Good afternoon and welcome to the symposium around evolving observation and real world data use with sensor based C. G. M. Across the diabetes spectrum at 18 2021. This symposium is funded by Abbott diabetes care and the CMB certified provided by the University of Massachusetts Medical School and CMI Education resources. And of course, as I said, funded by Abbott diabetes care, I'm professor pretty charging. I'm chairing the session. I'm professor of diabetes at the University of Leicester and I'm going to be joined by Professor Monica Keller, who is the president of the german diabetes society and medical director of the Center for Internal Medicine at instruct guard in Germany. So to start off with, I'm going to set us off by talking a little bit about the intersection of flash glucose monitoring technology and real world care in people with diabetes, looking a little bit of what trials can teachers and the implications of adopting CGM in the covid era and beyond. So I think, you know, with 100 years of Since the discovery of insulin it's worth looking back around how glucose monitoring has changed over those 100 years. Um and in fact even going back further, you've got urine testing and tasting in the in the very early days. You got urine testing with clinic test, urine dipstick testing and then around the 1980s when the first portable but glucose meters came out Over the last 40 yard years like glucose testing devices have got smaller, quicker, more efficient, more accurate. And then around the early two thousands we started to get continuous glucose monitoring and I actually my MD thesis using that C. G. M. Gold device there you see in the lower picture and now we've moved forward to and Liberal devices. These tiny discs have become ubiquitous amongst people with type one diabetes. And as well put put by a patient of mine, we've gone from seeing what the glucose was six hours before by testing the urine to devices that can tell us what our glucose is going to be 30 minutes in advance with the advent of continuous glucose monitoring. But every change, every major step in glucose monitoring has been met with a degree of resistance. And it's quite a big change from the healthcare professional community. Um you know, the big change from your intestine to blood glucose monitoring happened in the late 70s. And this is just a publication I found from the lancer and one of the early reports of blood glucose monitoring from my old institution, King's College London by Peter Song Stone, saying that 80% of people who tried this new device reported that self monitoring was a great help, But 20% said it was a nuisance and they prefer to go back to urine testing. But 92% said they would buy a machine if it was the right price. And going back there at that time. These devices was £200.. And I hope you recognize on kind of see those parallels with the introduction of continuous glucose monitoring with the vast majority of people feeling that this is a huge benefit, with a small proportion of people feeling that it's just a bit too much, a bit too much information, struggling to cope with it and wanted to stick with what they know and then the overwhelming challenges of funding new technology, the price increases and getting that into the healthcare system, improving the health economics of it. I was also thinking about how the way people monitor glucose and deliver their insulin really defines um people with diabetes. So, I just put in a search if you see that in preparation for this talk. I just searched person with diabetes and all the boxes with red show up pictures that came up with blood glucose monitoring or pen injection devices. And it shows you how that's the way we identify people with diabetes that they have stabbing their finger and getting those blood glucose readings. I just thought that was a very interesting take on what google thinks a person with diabetes looks like it looks like the blood coming out of their finger. But if we move on and see you know JDRF a couple of years ago published this roadmap for the future around something is around the kind of 100 year anniversary of its sorry. And if you see there, one of the big things in the middle is you are leaving needle injections behind and you are leaving finger pricking behind. And those are two key things that people with diabetes want freedom from as they move forward. One of the key advantages of course of continuous glucose monitoring is yes you get a bit more information. You can share it with the cloud. But I think the fundamental benefit is that people just measure their glucose more often and we know how important that is. So these are two graphs from the german diabetes, the D. P. V. Registry which is a register about 40,000 people type one diabetes. And you can see there across the patch on the left hand panel you can see that title glucose control is associated with greater frequency of glucose monitoring. And if you're looking at the people who are achieving that magical target of 7% HBO and see still not 6.5 they're doing 9 to 10 readings a day. And if you're looking at people who doing you know the average of 4 to 5 fingerprint testing a day. Their average A one C. Is between eight and 9% on the other side. And the other panel you can see when self reported frequency of blood glucose monitoring. Most people are following the advice of measuring at least four times a day. You can see the 4 to 6 of the average. If you map that back to a one C. That's why average HB one sees in many places above 8%. So what are the barriers why do barriers to test to measuring glucose more often? Because 60% of people with Type one diabetes and almost and more than two thirds of those Type two diabetes report that they measure their sng less than recommended. And I think this is a little bit like people always give themselves an allowance. If you're supposed to drink two drinks a day maximum, you have to slightly larger drinks than the normal. There's always that degree of pushing things a bit further. If you're told if you're asked to measure glucose four times a day Then you missed the other one here and there and it's quite usual that's why the average drops down to two or 3. But in these databases it's an adaptation from data from Kaiser permanently by Andy carter. The predictors of low frequency of blood glucose monitoring. And you can see that in people with Type one diabetes and instituted Type two diabetes in oral hypoglycemic treat, Type two diabetes and those on diet. You can see the main predictors of low usage are people from ethnic minorities, people with lower income and lower education non native english speakers. This was a study in the U. S. Of course um male gender and long duration of diabetes and then other behaviors such as alcohol and cigarette consumption. And if you look in that there's 5% of people with Type 21 diabetes or concentrated type two diabetes who never monitor about a third of people with type two diabetes on oral hypoglycemic. So diet never monitor. And if you look at people who are monitoring three plus a day it's only about 40% of the type ones, less than 15% of the type twos on insulin. And then for tattoos not on insulin it's good to 5%. So the advent of you know, simple, easy to use and relatively cheaper continuous glucose monitoring with free celebrate. The first is one of the first press releases from 2014. This is really revolutionary and I think one of the key differences when the key um really interesting things that happened was this was freely available and before it became reimbursed on health care systems such as the UK. You found people buying these devices and and improving their control, bypassing all the barriers or the steps, all the kind of hurdles that health care professionals put in place about these criterias we met. It's the education you need. It was so intuitive people pick it up and the more data you get, the better glucose control you have. And in so many ways this was getting changing and people were reporting, you know, people coming back to clinic had started using this kit were really reflecting on how much it changed the game. How knowing where they were being able to measure the glucose more frequently, really give them peace of mind, really help their glucose control. The better the glucose control, the less the diabetes distressed the better they felt. It was also a game changing for people on the other side of that table. For other health care professionals, we moved from these detailed diaries where we have scroll through and look at car braziers and glucose and try and get that map of data to the world of gPS, to the world where we can get that average look at those patterns and get detailed information what's happening all the time in particular, filling in those gaps. What was happening between those fingerprint readings, Looking at post meal excursions overnight hyperglycemia. And if you think about the impact of flash glucose monitoring the person, it's a real ripple impact. It was the huge, the biggest impact is on the person living with diabetes, but that indirectly also affects the people affected by diabetes, their carers, their family members, their Children, their parents, their work colleagues. Um If that person is more comfortable with diabetes has better diabetes control, there's that knock on effect and people around them. I've already said the way it affects health care professionals, butter glucose controlling the better data, better consultations. And now in this covid era, the ability to the remote consultations and ultimately all of those things impact the health care system. And we've seen data, I'll show you real world data around admissions and around the way we deliver care. So just to take that step back, one of the first randomized controlled trials of liberal was this was the impact city. You will be familiar with this. Uh and they took people with well-controlled diabetes. But what we sure saw there was a 30% reduction in hyperglycemia that started immediately. The patient started using the device. This did not take 3-6 months of learning what happened before they got the benefit. This was instantaneous and sustained and in response to that data and the kind of big demand from people living with diabetes and just buying this kit off the market, there was a big change in, in the way this was reimbursed. And if you look at it, Germany was a mixed reimbursement pathway in France, a top down pathway in England. Again, a mixed reimbursement with some um some criteria required and then in Italy and spain again that the reimbursement pathway in the, the budget holders are very different whether it was just England and the top down or kind of central or from local providers bottom up, But whichever where it was a liberal was now reimbursing most of those countries for almost all people with type one diabetes. And speaking of someone in the UK, um, you know, we had a great support from NHS England, the Central group and in particular, uh, call out my close friend partner Car, who really led the way in getting this policy adopted. And just a year ago or before things started kind of 2019. You can see those red places are places where there is no policy where the uptake of uh, reimbursement of liberal was less than uh, was zero. Pretty much. And you can see there's a few areas who had some limited reimbursement. And then a year after the policy was brought in in the UK, almost all places have gone green and the average uptake in the UK was 30 was 30% last year. That's grown to almost 50%. Um, bye bye june by doing this year, of course we're we started a bit later. The reimbursement was a little bit slower and then my colleagues in in european countries tell me that now it is almost unheard of to see people practicing that barbaric system where you stabbed your finger to draw blood in order to see what your glucose was. Um And this is the impact on health care professionals, isn't it? Now with liberal and certainly during the covid era, we have virtual networks doing video conferences, we have liberal views so we can connect with the patient and we have their data in real time. Um You know, we've had to learn how to do these clinics from home. I've been doing my clinics from home for the last year and our face to face clinical, but we still haven't started more than a year after pandemic. And I've got used to now setting things up home. We've learned different ways in which we should do remote consultations. We need to think about bandwidth, we need to think about multiple screens. We need to be logging into all these different tabs without electronic patient records. And we have to learn how to get patients to read that data off their devices where the connections don't work. And you know the this linked data has really facilitated a very different model of care. And I just want to highlight this was as a person I worked with during the early phases of lockdown. So about this time last year A 20 year old patient who never attended clinic every three months would be sent an appointment in transition clinic but never never turned off. She's been prescribed liberal but using it on and off anxiety, depression hated coming to clinic. And at that time we had done some risk rating because we knew that the impact of Covid was much worse on people with high HB one C. Uh and so with someone with the last major HBO and see about a year ago of 13.8%. We were able to get a telephone call and she picked it up and I hope you can see down there um Kind if you go from the bottom that's third of june up to 17th of june to the first of july and our average glucose that is starting to drop from 17.8 to 16.9 down to 14.7. I hope you see the variability dropping. And we were really able to engage with this young person during Covid in a much better way than we've ever been able to engage with her outside. And the two things that made that possible with the remote monitoring, the automated upload and the fact that we were contacted over the over the phone and we had data to speak to and we could help her get her control better. So in summary in this kind of introduction, I think to me I can imagine what a sea change S. M. B. G. was 40 years ago when it was introduced. Because for me, flash glucose monitoring has been a similar game changer. But more than me it's more about the people living with diabetes and them the data says and look at the real world evidence data. But later it showed improved quality of life that's given them freedom and it's given them improved diabetes control. And for us on the health care system the data show reduced admissions, reduced emergency call outs, reduced cost of diabetes to the health care system. Um And it's also facilitated remote care and telemedicine helped us reach people who are struggling to each before. On that note, I'm going to hand over to Dr Keller for the next session, the next talk, and then I'll come back and talk a bit about the real world data in a moment.
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