Welcome to 2023 A ANP. I'll be speaking about moving beyond hemoglobin A one C new standards for assessing glycemic control, practical action steps for establishing CGM based care in the nurse practitioner setting. My name is Celia Leveck. I'm an advanced practice nurse at MD Anderson Cancer Center. I work for the Department of Endocrinology and hormonal Disorders in Houston, Texas. I uh treat patients with diabetes and it's, and they're related complications. And on a personal note, I personally have type one diabetes myself. Uh I'll be, uh I have a cos speaker today and her name is Jennifer Goldman. She's a PH D CDC ES and ABC AD MFCCP. Uh, she's a professor of pharmacy Practice and clinical pharmacist uh in Massachusetts, basically. Right now, there's 37.3 million Americans with diabetes and it's the number one cause of death in people with diabetes is cardiovascular disease and it could be anywhere from 2 to 8 fold increase in CB death. Um, depending on glycemic control. It's the number one cause of blindness. The number one cause of nontraumatic amp, lower limit amputation. It's the number one cause of in stage renal disease and the number eight cause of death in the nation. And I actually think that might be higher because a lot of people on their death certificate don't list that diabetes was the cause. It would be like for instance, a mcardle infarction, but it's, uh, it's a costly disease and the percentage of people achieving diabetes goals, even with all of our drugs, we have more than 100 drugs on the market. Now, uh, between 2015 and 2018, only uh 50.5% of the people were able to achieve hemoglobin ac of less than 7%. And he the hemoglobin A one C and the non HDL cholesterol and the blood pressure goals. Only 22% of the people were able to meet those goals and 90% of the patients with type two diabetes, see primary care and not, they don't go to specialists like me at, at our center. So, so basically the best treatments for type uh diabetes is to achieve glycemic targets. One improves hemoglobin A one C. But at yet lowers the risk of hypoglycemia and reduces the risk of cardiovascular disease. And in stage renal disease and reduces the risk of weight gain. But hemoglobin A one c, although our glycaemic target is to be 7% or less, then they're not always equal. So you can have people with the same exact hemoglobin A one C and you can see the person at the top has a lot of glycaemic variability. And then the person at the bottom has lower glycaemic variability. And glycemic variability is associated with increased risk of mortality and cardiovascular death. The evolution of glucose monitoring, it started out with urine testing uh back in the early 19 hundreds and then back in the 19 sixties, we started with visual glucose testing strips, but most people didn't use those, most of those were at doctor's offices. And then glucose monitoring came out into the late 19 seventies. But still, at that time, most people were not using a glucose meter, they were still either on visual testing or no testing or sometimes urine testing. Uh It really didn't get popular up until the 19 eighties and nineties. Um And then in the late 1999 then glucose monitoring started out uh at the beginning, they were pretty big and they were cumbersome and they had a lot of inaccuracies. But now the most recent uh continuous glucose monitor on the market are extremely accurate. And uh uh basically, they're very small, very easy to use and more affordable than they ever used to be. And if you don't know already, but basically a continuous glucose sensor has a sensor that's placed under the skin. Uh sometimes they're placed for six days, sometimes 10 days, sometimes 14 days and sometimes six months. But there's a sensor that's under the skin and then there's a transmitter that transmits the data to some sort of a relay device and that relay device could be a smartphone, a reader, uh something like that and basically it's checking interstitial fluid glucose. And so you can see at the top right under the skin, you have sugar uh under the skin and then what the meter is checking is the blood glucose. And so those numbers might be fairly similar if the blood sugars are steady. But if the blood sugars are rapidly rising, the sugar gets into the blood first. So your meter is gonna read higher than the sensor. And if your sugars are rapidly falling, then the meter will read lower than the sensor. But if your sugars are fairly steady, then they really agree with each other and they're both correct. Sometimes patients will ask me well, my meter says one thing and my blood says the other then which one is right? And they're both actually correct. It's just that where is the blood sugar at that moment in time? Are the blood sugars heading up or the blood sugars heading down? Standard deviation and coefficient of variation are numbers that you'll see on the glucose reports on the uh from the CGM report. And there are two different things, but they kind of are pointing towards the same thing. Standard deviation is basically a spread around the mean and the higher the mean glucose, the higher the standard deviation. And the goal is if you take standard deviation times three, then it's less than the mean. And you'll see that on some of the glucose reports and then some of the glucose reports will report coefficient of variation and that's a slightly different number. And sometimes people get these mixed up uh but it's not influenced by means uh sensor glucose. It allows for a single variability and the goal uh is generally to be less than 36%. But there's some evidence that shows that if the coefficient of variation is less than 33% then that equals lower risk of long term complications. But certainly it should be definitely less than 36%. And high glycaemic variability is associated with increased risk of cardiovascular disease, secondary to hypoglycemia. And it's also associated with higher risk of long term complications. And so if somebody was steady high and it wasn't fluctuating a lot, they're actually at a lower risk than somebody that has a lower um glucose. But then it's fluctuating high and low and high and low. There's a lot of sensors on the market currently and uh there's different companies on the market and they all slightly do different things and they all have different bells and whistles and patients really should look at uh what is it they want in a sensor and what will their insurance cover and what would it cost them if their insurance doesn't cover it? The American Diabetes Association 2023 guidelines says that real time or intermittently scanned glucose monitoring should be offered to people with type two diabetes if they are on any insulin therapy. So it could be basal insulin only multiple daily injections or even insulin pump therapy and that they're high risk of hypoglycemia. Uh So if you have patients that are on a seon urea, for example, and having problems with hypoglycemia, then Medicare covers the continuous glucose sensor and they're capable of using it and it doesn't have to be the patient capable of using. It could be the family members. I have patients that are in assisted living facility situations or nursing homes and the family has the sensor on them and then they can come visit the patient and download the information and that kind of thing. So they can kind of keep track of that also um some of the patients because I'll see them during telemedicine visits, then they can do the scanning and all that, but their family member comes and helps them put it on. So the patient doesn't have to be able to do it completely by themselves. If somebody else is able to do it for them, there's lots and lots and lots of studies and this is just a few of them that show the uh the improvements of people's uh time and range and percent spent low uh with people with type two diabetes. A lot of people think sensors are for people with type one but it's not true. A lot of people with type two diabetes actually make low levels of insulin. And so they're at risk of diabetic ketoacidosis and hypoglycemia just like somebody with type one diabetes. Uh, but there's numerous studies that show uh people with basal insulin only, oral agent only. Uh people with cranial insulin only and they had better timing range, lower hemoglobin A one C and less hypoglycemia uh episodes. Uh and it doesn't really need, need to be continuous, it could be intermittent. And so there's different kinds of, of sensors on the market. There's ones that you scan and look at your number, it still keeps track uh in the background of what's going on in, in the, in between. But if you want to see your reading, you scan to see your reading. And as long as you're scanning at least every eight hours, then you can get a full 24 hour report. Uh but most people are scanning, you know, multiple times a day, what? And I usually ask people on, on um in, you know, on flash glucose monitoring to, to uh look at their reading before they eat and then again after they eat, so they can see the effect of, of food on their blood glucose. And then again before bedtime, so they're not going to bed with either a high or low blood sugar. And then if they have to get up during the middle of that, they can scan to see if they're, if they're low. Um, but there was a randomized control trial in type two diabetes on diet and exercise alone or other therapies, anything except cranial insulin. And it showed the intermittent, uh, gl- glucose monitoring where, where you wore a sensor one time and then maybe you didn't wear it for one or two more times and then you wore it again. So if you wore the sensor and then didn't wear the sensor, then there's still a significant reduction in a one. See, with uh improvement of hypoglycemia. And, uh, and, and they even sustain the improvement over the 40 weeks of during the study. And so if a patient doesn't want to wear a sensor constantly, if you just ask them to wear a sensor, say two weeks before they come in to see you, you know, if they're seeing you once every three months, then they can just wear one censor, uh, periodically before coming in. And then you have a, a report to look at. Um, and then with the flash glucose monitoring, there was a, a randomized control trial and it showed that even with just intermittent looking at your readings and didn't have constant readings, then there was significant reduction in hypoglycemia and then overall satisfaction. And I know my patients tell me all the time that, uh, they, once they start wearing a sensor, they get reliant on it. If they don't have those readings, they, they actually are upset by that. So some of the advantages of wearing a continuous glucose monitor include it can estimate uh the hemoglobin A one C if it's worn 70% of the time for two weeks. And what in my patient population, there's a lot of false hemoglobin. A one CS, a lot more false lows and false highs. But, but they're, it's hard to estimate uh the hemoglobin A one C if you have somebody that's checking blood glucose a lot, and then you look at the hemoglobin A one C, sometimes they don't match. It looks, sometimes it looks like their blood glucose levels are doing fine and that their hemo hemoglobin A one C is high. So that means they're high when they're not checking. But the sensor checks 288 times a day and it's checking uh before and after, during the night. So it's checking all the time. So it's actually to me more accurate than a sensor than a hemoglobin A one C. Uh it provides data when uh that's not given by fingersticks. So it does all the in between uh increases time and range, decreases hypoglycemia and decreases hemoglobin A one C. It helps the patient to see the effects of lifestyle on sensor readings and it alarms to uh the alarms help reduce the anxiety of the patient like if they're going to sleep and their blood glucose levels are normal. A lot of people are frightened they're going to have low blood sugar during the night. But if you have a sensor alarm that shows that you, you know, it wakes you up if you're going to be going low and it actually warns you before you get low, so you can do something about it, then that is a, a big peace of mind. It helps people sleep better and significant others also. And it shows the variability of the glucose where hemoglobin A one C doesn't show variability. So some of the disadvantages of continuous glucose monitoring can be cost. But now most insurances are covering the sensors and Medicare covers even if it's only one injection of insulin a day. And it also covers if somebody has two hypoglycemia events in one week on Sophon Aas or really any kind of insulin, but it's covered for insulin anyway, um interferences uh can be uh uh certain medications and certain supplements can interfere with the accuracy of it. And then sometimes there's contraindications like MRI S and cat scans and uh other uh diagnostic tests, you might have to take it off for that. And then there is a learning curve. And so sometimes offices are, are hesitant to put people on sensors because they think it's gonna take up too much of their time and time is really valuable. In a primary care office. You have a lot of things to do besides treating diabetes and you might not have the manpower to train and we have three uh CDC ESS in our uh office and we're fixing to get 1/4 1. But I don't use my CDC ESS to train on the CGM. I just have the patient call, the company and the company uh trains them on the phone. They can even do virtual visits with them to train the patient. Um Personally, when I started on continuous sensor, it's so easy. All I did was look at a youtube video and then the uh product support is very good. There's videos on how to do it and step by step instructions and inside the app, it kind of teaches you how to do it too. So it's pretty easy and skin irritation can be a problem, but there's ways to get around that. So what's good about continuous monitoring? It not only does it show you your current reading, but it shows you your rate of change. So it's basically how, how are you now and then, which way are you going and how fast are you getting there? And so if you stuck your finger and got a glucose reading of 200 but you had a double arrow down, which means that you're going to be 90 points lower in about 30 minutes, then you would make a different decision than if you were 200 your blood sugars were heading up. And so with 11 on the left, you wouldn't do any additional treatment for that. But on the right, you would probably take some treatment for that and some people are worried about, you know, they take up a lot of our time. Then how do we get reimbursed for our time? But there are billing codes that you can use to get reimbursed for CGM. And the 95249 code is if the patient owns the product and you train the patient, you can bill them for that. It doesn't have to be the provider doing the training. It could be anybody in the office that is trained to do that. Um and it could be an office um uh product too. Uh but basically the 95249 codes uh train the patient on how to use their device and it covers sy placing the sensor, training the patient, removing the sensor, printing a report and then you can bill uh one once for the device. If the patient changes devices, then you can build that code again. And then the 95250 code code is basically you're using your own professional CGM because they do have professional professional CG MS in the office. And it's, it does the same thing as the 95249 code only. It's uh physician owned or practice owned. Um The 95251 code is the interpretation by the provider. So that's an additional code on top of the other two for training the patient. And so this one is, is billed by the provider and you have to interpret the report and of a report that's at least three days old. Um And, and you can do that um ba basically once a month and then you with the uh if you're gonna do it on the same day, you actually see the patient, then you can do a modifier code. So you're seeing the patient, you're let's say you're treating their blood pressure and you're adjusting their insulin therapy and you're doing a bunch of other things. So you bill for that and then you would use a modifier for interpreting a report. So you can do that with or without the patient. So if you do an interpretation and adjust therapy and you're not seeing the patient, you would just do the 295251 code and how you analyze a report is basically, you look at a 14 day report more than 70% of the time and then you look at the variability. And so you're gonna either look at standard deviation or coefficient of variation depending on which report you're looking at. Um And then after that, you're looking for the average sensor glucose. And the goal is to be less than 155 mg per deciliter. And then you start looking at time and range. And so time and range is considered to be 70 to 1 80 you want to be 70% or higher and then you start looking at the low. And so the goal for to be 54 to 70 is less than 4%. And then the goal for being less than 54 is less than 1% of the time. So after that, then you can look at the high readings and if so, I'll look at the four first and then you can look at the tree second. So once you kind of look at this report, then you can look at individual days if there's any outlying days and then you can ask the patient, well, what happened on this day or I noticed that, uh, on the weekends you look like this, but the weekdays you look like that. So let's make a weekend plan.
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