Thank you, Doctor Wilmott for the kind introduction and for your insightful leadoff remarks. I'd like to welcome you all also to the 2023 easd meeting and I hope you'll have an excellent meeting. It's my pleasure to today to talk about optimizing the quality of diabetes with a focus on the A GP report and individuals with type two diabetes. I'm going to focus on both the measurement of quality and the management of quality and you may have heard this quote where you really can't manage what you don't measure. I think that's true, but I'd like to turn it around for our discussion in these next few minutes. And I'd like for us to explore is what you measure, helping guide you to better quality management. So, is the measurement metric you select really helpful to get you to better quality? These are my disclosures. I think everyone in the audience will agree. Um Whether you're here in person or you're virtual that we are living in the A ONE C era, that's what I'd like to label it since the DC CT ended 30 years ago. Yes, it's 30 years ago to this year. The A one C has been everywhere as a quality measure, how well we're doing with the glycemic management and helping guide our management. You see A one C in every algorithm. If A one C then do this. But what is quality diabetes management? Have any of you ever had to just write down your bullets of what quality management is? What if I ask you to take out a piece of paper and just write down your bullets, what is quality to you? Well, of course, I had to do it just to create this slide. So I put these bullets, um, minimal hyperglycemia, minimal hyper low risk of cardiovascular complications. Think about your weight and a healthy diet. Let's decrease the burden of diabetes. Let's have a system in which we deliver the care and receive the care that's efficient and cost effective and is personal to, to the individual. And of course, let's make it equitable. So there's a lot to quality. You'll have other uh great suggestions, I'm sure. But let's look at two reports. A lab report with the A one C. There it is, that's what you get. Maybe an asterisk saying this is out of the range of target or normal. And you might get this report, an A GP report that also has targets and goals and metrics and a visual. So how do these correlate with this, these quality measures I outlined? Well, I could just put some checks here and say, well, we have some data that says a one C correlates with hyperglycemia and risk of complications and probably distress and A one C sort of inversely uh correlates with equitable care. Uh So how about a GP report? Well, it does all the same plus a GP report, uh correlates or has a bearing on hypoglycemia. Uh a much more personalized and I'll just add that the A one C report. There's a building building data saying it can be helpful for us as we think about a healthy diet and efficient data into the earee hr directly. And it's, and it's, and there's some interesting cost effective data coming on the use of CGM. So that's the correlations with the measure. I'm really interested to know if these quality measures help guide us towards better quality, not just a check box, but do they really move us there? So I'm gonna just look very briefly, there's my little list over on the left and uh I'm gonna focus on whether they can guide us towards quality, just picking out the hyper and hypoglycemia for efficiency of time, although we could go through all of them. So here's the data A one C as our guide to measure quality and as our guide to get us there, we're not doing so well. In these past 30 years, here's a recent uh uh decade, uh uh several decades, put together a really nice article in the New England journal of medicine that shows only 50% of the time are we had an A one c of eight and only three quarters of the time, uh, under the I, I, I'm sorry, three quarters of the time were under eight and only 50% of the time under seven. How about hyper and hypoglycemia per se? Well, this is really some interesting data just out in diabetes care recently. Look at the top was type one diabetes hyperglycemia, emergency of visits still high and, and, and, and, uh, in the solid and not getting any better actually going up hypoglycemia. Well, maybe there's a little trend down, maybe that's with some newer agents, um, being newer insulins being used or, or A ID systems, but still really high in type two diabetes. Look at the hypoglycemia rates. It's not as high as type one, but boy, it has hardly budged over these decades and hyperglycemia although lower isn't improving. So I don't think A one C has been a very good guide to get us to this goal of better minimizing hyper or hypoglycemia. Let's take the A GP report and just very quickly say, how's it doing on hyper and hypoglycemia? Well, this is a meta analysis that many of you have seen or familiar with and it says if you use CGM versus BGM or standard of care. Look at that. A one C improvement. Yes, it did time and range, but I'm just focusing on even getting a better A one C almost all the time, the times where it didn't move so much to the left, which is an improvement is where the A one C was already good. And they were trying to reduce hypoglycemia. So A one C better hypoglycemia better. We can't say that about using A one C as your guide. I'll throw in this for extra before and after starting AC GM, look at the acute emergency room, inpatient vis outpatient visits, inpatient hospitalizations all dramatically reduced. Uh That's 61% reduction in those acute events using a GP report using CGM as your guide. And I'll just throw in this two people who are wondering well, does it really correlate with progression of retinopathy or microvascular disease? Like a one C? Does look at this from the DC CT data using derived time and range on the right. A one C on the left. It's the exact same type of correlation and significant correlation with a one C or time and range and retinopathy progression over the DC CT using the seven point profiles. They did four times a year for 10 years. I wonder if the GM I correlates with retinopathy like time and range. Does you may be wondering that too? No one's exactly written that out and studied it unless you'd like to go to the abstract that Doctor Earl Hirsch, who many of you, I'm sure know uh Coming up just this Friday uh on the sixth, at, at noon in Paris Hall, go and see his abstract. He's gonna take that same DC CT and analyze it using the GM I and see if it correlated with complications. I said I'm not gonna show the results and the conclusions because I want him to make a big splash with some really impressive data. I hope you'll go there. But if you look at his title, you might get a clue as to what he's going to say. So I, I hope I see you there having said that we come back particularly in the primary care setting and we're told over and over again. OK. Quality, quality, quality. I want to get there. I'm following the AD A EASD algorithm now that everyone here has seen 100 times uh since it's been out in the standards of care and, and, and, and all the diabetes journals. So how is CGM or a one C going to line up and helping me follow this algorithm? Well, I break down the algorithm just to these pillars. You got the lead in important features and you've got five pillars of care. Let me just pull up the A GP report on the right here and just very quickly tell you what I think uh how a one, how the A GP report addresses this form of quality uh management. I already told you how it did glycemic control. I'm putting a check there. I hope you agree with the data I showed you on the hyper and hypo improvements. How about weight loss? Should I put a check there or not? Well, just look what we're all learning. I'll bet you have patients who use CGM, who are not on insulin who are on diet and exercise and maybe a medication and they've looked at their readings on their, uh, smartphone and they've seen these spikes and they've said, what was I eating then? Maybe I could change what I'm eating to something a little different and they did and look what they found and they started to lose weight and they're having a healthier diet. So, or they said, well, they talk about sugar in my drinks and boy, I, I had a time and range of 3% and all I did was change those first and I got to 26%. No, that's not ideal. But look at that 23% increase in time and range just by changing the fluid intake composition. So anyway, I'm putting a check there on, on weight loss or healthier diet. Now, let's come over here to all these cardiovascular heart failure and kidney disease. And the algorithm basically says, please use more G LP one receptor agonist, um uh or dual agonist and SGLT two inhibitors. That's how you prevent the progression of cardiovascular renal disease. Well, what does that have to do with CGM? And the A GP report? Well, I go to this. Uh and this is a group of on duo who has a remote monitoring of patients with type two diabetes. I help them look at this data and, and they found when they were monitoring people with type two diabetes in this remote clinic, they had baseline CGMS on these patients and then follow up after four months of being on CGM. And we'd all agree that the profile looks incredibly good, But it was this supplemental figure that I found particularly interesting. Yes, this was amazing what CGM can do. But we've already shown that what it also did was realign the medication, stop the su stop the DPP four inhibitor, start A G LP one, reduce the insulin as needed. So it went to exactly what the ad A algorithm said we should be doing, use the most effective medications, get more GLP ones and SGLT two S in. So I'm putting a check there as well. And then finally up on the top leading into the pillars, are you using team care? Are you thinking about diabetes distress? Are you really talking about lifestyle? Well, can the A GP report influence those? I'm gonna give you my answer and then briefly show you um I think yes. And this team of Fisher and Polonsky and, and, and, and doctor Hessler and others showed that they've updated the diabetes distress measure, which I think is great. They have a standard measure now for type one and type two and a core, uh, measure we all can start to use. And they found that it was elevated, this diabetes distress feeling that diabetes was a burden in almost 62% of people with type two diabetes just when they surveyed them. And then I love Dr Polanski's project. He said, well, I'm going after that, I'm putting CGM in my educational program and I'm going to look for those aha moments like, ah ha, I can't believe that's what happened or that's what my profile looked like. And he saw better well being and time and range and physical activity and lifestyle changes. So I think that check was well deserved in CGMS potential. So I hope you see that, I think CGM is a better tool to get us towards the management. Now, let's spend the last few minutes talking about how to use the CGM to get those results. We're not in a randomized trial, we're in your office. Uh, and we're looking at AC GM report and it's got these three panels with the metrics and targets on the top and these are the targets. And I know you will understand, you'll, you'll look at these 10 metrics and that the ad A put in their standards of care. I just highlight the GM, I please pay attention. It's a personalized A one C I like to say, or it's the replacing the estimated A one C. So it's a valuable indicator for that individual of their uh exposure overall to glycemia. Then we have the five time and ranges, uh with the time and time and range, it's 70 to 1 80 highlighted there. How many of you think we should add? There shouldn't be five time in ranges. There should be 1/6. There should be a time in tight range, 70 to 1 40. Well, ask me what I think about it. When we get to the Q and A session, here's the, here's the A GP standard as it is 70 to 1 80 target. It's got the 10 metrics. That's why the ad A thought this should be a recommended as one way to look at a standardized report. It's got the metrics, it's got the targets. Uh It's got the key variables. Uh And we know there's some decent correlation time and range in a one C about 70% equals seven. Yes, that's an average. So you can be on either side of that time and range of 50 is 8, 30 is nine for the A one C. So you know that uh I think, and you know that the ad A and uh put this into its standards of care in 2020 in 2022 actually put the whole profile and in 2023 updated it with the current version and you note the current version just still keeps the exact same format, the metrics, but it moves the time and range bar over to the left, uh to highlight it. That's where we're going to focus a lot of our attention. It puts the A GP curve from midnight to midnight in the same color frame as the time and range bar. So I think that's important. You can spot hypoglycemia at a moment here in the, in the profile and then you have the daily views. So let's, let's look at how to interpret this A GP report. Well, we started off back in the very beginning of all of this interpretation and wrote out an A GP uh interpretation guide that had nine steps. And I thought, well, gosh, this is the background. Everybody needs to know about how to understand this new evolving therapy. And people said, yeah, thanks. It was a great educational tool, but it's got to be simpler if I'm going to use anything in my office. So uh others came up with a five step. This was very innovative, uh uh covered a lot of the same elements, but put it in this little uh stepwise path and primary care said, OK, nice, nice. You're getting there. But it's got to be even simpler. Uh If we're really going to fit this into our practice and simpler, didn't mean just easy but faster uh and yet still effective. OK. So we said, how about three steps? And we had a couple of different versions of the three step method. Now, we revised it just recently to make it fit the best language we we could come up with. And here's our three steps, determine where to act, determine where to act. Three steps, three panels start with panel, one, determine if action is needed. That's what you really want to do. You just want to know if you need action today or if you can pat the person on the back and to do that, we say, just look at that time in range bar and as a matter of fact, just look at the green and the red, the time in range and time below range. If they're not in their goals, which are very clearly spelled out there, then you need action. Then you say, well, OK, I'm ready. Then where is action needed? Just go right down to this panel and look at it and say, where is it really out of range? And people ask me over and over again. I'm sure they ask you over and over again. What should it look like? And this is what it should look like. It should be tight narrow and in range. Uh And that's what a profile looks like. And we're only going to get there if we then act on the data, start with hypoglycemia, first pick the medicines or lifestyle that gets you this flat, narrow and in range, more green, less red, flat and narrow and in range. And in primary care. I said yes Yes, yes, but be more specific. So we said there's four categories of time and range. You can be above both. Uh You can be in target for both. You can be out of target for both or in target for one or the other. And each one of these categories has a different treatment path. That's what was important. If you look at that time and range bar and you find which category you're in, it only takes 10 seconds to find which category, then you can say continue stop a sulfon aa decrease basal, start a GLP one increase insulin. Maybe. See a diabetes educator will give you a path that's much more specific. That's what people are asking for. So I'll close with these two cases. See if it makes sense to you. 64 year old type two, no CV D uh Metformin Glargine, 70 units. Here's the profile. OK, great. What do I do? Well, look at the profile, here's what I would do first if I was in my old mode, I'd say, oh my gosh, this is so interesting. So interesting. There's a stair step pattern. You're over basal, you go up, down, you drop, there's a beam score that's, that must be way too high. Well, I have enough data. I'm kind of uh I have a lot of lows but, and, and too many highs. My GM I is in a goal, I have a lot of variability. All the mean glucose, no CV D, you could go on and on for 10 or 15 minutes being marveled by all the data. But you want some action in two minutes. So how do we do that? So you go right back to the same profile and you say green and red 46 and 10, I need action. That's way out on both counts. Uh Too, too little. Uh not enough hype, too, not enough time in range, too much time below range. Find your category. It's very quick. It takes a second. I'm down here in number four. It says I got to minimize the hypo today and I've got to put a G LP one in as one option. What do you think? So, let's come back over here. OK, I'll follow your advice and see what happens. Decrease the basal insulin from 70 to 56. We tell you exactly how to do it between 10 and 20. Here's 15% then start a G LP one. All right. I know how to do that. So what do you get if you do these two things? Here's what we got. We got a profile that's now 88 in range percent and 1% below range because we uh made some titrations. This is after two or three titrations of the medicine. We got more green, less red, flat and narrow and in range, the Chloro gene is down to 30 now because we've ti traded up the G LP one. And my, my guess is that's gonna go even lower. So follow the grid and I'll close with this one. Same patient, same history. You recommended a G LP one. They said, OK, thank you. Thank you. But I can't afford it. What else can I do? So the grid still tells you come back to that same guidance and this time it says start a G LP one that's preferred. But if you can't, for some reason, like cost, then add a uh insulin before meals. And we'll give you the grid to tell you how to do that. You're not adding a G LP one. So you're going from glargine, reduce that glargine sometimes as much as in half and add the basil the, the mealtime insulin. That's what we did in another case and look what we got 82 and four. Yes, there's still a bit of hypoglycemia. That's because Bola's insulin is just not quite as effective in minimizing hypo as a G LP one, but still a pretty good result that we can fine tune. So I'll close by saying if you want to follow the ad a standards of care for management of type two diabetes and you know, these pillars, I would say align your measurement tools and your management approach. A GP seems to fit the bill there, follow the, determine where to act. Uh And if you want to use some of the tools we've developed on how to guide you or make your own best decision. I think you'll be pleased as you make these adjustments that you've really covered your bases in following the standards of care. So I thank you for your attention and I look forward to your questions uh later. Thank you.
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