I'd like to thank Doctor Wright for that explanation on how to use the ambulatory care uh glucose report, a GP report and my name is Jennifer Goldman. I am a professor of Pharmacy Practice at the Massachusetts College of Pharmacy and Health Sciences. I teach cardiometabolic diabetes in the pharmacy program and the physician assistant program at the university. I'm a clinical pharmacist at Wildlife in P D, Massachusetts. I've been practicing in family medicine and internal medicine for about 25 years and practicing in total for over 30 years. And at Wildlife, I developed the cardiometabolic program and direct that. Uh currently, I'm a certified diabetes care and education specialist. I'm board certified in advanced diabetes management. And at my practice, that's where I take doctor pharmacy students, fellows and residents on rotation. I will be discussing uh maximizing patient engagement and satisfaction with sensor based glucose monitoring and the new real world data confirming patient centric preferences for continuous glucose monitoring based care in the primary provider setting. This study in type one, diabetes exemplifies why achieving good glycaemic control early matters. If you have a person labeled person with diabetes a on the left who spends the 1st 10 years after diagnosis at an A one C of seven and then the next 10 years after diagnosis with an A one C of nine, compared to the person on the right here with, um, an A one C of nine, the 1st 10 years and then seven, the exact opposite. You can see that the person who spent the 1st 10 years early, so early control, early better control has a 33% reduction in the risk of cardiovascular disease and a 52% reduction in reduced E G F R. So this demonstrates here and this is in people with type one diabetes. Demonstrates that earlier intervention is important for a greater reduction in cardiovascular and kidney complications. Now, when we look at type two diabetes, so this is the UK P DS trial and these are patients who received intensive glucose lowering pharmacotherapy a diagnosis so early and that was compared to diet modification in the other group alone. And what it shows is that early intensive therapy, pharmacotherapy reduced the risk of any diabetes related endpoint. And this benefit was seen at 10 years but also recently data supported seeing this reduction 44 years later. So that is considered a legacy effect. So in both examples that I just went over type one and now in type two, early intensive intervention, decreased complications in both type one and type two. So the 2023 ad a standards of care, reinforce the need for early and intensive individualized treatment. Claims it is time to move on to time and range. While A one C gives you an average blood glucose over a three month period, time and range is the amount of time a person spends in the target blood glucose range. Continuous glucose monitoring is able to identify the time in range as well as the time above range and below range. So that problem solving can be done. So treatment plans can be changed, changes to medications or diet can occur to improve the time in range. In this survey, people with type one and type two diabetes were asked what was important to them. The factors with the biggest impact in their daily life was similar across the board. Food choices were number one impact for type one and type two diabetes. For people with type two diabetes who were taking insulin or not taking insulin and time and range was second choice across the board. So in people with type one diabetes, type two diabetes on insulin or type two diabetes, not taking insulin across the board time and range. So regardless of the type of diabetes with or without insulin, people want their blood sugars in the target range and they rate that high in terms of impacting their daily life for both people with type one diabetes and type two diabetes on insulin. The majority surveyed ranked having their blood glucose numbers on target all day is most likely to put them in a positive frame of mind about their diabetes and their health. People with type two diabetes who are not taking insulin ranked, taking medications as prescribed first and having blood sugars on target all day. Second as drivers for positive mindset. This is a survey done by Diatribe Foundation. O. Over 3000 surveys were completed and people were asked about success outcomes of current care priorities for diabetes care improvements and diabetes impact on quality of life. There were over 1000 respondents from each of the three groups, type one diabetes, type two diabetes, taking insulin, type two diabetes, not on insulin. And when looking at what makes a big impact on their daily lives, there were many differences between the groups which you can see except for one time and range was number one for all three groups. It is a major priority regardless of which group, regardless of type one or type two or insulin or no insulin. This study by Wang Nada and Alva was designed to assess treatment satisfaction using continuous glucose monitoring among people with both type one and type two diabetes. It was a prospective multi center non randomized trial of 935 adults in the United States. The participants used blood glucose monitoring with the glucometer device for six months and then switched to continue with glucose monitoring. The six months C G M was associated with a statistically significant increase in diabetes, treatment satisfaction in people with type one and type two diabetes. Compared to blood glucose monitoring, frequent daily scanning was correlated with a decrease in a one C. Here, you can visually appreciate the statistically significant difference in people with type one and type two diabetes with total treatment satisfaction scores favoring continuous glucose monitoring compared to blood glucose monitoring with a glucometer. When further drilling down. When comparing continuous glucose monitoring to blood glucose monitoring, there was a statistically significant difference with overall satisfaction of treatment of convenience of flexibility and of understanding diabetes. There was no difference in people's perceived frequency of hyperglycemia with either C G M or B G M in type one and type two diabetes. And in people with type two diabetes, not type one diabetes, there was a perceived difference in the frequency of hypoglycemia. What about the elderly? So the same investigators study diabetes treatment satisfaction of using C G M in 267 people with type two diabetes who are 65 or older and similar to the previous trial, they used B G M for six months and then were transitioned to C G M for six months. In this population of people, 65 older, the intervention of using AC G M was associated with significant increases in diabetes treatment satisfaction and perceived frequency of hypoglycemia was significantly less when compared to B G M. Frequent daily scanning was also associated with a reduction in A one C in this elderly population. Here is a visual representation of the statistically significant difference when comparing continuous glucose monitoring to blood glucose monitoring and treatment satisfaction. Among elderly participants. In this study of elderly people with type two diabetes, all measures of satisfaction were statistically better with C G M compared to B G M except the one, there was no difference with perceived frequency of hyperglycemia. There was improvement in convenience, flexibility, understanding, diabetes, recommending and continuing use and perceived frequency of hypoglycemia with the use of C G M. This data from the flare study in the this prospective nationwide registry, 1365 participants with diabetes used C G M for 12 months. Real world data demonstrated the use of C G M resulted in improved well-being and decreased disease burden as well as improved glycaemic control. 95% of users reported having a better understanding of their glucose fluctuations. 92% of users found it easier to manage mealtime glucose. 77% of users feel the number of hypoglycemia events reduced and 37% of users report engaging in physical activity more frequently. The use of C G M led to a 66% reduction in hospital admissions at 12 months and a 58% reduction in work absenteeism at six months in both people with type one and type two diabetes. Six months after getting C G M people with type two diabetes not on bolus insulin saw a 30% reduction in acute diabetes events. Kind of think about this. The use of a device AC G M sensor led to those outcomes, 66% reduction in hospital admissions, 58% reduction in work absenteeism from a sensor. In a real world study comparing glucose metrics between C G M readers and C G M connected app. So the reader versus the app app, users experience less time in hyperglycemia, lower average glucose and lower glucose variability than those using readers. They spent more time in range than those using a reader compared to the app. In 87% of patients that were sharing the data on the C G M platform with their physicians continued using sensors 12 months later, in both type one and type two diabetes, patients that use C G M reduce time in hypoglycemia without increasing their A one C. In the impact trial. In patients with type one diabetes, there was a 38% reduction of hypoglycemia with the use of C G M compared to B G M. And in the replaced trial, people with type two diabetes, there was a 41% reduction in hypoglycemia with the use of C G M over B G M. So, so in both trials, what was demonstrated was a reduction in hypoglycemia without increasing A one C all from the use of a device. A CJ M sensor in this data, what I want you to appreciate is that higher the time and range, the lower the complication risks. So the lower the time and range, the higher the risk. So you can see here both in type one and in type two diabetes, a comparative risk when a person is only at 58% time and range compared to 70 and 80% time and range. So the higher the time and range the decrease the risk, the risk of myocardial infarction, end-stage renal disease, severe vision loss and amputation are all increased with the lower time and range and all decreased with a higher time and range. So this is more very clear evidence of the value and importance of time and range for our patients. Improve risk reduction with time and range that we just discussed. The reduction in M I and end stage renal disease and vision loss and amputation as you can imagine, translates to a cost reduction. So by improving your time and range people with both type one and type two diabetes, it translates to a 10 year cost reduction in the billions of dollars range. So on the left, you can see by improving time and range 58% to 70%. Ok. 58% to 70% in people with type one diabetes. There's a 10 year cost reduction of 2.1 to $4.2 billion. And by on the right you can see by improving time and range from 58% to 80% in people with type two diabetes. The cost reduction is 4 to $7 billion. Hm. A cost reduction can also be seen just from improving the rates of hypoglycemic events in people with type one diabetes as a result of improving time and range. So these values, they are impressive. They are significant. If you reduce hypoglycemic events by 10% there's a 10 year cost reduction of $1.2 billion. If you reduce it by 20% there's a $1.7 billion reduction. If you reduce it by 30% there's a $2.2 billion reduction. And if you reduce hypoglycemic events by 40% as a result of improving time and range, the 10 year cost reduction is $2.8 billion. Now chapter seven in the 2023 ad a standards of care addresses diabetes technology. So there's some key recommendations in this chapter. One being that the use of the C G M device should be considered from the outset of the diagnosis of diabetes that requires insulin management. So that's type one or type two. It also recommends that people with diabetes should be have uninterrupted access to their supplies to minimize gaps in C G M use. I will review a few of the other highlights in this chapter that now the standards of care are available online, including this chapter so that the entire standards and it's also available uh in an app that's free. So these two recommendations truly focus on individualization of devices and education devices should be chosen based on a person's needs preferences uh in skill levels for them or for the caregivers. So, so if the caregivers skills and preferences, let's say it's for a, a young child or a person with an impairment. So we need to think about the patient or the caregiver if that's the situation. So not only does the patient require education but so will that caregiver? And it should not be just initially in one and done. You need to continue as an ongoing process and make sure proper use is continued in understanding for everyone involved. The standards also have a broad application in people with type two diabetes on and off oral therapies. It may be helpful in people who are altering a nutrition plan or a physical activity plan or if they're using medications that can cause hypoglycemia, continuous glucose monitoring should be offered for diabetes management in adults with daily injections or insulin pumps. And the choice of the device should be based on that person's needs and their preferences or their circumstances. The standards of care also recommend that people using basal insulin be offered C G M with the choice of the device. Again, based on that person's needs preferences or circumstances. The last recommendations that I'm gonna highlight from the standards is that C G M should be offered to youth with type one diabetes or type two diabetes who are using multiple daily injections or an insulin pump or to their caregivers. So, depending on their age and, and whether they're doing self-care or not, the choice of the device, again, based on that person's individualized circumstances, preferences and their needs. So what would I say are important takeaways or take home points better, glycaemic control, early, early intensive therapy leads to the legacy effect with a greater reduction in the risk of diabetes complications compared to later implementation in both type one and type two diabetes, continuous glucose monitoring. The use of AC G M leads to better patient satisfaction, improved quality of life among people with diabetes and a significant reduction in hospital admissions and work absenteeism. I also showed you data that, that shows that improved time and range results in a decrease of M I end stage renal disease, severe vision loss and amputation as well as billions of dollars saved over that 10 year period. So significant cost savings in both type one and type two diabetes. The ad a standards of care recommend the use of C G M from the outset of diagnosis in people with diabetes requiring insulin as well as for other situations and type two diabetes, whether even for physical activity or if they're on medications for hypoglycemia. And lastly, health care providers are in a key position to educate and provide continuous glucose monitoring to really help improve outcomes of our patients. With that. I thank you for your time.
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