Video CGM-Directed Management to Improve Outcomes in Persons with T2DUsing CGM to Optimize Therapy at the Front Lines of Diabetes Care Play Pause Volume Quality 1080P 720P 576P Fullscreen Captions Transcript Chapters Slides CGM-Directed Management to Improve Outcomes in Persons with T2DUsing CGM to Optimize Therapy at the Front Lines of Diabetes Care Overview Continue To Test Back to Symposium thanks so much Lucia for getting us all warmed up really talking about the utility of C. G. M. And so I'm going to switch a little gears here. I'm going to go into that actual integration into that front line type of clinical scenario. We're going to discuss the C. G. M. Directed managements to improving outcomes with persons with type two diabetes. Really putting it into practice utilizing C. G. M. To optimize that therapy at the front lines of diabetes care. Dr Eden miller. I work at my clinic, diabetes obesity care in bend Oregon and I'm affiliated with ST Charles Hospital. So let's start a bit. You kind of already know this but I really wanted to still down so you have a great understanding of what the person with diabetes and what the clinician or health care provider with I with who is prescribing, see GM can really get out of it. So let's talk a little bit about that person. C. G. M. Is amazing how it brings diabetes out of the past out of that retrospective average metric. It brings it to the present. It helps predict the future, but it also engages the patient in a way that we're really all looking for. We know that this is a shared decision making. We know that this is something that we want the patient to feel empowered to manage their own disease. After all my motto is to turn patients into experts on the very condition that they have and so when I think of C. G. M. I really think of a new opportunity for them to personally see their own glucose journey. And so a very much is individually driven. We want to orient them. So persons can understand that theres trend arrows up and down and stable. It will allow them to see the rate of change really to prevent hypoglycemia but also to be mindful of hyperglycemia as well. I think the feature that we really didn't anticipate C. G. M. Would provide so much insight is that we're finding that food has a very customized or personal effect. You know, I know we talk about what we call glycemic index or good or bad foods, but there is definite insight with utilizing C. G. M. With persons with diabetes to understand specifically how particular foods affect them. Many individuals with diabetes have been blinded to this. They don't know that oatmeal maybe seems healthy but doesn't really agree with them in terms of their blood sugars. And so we can see that effect of food. We can see that time of day. Uh the diurnal effect of diabetes, the coming the going ebbing and the flowing as well as illness right? When individuals are sick or when they're stressed. This is an also illumination of what occurs with glycemic management and then finally it allows for loved ones who are concerned and worried. We're all fearful of hypoglycemia and including the clinician. But when a person and a caregiver a loved one has that ability to monitor to be part of that glycemic journey, Part of the diabetes burden to lift it. It really makes them feel empowered. Now, I don't want to forget the clinician because the prescriber besides giving the patient an opportunity to engage at a higher level on their own disease. It's really not a distress. I don't see C g M as a distress. In fact, I see it as an empowerment opportunity to fully feel like you're in charge of your own directive with your own glucose. We are as commission is exceedingly fearful of hypoglycemia. It is there. But sometimes we avoid it by having hyperglycemia and that's not the safest way to do. In fact, we know that if we can understand time and range, understand directional arrows, that's way better to prevent hypoglycemia than trying to keep an A. One C at a level that probably actually confers a greater risk of hypoglycemia because we have what's called glucose variability. And so this enables them to protect them on their self as well as we have therapeutic impacts, right intensification of insulin or any other medications as well as the intensification that we're really able to reveal what that therapeutic change and how it impacts glucose by downloading the reports. And if I can just pause for a moment and say, this is probably a key that I want to encourage all of you to really equip your practice to really create a workflow so that you can download these ports reports, you can engage in that medication adjustment and that awareness of the glucose journey because as we have opportunities to intervene with that glitchy mia in that real time fashion it's really going to help with overcoming therapeutic inertia. And that compiled principal data is immense. There's gonna be new vocab for you to learn, there's gonna be some new metrics for you to be aware of and so don't be daunted by it. Just start that journey begin that right. They say a job begun is 50% done. So understand when you see those reports identify that hypoglycemic chris that's the first thing we want to be aware of. But then we want to be mindful of glycemic excursions because glycemic excursions that you know hide a low that variability is what's really gonna be driving, how shall I say complications and as well as driving the risk of hypoglycemia, we want to have a target. We want to give patients that that work to do that goal to get and that's that time and range. And so be familiar that 70 to 1 80 what an opportunity to visualize the data to see it from that A G. P. To incorporate it in the office in that interaction ride on it, share it with them help them reflect on it later because we're trying to empower them to do you know their own disease management. So when we talk about kind of who specifically can benefit from C. G. M. I know we we often talk about who's going to benefit by who is it being covered for? I don't want you to necessarily look at that because coverage changes and understand we should put the patient first. Yes I understand barriers our coverage. There's ways around it. Uh You know we've seen intermittent C. G. M. News. We've seen cash pay for it. Of course you want to go through um you know those medical benefits. But let's talk about who could benefit from that. In my opinion all persons with diabetes that are two and above who want more engagement need more engagement with their disease. They're going to get something out of it. Don't put C. G. M. In a silo where it's just hypoglycemia or it's just for people on multiple daily injections. Yes. Certain insurance companies, especially Medicare requires that you're on three or more shots a day. But that doesn't mean that that's where its utility lies outside the U. S. We can use C. G. M. For those pregnant with type two diabetes inside the U. S. We're not quite there yet but of course still can use it for those Type one pregnant patients. I would also suggest analyzing those people who are at risk for hypoglycemia. Those are on symphony areas. It it happens a lot more than we really want to be aware of. I think those on basal insulin we often see that over basil. Ization that contributes to it. Of course multiple mealtime injections or insulin delivery devices are pumps. I think all persons on a pump should be on A C. G. M. Many of them are integrated and I think there'll be a requirement in the future for them to fully be effective. Now, if we want to think of those related to age, those are advancing age, higher risk of hypoglycemia complications. Those who have trouble with cognition or secondary family members or institutions are monitoring their blood sugars, complex patients with multiple disease issues or multiple medications and of course, don't forget the kidney diseases. They get a lot of glucose variability, they get a lot of meds that hang around and so they're at increased risk for hippo and we want to avoid hypoglycemia in that coronary artery disease because arrhythmias that are generated from it can be quite detrimental. And then those individuals that are not highly engaged, right? We call it the reluctant engage ear's in Type two diabetes management, Those persons with poorly managed diabetes who could just benefit from that illumination what their individual journey is and to empower them to know how foods affect them to know how the medication adherence or lack of adherence, the activities of daily living. So you can see that this health care provider thinks that all persons the diabetes will benefit on some level. It's just how you look at C. G. M. And what it provides. And so we really urge you to start intervening and integrating this in your clinical practice and everyone's gonna win. You're gonna win as a prescriber your patients are gonna feel much more empowered and and equipped like they feel like they can intervene with their own disease. So if we look a little bit at overcoming therapeutic inertia because you know, it's one of the things that I do with the american diabetes association on the co chair for the Educational Department really identifying barriers and that's really imperative as as prescribers to be very real with ourselves with our own barriers because it seems like prescribers have more barriers than even the patients do. And so when we look specifically at inertia and at those barriers they looked at the effect of freestyle libre. This is one of the posters that was presented at the a day, it's a retrospective cohort using the Canadian private pair claims databases. And so they wanted to look at therapeutic inertia to see if they can look and see if tools such as the freestyle libre would help overcome this inertia for advancing therapy. And so they compared it with fasting or I'm sorry, just blood glucose monitoring and looked at whether treatment intensification was done. It had quite a bit of patient looked at it looked at 100 and 50,000 patients with type two diabetes in 18 and above in Canada over the two year period and they tear them out based on no therapy mono oral therapies? Multiple oral therapies, injectable GLP one receptor agonist plus or minus with other therapies as well as multiple insulin injections, both basil and M. D. I. So you can see pretty much everybody all the individuals from the very beginning to the very end. So about 373,000 individuals qualify for that inclusion criteria across all those cohorts. And the freestyle libre groups were found. And what they indicated is that when you looked at all the different groups, right, the utilization of freestyle libre on all those groups had a statistically higher probability of treatment intensification. So, from the standpoint of the patient as well as the prescriber knowing that data through the freestyle libre helped overcome what we call that delay in treatment intensification. Which is something that we must address in order to get them to go to help with that overall legacy effect. So here you could see how the treatment cohort with the freestyle library and the control cohort was the finger stick. And we see the statistical significance and it was broken out into either naive to diabetes therapy prior or on existing therapy. And you can see that the cohort was the non insulin users versus the insulin users with the freestyle comparative in the treatment versus the control. And we see the relative risk over 24 months. And that is that that relative risk of inertia, in other words, how much more times were the control cohort? The just self monitoring blood glucose or that lag for intensification. And we see in all groups We had a you know, one 86 all the way up to 2.81 relative risk or exponential lag and treatment. And so what they suggested by this retrospective is that when you utilize freestyle libre in those individuals with diabetes, they were more likely to intensify their treatment. And I think that just goes to show that this tool helps its dual facing. It's for that of the person with diabetes as well as the prescriber. And this enables them to see the glycerine mia. And I think to both come to that agreement for intensification. Now this was a study that I participated in with my colleagues listed here and that was really looking at the A one C reduction after the initiation of the freestyle libre. We did this a couple of years ago as a poster presentation in 2020 and we looked at those individuals with type two diabetes who were either on only long acting insulin, not M. D. I. So just basil insulin for those that were on non insulin therapies that could be on injectable GLP ones or any other oral agents. And it was looked at to see to get a baseline a one c six months and then to go six months and 12 months. Looking at their current a one c while they were on the freestyle libre system and then dividing them into those groups of those long acting and those non insulin. And so they looked retrospectively at the de identified data. They got the data from the library view. They did quest diagnostics to do an index primary baseline as well as six and 12 month A one C. And they tried to get it as close to that. You had to be greater than or equal to 65 at the beginning uh six months prior to that that index baseline initial one that's that was completed. And we actually, as researchers were quite surprised here we see on the left hand side what we call the pool data. So that was all comers basil insulin plus everything. And we see that in the first six months that by just using the freestyle libre system you had a .8% and would see reduction that continued on not quite as robust at .6 but was still present even at that 12 month time frame. Now I think what was most astounding to us is if you look at the second graphic you'll see that the greatest agency reduction of 0.9% was seen in the type two population that weren't on insulin. So that really kind of breaks the ceiling away from C. G. M. Being just something on insulin in addition but it also validates that basal insulin individuals could benefit as well. And so it kind of takes C. G. M. Out of the hypoglycemic arena and into the glycemic elimination and and control. And that that's not surprising that that group who we traditionally don't really talk about glucose management and benefited the greatest when they weren't on insulin and that persisted even at 12 months with 120.7. So I think this trial really kind of solidifies the different modalities that C. G. M. Can provide persons irrespective of what particular therapy that they're on. So as we have really established a nice foundation of the concepts that the CIA did with C. G. M. As a utility looking kind of at the evidence related to it. I know some of you might be saying oh but I just don't have time. Well I'm here to say that you don't have time not to do it because each time you're overcoming barriers you have all these things that are there. The engagement, the inertia and I'm encouraging you to pause and really create a workflow that helps for you and your clinical staff of how to integrate C. G. M. So I'm gonna give you a few pointers or hips are tips that kind of kind of help you just set aside that time create that workflow and make it seamless integration into your practice. And so I start with my schedule or or my front office staff and one of the things I do to help kind of integrate C. G. M. And even overcome a nurse and diabetes is something that I helped develop with the A. D. A. And that is the developing diabetes only appointments. I know some of you in the primary care realm so you don't understand I'm dying and I say I get it you know I get you got ankles and depression and that kind of thing. But diabetes is going to be there today and the next day and the next day and it needs to be prioritized whether you have those diabetes related appointments based on a scheduled follow up with A. One C. Or if you at least do it in at least a six month or 12 month frame where you say okay listen we're also going to tack onto that A C. G. M. Appointment where we're going to integrate this and utilize this with you be prepared now if you have individuals who are already on C. G. M. My front office staff after creating these diabetes only appointments. When they send them the reminder they say to them bring your diabetes related technology bring your C. G. M. Bring your connected devices, make sure you have it if it's not on your phone if you have a reader. And so when they come and check in my team at the front office starts the process of accessing that diabetes really technology data. And in some cases my front office staff does have on their screen in front of them the ability to to plug it in. If if my medical assistant who is my diabetes champion is busy. We don't just have one person who does it. We have all individuals that are trained in the workflow and so you have to be essential that you have the applications or you have those. How should I say the directive desktop areas to get the to acquire the data? Unfortunately there's not a lot of them. There's very few cords many times. These are cloud based, especially if you're using the phone and at my office when you get to see GM you've been invited. So you already have your account. And so in some cases my front office staff can go in with the name and attach the C G. M. Already to the chart. And so it really depends on who and why, how you want the workflow. Now some of you might be saying, well I work in a very large conglomerate that has a locked down system in terms of its ch are you just need that administration to allow you to create on your desktop that pass through and then it gets sent as a pdf. And so depending on how you need to pause and make sure you do that in my office. I I am the boss. I don't have any barriers but I understand that you live in different arenas, you could also get a secondary computer, a laptop that just as a stand alone may be connected to the internet that could be sent through a secure location as well. So there's many ways to overcome that. So identify those potential barriers and find a way to work around it. And then finally at our front office staff if they're unable to do that they're ready to pass it on to the individual who is our diabetes champion in our office that is our medical assistant or our back office staff. They are that champion. They're the one that really knows how to do it. But understand I think all persons in the back office need to know how to do it but if you want to have that one who is familiar with the components of the C. G. M. System what what does it look like? Do you have samples, How do you apply it and set it up? What are the phone based applications? How do I troubleshoot with that? In addition they know that if the ambulatory glucose profile that that heads up display that data that you're gonna do in the middle of the office that if the front office staff can't do it that they have to be ready to say okay um I see you have the diabetes appointment. I'm gonna go into that view and download the data that's there through the cloud or they plug it in? Not too hard. They take the reader, the standalone reader not a phone, the standalone reader and plug it in. And so after creating a clinic profile on these particular applications then you're ready to download and you upload it to the chart. Now that uploading to the chart can be done through the pdf. Many of you are like oh I want to integrate it straight into my E. H. R. I'm like do you really want to know every single data point? That's a lot of integration in the HR. So what I've done is created a macro in my chart where I put the time in range and hypo or I just pull it up through the pdf portion of the visual and I share it and print it out and then send it on through the secure patient portal. So one thing that I like to boast a little bit is my medical assistant, she goes into my charts or in my schedule the day prior and uploads all the C. G. M. S before I even get into the office that day. So you see how that workflow is. You really hone it in and and I have one in a for the entire office and we can do it as well. It's just you have to pause and really find out what works for you and occasionally have to do some plug in or troubleshooting and then finally my application of C. G. M. In the in the practice is done by my medical assistant. We built for that but they're able to put those sensors on in less than about 3 to 5 minutes and get the patient all ready to go to come in and follow up with it. So here's just a brief introduction of kind of the beginning to end. We have the freestyle libre iphone app, the 14 day library too. And and the brandy library three. Right now we're happy to announce that was announced that the 88 the android app isn't out yet probably be out momentarily and the IOS app is out and so my staff when they apply the sensor in the office, they download the right there or they get a reader or the hand reader a prescription. And then the patient will have that link 14 day on their phone. That's the application that they have. Uh and that link up is for loved ones and so you have that loved one who wants to follow up through the library link. The person with diabetes sends an invite. That's kind of a permission and the link up application on the other the loved one's phone is allowed to see the data. That's all the privacy thing. And then you as the prescriber you want the library view all the freestyle library systems. I don't care what they are 14 2 and three are going to be downloaded. Either cloud based or actually plugging in the reader as you can see on the left hand side and that's where you're going to be obtaining that A G. P. Data. So here's a similar kind of work floor for the decks com the decks com phone based app is IOS and android for G six. Right now the share app is for those that are loved ones. One of the other things that often doesn't get placed on a person with diabetes using the decks cop is the clear decks calm as a clarity up. That needs to be on the person with diabetes bone as well to kind of generate those reports. And then for you as the prescriber the clarity application on your desktop software in order to download those. Um and those are also cloud based there are readers as you can see on this slide that can be plugged in as well and so you can see it's a rural similar workflow. Some of the other ones now Medtronic has generally just the phone based application and that's the connect for those loved ones. The care link which is for your desktop software and then just the Guardian system application from the app store for those who are utilizing Guardian. And then finally we have the ever since which I will just discuss briefly and that has just a phone based application and you have to get a pass through for your desktop for that. But many uh the implantable uh sensi onyx is very limited and so I do not have a particular slide for that. So let's go through the basics of billing because your time is valuable. I had a fascinating conversation the other day about a person who are prescriber who was like I love C. G. M. I do it but I just don't feel like I could build for it and I go what do you mean you can't build for it? And she goes well I just don't know and should I do that? And I said do you build for an E. K. G. Do you apply an E. K. G? Do you get that data? Do you do it diagnostically? Do you dictated in the chart and bill for it? She's like absolutely. And I said you should do the same thing, this is a your knowledge, this is your skill set, this is your time. And so the basics of building for C. G. M. R. Really who owns the equipment? Does the patient on it? Is that their sensor? Is it something they got from the pharmacy? Is it something that's going to be forward facing to them? Or is it a provider owned sensor meaning that you have a professional C. G. M. That you have purchased apply to your patients? Those are two unique codes and I'll make sure and discuss those now we really want 72 hours of wear it. You really want to get to that three days because that's Medicare, that's all that you gotta have at least three days of data. I like to try to get to 14 but if a sensor falls off early and it's less than that time frame I would start over. As I mentioned you you're downloading those receiver in the office or cloud base, it's put into the chart and electronically transferred. I mentioned it in the notes, I mentioned that I discussed it. You can either do it at the time of visit with an E. N. M. Code or you can do it as a stand alone like a cpt where you're looking at the C. G. M. At a different time from the appointment and then you're going to discuss it later. But to me it seems easier to just build it as an E. M. M. Code with either an in person or virtual visit. I do them virtually or telemedicine. Which is amazing how you can monitor people from afar. And so it can be charged on that day of the download or any time for analysis. It's just how you do your billing. Uh And as indicated that any person who has an M. P. I. Number. Those are the ones you can build if you don't have an M. P. I. Number you're not able to build. And so that billing is tied to that N. P. I. Or prescriber number. So here are these codes that you need to know. There's not very many of them talk with your billers so they're very familiar with this but there's really basically three cpt modifier codes and that's the 95249 which is the personal so that's owned by the person they're going to be seen and it's forward facing to them. You can actually build for that application. Like I said when my Emma goes in there and puts the app on their phone puts the sensor on my bill for that personal C. G. M. That start up in training and we really want that 72 hours. Of course we're intending it for the you know 10 to 14 days depending on which center you're looking at. You wanna don't wanna build for this more than one time per month. I I generally keep the rule of about 2 to 3 months in mind. So then if we look at professional C. G. M. And for some of you who are a little reticent at doing C. G. M. Professional is your low hanging fruit. If you purchase a professional C. G. M. In your office it's not a high expend you have a reader to download that data later. That is something that you can do without any resistance, no authorization with that Medicare Medicaid and commercial cover that And it might feel a little bit safer for you to do that but understand that patients not going to get any data from that. It's blinded. Generally there is one that that is forward facing to the patient for the most part is blinded. Now that's a higher reimbursement for the 95,250 because you had to purchase the sensor so it's a higher built in. But it's also one of the easiest ways to incorporate C. G. M. But you're really missing that patient forward and so maybe you would start with that and then transition to the personal C. G. M. Now when you bring them back into the office which I encourage you to do 2 to 3 weeks after every initial C. G. M. Start really bring them back in. Make sure it's fresh, make sure that they've written a little journal about all the different foods and meds and things. So that way they can really highly engaged in it. You're gonna build a 95251 which is the C. G. M. Interpretation. It doesn't matter which sensor you use whether it's personal or professional, it's still the same number and you want that 72 hours of data. You want to cite it just like you do an E. K. G. That you spent time additional time that reviewed it. You discussed, you give them a handout, you emailed it to him, you made therapeutic decisions, whatever right you want to make sure that you're utilizing it and then you can add that E. N. M. Code onto it as well and I use the C. G. M. CPT code as my time for that one and then the PNM is whatever time for that PNM code so you can see not very challenging to do yes, you should be reimbursed for your time and your your expertise and make sure you have a conversation with your bill or regarding that. And so in closing, I really want to emphasize that you need to take the time now to establish a clinic workflow and to familiarize yourself with diabetes related technology. This is gonna save you countless hours and maximize patient interaction. I know at this side you're like, oh I don't have time for this, you don't have time to waste. And so being proactive about this, developing that pointed way of integrating C. G. M. It's gonna be a time saver for you and please feel free to contact me personally at any time. I love to share my experiences of how I've done it and I really much appreciate your attention. I hope that this has been beneficial and encouraging to you for utilizing C. G. M. In your clinical practice Published June 21, 2022 Created by Related Presenters Eden Miller, DO FounderDiabetes and Obesity Care LLCSt. Charles Hospital Bend, OR
