Thanks James for uh setting the table for uh the presentations today. I'd like to welcome everybody as well to the this year's American Diabetes Association. My name is Stuart Harris. I'm a professor at the Sulk School of Medicine and Dentistry at Western University in London, Ontario, Canada. And my focus for presentation is to talk about health care utilization. So is continuous glucose monitoring. The key to managing health care use in persons with diabetes. These are my disclosures and I have three learning objectives. The first is to assess the role of continuous glucose monitoring in diabetes management. And we've heard a little bit about this, but I'll just uh uh just touch on it as a as the part of the intro. Then to review the literature assessing the effect of CGM on diabetes related health care utilization. And I've tried to focus on the most recent data that has become available in the published literature in recent Congresses. And then finally to examine the factors causing disparities in CGM use between individuals and different populations. So let's get started. What role does continuous glucose monitoring have in diabetes care? Well, just this uh small cartoon demonstrates the uh the many added advantages comparing CGM to capillary blood glucose testing. And as you can see, uh con the continuous readings, predictive trend, data, optional alerts, wide data, accessibility and shareable and low burden of use. All of which CGM use has its advantages over CBG. This publication by Die Tribe did a beautiful job identifying the huge burden that people living with diabetes have to face on a daily basis. Uh Up to 42 different issues broken down here as you can see on the left. And you compare that to the amount of time that we have as clinicians and interactions with our patients or the person living with diabetes. And you can see how tiny amount it really has is an impact uh overall in the daily lives of people living with diabetes. So there are two basic systems sensors that are widely available uh in the United States and across the world. And that is the Dexcom and the uh uh Freestyle Libra and these are their reports from clarity and Libra view. And as a clinician when I walk into my uh uh clinical encounter with uh my patient, if this is up on the screen in 10 seconds, I know everything we need to discuss and I have the power of the reports to share and point to where the issues are lying, whether it's uh above time and range plus perennial hyperglycemia, time below range. And the variability day. To day as well as the added advantage of an estimated sensor derived A one C CGM improves clinical metrics. Uh And we now know that there's many, many randomized controlled trials that have demonstrated benefits in reducing A one C. I'm just listening a few here for type one and type two. Uh hypoglycemia is also reduced. And these studies uh have uh documented that with reductions in hypoglycemia improvements in time and range as well. Uh In a number of other studies, including the recently published Canadian study, the immediate which is people not on insulin using CGM with additional uh lifestyle education. And uh the evidence is now emerging that improving time and range, uh actually has a predicted long term improvements in reducing complications uh as they are listed here. So comparing someone who has an A one C above 70% versus uh individuals with below 50% this has now been correlated with the reduction of 46% in risk of severe hypoglycemia, uh minus 40% for a risk of microvascular complications and even a projected 31% reduction in uh overall maze. Not only do we have clinical benefits that are uh being identified uh by all of these studies, but now we have recently publications showing how there are improvements in quality of life using validated instruments uh for people living with diabetes. And as you can see, there are quite a few studies showing improvements in quality of life. And finally, even really very most interesting is how CGM views can improve and reduce absenteeism as identified in these two recent studies, future and flair. So there is robust data across age drug type insulin secretory capacity and duration of CGM use uh for people uh uh who uh have access and use CG MS in their daily lives. So what effect can continuous glucose monitoring have on health care use? I'm gonna break my presentation into these following uh themes. So we're gonna talk first about hospital use and I'll, I'll show data specifically on inpatient admissions and emergency department visits. Then I'll talk about outpatient visits and then finally, I'll talk about whether there's any evidence around cost savings. Let's first look at inpatient admissions and I'm gonna take a global uh view on all of this uh showing you data from not just the United States but other countries as well. So the first study that I'm gonna show looks at CGM use in the VA population by Raven and colleagues uh demonstrating a reduction in all cause hospitalization. This is a retrospective observational va study from 2015 to 2020. And you can get that included both type one and type twos. And this study showed that there was a 25% decrease in all cause hospitalization amongst individuals with type one diabetes using CGM versus non users. And this was statistically significant for type two. There was an 11% decrease in all cause hospitalization amongst people with type two diabetes using CGM versus non users. And again, this was also statistically significant uh CGM reduces inpatient admissions. And now looking again at another study from the US, uh uh looking at visits uh post CGM initiation at six and 12 months free and post index. The next study is going to look at uh uh another database, the Enova on insight study uh uh published and recently presented by Earl Hirsch and colleagues. And again, this is looking at type two diabetes Medicaid beneficiaries on basal insulin. And you can see pre and post findings here that there is a reduction in visits uh for individuals once they were initiated on CGM uh on basal insulin, the same kind of uh profile and and benefits and reduction are seen for those who are on MD I uh insulin. And finally, in another study from the US, they looked at the Optum database, the Optum Clinic formatic study uh which was from 2018 to 2021. And again, for people with type two diabetes on intensive insulin therapy, you see a statistically significant reduction in all cause uh inpatient admissions for individuals who receive CGM. So overall looking at these three studies, you can see that there was hospitalization decreases, that range from 16 to 50% quite, quite impressive reductions in all cause hospitalizations. The next study that I'm gonna highlight comes from France from Gert and colleagues looking at CGM reduction in ad E specific hospitalization that is a change in percent of acute diabetes event related hospitalization after long term CGM use versus no use. And here we're looking at a uh one year before retrospective look and then one year after and two year after. And you can see that in individuals with type two and basal insulin therapy. Over from 2017 to 2018, there was a reduction in percent of uh ad E related hospitalizations. Uh And the same was seen, the same kind of uh uh uh profile was seen in reductions for individuals with type two on MD I or insulin pump uh after initiation uh with CGM. So, these were driven in in specifically by reductions in hospitalizations for diabetic ketoacidosis and severe hypoglycemia. And analysis showed that this was irrespective of age or insulin regimen. Looking at a uh another us study of ad E related disc glycemia specific admissions. This is a retrospective obser observational va study by Raven and colleagues. Again, looking from 2015 to 20 twe 20 comparing 12 months of CGM use compared to SMBG use. And for type one diabetes, you can see that there was a 31% decrease in hypoglycemia related hospitalization and for type two diabetes, a 13% decrease in hyperglycemia related hospitalizations. And these were statistically significant. Uh at this year's AD A I will be presenting uh on Sunday if uh uh those of you who want to come by and see the poster uh data from Canada called the frontier study. And this is a retrospective cohort study using data from the Institute for Clinical Evaluative Sciences Database to measure percent change in hospitalizations for DK A or severe hyperglycemia. After 24 months of CGM use in Canada, we have universal health care in the province of Ontario, the largest province uh in the largest population in Canada, we can track all healthcare utilization for everyone in the province, which includes 1.3 million people with diabetes. So that's where we derive this data. Um And I'm showing you data from 2019 to 2020 over 45,000 individuals who were uh on CGM and looking at breaking it down into two age cohorts. So for those less than 66 years of age, you can see there was statistically significant reductions, a 26% reduction in DK, a 19% reduction for admission, the hospital for hypoglycemia. And for the an even greater impact for the older population, greater and equal to 66 years of age, 40% reduction in uh uh DK A admissions and 26% reduction in for severe hypoglycemia. Now, the effect of CGM persists across device type. And this next study I'm gonna show, tried to compare using uh uh uh uh a large uh using a database uh with a retrospective study of IBM market scan and IBM explorers. E hr and they compared AD E and all cause hospitalization free occurrence, six months, post initiation of both of either freestyle Libra flash versus Dexcom. So this, they used a propensity scoring approach to try and create two cohorts to agree and post and look to see if there were any differences between the two systems. And as you can see here for type one diabetes, there was quite a dramatic reductions, nine, approaching 95% uh for uh all cause hospitalization, free, acute diabetes related event free, hyperglycemia, event free and hypoglycemia event free. Uh very, very high rates in the nineties and no difference between systems. When we look at type two, very similar findings, no difference between Libre versus Dexcom. Uh both showing that they uh dramatically reduced hospital uh hospitalization uh in general for both hypo and hyper glycemia and all cause hy hy hospitalization. And further sub analysis, further sub analysis in the publication showed no difference in effects by age, gender health care practitioner type or insulin pump use for type one or type two diabetes subgroups. So now let's look at emergency department visits and I'm gonna be using some of the same data because the publications looked often at hospital use and ed visits. So going back to the Enova on insight study from 2017 through 2022 in individuals less than 65 years of age on Medicaid type two diabetes on basal insulin. You see that there was a reduction in numbers of visits to the er uh post CGM use and these were statistically significant. Uh looking again at those on MD I, you seen this, you see the same kind of trend with reduction in overall visits so that emergency department visits in these publication in this publication, uh uh demonstrated a decrease by 12 to 17% in individuals who had received and were using CGM devices systems. When we look at CGM reduction for ad e specific uh emergency department visits, we go back to the Optum clin formatic study. And you can see that regardless of where uh using I CD nine I CD 10 codes, uh regardless of whether the code was in any position for hypoglycemia or hyperglycemia, that there was a reduction in number of visits uh uh on intensive insulin therapy. And if the outcomes for the code was in first or second position, a similar kind of trend was noticed going back to the Canadian frontier study uh that I'll be presenting on Sunday CGM reduces disc glycemia specific ed visits as well. So we saw a similar kind of trend in the Canadian cohort uh for DK A and severe hypoglycemia for those less than 66 years of age. There was a 27% reduction in DK A and a 22% overall reduction in severe hypoglycemia between between 2019 and 2020 an even more dramatic impact for the older cohort, greater and equal to 66 years of age. With 50% reduction for DK A uh presentations to emerge and 30% reduction in severe hypoglycemia. What about out outpatient visits? So, let's look at some data again. Going back to the innova and insight study uh with type two diabetes on basal insulin. You can see that uh uh that there was uh for both those on uh basal insulin and beneficiaries on MD I, uh regimens, outpatient visits decreased by 6 to 7% post CGM use despite increase for those with low outpatient visits, pre initiation with CGM. Now, the big question of course is does this also have an impact on mortality? And just recently presented at ATT D by Raven and colleagues was another was a look back at the VA study which showed a very dramatic 57% reduction and decrease in mortality amongst type one diabetes CGM users versus non users. After 18 months, post CGM use a highly statistically significant and uh 14% decrease in mortality amongst type two diabetes CGM users versus non users after 18 months of CGM use very dramatic findings. Finally, let's look at cost is this cost savings. So this particular study uh by uh Norman Edel, looked at uh uh retrospective cost effective in the study on administrative claims for commer from commercial and Medicare advantage uh in the diabetes Research database from 2017 through 2019. As you can see here, there was cost saving seen for inpatient stays, outpatient visits and often visits as well. So yes, evidence that this is cost saving. Another study going back to the uh Hannah article uh uh looking at the coding uh uh for hospitalization and and emerge shows that uh there is uh savings seen uh for both emergency department and inpatient visits. So where does that leave us now? Well, if you look at the guidelines, you can see that the evidence has built and built and built in the most recent standard of care. The 8820 in 2024 you can see that the level of evidence is very high A or B for both type one and type two diabetes on insulin. Uh And even the evidence is now growing uh for non intensive insulin and is therefore being recommended for anyone who's receiving insulin therapy uh with very high level of evidence. And this, I show you the 2023 to show you that the level of evidence, the recommendations are the same, the level of evidence has improved. And if you look at other guidelines, uh uh Ace and ipad and diabetes uh Canada, uh they are, their publications are already out of date uh because they've not incorporate corporated the most recent evidence. So I think we would go along with the uh standard of care for the eight from the 88 in 2024 with the highest level level of evidence and recommendations for use. Now, the use of CGM is increasing and this is uh showing over the last decade. Uh the last data that we have published. But we know that the in the use has continued to grow across the United States and other countries. But the real question is how high we cannot really call this standard of care until access is complete and available to anyone who meets the qual. The guideline recommended uh qualify qualifications for use of CGM. So there are many barriers to CGM use. There's a person living with diabetes level factors that are listed here, there are health care practitioner level factors. And I really point out particularly in primary care, cognitive bias and concerns around competing demands and tech literacy. Um and then finding system level factors which may ultimately be the major barrier and limitation to facilitate access to all individuals who who require and meet the criteria for use of CGM according to guidelines. And really to point out here medical uh racism as a a major issue that needs to be dealt with moving forward. So in conclusion, CGM use reduces hospital use overall including inpatient visits, emergency department, admissions and outpatient visits. CGM use statistically significant decreased the number of hypoglycemia related emergencies in uh people living with di with type one diabetes as well as hyperglycemia related emergencies. In those with type two diabetes and the evidence has highlighted that CGM use was associated with statistically significant reductions in health care costs especially for as it relates to inpatient care. And finally, CGM is a clearly effective tool to reduce overall health care use. And strategies moving forward have to help redress disparities in CGM uptake as a major prioritization. I wanna thank uh my colleagues who helped me put this slide deck together, Doctor Alexander Razy Leaming and Jude Hampton. And I thank you very much for your attention.
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