thank you Dr Peralta for that kind introduction and thank you to Abbott for inviting me to speak at this 80 symposium on their behalf. And so my my topic is about the role of CGM basic license management in the age of telemedicine and the lessons we learned, particularly the U. K. During the Global covid 19 pandemic. Um and so I'll be talking about how we applied season technology, the IGP driven Care in our clinical practice in the UK. So the Flash journey in the UK has been a bit of a tortuous one if you like. Flash or freestyle libra was first available to self fund in the U. K. In 2015. Um and then in 2016 we had the impact study which was the RCT that showed the benefits. And there's a strong patient led campaign particularly led by our patient organization diabetes UK. That pushed to get free sound library to get flash monitoring onto our national prescription. And so gradually over the course you can see there in that little corner there was a small start in prescription in 2018 and there was some criteria that had to be filled in. People had to be measuring their glucose a certain number of times. I have problematic hyperglycemia and gradually over time different areas started to come online at that time. It was also noticed that there's a big need for education information up skilling of the health care community at the time was chair of the diabetes technology network in the UK. And so we managed to create some DTN UK online modules to support people living with diabetes but also um Health care professionals in understanding how to use flash. And actually that was very timely because as the COVID pandemic hit in 2020, those online modules became a huge source of support for people on virtual starts and I'll talk about that a little bit later. So of course the UK has come a long way since 20 and 19 where it's very patchy adoption. All those red dots are places where parts of England where we could not get access. But actually by the start of the Covid pandemic by 2020 that whole place is now green and that one dot that's lagging behind the latest last area to come online is now on board. And actually average flash prescribing is about 60% 70% of type ones and rapidly increasing month one month. So we're looking close to a complete coverage and of course we're a little bit behind our european colleagues but that's the journey we've had in the UK in the UK. We've we've got a very good national data collection portal and Emma will Mark one of my colleagues lead with her with the A. B C. D. You can actually break audit and here you can see the results from that. We're showing a about 1.5% about 1% of nine million Baltimore reduction in HBO and see after initiation of libra in the real world and more importantly, very similar to data presented from the french service reductions in DK reductions and admission hypoglycemia reduction in severe hypoglycemia. Now, a lot of the work in the UK actually pioneered by a team in Edinburgh, led by fraser Give and here they published some data with the need to jam their um, showing what happens when you introduce freestyle libre in a widespread basis across the region. And if you look at the panel on the left there, you can see if they look to 4 to 5 years before All these people had pretty stable HB one c. And then if you see assume they start increasingly where there's an immediate drop of about 2 to $4 million per mole, About a 0.5% a onesie that sustained out to two years. And the people who did not start freestyle libre stayed at where they were even went further. They also are able to show significant reductions in H B and C of course. And then DK admissions and the panels on the right there show the rates of D. K. A divided by whether what the baseline, A one C. Was, what the gender was, where they had prior pump use or based on their index of deprivation and the blue lines that show the rates of people not using freestyle libra and the red lines that shows the rates of people using freestyle libra. And so it doesn't matter what your a one C Is what your event rate, whether you what your gender was, where your prior pump users or your your deprivation, freestyle libre worked across the board introducing DK admissions. One of the other concerns people had was as people started using freestyle libre, there were rapid drops in A one C. And we will I mean I'm sure many of you in the audience will have seen drops on HBO and sea of over 2%. And with that, as clinicians were always worried about that thing we saw in the D. C. City about progression of retinopathy. And these are really encouraging data from again from fraser, given the in the Scottish team looking at responders versus non responders. So people have dropped by more than half a percent versus not in the left hand panel. And you can see rates of retinopathy are very similar. In fact. Um no statistical significance on the right. There's kind of a correlation there with the change of a one C. And you can see there there's a big proportion of people all baseline. A one CS has had a drop of more than 25 or 30 million miles for more. That's a drop of 2 to 2.5%. And whilst there was those red dots there may be a little bit more in those they're really those who started in a onesie of over 110 people starting with an agency Over 13%. Many of those would have gone on to develop problems Anyway. But if you look at the vast majority of people, particularly those starting with an agency under 100 million miles from all, which is around about 12% really. The risk of retinopathy was was minimal there. So with the current pandemic, we really got involved with telemedicine and this has really enriched the patient physician communication and allowed very direct engagement with our patients. Um in a way sometimes that wasn't possible face to face. And in terms of the, one of the most powerful features have been the way we've shown patients how to see their own data, how to look for patterns, to look for problems in their own data and people are looking at their data, looking at the time and range, looking at their ADP and identifying I've got a problem with my evening meal. I've got a problem with overnight hypoglycemia and that's actually triggered more of a two way communication between people living with diabetes and us. The people supporting them. We of course can review and analyze data, seeing what's happening in some places. We've found people who are problems and contacted them proactively as well. And again, the environment, which would work has changed dramatically. So when we moved as soon as the first kind of hit, COVID happened earlier on in 2020, we moved all of our activity actually online. When at the time I was working at King's College Hospital and as part of that activity, there are a few tips we learned to make telemedicine more effective, more beneficial, more smooth if you like. And the first thing was stable bandwidth. We had a lot of in our health care professional, I was at home with my wife and two Children. Everyone was on on the internet. And so having a stable bandwidth was important with all four with four or five computers in the house doing telemedicine. The same was true on the patient's side as well. And often, you know, tricks like let's cut off the video for the bits that we don't need it. Let's bring it back on for the bits that we do and manipulating that to make sure we have the right band with think about the background, um using a blurred background so you don't have people popping in and popping out and maintaining your security for like using headphones to make sure that you're maintaining as much as possible. The security and confidentiality during those conversations, when you're speaking to people, making sure that they are in a safe environment, making sure that they're okay to speak and for you to share things. And you know, often I'd recommend patients use headphones as well. Just that they have that confidence, confidence in the environment they're working with, um confirming the identity, the new patients that we were seeing. We have to find ways to confirm identity of patients that we didn't know. I took on care for patients. My colleagues have been working on the wards during covid work and I took on care for their patients. People I hadn't met. And so just making sure you're speaking to the right person was important and supporting them to say do you want to bring someone else in the conversation so we can speak to them. Which was unique actually because in the past people that often turned up to clinic alone because they're partners wouldn't take a day off work. But when you're calling them in their house, when they're working from home, it was the first time that you could communicate with their partners and explain things and that helped the way they manage diabetes between themselves. And then for us in clinic of course at the moment many of you will have been working with multiple different data providers. We've got clarity, library view, care linked, glucose. So the hospital electronic health records having fast tabs opened up so that we can link onto whichever the next patient um device the next patient is using. And then often of course if the computer went down the band with dropped off, we would be ringing patients and making sure that we had our phones with the caller ID withheld um and informing people that if they get a block caller that might be from the hospital so they can they can pick up because a lot of patients we offer them a choice of of face to face video or telephone. And a lot of patients choose telephone um uh priority. And then at the bottom there I've got a little picture of my setup and the fact that actually running telemedicine clinics needs a lot of screens. I have a screen which fuse for video. I've got a screen which I'm logged into the HR hospital HR. I've got a screen where I'm typing my notes and so one of those computers extra of course. But that's the sort of setup that we've found that we've needed when we're working. And what particularly what devices like library where we've got patients in the clinic account have allowed us to do is I can look at at this sort of database data bank. Um and I can identify people who are connected. People who are not connected. People are not uploading. I can identify people's average glucose. And you can see a list of people have ranked them by the average glucose and you can see there are quite a few patients with average glucose is above 15 above 20 minute miles per liter. People who are really struggling with diabetes. People who during the covid pandemic we were really keen that we we went towards and we um we worked with And just how we can make a difference remotely. This was a 20 year old patient that had multiple DNA. Had not attended the transition clinic for the last three or four years really maybe just had one or two contacts. And although she's been prescribed freestyle libra should use it on and off and we can see very limited upload. Um There was a history of anxiety and depression and she hated coming to clinic, which is the main reason why we could not get hold of us. But um she was triggered on red during three hours. So we you know ranked all our patients. We could see she was someone who's running really high. We contacted and we got around and she picked up the phone because she didn't know who it was really. But that triggered the conversation. We could get her on a video. We could chat to speak to see her set up. Um and then you can see and I spoke to in June 20, July 2020 and then as you move forward she's got really high glucose levels. But over time she felt telephone was less threatening than clinic. We could focus on the process is just get your scanning done. Let's target two times a day when you're eating. Let's target tying that scan with an injection of insulin. And then just using that scans per day metric on her reader because she was using a reader rather than anything as a tool to just let's build up by one or two scans per day. Let's get it going, linking those scans and over up it is a number of injections per day. Again that sort of H. B. And C. We knew that she wasn't injecting for all the meals and then she watched that time and range come down with every additional injection she did and that motivated her. We're able to keep on a on a monthly a monthly check and actually you know this was three or four months into the scheme and you can see that we've got a G. M. I. Down to 9.5% which was the first time she was under 10 and you know that's how you can make a progress remotely at the time. Um You know there was a lot of challenges and barriers to accessing telehealth and so Hannah Ford who was a clinical fellow who came to work with me um just to around technology did this survey of provisions and HCP experienced the remote care delivery and technology training and at that time I think this has done Kind of just towards the end of 2020 we found that 20% of all consultations at that time we're having face to face, 50% were by telephone and about 10% by video. And we asked people about the duration of these calls and video and face to face calls tend to be about 30 minutes but people felt telephone calls were short of 15 to 20 um 15-20 minutes and then if you look at the barriers or facilitators you can see that access to patient results. The fact that you can look at you know library data and find out what the what the glucose readings were without them coming in was a big facilitator for many patients. Although some units strong to get this access to patients by state. Again the video system platform again kind of mixed results there some teams finding that a big barrier they couldn't set it up. They had local internal issues other people finding it really helpful. One of the main barriers was patient familiarity with technology so getting patients to log into video calls getting patients to accept the phone's getting patients to set up technology at home was still a barrier for many of the people. Um For some there was some hate cp for marriage familiarity attack was also an issue. Um And then again you can see in blue a big barrier was clinic set up getting software approved set up within the hospital setting was was it was a big challenge. Certainly at that point during the pandemic. As I said I was the chair of the diabetes technology network. And we tried to put together a lot of resources that would support people both healthcare professionals and people living with diabetes. And and these are free to use for anybody you don't even have to be a member to access these. If you just search for D. T. N. U. K. Education you can access any of these. Um We've got educational resources of people living with diabetes. Um We've got expert views and devices there with two of our expert educators going through a range of devices, pumps, sensors, closed loops and you know infusion sets that would allow you know in clinic we'd be doing this face to facebook this virtual world. We've created that virtual environment, the virtual show where industry can showcase their their their devices. And then we put some best practice guides together these to guide health care professionals on using pumps using CGM and pregnancy how to deal with people who come into hospital. This is our range of educational modules that are really targeted towards people living with diabetes. And you've got a list of um freestyle libre education program and then a C. G. M. And M. And pregnancy education program. You can see that and this breaks the information up. And so if my patient has a problem with exercise I just refer them to the module and exercise done by dr part Narendra and rob andrews. If they want to talk about fat and protein. Nicola taylor is a dietitian isn't a program on that. If you're talking about how to adjust your basil or bonus then Jackie Elliott and others have done have done sessions of that. So it's really targeted videos where they can look at different topics. We also realize that we have to take our technology training online. And so um we we pulled together a protocol if you like. That could be used. And again to try and get over that barrier of hospitals and systems saying, well what's the safety of doing this? So as the professional body involved with diabetes technology, we put together this flow chart for commencing pump therapy remotely for commencing CGM remotely. And we published some of these in this paper that you see up there at the same time, I think we're very aware of being aware of the digital divide technology allowed us to access some people who never came to us, particularly younger population, but we were aware of maybe um being removed being not able to reach some of those people. And so we made a point of screening for the Digital Invisibles. People who weren't connected up to lee bravely weren't connected up through our online systems and we have to support the tech naive in step wise manner and maybe some of those technologies people, we're our own team members who who weren't that familiar with doing online things supporting people online. You know, it's much easier to go through a menu of a device on your when it's in your hand, but doing that remotely needs a bit more skill needs a bit more practice and a bit more confidence in what you're what you're doing. And again, this was a module for getting so in the UK at the time to get free star library we have to get people in and give them some education information and how to start and actually we converted that say well go to the online training modules that I've just shown you do the virtual training session, if the patient confirmed have done the virtual training session or this kit, get it sent to the patients then um and then have a clinical training with this with the DS and if you need to or if not appropriate, the patient can start using it without but you know providing patients that security that information with the online deputy technology network resources was very valuable in that thing. Another thing we started using a lot that the digital and telemedicine movement facilitated was using a lot more apps and other digital resources. And so this on the left here these pictures are um and that that I use a lot which is called diabetes m because with more and more people using freestyle libra using CGM technology having incident onboard become really important because people see the high glucose readings and want to correct it. And traditional teaching has been don't correct between meals because you don't want to stack but people are seeing high readings, they're getting an alarm and they want to do that. And so one of the apps that I really like is established and the reason for that is because it's got these arrows for glucose trend and it makes adjustments to the recommendation based on those glucose arrows, other apps that I've used in the Dario and then my sugar and of course the carbs and cals app and so my my these are it's on my phone directly and I can talk people through how to set it up and how to use them during my consultations. The other thing was of course in pumps, getting people haven't been, some people haven't been uploading the data from their pumps and a lot of data is stored on the pump and so I have the this map of the menus available on my computer so I can talk people through so I can get if you look there the second tab there is history and graph so I can guide people on their pump to find their history data so I can know what their total daily doses, I can know what the basic bonus settings are. I can actually get information on on how many bonuses they're doing per day and get some of the information that you might get from an upload in case the patient hasn't done one and avoid that being a wasted consult and the companies themselves have been promoting a lot of innovation in technology and so you know for the innovations that Abbott has brought to the table our news patients started clinics which are held in person or with a training person from the company and they provide samples and they do this in big groups, their virtual starters which started clinics which are done in a life storm platform where patients can log in and be supported in a virtual environment to start pumps. And they've also set together regional starter clinics where maybe different units can come together. Training can be offered out across the region and the company can also support some follow up clinics for technical troubleshooting within that And the other has also started a national on demand started clinic with national access that facilitates online patient starts and and they've had a lot of success with that and in fact in the UK they had more than 64,000 patients have attended. A company led New start a clinic in the UK have had 6.5 1000 of these events run by the company to support healthcare professionals in getting people on border to technology and then about 10 people per event of the So these are relatively small where people from the comedy can support patients in the on boarding, the technical aspects of onboarding. One of the things that really kicks out a lot of their virtual stuff was again work by fraser give up in Edinburgh and when the freestyle libre had been approved, they identified 1000 type one patients from there from their population and booked four sessions in a big theater room with 250 people plus makes the fraser down at the bottom there providing the information, not just on how to set things up and getting to 50 people set up on labor at the same time, but then showing them what to do with the information and actually on the Edinburgh David is an endocrinology website edict. There's some lovely graphs and and videos and education on how to use information going beyond what the company can provide because we're providing education permission and how to use the trend arrows, how to deal with different readings at different times. And in those sessions, fraser trained everyone and gave them the cheaper prescription. So that was one of the larger scale onboarding that, that I've been aware of the virtually started clinics that people might be aware of. And I'm not sure that these are available in other countries in europe, but again, you have a patient invitation letter, virtual guidance you get then get emails to log on to live storm. So you can get a training deck and you get the guides. So lots of resources there, along with following following webinars for patients with diabetes to use to support us to get them up and running without our intervention. And of course there are some people who will need that 1-1 hand holding, who you need to walk through. But the vast majority of people, you can kind of refer onto some of these resources, be they self run, be the company led, be they regional events and it's just getting people on board it onto this technology. As I said, I would have done in 2021. They've done 2000 events with 23,000 patients who have gone to one of these virtual started clinics and again with about 10-11 people per per clinic. Now during the pandemic, um we're also interested in what happened to people's glucose control. And I was involved with Emma walmart and jerry Raymond and the team from Abbott there to look at data from the pre style library during Covid. And what we did was we looked at the time and range in the four different age groups that when you log onto labor review, you record your age into these four different groups which is 18, 25 26 to 49 50 to 54 or 65 plus. And you can see there when lockdown happened Toward the end of March or toward the end of March, there was an increase in time and range across all the age groups. The biggest increase came in the youngest population. But wherever people were, they had an improvement and you can see those people who are 65 plus, they started off with almost 60% time in range and gained about 5% even in that group. And if you look at the, you know, the same data there in the Um on the table, then you can look at percentage responders. A percentage with a increase of 5% time in range. But a third to 40% of patients improved during that as soon as lockdown happened, that was sustained out for three months during that time as well. If you look at time below range, this was not at the expense of hypoglycemia. So there was no real change in time below range at all during lockdown. And they just spoil a game by reduction in time above range. Um and if you look at that time above range where you can see in all age groups, dropping down in all the age groups. And we also thought, well maybe that was because people were at home now, they were scanning more. But actually if you look at the scan rate apart from the very youngest group, the one in blue were scanned from 14 to about 15. Overall scan rates didn't change. And maybe this improvement in time and range was just people doing a bit more with the data or maybe it was a result of this reduction in variability of lifestyles, no commuting less, eating out less socializing and maybe that's where the benefits were. It's interesting to see. And if you look at the percentage of people who are achieving time and range and time below range, eight easy targets, A 70% time in range and 4% time below range, you can see actually the percentage getting both was was pretty low, it's below 20. Below 15% across all the all the groups but it increased um during lockdown and my final couple of slides, I just want to show you some really exciting data that's presented by my colleagues and I will martin lolly retina as part of the Flash UK team at diabetes UK here and these are, there's going to be a presentation about flash UK later on the 80 D here. But just some headline views. This was a randomized controlled trial of freestyle library to in people with type one diabetes but with a raised HBO and see above 7.5% it was people had to be over 16 and beyond incident at least 12 weeks and excluded severe hypoglycemia, hyper unawareness of course. Um if you look here, you can see that in this flash UK trial there was a significant reduction in in time. Sorry, signal improvements rather in time and range. With the reduction in time below range, you can see time and range went from 42 to 52. That's six months. Um And if you look at the estimated a one c I think it's dropped from 8.6 to 7.9. Very similar to the changes seen in the gold and diamond are cts of real time. See gM there and very much in line with the data seen in the A B C. D. Audit of that. I showed you at the start of the presentation. So in summary, I'd like to say that flash glucose monitoring has been game changing certainly in the UK, but but as well across europe and the more data we collected, the more we realize that the ways in which this is facilitated healthcare, I think COVID-19 pandemic has really forced us to all to change the way we follow our patients. Um it's brought in prioritization that we can do based on data, virtual consulting allowing us to reach people we couldn't reach before allowing us to make those consultations easier for people. But it's very important that we manage that balance between face to face and virtual care. I think it's forced us to rethink our pathways and become more trusting of virtual care things that we would never have done virtually start setting people on pumps and closed loops, getting people even into C. G. M. That we would have always done face to face. We've now done remotely and we realized that people get on with it and we get similar outcomes. Its automated aware that we've got to think about that digital divide and we've got to think about the risk of this virtual world increasing health inequalities, something we need to be aware of. Thank you for attention
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