Hi, good afternoon everyone, welcome to today's ADA webinar, our hands-on tips to improve diabetes care. I'm really excited to serve as the moderator today. My name is Dr. Daniel DeSalvo, I'm a pediatric endocrinologist in Houston, Texas at Baylor College of Medicine and Texas Children's Hospital. And today's session will feature two amazing panelists talking about empowering adults with diabetes, strategies to support CGM use and diabetes self-management. If you look on the left side of the screen, we've got today's agenda, a few housekeeping items that I'd like to go over. First of all, you've got a chat box, that's where the ADA staff are going to be dropping some links and some other things there for you to take a look at. I also want you to check out the Q&A link on the bottom. As our panelists are presenting, feel free to start asking some questions there. And that's where you can ask those questions to the panelists. I'll ask those at the end of today's session. And another thing that we'll have today is a fun kind of interactive tool called Kahoot. Here's a look at Kahoot. So take your devices, take your tablets, go ahead and type in kahoot.it, which is shown here. This is where this kind of interactive game-like platform is going to be used to present to you some knowledge-based questions, opening the questions and collecting your answers in real time. So type in kahoot.it. The game pin for today is 412-1544. That should also be available in your chat. So please interact with Kahoot.it as our panelists ask those questions in the slides ahead. Okay, I want to remind you guys that the next Hands-on Tips to Improve Diabetes Care webinar is going to be featured on Tuesday, June 11th at 3 o'clock Eastern time. Should be a great webinar, so I encourage you guys to actually register for that now. Check out the chat. There should be a link to register now for this session on Cardio-Kidney-Metabolic Essentials, a Primer for Primary Care Providers. Now I'd like to really take this time, it's my honor to introduce to you our guests and our panelists. First of all, we have Dr. Kara Mizukami-Stout, who's an Assistant Professor of Internal Medicine in the Division of Metabolism, Endocrinology, and Diabetes at the University of Michigan and the Lieutenant Colonel Charles S. Kettles VA Medical Center in Arbor, Michigan. Dr. Mizukami-Stout's clinical interests include type 1 and type 2 diabetes. Her research interests include diabetes health services research with a particular focus on implementing technologies to improve diabetes self-management quality of life. So we'll get to hear about some of that from Dr. Mizukami-Stout today. Our second panelist is Dr. Molly Tannenbaum, who's a licensed clinical psychologist and researcher. She is a Clinical Assistant Professor in the Department of Medicine, Division of Endocrinology, Gerontology, and Metabolism, and by courtesy in the Department of Pediatrics in the Division of Endocrinology and Diabetes at Stanford University School of Medicine, a place that's near and dear to my heart. That's where I actually did my fellowship training. So Dr. Tannenbaum's work has focused on developing onboarding support for adults with type 1 for adopting CGM. So this is a very ripe topic for us to hear from, from Dr. Tannenbaum. And at this time, I'm going to hand it over to Dr. Mizukami-Stout and Dr. Tannenbaum to introduce themselves and let us know about their disclosures. Take it away. Thank you so much, Dr. DiSalvo. My name is Kara Mizukami-Stout, and here are my disclosures. Look forward to this panel. Hi, thank you. I'm Molly Tannenbaum, and here are my disclosures. Everyone hear me okay? Okay. All right. Make sure, okay, there we go. Well, thank you so much, Dr. DeSilvo for that wonderful introduction. I'm thrilled to be here today to talk more about strategies to improve the use of continuous glucose monitors in diabetes. Starting off, which are known barriers to using diabetes devices such as continuous glucose monitors in outpatient settings? So we'll have 20 seconds to answer this question. That looks good. I agree. So let's go ahead and get started. So my objectives today are centered around how to get this wonderful technology into your patient's hands. And I'll begin by briefly going over the necessary equipment, the prescriptions and the insurance coverage. I'll then switch gears to provide more examples on how to use this data to tailor diabetes management approaches. So starting off, Dr. DeSalvo already discussed how wonderful these devices are. And I wanted to emphasize that CGM devices are really game changers for both type 1 and type 2 diabetes, improving glycemic outcomes, reducing hypoglycemia and improving quality of life. So why isn't everyone with diabetes using a CGM? What are the barriers that clinicians and patients face when starting new diabetes technologies? So this study took a closer look at just that by conducting an online survey of endocrinologists and primary care clinicians who care for people with type 2 diabetes using insulin. I don't think the results are really that surprising. Of the approximately 200 clinicians surveyed, the top barriers cited were cost and insurance coverage challenges, device complexity and patient acceptance. I'll spend my time today discussing the first two barriers in more detail, and Dr. Tannenbaum will then explore the crucial elements of patient acceptance in her talk. I'll clarify that today's talk is specifically in regards to personal non-implantable CGM devices available by prescription only. If you are new to prescribing personal CGM devices for your patients, it's crucial to understand that equipment. And that's because each piece of equipment requires a separate prescription. So in short, there's a sensor that measures interstitial glucose every five to 15 minutes that can be worn for up to two weeks. Some devices require a transmitter to transmit the glucose reading to a receiving device where the user can then view the glucose data. And this receiving device may be either a smartphone app or a separate reader device. And in addition to the glucose data, there may be a variety of other features that are device dependent. I think it's important to set up expectations on what CGM devices can realistically do to set up the potential benefits for our patients. So CGM devices can measure interstitial glucose, they can alarm for low and highs, and they can demonstrate trends over time to provide insight into potential treatment options. On the other hand, a CGM device cannot give insulin, that's an insulin pump, a CGM device cannot give insulin, that's an insulin pump. It also cannot tell clinicians or patients what to do with the data. So we have to equip ourselves and our patients on what to do with the data because there is in fact a lot of it. Looks like we're missing a slide here. So I had a slide on the available systems that might show up here later, but let's see here, I'm gonna move on to the next slide here. So recall that the out-of-pocket costs and insurance coverage challenges are the most cited barriers to using CGM. So luckily, because of the accumulating evidence for benefit for CGM in diabetes, coverage has expanded dramatically over the past decade. And so the key usually is, is how is CGM covered? Is it covered as a pharmacy benefit or as a durable medical equipment benefit or DME? So for example, Medicare covers CGM for any person with diabetes using insulin, typically as a DME benefit though. And Medicaid varies state by state and private insurance plans differ from plan to plan and year to year. So for example, here in Michigan where I practice, Michigan Medicaid does cover CGM for insulin treated individuals with diabetes. Although private insurance plans do differ substantially in their coverage, there may be state specific resources available to help clinicians and patients determine their coverage. So for example, here in Michigan, we have an organization called the Michigan Collaborative for Type 2 Diabetes, and they provide an updated coverage guide for medications and devices. I'll provide a link to this and a few others at the end, but your state may have more resources to help you determine this coverage. Also, a little bit out of order, but. So let's talk about then accessing the CGM data. So why is this important? So we need to be able to access it in order to be able to determine what to do with this data. And so there are several options to do this. If your patient is tech savvy, or your hospital or clinic system has particularly stringent restrictions on using CGM downloading, your patient can send you a report as a PDF file. However, having CGM downloading software can certainly streamline the data review process. And listed here are the separate softwares for each type of device. If allowed by your institution, I find it's easiest to have a practice account that links to your patient's individual account. So, I showed an example of the Dexcom and the Libre softwares earlier, and both of those function essentially the same in that if the patient has their individual account and your practice has their practice account, that data streamline is fairly streamlined to facilitate data transfer. In addition, Dexcom has something called an authorization code that your patients can give you. They authorize a 12-digit code, and all you need is that code in order to be able to access their data. And again, there is a lot of data, so how do you know which reports are the most important? How do we make this review process simple? And to quote bank robber William Sutton, we go where the money is, so I highly recommend going to where the money is. And in short, this is the ambulatory glucose profile, or AGP. So this report provides a very nice summary of the pertinent glucometric data. So most importantly, as shown here, the time and range and the glucose management indicator. So this slide is a reminder of what the time and range goals are, as well as the time below range, which is crucial to really recognizing and preventing life-threatening hypoglycemia, which would facilitate personalized management. Additionally, the AGP also has a trend line that demonstrates the median glucose value, as well as the variation around the median in a 24-hour period. And this is a wonderfully helpful demonstration that visually allows for a quick view of fasting and postprandial glucose values in order to find patterns to act upon quickly in clinic. Again, these are the personal CGM devices that are currently available by prescription here in the United States. Notice I do not have the Dexcom Stella listed. That is an over-the-counter CGM that's going to be available later this year. So how do you prescribe a CGM? So as I mentioned, CGM may be available as either a pharmacy benefit or a durable medical equipment benefit. If it's a pharmacy benefit, you send it in like a regular prescription. And each individual piece of equipment needs a separate prescription. If it's a durable medical equipment benefit, there are a few extra steps. You need to know, first of all, what the preferred DME supplier is from the patient's insurance. You may need an order for the device itself, a certificate of medical necessity. And then importantly, there is typically three elements in the patient's note that is needed for you to document. So I do highly recommend setting up a smart phrase to consistently document these elements of diabetes diagnosis, number of insulin injections, and the frequency of recommended fingerstick glucoses. And just because they've started on a device doesn't mean that it's guaranteed to continue it. And in fact, certain insurance companies do require you to see a patient back within a specified period of time in order to continue their CGM prescription. So for instance, Medicare requires that we see patients back within six months. So in addition to the CGM ambulatory glucose profile, there's also these daily logs, which are an additional feature, which I find very helpful to personalize management further. So for instance, this person has logs, their carbon intake, as well as their glucose. And you can really see how that insulin adjusts their glucose levels and how to make tailored adjustments based on that data. So if you're not aware, you can actually bill for CGM codes as well. And there's some billing credit available for both the initial training as well as subsequent review of CGM data. So this includes code 95249 for the initial CGM setup, which can be billed by a variety of different clinic team members. As a physician, I use billing code 95251 for subsequent follow-up and CGM review. And this can be billed up to every 30 days based on a minimum of 72 hours worth of CGM data. And this report does need to be uploaded into the patient's chart. This is that example of the LibreView report. Let's go through a few cases where we have used the data specifically to identify glucose trends, which led to tailored recommendations for the individual patient. So starting off, we have case one, a 35-year-old woman with longstanding type 1 diabetes, nonproliferative retinopathy, and moderately increased albuminuria. She uses multiple daily injections and has been wary of wearable diabetes devices in the past, which Dr. Tannenbaum will talk more about here in a few minutes. And so I advise a short-term professional CGM trial because you can see on the left, she is checking a finger stick glucose four times per day, but it's difficult to make patterns out of this sort of data. So after she wore her professional CGM, you can see here on the right, there are more discernible patterns, including a pattern of fasting hyperglycemia overnight, both highs and then lows after meals. And her time and range is 23%. So this really kind of corresponds with her in-clinic agency, which was 10.2%. Because of her experience, though, with the professional CGM, she was really much more open to using a personal CGM device, so we went ahead and ordered this for her. And you can see after two months and then a year of using a personal CGM, she has had dramatic improvements in terms of her glycemic control. So her GMI is now down to the 7.5% to 7.9% range. Her time and range is up to the 56% range, and this is sustained. Because again, she's now built up more trust for diabetes devices, she was actually more open to then pursuing a hybrid closed-loop insulin pump. And so she's been on this now for about a year, and you can see she is doing excellent. We've had increases in her time and range, reductions in hyperglycemia, but most importantly, she's happy with the technology, and this has really built up trust for her. Let's shift gears to a case of type 2 diabetes. So this is a 65-year-old man with long-standing type 2 diabetes, moderate albuminuria, pancreatitis coming in. He's on a basal bolus insulin regimen, metformin, and empagliflozin. And he has his CGM on, and you can see he's actually not doing too bad. His target range is at 68%. He is having a few more lows than we would like at 5%. It's not really until you see the trend line, though, that you can make out those patterns. You can see a pattern of fasting hypoglycemia overnight and in the early morning, and then a pattern of midday highs that really correspond to him with post-lunch hyperglycemia. So this tells me this fasting hypoglycemia that we need to go down on his basal insulin by at least 10%. He also needs a strategy to really hone in on those postprandial highs that he's having after lunch. So we discussed some options, including reduction of carb intake with lunch, increasing insulin as part of lunch. And he really elected to reduce his carbs, and actually he's doing quite well with that. Let's go to our final case here. So a 59-year-old woman, 20-year history of type 2 diabetes, taking the max-tolerated oral or non-insulin therapies, and she's really been wanting to avoid insulin. Because of this, she's been following a relatively low-carb diet, aiming for 75 to 100 grams of carbs per day. Her A1Cs with this have been in the 7% range. However, she comes in today, there's a lot of stuff going on in her family, and she's got a lot more stress than she's had to deal with in the past. Because of this, sticking to her diet has been more challenging recently. And we download her CGM, and in fact, you can see that her A1Cs, again, typically in the 7% range, her GMI is 8.8, and her target range is 12%. And on her trend line, she's really kind of running high all day. And so we really use this as an opportunity to discuss realistically what are options that she would like to pursue at this point. And given her family stress, she said, I think it's time that I need to go on a little bit of insulin to give myself a break. So we went ahead and started her on a nightly dose of insulin, and then we'll continue to reassess in the future if that's a strategy that she prefers going forward. But you can see how CGM has really provided some opportunities to tailor therapies for both the clinician and the patient. Here are some of those resources that I commented on earlier on getting started on CGM devices. And I'm happy to take any sort of questions. But first, we have another follow-up question. Clinicians can bill for reviewing continuous glucose monitoring data with their patients with diabetes. True or false? We have got 20 seconds here. Okay, good. It is, in fact, true. RNs and dieticians can bill for the initial placement. The follow-up CGM review, unfortunately, has to be done by a physician or a physician extender, an advanced practice provider. Okay, with that, I think I'm going to have Dr. Tannenbaum take over. Yes, and Dr. Mizukami-Saw, thank you for an excellent presentation. Just a reminder for all of those in the audience, thank you for tuning in. You can place your questions in the Q&A, and after Dr. Tannenbaum's presentation, we'll have a chance to ask and answer those. Thank you. Sorry, my unmute button had disappeared. So anyway, hi, everybody. First of all, thank you to Dr. Mizukami-Stout for a really wonderful job talking about the benefits of CGM, how to get folks started with using them. And I really loved hearing all of those cases. They were wonderful. As a psychologist, I'll now be talking about how, as providers, we can help support people with diabetes who are starting to use CGM. First, we're going to have a true or false question. New adopters of CGM can figure out how to use the technology completely on their own. True or false? 10 more seconds to answer. Okay, good. Yeah, I mean, I think that there's probably no all or all or nothing here, but I am for education and support, which I will be getting into in a bit. All right. So because we know about all the benefits of using CGM, we know that CGM will be increasingly important to the work that we all do to support people living with diabetes. The question is, how can we as providers support the uptake and sustained use of CGM? Because starting on CGM, maybe from the outside, could seem like a no-brainer because there's research on all of the benefits, we know how far technology has come, but it can actually be a big deal for the person making this change. Maybe they've never worn a device on their body before. Maybe they've never had alerts before or had someone else ask them, hey, what's that on your arm? We know from research that we've done that these are some of the areas that can present challenges to people who are figuring out how to live with CGM. And both in my research on CGM uptake and in my clinical work, I've had many conversations with people who are making the switch to integrating CGM as well as closed-loop systems into their lives. And so I'm going to talk about some key areas that I think are important to touch upon with folks in having early conversations when they're getting started using this technology. Because I like to think of starting a new device as preparing for, as starting on a journey. And as providers, we want to prepare people with diabetes for this journey by equipping them with practical tips and knowledge, with problem-solving skills and coping skills that they need to get started on CGM and to continue to use it over time. And then the hope is that along the journey, when they encounter any hurdles or issues, especially ones that they haven't faced before, they'll know some of the steps that they can take. Not only that, but we want to do this in a way that centers each individual and their own priorities and their quality of life. And just a brief word about the ADA standards of care. It says in the chapter on diabetes technology that no device used in diabetes management works optimally without education, training, and ongoing support. That's why we're talking about this today. And I'm going to be focusing more on CGM onboarding, which I think is important for a few different reasons. First, it helps with setting realistic expectations. It helps us to prepare for common pitfalls that can happen with the technology. And it can help with identifying both personal and shared goals for using CGM. So I think all of these things are valuable aspects of CGM onboarding that can help set someone up for success. And just a word about common pitfalls. So these are things that a lot of people experience at some point when using CGM, such as having bleeding when inserting a sensor, having a sensor fall off, losing signal, and compression lows. And if these are being experienced for the first time, maybe without knowing that they could happen or how to handle them, that could be pretty distressing. But if someone's prepared and knows how knows that these things can happen and and knows what to do, that could make the difference potentially between continuing to use the device or maybe deciding that, you know, it's already causing too much stress and headache and not wanting to continue to use it. Besides covering these common issues, it may also be important to address some key themes, which we learned from our research were main barriers to device use for this was specifically what we learned from adults with type one diabetes. And so after cost, we learned about the issue of not wanting to wear devices on your body all the time. There's the all of the data and the alerts and the time and energy, mental energy that it can take to learn a new device and technology. There's the fact that people, other people, could see the device potentially or hear it alerting and that might bring on attention towards diabetes. And then some people felt nervous that the device wouldn't work or that they couldn't trust it. With everybody who I talk to, before we get into specific barriers and concerns for each person, I like to talk about the big picture. Mainly, why do they want to be on CGM? What are their goals and expectations? And what are they most worried about? Here, I think it's important to get at everybody's why. Why does someone want to be on the device? And I put a list here that is by no means comprehensive. But I don't mean, you know, why does your doctor want you to be on it? Or why does someone else, you know, why does your spouse or family member want you to be on this device? But this is about identifying and naming individual personal priorities. So I might ask, what made you decide to try CGM? And one person might be motivated by just having an alternative to poking their finger, and that is enough. While another person may really value having the alerts overnight. So it's important, I think, this conversation for us as providers. But I think it's even more important for the person who is thinking about starting on this technology to identify this for themselves. Why do they want the device? You know, what do I care most about? What do I want it to do for me? And this truly is going to look different for everyone. And then I think it's helpful to unpack worries and concerns when starting on CGM. So this is also helpful for us to know where to direct our focus first when we're thinking about providing education and onboarding support. So here are just, you know, some potential concerns someone might have about pain or discomfort. Will it stay on? You know, will they get skin irritation or a rash? Will the alerts be bothersome, either to the person using the device or people around them? And then, of course, you know, will I be able to trust the data? And, you know, we want to know these concerns because it's going to help us. You know, for example, if someone is still working on just being able to keep the device on their body, have it stay on, be comfortable, that's going to really be the first step before getting into things like customizing and fine-tuning alerts or trying to figure out whether or not or with whom to share CGM data. And if someone has had any past experiences with devices, and especially, you know, if there were any past negative experiences, that can really affect some of these worries. So I think it's really important to talk about these things and know what kind of thoughts and feelings someone's bringing into their So then by clarifying someone's why and their concerns together, kind of in the same conversation, we can then say, well, how can we work through and manage some of these things that you're concerned about that are, you know, valid concerns to get the benefits and to work towards the goals and the reasons why you do want to have this as part of your, you know, the way you take care of yourself with diabetes. So someone might not want a device on their body, but maybe they're willing to wear it because it helps prevent lows. And this is a very person-centered conversation because you're eliciting and then centering their individual priorities, and then you can help as part of their care team to support them in working through some of the concerns that they're having. And then you'll also be able to get a good sense of which of these four areas will be helpful to spend time on, whether it's wearing the device, living with the data, navigating social situations, or building trust in the CGM data. So I'm going to now give it just an overview of some of the kinds of things that can come up in each of these areas. And you'll also be able to get a good sense of which of these four areas will be helpful or building trust in the CGM data. So I'm going to now give it just an overview of some of the kinds of things that can come up in each of these areas. And not everyone might need to spend time focusing on all four. That's why it's good to kind of have a more broad conversation first and then can narrow down, but I'm just going to give a little overview. So when it comes to wearing devices, first and foremost, someone needs to be able to wear it and keep it on to be able to benefit. So we may want to talk about really concrete tips and strategies here for keeping it on. So things like over patches and things to help with the adhesive. We might be talking about, you know, moving the device around to give your skin a break. And then placement, where on the body to put CGM, placements that might be less likely and, you know, kind of troubleshooting around if they do end up getting a compression low, and maybe they're putting it in a place where they're more likely to sleep on it. And then it might also be important to talk about what to do when a sensor falls off or comes off early, which will likely happen at some point, never at a convenient time, can be very frustrating. So letting someone know, you know, here's where and or how and when you can advocate for yourself to get a replacement sensor and that it can be worth taking the time to do things like that. And in getting someone set up with CGM, it's also important to talk about customizing alerts to try to minimize alert fatigue early on while keeping in mind individual diabetes management goals. So I really like to think about long term sustainability here. So what they go with at the beginning will likely change. And I like to emphasize alerts are not set in stone, and they're customizable for a reason. So one example of this is someone might, you know, initially say they might set their high alert at 180 or 200, because they know, okay, well, this is my target range, and I'm trying to not go above that. So that's where I'm going to set my high alert. But if in reality, in their daily life, with their current management, they often go above that, that means they're going to be getting a lot of alerts, which may lead to either, you know, learning to tune them out, wanting to shut them off entirely. And so to begin, it might be, you know, a strategy to start higher, and then think about bringing it down gradually to try to balance long term sustainability of using the device with providing information that can be actionable. And then similarly, if someone's goal, let's say, and one of the reasons that they want to try CGM is they want to bring their A1C closer to the target of 7%. But they've turned off their high alert, or have set it quite high. So it's not really ever, you know, going off. In that case, it might be worth talking about whether, you know, the role could have an alert, it could potentially be helpful in helping to address hyperglycemia a bit earlier, since that would be in line with their diabetes management goal. Then I also like to go over what the trend arrows mean. As you can see here on the slide, it's just the arrows, it's not numbers. And so and it can evoke feelings when someone sees especially the arrows pointing up or down. But just to kind of go over well, here is here are the actual rates of change that they're tied to. And that can be quite grounding. Finally, I think it can be helpful to normalize this idea of hyperglycemia, which is a term that I learned through someone who was helping us put together some study materials, but just this idea that when someone gets CGM, they may be likely to want to stare at the data a lot, especially early on. So but just, you know, I like to kind of normalize, it's normalizing So but just, you know, I like to kind of normalize, it's normal, long term, doing, you know, staring at the data all the time may not necessarily be helpful. And so it's something to keep an eye on when we're thinking about, you know, what's their relationship with the data going to be over time. And we may want to say, you know, here's what it really just from the provider standpoint, here's when it can be meaningful and important to look at the data at these certain times. And then maybe if it makes sense, and this is maybe not right at the beginning, when someone's just getting started, but down the line, if it seems like they're feeling overwhelmed by by the data to talk about strategies for taking breaks, which honestly, can be it's it's harder now, because the data is so easy to get on someone's smartphone, that it's actually, you know, it's hard to do that, that but worth talking about. We may also want to talk about how someone will navigate social situations and their CGM. So if someone's already pretty open in their lives about the fact that they live with diabetes, then adding a device, like CGM may just kind of be an extension of that. But if someone, you know, especially when someone hasn't disclosed to people, or many people in their life that they have diabetes, then having a device added in that could make sounds might be visible to others might bring attention and kind of raise the question of disclosure in a way that it hadn't before. So for example, if it's, you know, summer, and someone's wanting to wear short sleeves, or go to the beach and wear a bathing suit, things that come up around school and work. And if someone's worried about an alarm going off during a test or during a meeting or a presentation. So I think that these are also really important conversations to have, if you learn that these are concerns for the person that you're talking with. So if someone has concerns about going to the beach with friends for the first time, and it's a group that they haven't disclosed about diabetes to yet, you know, these are examples where we might, and I've done kind of problem solving exercises and also mini role plays to kind of talk through, well, if you do get a question, let's talk about what would you say? How would you answer that? You know, what's the shortest version? What's the longer version? And kind of giving them different choices and ideas for what they might say. And also, I think, through these conversations, it's really important to come back to, well, you know, what's the why? Like, what are the reasons for you that it's important to have your device in this situation? So for a person going to the beach, it might be really useful to have access to the data. And so they might want it for those reasons and be concerned about navigating a social situation. And so we've been able to kind of talk through and prepare has been really useful. And I think it's often the case that the things that someone is concerned about, about the questions they might get or the ways that someone might react, that it ends up that they're pleasantly surprised by how other people respond. So it's kind of an opportunity to do many behavioral experiments. And I think the point here is to try to meet someone in their life where they're at, and then think about, you know, whether small experiments that they might want to try in their life, you know, how those things could fit in with their larger management goals. Finally, I like to talk about accuracy of the CGM and building trust in the technology. Trust is something I like to talk about as getting built over time. The process is not necessarily linear, and trust can be broken and then might need to be rebuilt. So I see it kind of on this continuum, which on the low end, if someone really does not trust the data from their CGM, they're probably still going to be checking their finger stick a lot. They may not get the same kind of peace of mind. But if something were to happen with the CGM that malfunctioned for some reason, they'd be probably really ready to step in and kind of move through without that data. On the other end, if someone has really high trust, they may have more peace of mind, because they trust the data, they trust the alarms. But then if the CGM falls off unexpectedly, or something goes wrong, and the person trusted their CGM to the point where they're not carrying around a backup, not having their meter with them, they may be less ready to kind of step in and manage those situations. So what we want to work towards is kind of being somewhere in the middle, this idea of building balanced trust and expectations, and then having the backup plans available just in case. And as part of balanced trust, we may also be talking about times when someone might trust the device more versus less. So it's not all or nothing, but maybe there's situations like the first day of the sensor compared to other days of the sensor use, or if numbers are changing rapidly. Or if they're just, their body doesn't match, what they're feeling in their body doesn't match what the sensor says, that it can be okay, and sometimes a good idea to double check. So I hope that I've been able to provide you with a rationale for CGM onboarding, since we want to support people who are making the transition to new devices, so that they can have a smoother journey. And just to wrap up, I wanted to again emphasize identifying each person's why, preparing them for common pitfalls and hassles, and how to manage those. Framing the idea of trust as a process, and that the device has to earn your trust over time. And then the last thing is that I think there are a lot of resources that can be helpful here. So I get to be part of a multidisciplinary team, where I think each one of us plays a different role in supporting someone's device journey. Connecting with peers, whether that's online or in person, can be very valuable just to know other people's experience with these devices. And then finally, I think it's important to know other people's experience with these devices. And then I wanted to call out, there's a website called diabeteswise.org. There's a version, I put the link here for the healthcare provider version, and there's also a version for people living with diabetes, to learn more about the different devices that are out there now, to get stories, first person experiences from device users, that can help with decision making when someone is starting out on their device journey. I will stop there. Thank you. Oh, here's our last question. Users should start with the default alert settings on their CGM and customize them only after adjusting to the device. Okay. I think customizing can some amount of customizing can happen at the beginning, but good answers. All right, thank you. Well, thank you so much Dr. Tannenbaum, Dr. Mizukami-Stout for sharing your expertise, your passion, a lot of helpful resources. I think this is very balanced. I mean this technology can be so helpful for people with managing their diabetes, with alleviating the burden of diabetes, with optimizing glycemic outcomes, but you know there are issues that come up also and challenges. I thought it was very nice that you guys described those and some practical tips for overcoming those. So remember this is the hands-on tips to improve diabetes care. These are five, one for each finger, tips that our presenters provided today. So go ahead and take a look at these. Feel free to write them out on each of your fingers, take a screenshot of this, whatever is helpful for you. And with that we're going to move into our Q&A now, just for a reminder to all of you, and I've seen the questions coming in, you've got the Q&A feature at the bottom of your Zoom where you can ask our presenters your questions. We've already had some nice ones that have come in. I'm going to start off with this one. So first question is, you did a really nice job, both speakers, of providing some helpful tips and tricks on onboarding, on education and training. What does that look like in practical sort of clinical practice for each of you? Who is it? Is it the provider? Is it diabetes care team members who provide that education and support? So I think it looks different depending on what the resources are in your available institution. And so I practice at two different locations. I practice at a VA medical center where we have, it's us, you know, it's me and the rest of my clinicians, and we have two nurses, and we bring in support from other places, primary care resources, like within diabetes education and in a primary care setting to try and help set up classes for CGM so that we can try and reach as many people as possible, because that's the resources that we have available to us at the VA. On the other hand, where I practice at the University of Michigan, we have a lot more resources. We have that multidisciplinary team. And so, you know, we have a whole team of diabetes educators who I can help ring at any moment. And so it really kind of depends on your own personal clinical scenario, and that should be kind of tailored to every individual. And I don't think that there's a right answer. Yeah, I think I was gonna say something similarly along those lines. The idea of a CGM class sounds really great. I'm part of a multidisciplinary care team, and I'm not always part of the team. So if someone's particularly reluctant or unsure about getting started on a device, that might be where I might come in at that point. But if I, whether or not I'm part of it, I think there's endocrinologist, nurse, diabetes educator to support getting started on CGM. Thank you guys for providing that perspective. I think one of the beauties of these webinar series is that there are people from all walks of life in the diabetes space, clinicians, educators, adult, pediatric. Thank you guys all for sharing the same kind of mission and vision to help people thrive on their journey. And I think what you said is true. You know, you can kind of tailor it to your unique practices. So the next question that that folks are asking about is, Dr. Mizukami-Stout, you mentioned that with private insurance, sometimes CGM is offered through DME channel, sometimes pharmacy, sometimes both. How do you sort of help your patients decide which channel to go through DME or pharmacy for CGM supplies if they have private insurance? So this differs also based on the location. I feel very, extremely fortunate here at the University of Michigan where, because we see a lot of patients with diabetes, this is, you know, it's a challenge navigating insurance with not only technologies, but also with medications. And so we actually have a team of pharmacy technicians who will help us to navigate and say, this is like the process for this individual patient. If I'm at an off-clinic location, I will refer to that coverage guide, which will also, it also delineates whether or not it's a DME or a pharmacy benefit. If it's a DME benefit, then unfortunately, I have to turn around and tell a patient, say, you have to call and see which DME company your insurance prefers. Set up an account and then let us know when that happens. And we'll take it from there. Got it. That's really helpful. One of the educators I work with one time said, why does the D and diabetes have to stand for difficult sometimes? You know, there can be these challenges, but, you know, I think oftentimes we're seeing a lot of the challenges be, you know, the burden is getting lighter. Certainly with pharmacy, the ease of e-prescribing, it can be nice from the provider perspective. So thanks for sharing that insight. Next question. There's a lot of questions about sort of the data and how it can be sometimes overwhelming. Dr. Tannenbaum, you used that term hyperglandemia. I had not heard that before. I really liked that. People are asking, so that's, you know, you were talking about from the perspective of the person with diabetes. How about the remote monitor, whether that's a partner, maybe it's the parent of a young adult who's living away for the first time, maybe it's, you know, the son or daughter of an elderly person. What about hyperglandemia for the follower and what tips do you provide around that? Yeah, that is a really great question. And it's probably going to be a different conversation with everybody. I think, I mean, I like having a conversation early on, and just, well, I guess, kind of stepping back in time and saying, like, well, what was the intention for the person using the device? What were their goals when they decided to share their data? And depending on who they're sharing with, what their expectations, what they wanted. So I think just centering it there is probably what makes, you know, where I want to be. And also understanding, you know, if the follower is having feelings or burden from hyperglandemia, like, how is the person who, you know, with diabetes experiencing that, too? So just kind of trying to understand, well, what were the goals of sharing? And then clarifying them. And then also, you know, possibly customizing and tailoring, like, well, what data does this person need to have? And when? And then kind of going over, I mean, I call them kind of rules of engagement. But when, you know, as the person sharing data, when, when do you want, you know, what are the things that are going to be most useful to you? When are you going to want to hear from this person who you're sharing data with? And kind of just starting there. And then it might be something where it's a conversation that is had all together, or, or separately, you know, with the follower to kind of reframe their role. But I think just kind of defining the roles. And what was the purpose? What's the original purpose of doing this? And do we need to kind of refresh and have a new conversation about that? Sure, yeah, I mean, that's really insightful, right? So the communication is so key, setting those expectations. And then just as you said, what are those rules of engagement? And maybe they change over over time. You know, the same way that you said that you got to be thinking about the alerts, where are they? How do those change? Maybe it's the same thing with remote monitors and caregivers? I know, in my practice, as a pediatric endocrinologist, we do a lot of kind of preparing for when they when the teens or adults move away, what does that look like, etc. So thank you for providing that that insight, Dr. Tannenbaum. Next question for kind of either one of you or both. Jan asked what you mentioned one of you, I think it was you, Dr. Tannenbaum, you mentioned compression lows as being one of those things that can sometimes be a barrier, or something that comes up in the data. And she just asked, what are compression lows can provide a little bit more insight on that. So someone else could probably explain the physiology of that better than me. But I can just say what I often hear is, you know, especially when someone is new to CGM, they don't know this could happen, they put it on, and whether it's on their arm, or, you know, wherever on their body, and then in the middle of the night, they wake up to a blaring alert that can be just very distressing. And it says, you know, maybe they're in, it's saying they're in the 50s, or the 40s. And so what can often happen is then treating saying, I must be having a low treating that low. Though sometimes if they do then do the finger stick before treating, they might see, okay, actually, I'm, you know, 100 and something. So a compression low, they happen. And once someone if someone knows that they can happen and is prepared, then they if they wake up in the middle of the night, with that kind of low, they might just like check in with their body, say, wait a second, do I feel low or just take a moment to finger, you know, double check with the finger stick. But if they're just, you know, panicking, and then treating, and then they end up high, you know, I think these things, it can be very distressing. And also, it can really damage that, you know, when we talk about building trust, if someone is brand new to this, and then it's waking them in up in the middle of the night, and it's totally off, you know, that's going to really hurt that sense of trust that we're really trying to build. So I think it's important, you know, when someone has a heads up, that that can happen. It can, that can be a way to get ahead of what could be a distressing experience. Yeah, I think that was well stated. I mean, just as you said, those compression lows is when the person's laying on the sensor and transmitter at night, it can cause a false low. And so just as you said, check in with your body. I tell my patients when in doubt, pull the meter out, make sure it is indeed that low. If it's not, if they just turn over, then in the next five minutes, those glucose readings will come back up to normal, versus if they are low, obviously need to treat. Sometimes you'll see a sudden drop off in glucose. So you can kind of tell by glancing at the at the data that it may not be real. So thank you for providing that context. The next question is for you, Dr. Mizukami-Stout, you shared some really insightful cases that people provided a lot of kind of feedback and gratitude about. So thank you for sharing those. And people are asking specifically about the role of CGM with type two diabetes, and specifically with multiple agents that might be used metformin, insulin, SGLT2 inhibitors, GLP-1 receptor agonists. How has your practice changed in the last few years as it relates to CGM and type two diabetes? Absolutely, I think there's a lot of a lot of benefits to CGM and type two diabetes. If you look at the guidelines, and they are really advocating the use of CGM specifically for those who those patients who use insulin. And that's based on some of the larger clinical trials that have shown that there are probably benefits for non-insulin users as well, for adjustments in terms of lifestyle and behaviors. For the most part right now insurers seem to be covering more generously for insulin users. And so I, the way I think about it is in terms of the physiology, what patterns am I seeing? Am I seeing overnight lows? Or am I seeing postprandial hyperglycemia? And I think about the agents that are going to then affect those patterns, right? So if it's overnight, if they're having fasting highs, that is a basal insulin problem usually, right? So that's when I usually reach over to my insulin, or sometimes an SGLT2 inhibitor, sometimes pioglitazone, like insulin sensitizer. If they're having more postprandial highs, that is something like their body is not processing carbs the way it should. What are agents that help with that? Certainly, cranial insulin is helpful, but there are other things as well. So the nice thing about type two diabetes is there are a whole plethora of different options, you just have to know when to turn to the right one. And I think it's really nice because CGM does allow that tailoring, rather than this algorithmic approach of let's add, let's start with metformin, let's add this agent, let's add this agent. Well, thank you, that was really helpful. And it's amazing that we're at this place now where CGM is sort of front and center as an anchor in diabetes care. It's actionable for the person with diabetes, but just as you said, Dr. Mizukami, also for us as clinicians, and diabetes care team members reviewing the data, thinking about the right therapy, as Dr. Tannenbaum said, what is the why and meeting that person where they are with that. So thank you guys again, so much for a really insightful presentation from each of you for an engaging Q&A. It's been great to be a part of this hands on webinar. Thanks to the ADA for organizing. A couple things to the audience. Thank you guys for tuning in. As I said before, we're all part of the same tent. Thank you for being a part of this mission to help people thrive on their diabetes journey. Be on the lookout for an email sometime relatively soon, where you will have a post test that will allow you to complete that to claim continuing education credit. Also be on the lookout sometime by the end of this month, this webinar will be posted on ADA's Institute of Learning Library. And as I said before, at the at the outset of today's presentation, the next ADR webinar is coming soon, I think it was June 11. If you scroll up to the top of your chat, there was an opportunity to link for that. And thank you guys all again so much for taking your time to be part of this. Hope to see some of you at ADA scientific sessions. Molly, Kara, it's been great working with you. Thank you all. Have a great day. See you later.

ADA webinar

improving diabetes care

Dr. DeSalvo

Dr. Mizukami-Stout

Dr. Tannenbaum

CGM devices

empowering adults with diabetes

diabetes management

onboarding support

personalized education