Hear about the benefits of continuous glucose monitoring (CGM) and tips for getting patients and providers on board with this advanced technology.
Link to CME: Claim Credit - https://bit.ly/3dQPQwT .
Continuous glucose monitoring (CGM) is a great tool that improves clinical outcomes for people with diabetes; these individuals are often happy to get this new technology.
However, there can be some initial barriers that both people with diabetes and clinicians need to overcome.
BARRIER 1: Wearing something on the body so other people know the person has diabetes.
SOLUTION 1: Let the person see the size of different devices through demonstrations and show possible discreet places on the body where they can be worn.
BARRIER 2: Cost of the CGM.
SOLUTION 2: Find out insurance requirements to see if the CGM can be covered and what is required for coverage.
BARRIER 3: Too much information from CGM can be overwhelming for the individual.
SOLUTION 3: Make sure alarms and alerts are set appropriately to avoid alarm fatigue—have the alerts go off when it matters most, like during hypoglycemia. Look at the device at key times only, like before meals, before bedtime, and before activities like exercising and driving, and utilize CGM to determine glycemic trends.
BARRIER 4: Clinicians are hesitant to embrace CGM technology.
SOLUTION 4: There are various resources available to help clinicians understand CGM technology and to assist in integrating CGM into their practice settings.
Presenters:
Carla Cox PhD, RD, FAADE
Certified Diabetes Educator and Clinical Dietitian
Mountain Vista Medicine
South Jordan, Utah
Diana Isaacs PharmD, BCPS, BCACP, BC-ADM, CDE
Clinical Pharmacy Specialist/CGM Program Coordinator
Department of Endocrinology, Diabetes, and Metabolism
Cleveland Clinic Diabetes Center
Cleveland, Ohio
Provided by the Endocrine Society in collaboration with the ADCES.
Supported by an educational grant from Lilly.
Carolyn Skowronski, PharmD: Hello and thank you for joining us. Today’s podcast is a feature of a multicomponent program provided by the Endocrine Society and developed in collaboration with the Association of Diabetes Care & Education Specialistsand Clinical Care Options. This podcast is part of a continuing medical education series on continuous glucose monitoring, or CGM, in patients with diabetes.
This program is supported by an educational grant from Lilly. During this podcast, 2 certified diabetes care and education specialistswill address the barriers that patients have toward adopting the use of CGM as well as challenges clinicians face within the practice environment.
To receive credit for this podcast, in the show notes, there is a link which you can click on to evaluate the program and receive your credit. Also, Podcast Pearls that summarize key takeaways from this activity are included in the show notes and are also available to download as a PDF at the link included in the notes.
So now to introduce our presenters.
Dr. Carla Cox has been a diabetes educator for over 30 years, with the last 10 years dedicated to the technology aspect of diabetes care, specifically continuous glucose monitors, insulin pumps, and integrated systems. Dr. Cox presently works in a pediatric endocrinology practice.
And Dr. Diana Isaacs is a clinical pharmacist and a diabetes care and education specialist. Dr. Isaacs works at the Cleveland Clinic Diabetes Center in the area of medication management, where she also coordinates the continuous glucose monitoring program.
And Dr. Cox will lead off today’s podcast.
Carla Cox, PhD, RD, FAADE: Welcome to our podcast today; we’re glad to have you here. Continuous glucose monitoring has been shown to be an effective way to help manage and guide persons with diabetes. The challenges to the incorporation of these technologies are varied, and we will share a few we have noted in practice and offer some salutations to those barriers.
When we look at persons with diabetes, why would they NOT want to try these fantastic new advanced technologies to help them with their care? Some of our observations include the individual may not wear want to wear something on their body and be visually obvious that they have diabetes. Diana, how might you help this individual overcome this barrier?
Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDE: Yeah, that is a great question, and there’s a few ways we can go about that situation. So one, I really like Professional CGM. So that is where the device is owned by the clinic and actually lent out to the patient for anywhere typically from 3-14 days, depending on the device. And so, this is really an opportunity for the person with diabetes to kind of take a test drive of it, and then get experience of where on the body it goes and a better feel for kind of the size of it. A person often finds that it’s not as big or as bulky as they thought it would be, and that there’s a lot of discreet areas on the body that can actually go.
Another thing I think to consider is, you know, with technology, right, we have insulin pumps and we have continuous glucose monitors; they both are worn on the body. And so really, I think if a person is new to technology, really we should be looking at CGM first. And so, if you’re going to wear one thing on the body, there’s actually data, like the recent COMISAIR study, that showed that it’s really CGM itself that can drive down the A1C levels. So, I would definitely encourage that. And then you can always even use—now we’ve got smart pens, too, or a person can go onto an insulin pump later.
And then other things, too, are just letting patients know about their different options with the different devices. So like, for example, you know, some vary a little bit in size, some are smaller, some are larger, have an attached transmitter. We know now, you know, Eversense is actually implantable, but the outer transmitter can be easily removed. And so just presenting these different options to the person and seeing what they feel most comfortable with.
Dr. Cox: Thanks. And I think the Professional model’s a good idea, too, to let them take one home and wear it for a little while and see what they think.
Another barrier that we hear a lot is cost. And so how do you address that with individuals?
Dr. Isaacs: Yeah. So cost, right, is always an issue, and it’s not just with the technology, right—it’s with insulin and other medications, too. So I think first of all you’ve got to find out what the insurance plan even covers. So there’s often this conception that, oh, it’s just going to be expensive.
But actually, recently many insurance plans have been improving coverage. I mean, especially it’s been great now that Medicare covers for people with type 1 and type 2 diabetes. There are certain additional requirements, like a person does need to be taking multiple daily injections, and they actually need to do 4 fingersticks a day to initially qualify. But that’s great because there’s tons of people that do meet that criteria that could actually be getting CGM and may not realize it. Many other plans are starting to improve their coverage. So, I would just really encourage people to find that information out before assuming that it’s going to be too expensive.
And then on top of that, so, you know, there’s a lot in the works in terms of trying to lower the price and trying—you know, we have one company already that has the disposable transmitters. There are others that are working toward that, which have really made it more affordable to the point where some people choose or, you know, to pay out of pocket for it, and it’s not as expensive as it once was.
And then as we talked about kind of with the first barrier, the Professional CGM is an amazing underutilized tool. So, this is an option where people could be wearing—often insurance will cover it at least twice a year; some insurance plans will cover it 4 times, some even more than that. And so, this is a benefit that, hey, if a person can’t be wearing it all the time, at least they can get this intermittent use to learn from it and gain from that data. So, I think, you know, there are—you know, cost, of course, is still a barrier, but these are some ways to get around that.
Dr. Cox: For sure. And I’ve had some persons that have decided to buy a sensor and found it less expensive than even their copay to get strips for the glucometer that they want. So that’s another thing to look at.
Another barrier is too much information. So, I actually had a lovely patient who was almost paralyzed with the amount of information on her sensor. And by providing support as needed, encouraging her to look at trends and patterns, not those absolute numbers, and turning off some of the high alarms, she began to be comfortable with it and now is a strong advocate. Diana, what have you found with this barrier?
Dr. Isaacs: Yeah, so I think this is very real. People say, you know, it can be a lot of data. It can be very overwhelmingly. So, the first, you know, tip for success is working with a diabetes care and education specialist, make sure a person gets the right training of how to use their device, and then customize those alerts. And, you know, it may be better to turn most of them off in the beginning except for maybe an alert for hypoglycemia to allow for safety.
The other thing is explaining. I find it very helpful to explain what the data mean and put it in perspective. So, we—like, for example, going through that time in range is actually 70-180, and to achieve the desired outcomes such as, you know, an A1C of under 7%, you actually only have to achieve 70% time in range. I find that very reassuring because that’s like a C, right—you don’t have to be perfect; no one has to be perfect all the time to achieve these, you know, the desired outcomes.
And then, you know, the last thing is just that it’s data, It’s not good or bad; this isn’t a report card. And so, we’re just using the data to help the person to feel better and to help achieve their goals. And so, I find those types of tips kind of put it in perspective and really assure the person.
Dr. Cox: That’s great. I think another thing to do is encourage them to just look at one piece of information. For example, they could look at after breakfast—is that when they’re rising? And kind of focus on that for a few days so they can get a sense of how foods are fueling their glucose values, rather than look at the whole day as an issue.
Dr. Isaacs: Yeah, that’s a great point, that’s a really great point.
So, I’d like to go ahead and switch gears now, Carla, and ask you a few questions. So, I’ve noticed, you know, in terms of clinician barriers. We talked about what impacts the person with diabetes, but some clinicians may be hesitant to embrace new technologies. So, one barrier that I found is concern regarding how to operate these new devices, there’s so much new things coming out and how it works. So how do you go about approaching that?
Dr. Cox: That’s a great question, and I think so much technology’s coming out so fast, it’s a little overwhelming. But sometimes the office and providers may not be fully onboard with all the sensor options, and if you’re one of those offices, consider having a representative from each of the sensor companies come to your office and provide an overview of the technology. Perhaps start with one brand based on your clientele and become familiar with it and the download, and then move on to other options, rather than trying to incorporate all of them initially.
Another big key is wearing the device. Almost every company will allow you to have a loaner and put it on, whether you have diabetes or not, and you really—it’s a wonderful and very effective way to learn the ins and outs of these pieces of technology.
The AADE now offers a certificate program which can broaden the understanding of providers and staff of utilizing these systems as well. And then another thing is to talk with other centers that are similar to yours. So, if you’re in family practice, for example, what other family practice places are using technology and integrating it, and how are they doing that? Rather than just trying to start out on your own picking and choosing, maybe seeing what other people have done and how successful it has been.
Dr. Isaacs: Yeah, I think those are all really great points. I know I found I try to wear all the different devices, and I found that to be really helpful in understanding how they work, and then being able to train people on them.
So, another barrier is, you know, just workflow, right, with the clinic. We know that these devices may have different downloading systems and that can really affect clinic workflow. So, what do you think is a way to kind of approach that barrier?
Dr. Cox: Well, clearly it depends upon how your clinic is set up to start with. But generally, if you start a program within a clinic that is efficient and works smoothly, it can be a bit daunting for all of us. Industry representatives can be helpful again, along with talking with others who have brought technology into their clinic settings, as we mentioned before. Starting small and as you become familiar with one system, consider adding more.
One facility where I worked has an MA or an LPN insert the device when the person with diabetes returns for a visit. The device is then downloaded and reviewed by the diabetes care and education specialist who then reviews the data, makes recommendations, even puts them in a chart form, and then that is reviewed by the healthcare provider that can charge for the interpretation. So, the workflow is an MA inserts it, the download goes to either the front desk, the person, or the CDE. The CDE kind of interprets that information, and then it is read and reviewed by the healthcare provider. And that is a charge that will help you support the added work of having these technologies.
Dr. Isaacs: Yeah, those are great approaches. Another thing that we do in our clinic is we really tried to streamline the Professional CGM. So, to kind of optimize that, what we do is we do them in shared medical appointments where we actually will have 4-6 people. We’ll train them all together on how, you know, explaining what the device does and how it works and calibrations if needed, and then we bring them all back together 7 days later for review of the data. And so, they actually learn from each other, and it’s a whole lot more efficient.
Before I came to my position, the old way as they were doing one at a time, and it was actually like a 3-part visit of putting it on, bringing them back to download, and then bringing them back again to go through the data. So, we found that was a great way to make it more efficient.
And Carla, another barrier I want to ask you about is just the cost of staffing for setting up the CGM and follow-up. I know many places might be concerned about the costs that go into it. How would you recommend approaching that?
Dr. Cox: Yeah, that’s another great question. So, the beauty of sensors is there are now codes for setting up the sensor and reviewing the data it provides. So, you put the sensor on and then download within 3 days; you do need 72 hours’ worth of data, and then you can put in the charge—it’s a 95250. And then you also get to charge for the review, so you’re getting 2 costs out that help you support the added personnel in your office that may be required to make this run smoothly. So luckily there are now these codes that help us support this kind of program.
Dr. Isaacs: Yeah, with that, and there’s also even a startup code, too, for the personal CGM, the CPT 95249. So, there’s definitely ways to generate revenue from these services.
Dr. Cox: Correct. So, it should help you cover the costs without incurring more—so once again kind of busting that barrier and allowing you to incorporate this into your practice.
So, I think overall technology is here—it has been proven to improve patient outcomes. And learning how to fit it into your practice and encourage your persons with diabetes in your practice to use it will be a great addition to the goal of helping them achieve glucose targets that help keep them healthy.
Dr. Skowronski: Well, thank you very much, Dr. Cox and Dr. Isaacs, and thanks to listeners for joining in. As a reminder, to receive credit, click on the link in the show notes to evaluate this program and receive your certificate. Also, a copy of the key highlights from this podcast is available online at clinicaloptions—that’s one word—.com/cgm, or you can follow the link in the show notes. Thank you.