fascinating how some activity for people like even a walk will just drop them so much and then others they'll notice they'll exercise will either have no effect. Some people actually the rise especially with strength training and then there's other factors. There's like the environmental the outside the the heat affects some people. A sunburn affects some people. And so the point of all this is that everyone is an individual. And so the best way to learn how a unique individual is affected by these factors is through C. G. M. And through going through the report together. So this leads to really that collaboration step right? That technology alone. Yes it helps for sure. You put C. G. M. On someone and usually you will see some a one c lowering sometime and range improvement. But it's just a little to really maximize it. You go through the data together. You come up with oh the patterns how this I mean I had a patient it was she put notes into her C. G. M. Showing how a certain brand of apple she saw raised her sugars versus another. And so she made the choice not to buy that other brand of apple. Um But it's just fascinating what people can learn. And often the classic example that comes to mind is how we we teach about how you know eggs are not expected to raise blood sugars but cereal oatmeal generally does. And even though we teach that to patients it's something about how people wear it and then they come back to me and they'll say oh you'll never guess what I what I learned. I saw what oatmeal does to my blood sugars. So anyway it's very very reinforcing but we have to figure out well what's the cadence gonna be of who reviews the data and how often. And I do find immediately when someone starts C. G. M. To set a follow up after that first sensor where you know something within 7 to 14 days to review that initial data. Often we can come up with some really good changes at that point and then uh setting another follow up maybe within a month or two And then it can be less often after that. But often in the beginning there's just so much learning that is happening so in thinking about incorporating C. G. M. Into your practice I think it's really good to think about who is on your team and recognizing that each clinic each system may be a little different in terms of who do you have on your team? Of course the person with diabetes is at the center of it. But then thinking about your resources. Do who you know your physicians, your nurse practitioners, your P. A. S. Do you have a diabetes educator or diabetes care and education specialist? Do you have a pharmacist? Can you utilize your medical assistance, your nurses and then figuring out how could these different people be in the roles to identify patients for C. G. M. Right? Help them to configure it. And then that collaboration and this will be different based on each practice. I can tell you in ours we really have been utilizing our nurses to help identify patients for C. G. M. And provide that initial education and training. And then we've been utilizing our pharmacists a lot for that follow up for that that configure and collaboration going through the data together and downloading that data but every practice can be a little bit different. The key takeaway is having a team. Yes one person could do it all but it's so much easier when you have a team that can help out that you can rely on. So continuing on with this collaboration, I did want to share this framework to review the data, recognizing that it can be a lot right. It's a different way of looking at data. And so this model is called data we emphasize throughout reviewing data with a patient that at each step it's really it is information. It's not good or bad. It just is information. Right? And the first step is you obtain the data right in whatever respective system that you choose. Usually we use the device specific system but there are some that can download multiple devices and also at this step I like to provide an overview to the person with diabetes about kind of just general what the goals are and what the data means. Second step is assessing safety and this is looking at hypoglycemia. The reason why we focused on hypoglycemia first is because it is a safety issue and also hypoglycemia so often leads to rebound hyperglycemia. And so if we can reduce the hypoglycemia often we're going to be able to increase that time in range. The third step is focusing on time and range and looking at days. I love to find a day where time and range is the highest and ask all about it. Or maybe you can find a certain time of the day where time and range is consistently higher than others. The idea here is we try to replicate what is working well. This is a little counterintuitive to how I was initially taught because as a clinician, as a health care professional, I do just like I want to help people and I want to fix things and so sometimes I am drawn to like the mountains of hyperglycemia, right? And I want to just talk about that and fix that. But it's actually much more motivating to the person living with diabetes to focus on what's working well and replicating just doing a little bit more of that right now. The fourth step is we still talk about the areas to improve, we can still look at the mountains of hyperglycemia. It's just not the whole emphasis of the conversation and then fifth step we take all of that together and come up with an action plan. So I'm not going to go through a detailed example but I just wanted to show you an initial C. G. M. Report where we went through this model together where this is the this is the ambulatory glucose profile report Where I've downloaded the data and in this step I would explain to the person what I'm seeing, especially focusing on time and range and explaining what the goal is and how that 70-180 and what the goal is for optimizing that that 70% or more And then looking at safety, right? And seeing this this person spending 7% of the time in hypoglycemia and especially I see that that's happening. It looks to be overnight. So I would try to address that and figure out what strategies we can do to resolve that Then time and range. I picked one of these days at the bottom to talk about that appears to have high time and range. And so one example could be like the 26 it appears there's more time and range there and then we look for areas for improvement. So I might ask about one of the times where I see more of that yellow, right and maybe what factors contributed to it and then taking all of that and coming up with an action plan and so this was the person's follow up report just briefly I can tell you we made some medication adjustments. We ended up reducing the long acting insulin a little bit and made some lifestyle changes through the learning and through the discussion that really was able to reduce that time spent in hypoglycemia while optimizing that time and range now. In addition, C G. M data really offers a great opportunity for remote monitoring and population health. And this is an example. This is an example from the library view system of how you can actually organize your panel and key in on certain metrics like the time spent in hypoglycemia. That's the time below target here or glucose variability. You could look at time and range or average glucose and with many of our systems now connected to mobile apps where they're constantly being updated, that data is fresh. It's current, it's active. It's right now right. You can really hone in and proactively reach out to patients that are not meeting their goals or where you are concerned about safety and Take action versus waiting until their next appointment in three or 6 months. So I want to spend the rest of the time just talking about some additional potential barriers and the solutions to them. Who hasn't heard this before? Right. A patient calls you they recently started C. G. M. They say my sensor fell off early. What should I do? So there are tons of options to help it stay on and with it being summer and hot and humidity we should definitely proactively tell people about these options. So on the top you see many options to help it stay on better. So these are things we call them overlays that you can put on top of the sensor and they come in many fun designs if you're into that or you can get clear as well. And then there's also options for things to put on underneath it to make it tackier before you insert the sensor and that will help it stay on better. And often we may use both of these together. Also if a person sensor does fall off early, I always advise them to call the company and that's because it's really difficult to change the prescription or to have a pharmacy be able to dispense additional additional sensors. But the companies are generally pretty generous about if you say oh this fell off early or I had to remove it for an M. R. I. Or C. T. Scan. They're great about replacing them. So I always encourage people to do that. Now another thing, another big headache that sometimes happens is you send your C. G. M. To the pharmacy right? Um and they ask for a prior authorization and you do the prior authorization and then it gets rejected and everyone just kind of gives up hope and you say okay I guess it's not approved we can't get C. G. M. For our patient but turns out it would the person has criteria would meet criteria. They can get it. It was supposed to go through the durable medical equipment route. So something to know is if a patient has Medicare it generally should it needs to go through the DME route so you can save yourself a lot of headaches by sending it straight to D. M. E. And there's even there's a great program called Parachute where you can do everything online and it connects you to multiple de mes. Otherwise I would recommend talking to the respective companies and finding out in your local area which de mes generally provide the coverage for which insurance plans so that you can save headaches and go to the right place right away for commercial. Generally we do pharmacy works very well and then Medicaid will be very dependent on your area in Ohio fortunately Medicaid now can go through pharmacies as well. Another question that comes up quite frequently is gosh like my glucose I checked a finger stick and it's different than my C. G. M. Like what's right what's the source of truth? Right so we do know with C. G. M. That there is a slight lag time compared to be Gm. What this means is if glucose is rising or falling really really quickly and a person checks the finger stick. It may be different than what the C. G. M. Set. So let's say a person recently ate and it's rising right, the finger stick is probably going to be a little higher and you would expect the C. G. M. May be lower but it's going to have an arrow going up. That's just because they're measuring different body components. The B. G. M. Is measuring capillary glucose. C. G. M. Is measuring interstitial, they're still accurate. Um That being said there are certain times when we do want to advise a person to check with a finger stick and certain devices still require calibrations. So there's still going to be certain times where with those devices a person needs to check the other is if symptoms do not match the reading. So an example that comes up would be, let's say the C. G. M. Devices saying the person's like 57 the person says well I feel fine. Do you want them to start drinking tons of juice? So that may be a time to do a finger stick. Sometimes Technology is not always perfect 100% of the time. You also can get something called a compression low like if you have the sensor on your arm and you put your sleeping directly on it. So those might be times to do a finger stick and there's also certain interfering substances with different devices. So we know for example vitamin C interacts with the library. Um we see acetaminophen with the Guardian, we see hydroxy oreo with Guardian and the G. Six. So if a person is using some of those substances those would be times to verify. And they wanted to emphasize a quote from the american diabetes association that says every person using C. G. M. Should have access to a meter and test strips and this is important. Even with devices that don't require any calibration, we still want to make sure that patients have a backup method to be able to check. Also every device has a warm up period and during that warm up period they're not going to be able to see their glucose readings. So every person should still have a prescription. That being said we don't expect them to use to have to check very often or to use very many test strips as long as they're on a device that does not require calibrations like the G6 or the library. So I know we've gone through a lot of information today. I just wanted to leave you with a few summary points. So C. G. M. Has demonstrated many improved outcomes to experience maximum benefit People with diabetes need education and training on the devices and the healthcare team needs to be trained and how to use the data and we talked about how the data model can be used to go through data with patients. The I. C. C. Framework that identify configure collaborate framework is a tool that can really help us to address many of the barriers that we mentioned related to C. G. M. U. S. And then lastly there's many ways that the primary care team can help with C. G. M. Access initiation, education and collaboration of the data to ensure optimal use and the maximum benefit. And then I just wanted to leave you with some great technology resources especially because diabetes wise website. There's one for patients and there's one for health care professionals. This helps you stay up to date on all of the different device options, see GM and others insulin pumps connected pens. It helps patients choose the best device for their individual needs. So I highly recommend that and then also other resources from the American Association of Clinical Endocrinology, the Association of diabetes care and Education specialists in the american diabetes association. And with that I want to thank you so much for attending today and wishing you all the best
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