Hi, everyone. Hi, everyone. Welcome to today's Hands-On Tips to Improve Diabetes Care webinar. Today, our panel is going to be talking about expanding CGM use in your clinical practice. I'm Caroline Richardson. I'm the moderator today. And I'm currently chair of family medicine at the Warren Alpert Medical School, Brown University. We're going to spend the next hour together following the agenda that's on your screen. And we're going to send you some important links that you can use through the chat box. We're also going to be having some quiz questions during the talk that you can answer. And you'll see them pop up on your screen. And you can click the answer that you think is correct. And we'll be using a Zoom Q&A box for questions that the panel will answer at the end of the session. So for this webinar, we'll be using Kahoot. It's an interactive game-like platform that you're going to be able to respond to. You can do it on your mobile phone or a tablet. You can also use the device that you're viewing the webinar on right now. You just need to open a second window or tab in your browser to do it. Connect your open browser and type Kahoot, K-A-H-O-O-T, dot IT. And then enter the game pin. Today's game pin is listed in the chat. But it's also 602917 if you missed it. And we're going to go ahead and give you a few seconds right now to go ahead and get Kahoot open and enter the game pin again, 602917. And just a reminder that we have another webinar coming up on Tuesday, November 12. And that's going to be our next hands-on webinar, Optimizing AID Systems, A Case-Based Strategies for Individualization. And you can register in a link that's already in your chat box right now. And I just want to introduce the two panelists for today's webinar. Dr. Sarah Cote owns and operates a private practice that exclusively treats patients with diabetes. She has 13 years of experience in the practice of internal medicine. And she's served as the communications director for the 8A's primary care interest group leadership team for the past two years. She is the board chair for the ADCES for the state of Maine as well. And Dr. Joe Aloi has practiced clinical endocrinology for more than 20 years. He believes in providing optimal care for people with diabetes through expanding use of diabetes technology. And he's an active educator and researcher at Wake Forest School of Medicine. And I'm going to give the panelists a minute, starting with Sarah, to describe your disclosures. That's to Sarah Cote. I have no disclosures. I'm Joe Aloi. My disclosures for research support are listed there. Thank you, everybody, for coming. We really appreciate you being here. Let's get started with expanding CGM use in your clinical practice. Answer is, all of the above. What are continuous glucose monitors? They are wearable devices available for patients with diabetes that monitor blood glucose via interstitial fluid every few minutes. There is a time delay between interstitial fluid and blood. Blood is still the gold standard, but there are barriers to frequent testing. Older versions of CGMs may have required scanning with a reader or a smartphone. Newer versions now are constantly sending data to apps and readers and can allow, can hold data when away from phones or readers. They have different standards for accuracy than a finger stick glucose meter, and they will differ at times, but should not be more than 40 points off from a finger stick meter. Why are they useful? They allow for real-time glucose monitoring, which has its advantages for clinicians and patients that finger stick monitoring does not. Patients can see in real time how daily eating, activity, and events impact their glucose, and they can make adjustments quickly to improve their glucose every day. Clinicians can see more information about blood glucose over a longer period of time. They have more data points to consider, and they can see fluctuations in glucose. They can see the impact of medication changes and engage in more precise discussions about glucose control. How can primary care providers utilize CGM data? For example, a 51-year-old patient with type 2 diabetes comes to the office for a three-month routine follow-up. The patient is transferring care from a previous provider. The current medications are Lantus 25 units in the evening, Metformin 1,000 milligrams twice daily, and Jardian's 10 milligrams once a day in the morning. The patient reports they are using a Freestyle Libre 3 device for glucose monitoring, and the patient complains of low blood sugar overnight, but high glucose at bedtime. The patient is due for their A1C, which is done via point of care testing in the office, and the result is 7.8%. The provider advised the patient to increase their Lantus to 30 units. However, the patient reports that they have lows in the morning. The patient offers to show the provider, who's not familiar with the Libre 3 device, their recent glucose. So on the screen of an app, if a patient is sitting with you in your clinic, you'll be able to see this information. You can see here the patient is going down overnight, but has rising glucose in the daytime, and particularly after meals. You can also see their time in target. You can see that they're having 5% lows, and they're also having some elevations. Without knowing exactly how to use the Libre 3, the provider can clearly see that the glucose in the morning is low, but in the evening is higher. The time in target graph indicates that the target range for this patient and how much of each day is spent in which area, and the provider can see out of range glucose at dinnertime, initiating a conversation regarding modifying dinner meals to help with glucose, the provider will consider then splitting the Lantus for 10 units in the morning, and maybe 15 units in the evening to try to even out their glucose, and the patient is more comfortable with these steps. So continuous glucose monitoring offers precision medicine at our fingertips. Many patients are wearing these devices to manage their glucose with or without insulin. Providers don't have to be familiar with every single nuance of the devices, but they can quickly get very meaningful information that an A1c may not provide. Many studies have shown that adding these devices to a patient's regimen is as good, if not better, than adding a new medication, and some studies show that adding a CJM lowers A1c similarly to adding metformin, about 1% to 2% in patients. So as time goes on, this provider sees many patients who are using these devices, and starts to become more familiar with them, and is feeling more confident in reading the information on the apps and readers, and the provider feels that she's having more impact on her patients with diabetes during their visits, and seeing improvements in their glucose at follow-up. She wants to start to prescribe CJM and see more glucose information, but is not sure how to get started. Prescribing CJM seems a little daunting, because there are many brands and different things to consider. We hope that this makes this a little easier for you. There are two main commercially available devices by prescription. They are both compatible with most smartphones. Patients can check their app stores to see if they have a compatible device. Both are affordable for commercially insured patients with or without insulin, and are available at retail pharmacies. There are copay cards available through the U.S. that bring the cost down to about $75 or less for a 28 to 30-day supply. There's a Freestyle Libre 3, which is a 14-day sensor, and you would prescribe two devices every 28 days for glucose monitoring. There's also Dexcom G7, which is a 10-day sensor. You would prescribe three devices every 30 days for glucose monitoring. Medicaid or state care patients and Medicare patients have different restrictions. Medicaid and Medicare patients are usually required to be on one shot of insulin a day, or you're required to prove that they've had two documented incidences of level 2 hypoglycemia, which is a glucose under 54, or one incidence of a level 3 hypoglycemia, which is a low glucose that requires third-party assistance. Some states have more stringent requirements. Here in Maine, often our state aid wants a four-times-a-day blood sugar check for two months before they let us prescribe continuous glucose monitors. So, you have to check with your state care plans. They, patients with Medicare will receive a reader, even if they don't plan to use it. The readers are only replaceable about every five years, even if they malfunction. Most people can use apps on their phones if they're compatible. Some plans allow for devices to be filled at retail pharmacies. Others will require them to be filled at a durable medical equipment provider. Patients who would like to pursue CGM can call their plan and ask where a script needs to be sent. The DME requirements for Medicare patients only require providers to provide a note every six months. Documentation will state that the patient is currently using the continuous glucose monitor. And we use Parachute. It's a good website to send in prescriptions to DME suppliers and communicate to them and for them to communicate to you about documentation electronically. And providers can bill for placement during visits, as well as reading data from these devices. Medical assistants, PharmDs, and RNs can place devices. They can educate patients on use and download reports for providers to review. Devices are simple to use and made for home use. And many patients can be prescribed them and put them on at home with no direction from providers. CGMs enable remote patient monitoring in cases where access is difficult. So some tips and takeaways. If your patients are wearing CGMs, start with looking at their apps to fill in some of the gaps in knowledge of their blood glucose. To guide and counsel on lifestyle habits or to inform your treatment decisions. CGM is accessible for almost any patient with diabetes. Consider CGM as another treatment tool that enables patients to engage in self-management and prescribe them if they're affordable. Answer was false, you all did great. I'm going to pick up where Sarah left off she sort of queued this up real nicely for me. This is a picture of Wake Forest, as the Cancer Center, which is right next to my office. Next slide. And I can summarize, we have a quiz, looking at the benefits. And all of the above, and I'm going to touch on a couple of these points. So this slide summarizes 20 years of clinical care, but next slide. It's really relatively easy to identify diabetes. I'll set this up to make a point that we've had insulin for 100 years. If you look at that cascade of all of the different medicines that we now have to treat the hyperglycemia, we now have as many medicines to treat hyperglycemia as we do medicines for hypertension. The little upper left-hand panel is just to illustrate that if we look at the ABCs of diabetes management in terms of A1C control, blood pressure control, cholesterol control, that really we're not hitting a benchmark much under 50% of patients. Other CDCs, morbidity, mortality, if we pick an A1C of less than 8%, a very few percentage of our patients would be less than seven, but 75% are under eight, but again, less than 50%. So where is the gap? You can see personal CGM has been with us for at least 20 years, and we have automated insulin delivery, beta cell treatment, lots of discoveries, but we still have to help the patient manage their hyperglycemia. And I feel the gap is information. Next slide. And it makes the question of how important insulin is, but how do you manage it? And this is from Google photos looking at very shortly after the introduction of insulin, making the point how important insulin is in managing diabetes, but it's absolutely necessary for life and has lots of roles in metabolism. Next slide. And we're going to talk about this by illustrating the AGP in a patient case, the ambulatory glucose profile. Next. This is a way of getting all the information into one place, but why do we need technology? And these are some of the bullet points in one of the Kahoot questions, but summarizing an awful lot of data in general, improve glycemic control, as Dr. Cote mentioned, it's the equivalent of adding an oral medication in many studies by drops of the hemoglobin A1C of 0.8 to 1%. Clearly reduce hypoglycemia. We have predictive alerts in the CGM that can notify a patient before they get low or as they're getting low. It gives you that daily fluctuation. I tell patients if they take the same medication, eat the same meal and do the same exercise, they're still going to have fluctuations in their blood sugar and potential improvement in quality of life. And I list potential because we need to balance that information, which many people with diabetes appreciate and can use with that information that can sometimes increase diabetes distress. So walking through this slide, the far right panel is the group of patients I take care of, adults, but the solid black bar is no technology. And this is data from the type one diabetes database, the T1D exchange, and they are averaging an A1C of 8.2%, which would surprise you. These are all type one diabetics, so all persons treated with insulin from what I just showed you about the national averages. You give them a pump and the average is 7.8%. So the message here is delivering insulin isn't enough, you have to know how to deliver the insulin. If you put CGM, you do a little bit better and pump plus CGM does better. And if you look at children and adolescents, the pump plus CGM seems to do better than any of the other combinations. Next slide. Centers of care currently is recommending CGM for all people with diabetes on multiple daily insulin injections or pump therapy. Time and range, which we're going to talk about, it's been validated and the consensus is 70%, which is equivalent to an A1C of 7%. Next slide. Other organizations are making the same recommendation. I think when CGM first came out, it was presented almost as this overwhelming amount of information you get, which is why I want to spend time on the AGP because for most of my patients, this is the majority of what I have to look at and discuss with them, although there's much more data you can dig through. Next slide. So the ABCs of the AGP, A, time above range. And you can see that there, there's time that are high and then very high. B, time below range. Next slide. And we like that to be less than 4%. And C, time in control. As I just said, we want that to be 70%. I tell my patients, the more green, the better. You can look at this, a picture sort of gives you a global perspective. This person set up their target range, which is standard at between 70 and 180. And the black dotted line is the average throughout the day. And you can see this particular patient never gets there. They're always high. And you can see a bit of a spike later in the day, which probably represents supper. Next slide. Other information on the AGP, the average glucose. Some of my patients just really like to know what their average glucose is. I'm going to talk a little bit more about goals for that in the next slides. Standard deviation. Eventually, I think this is going to be a focus of care. It gets into glucose variability, which is thought to be connected complications. The glucose management indicator, I know I'm throwing a lot of abbreviations here, is an estimate of what the A1C would be. The Food and Drug Administration didn't like printing on this that this is an estimate of the A1C, so we had to give it a different name. But what it's doing is saying an average blood glucose of approximately 280 is an A1C of 10 or GMI of 10. Next. The glucose management indicator, like I said, just based off what the mean blood glucose, if you see the yellow bar there, highlights a GMI of 7. Average glucose of 150. I like to keep 150 in my mind, because I know they're going to be close to an A1C of 7. And approximately 200, because that's a cut point for 80. And the link's there, and you can find out more information about it if you'd like. Next. So a case, this is Frederick Banting of Banting and Best, but he illustrates a 60-year-old patient. This is a frequent referral. We have an urgent insulin start clinic, and we don't always start insulin in that clinic, but this is the type of patient we see. He's been diagnosed for eight years, he's obese. He does have nonproliferative retinopathy, already has a complication, which suggests he's probably had diabetes longer than he's been identified with diabetes. Doesn't exercise much, but we just found out he needs a knee replacement, so maybe he can exercise. He's on maximum doses of a sulfonylurea, metformin, and a DPP-4 with an A1C of 9. He does do blood glucose checks three to four times a week, but he really doesn't feel like his provider or he does anything with that information. And he sees that his fasting blood sugars are generally good, because he wants them less than 200. And he's not pregnant, so he's not doing after-meal blood sugars. So he's got some intermittent ones that are high, but he thinks these are the minority. Next. This is a professional CGM. I was trying to engage the patient, and this is a sensor that's blinded. He doesn't actually see the data. We talked about dietary changes, exercise changes, possibly starting insulin, but we put this on to bring him back and review it, and I think this is a big motivator for the patient. I tell my residents, fellows, students that patients never lie to us. I mean, as providers, we accept what they tell us, but they give us wrong information. So by looking at his fasting, as you can see, about seven in the morning when he's getting up between eight, on average, he's around 180. But the rest of the day, as soon as he starts eating, his blood sugar goes up. And there's a huge trail after the evening, and he's going up until about three o'clock in the morning. And if you ask him about that he offers, well, do you think that's that snack I take before bedtime to settle my stomach? There's a lot of self-discovery with this. Next. Based on these points we made, we actually started this patient on a GLP. He's trying to get a knee replacement. They set a goal of 6%. We can show that the average blood glucose drops within two to three weeks, and we don't need to wait for an A1C. And I've talked with our orthopedic department, and they're happy to see that GMI or that average glucose down below or around 150. Next. So another way of looking at this data, and I will tell you in full disclosure, I've been trying to get this into our medical record. This is borrowed from the International Diabetes Center. But patients can send their information to a cloud-based data repository. It's different for each sensor. And that's where we, when they come to see us, pull their data. Or if we're doing remote patient monitoring, that's where I look at their data. If they're using their phone, it goes up without any effort. They don't have to upload anything. But what if I didn't want to go through all that? I was in the patient's EMR, and I just wanted to click a button. So there is a process where all that data in the cloud, when you order it, and what they chose to do is order it as a lab value. The things we just talked about, time above range, time below range, prints out as a lab result. Next. If you want to set different parameters, if you want to know if the patient's above range, less than 5%, or what many people are talking about, if their time below range is greater than 4% for a few days, you can actually get a prompt. And you can see these discrete values that pop in as a lab, and it can go right into your note. We're working to get this in. It is a problem with our industry, our institution. They don't want any other outside apps putting information in. But it is possible. Next. So all this time and effort, this is one situation where I think providers get rewarded. I will not say unfairly, but relatively at a high value. So we talked about professional. The code's there. Anybody can put the sensor on. We have a process for it in our clinic. I will say early, we use this a lot. We don't use it as much anymore, but we still use it for new patients that don't have any knowledge about this, and they're a little hesitant to get a personal sensor. Personal, they can connect to that cloud-based repository that I mentioned. You can bill for interpretation, and I'm going to talk a little bit more about that in a minute. And most insurers and Medicare allow for a monthly charge. The reason why I say that is some of our patients that we're trying to get to goal, prior to CGM, we'd be getting pictures, phone calls, writing down blood sugars, calling the patient weekly, trying to adjust their insulin, and we wouldn't be compensated for that. Now, at least on a monthly basis, if we're doing remote patient monitoring with a phone call, we can at least drop a CGM charge. If I place a personal CGM, and this happens occasionally, patients come to me with a CGM in their hand. Another provider prescribed it, they didn't know how to use it, and I can go through setting up alarms, setting up goals, there's a charge for that. The report needs to be brief. We have a smart phrase, which is there, but you need to say that you've looked at 72 hours of data. You can put in those parameters, time above range, et cetera, and what your recommendation is to the patient, what you discussed with the patient, and frequently, I do this remotely. This morning, I did four remote patient visits. I do it at the time of a visit with patients visiting me face-to-face. Next. This is a breakdown in general. It's different where you're practicing, but Medicare, what they reimburse for that personal CGM startup. Private insurers pay a little over $100. My work effort, how I work with my faculty is RVU-based, so it's 1.96 work RVUs, which is about a level four follow-up. 95250 is that professional CGM placement. Who decided that would be 4.4 RVUs? I'm not sure, $300, Medicare, $150, and the CGM interpretation, $35 roughly for Medicare. Says private insurers, 98. In my market, we get paid approximately $75, and the work RVU is about one. Is that important? I will tell you, I work with a clinical pharmacist, and between the two of us, we had to justify her position. She does a lot of insulin titration for my patients, but for the year to date, ending in September, she collected with me about $100,000 based on reimbursement for CGM interpretation and some of the things I talked about. My takeaway message is for you to think about. I hope listening to us and going through the details of the why, the how, understand that it's easy to initiate. When CGM is growing, there's currently at least one over-the-counter CGM. A lot of my patients that don't have diabetes are using it to assist with weight management. If they're doing intermittent fasting, if they're looking at what meals are bumping their sugar up as much, they're looking at the impact of exercise. If they have prediabetes, and they're a very potent patient motivator because they can actually see what's happening, demystify different meal plans and how they affect their sugar, clearly reduces hypoglycemia. This is a solution not approved for use in inpatient, but we allow our patients when they're hospitalized to use their sensor precisely for minimizing hypoglycemia because they can get an alert and alert their caregiver. Can improve the quality of life for some persons with diabetes. I think that's the majority. I'm looking at the times, I'm going to give you a brief antidote because we have time. But the first woman I started on personal CGM, I was a little hesitant to try and once adopting it, it was about almost a year into this, she made a comment that I'm so glad I did this, because I can now let my husband work day shift, and work nights and be flexible and get promoted. And I was kind of curious, I said, well, how does this affect that? And he goes, well, prior to this, my husband was my glucose sensor, because she had a lot of nocturnal hypoglycemia, and she had fear of being left alone. So her husband didn't travel, his husband didn't take an opportunity at a job to work different shifts, and it has lots of ripple effect. But clearly, I think for the majority of my patients improves their quality of life. You've looked at the numbers, you can think about it. But I think the work effort and downloading a few apps or getting more experience and looking at what the patient's doing, you can improve your expertise in this. And it's cost effective, because it's one of the things that you do in terms of patient management, that you get paid for that out of office experience or that phone call. And CGM can facilitate self management. There's several studies looking at weight watchers with or without CGM. And as we've said several times, really facilitates remote patient monitoring, because I can see what's happening with their blood sugars, we can touch base by phone or by video visit. Some of my patients like to see their data, they can look at it themselves, but I showed them during the course of a virtual visit with video. And I think it enhances their satisfaction with their care, as well as their self empowerment of managing what's a self managed illness, or management problem with diabetes. Next. Well, the reason why it's false is because Medicare does cover, as Sarah pointed out, for severe hypoglycemia or level 2 or level 3. And we've actually been able to get CGM for patients that are on sulfonylureas. Sulfonylureas are not my first or best choice, but this was what they're being managed with to help protect them from hypoglycemia. I appreciate everybody's attention. I think there's a lot of questions popping up. Okay. Just look through these five take-home key tips that we have. And while you're reading through those, think about any questions you may have for our panelists. And I'd like to thank our panelists for the wonderful presentation today and introduction to CGM and using it in your practice. So we do have some questions in the Q&A. If you have more questions, go ahead and type them into the Q&A section. Some people have been putting questions in the chat, and we'll try and get to those, too, also. All right. So let's go ahead and look at the Q&A box. There is a question here that says, what billing codes can RDs use? I don't know. One of the panelists want to take that? I'm not sure what codes RDs can use. I think it depends on your state licensing and prescribing requirements. I would look into that. I'm not sure if it's the same CPT codes as it is for nurse practitioners, PAs, or physicians or pharmacists. But that's definitely something to look into. I can add what they can't bill for, but that's the interpretation. So our educators, our RDs, our clinical specialists will sometimes refer the chart to me if there's a CGM they want overread. They sometimes prep the interpretation, and they deliver the message to the patient. So it's a way of capturing it. There's been a big push to add other people to that, but that's people following Medicare. We've had our RDs place sensors, but to be honest, I'm not sure whether we've been able to charge for that, although we have our MAs do it for the professional and the personal and set them up and recharge. So there's a lot of questions about billing here. Another question about whether FQHCs can bill for CGM. Any thoughts on that? Again, going back to who can bill for the CGM interpretation, right now it's basically licensed providers, PAs, NPs, physicians, clinical pharmacists. I don't know if they've been added yet, but that's coming, I hear. So that's important for me since I work with a clinical pharmacist to give her some autonomy, but they can't bill for the interpretation. So you can collaborate with someone. I don't want to get into the weeds, but I have a remote clinic run by a pharmacist and two RNs and actually in the place that's underwater now in Western North Carolina. And they will collaboratively, we meet and we look at things. So I feel ethically, I've done the interpretation and it's communicated to the patient, but that's not what you're asking, but there's kind of workarounds. But at the end of the day, the person doing the billing charge for that 95251 needs to be in that list I just said. Thanks. So there's a couple of questions about actual how to use the device. One question about whether putting it on the back of the arm is the best place. Sarah, you want to take that one? Sure. So the Libre sensors traditionally have all been back of the arm for ages 13, I believe, and up. Underage has different placement because of their body habitus. So if you work with children, it's usually leg placement for some of those sensors. The Dexcom G6 is an abdominal sensor. So that's the two-part sensor that is sort of being phased out unless it's being used in conjunction with a compatible insulin pump. So most people are getting Dexcom G7, which is arm placement, FDA approved for arm placement. Some folks put them wherever they want and they should be counseled that it may or may not be as accurate because we are not sure based on the manufacturer recommendations. I just want to say she's absolutely right. Oddly enough, I just had a patient yesterday, but for a variety of reasons, the sensor, he cannot place it in the FDA approved position because the reason why is that's where they did the study to minimize any variability. I would say some of my patients like to put it sort of close to their back, which can be a problem if they sleep on their back, because if you have continued pressure on the sensor, it impedes that subcutaneous fluid and you can get a false low reading, which we call pressure hypoglycemia. So I do pay attention to where they're putting it, but Sarah is absolutely right about where the FDA approvals are. All right. And I think it's important to know that different patients have different preferences about exactly where the sensor goes. Some people end up putting it a little bit farther out to the side of their arm and then it can get, it can hit on the edge of a doorway. Some people put it farther to the back. And people usually over time adjust the exact location to be out of the way as much as possible and not to get knocked off. I usually put it farther to the back. I usually recommend Panther for the guideline for CGM troubleshooting. So if you just Google Panther CGM troubleshooting, it'll pull up a nice list of things that patients can do to keep them on. So overlays, extra sticky stuff on the skin, what they can do if they get skin irritation, and then rotating sites and all that business. It's a nice little guide for folks. All right. There's one more question about how to use it. A question about seeing day-by-day weekly reports on the app. You can see all of that information. You can see a daily. So on the Libre 3, they won't be scanning. So they won't have a logbook, but you can see a daily pattern versus a monthly pattern in the menu. And you can see averages, 7-day, 14-day, 30-days, and 90-days. And it's based on time. So I believe it's six hour increments, midnight to 6am, 6am to noon, noon to 6pm, 6pm to midnight. So it does give you quite a bit of information about what's going on. The Libre 2 is the one that's a flash continuous glucose monitor. That means that the patient will scan it every time they want to see their blood sugar. They need to scan it every eight hours in order to capture all of their glucose data for the full 24 hours. And that's where you'll see that logbook, where you can see those points in time where they scan, as well as the overall picture on the graphs on the screen. And then one more question about placement. For older adults who have minimal fat on the back of their arm, it may be difficult to place it. Is there something you can do about that? I think sort of some of the alternate sites that we all mentioned. I've got one gentleman who likes to use the top of his leg. I've got another patient that uses their abdomen. And now that they're smaller and flatter, it makes placement in other sites a lot easier. And as you pointed out, Dr. Richardson, the most common problem I was having in the beginning when I was doing this is people catching the sensor on the door, or when they're pulling their shirt off. So you do have to think about it a little bit. But I have not run into, the only patients I've run into problems with their body composition, let's say that, have been patients with scleroderma. And they're few and far between. But the finger sticks aren't also very accurate with them. And it's a problem I haven't quite solved. But I've now had a few patients where you get unreliable readings. But that's the only one that bubbles up as a problem I watch out for. I'm not sure how to manage. And if Sarah has any other advice or you, I'd be more than happy to hear it. So we have a couple of questions about the sort of the workflow when a patient comes in with a CGM. How do you manage what happens with their data? How do you move them through the clinic and get their data off the smartphone? And then also sort of related to that is, do you recommend one person orders the CGMs to make sure they get the correct one ordered or they know what they're doing? Or just should all the providers be able to order their own CGMs in a practice? I can tell you what we do in our practice very briefly. But we spend a lot of time making sure they're connected to the device's cloud site. And if that's the case, we have, again, the two most common now are Libre and Dexcom. And they both have LibreView and Dexcom site. And we have them on Google Chrome with the saved password. And I can go in and pull up the patient in the clinic because it's all automatically going up. For those patients that have a receiver, not their cell phone, we do have a station where when they get checked in, it gets downloaded. And that sometimes does slow down the process. When it does, I just look at the receiver. And from the ordering, and Sarah can probably talk about this a little bit more, but we've almost gone as much as we can to the online ordering through Parachute. And in that sense, it's going, all our providers, we have seven advanced practice providers and eight physicians. And that actually makes it pretty simplified. Yeah, I would say it depends on your clinic workflow, how you set it up. You can have, if you have somebody who needs to plug in a reader, your medical assistant can do that very easily, plug it in, upload it. And then when you go in to read it, it'll be on the screen. And then you can just download and drop those reports into your EMR a lot of times. I like what Dr. Aloi showed where it like automatically goes in as a lab result. That's like pie in the sky, like the best way to get it in. But, you know, sometimes I find myself, if I'm in a pinch and we can't get connected, I think the worst thing for me about CGM is the passwords. So people have to remember their password when they have to log into the app in order to be able to share their data sometimes. And so that takes up too much time. Then I just pull what I need off of their app and type it in as we're talking. And that just has to suffice. As long as you meet those few requirements, time and range, average glucose, and then something meaningful that you're garnering from it, I think you'll be okay in terms of like billing and things like that. And so I think an interesting question that came up that's sort of related to this is that the newer CGMs that you don't require a prescription for. So both Abbott and Dexcom came out recently with over-the-counter CGMs that patients can order directly from the company without a prescription, without a physician. And they're presumably interpreting their own CGMs without medical supervision. But I think we're going to see more of these walking into our clinics in the near future. And they can be uploaded just as well. So there's the Dexcom, Stelo, and the Abbott lingo, both of which can be ordered by patients online and are delivered directly to their mailboxes without any physician involvement. And so- I can't- Go ahead. I can't speak to the Libre version, but I can speak to Stelo. Their app is actually really good. They have a lot of information that is not- It's not medical advice, but it's saying, the past seven days you've woken up with an elevated glucose. What's that about? Have you tried to change your evening snacking? Have you- So it gives you like real world advice, not advice, but feedback about your glucose. And so it helps the person who's wearing it ponder those questions on their own, just like somebody would if you gave them a Libre regular one that we had prescribed. It doesn't talk about medicine. So it's never gonna say, is your Metformin working? Or maybe you need to decrease your dose of insulin, but it does say, you know, maybe you need to talk to your provider at some points if it notices a trend. And there's a question that says, I think Dexcom recently came out with Stelo. Should I look to use this CGM or the G6 and G7? And what you just said, Sarah, is really important. The Stelo and the Abbott Lingo are explicitly stated not to be used for patients with diabetes who are on insulin in particular. So I would imagine they're probably not covered by medical insurance because they're designed and marketed as non-medical devices, not for managing medication, definitely not for managing insulin. It's unclear to me if they're any better or worse in accuracy than the ones that are, but they are not regulated the same way and they don't require physician prescription or oversight. So there's explicitly stated, don't use these in patients on insulin on the boxes of these devices. I think if you have a patient with diabetes who is covered for a CGM, you probably wanna order one of the ones that's a medical device and that is allowed or certified by the FDA to be able to be used for patients with medication use and the supervised vision of a physician. But if you have a patient who doesn't have coverage for a CGM or as pre-diabetes or obesity is working on glycemic control as well for weight loss, or for getting rid of their pre-diabetes or avoiding progressing to diabetes, then these non-insulin CGMs may be more appropriate and accessible for your patients. All right, what other questions do we have here? A question about recommendations on patient signing agreements for primary care clinics to allow for remote monitoring. We all do this, but that end user licensing agreement that you agree to when you log into the sites kind of covers that. So we do not, I don't know there's a specific concern about sharing the data or whatever, but we do need their permission if we're using a third party like Tidepool or Gluco to bring the data into our EMR. That's another way of doing it, which is part of the reason we haven't tackled it to re-consent everyone. Yeah, so in order to give you access electronically to the data off of one of these CGMs, a patient has to put a code for your clinic code into their app. So that's how they're giving you permission to see their data. And I don't know, we don't use any other forms or have any patients sign any other agreements. We just say, if you put our code into your app, you're giving us permission to see your data. And they can rescind that at any time. Yeah, they can just delete that and then we don't have access anymore. Sorry. Okay. There's a question about Eversense. Anyone ever had any experience with Eversense? I don't have anybody close to me that places them and that's the barrier for my clinic. The next closest place is in Massachusetts. I'm in Maine. So I don't have any clinical experience with it. Do you? Yes, but no. I helped one of our nurse practitioners get certified. I'm not personally certified, but Jamie has placed about 10. Part of that was we don't really have, we're in Winston-Salem, North Carolina, and there's no one close that does that. And we get a lot of college students that need the sensor replaced or taken out. And it's probably the most accurate sensor. You still have to have a receiver over the implanted sensor. And sometimes they're a little difficult to take out. I think the 360 day approval has come through. So that's been my sort of barrier because I didn't want to be changing these things every three months, then six months. But now that is, I think we might be using more. I think the con of it is that when you take off the receiver you don't get any data. So if somebody is going to bed at night and doesn't like to sleep with it on, then they're going to lose that hypoglycemia and those types of things. And I don't believe that it's currently compatible with any of the pumps. Not currently. I think beta bionics is saying that they're going to be, but again, it's the patient's choice. And I try and give them information and then sometimes they ask me what I would use. I don't see a particular benefit. It sounds nice, but as Sarah said up, I mean, you have to have the, you're still tethered to a receiver and that's the biggest sort of hurdle. So it's not really invisible implantable. And then as you said, when you take it off, you don't have that warning for hypoglycemia. But I- For the people who might not know what the Eversense is, it's actually inserted sort of with a minor surgical procedure under the skin and it stays there for a year and it acts as a glucose detector. And then you have the sense, a sensor that reads that detector that's placed over the skin. And it's, you know, there are lots and lots of new technologies coming out to sense glucose, including your Apple watch will probably do it soon. And so these things are changing. I think an implantable sensor for a year it's a great thing, but most people haven't started using it very much yet. And it's not one of the main parts of the market yet, but I think we'll see lots of new technologies coming out in the next couple of years that will make this easier to do. And we'll see lots of people who don't have diabetes bringing in their glucose tracings from their non-prescription glucose monitoring and asking questions. So it's good to get used to answering these questions and understanding them. Some people said that they use, they have sample CGMs that they give to patients just to get a 10 day reading on how they're doing. I think for type two diabetes in particular, especially for people not on insulin, giving people a sensor for a short time, not necessarily forever, but just for two weeks here or two weeks there can really help them get back under control. What do you guys think? I agree. I agree. I think. I agree. No, I do it all the time. I mean, some people don't want to be reminded they have diabetes. They don't want to wear the sensor, but I ask them if they can at least do this to help me out, particularly if there's a problem in identifying overnight hypoglycemia. I'm old enough that we used to ask our type ones to get up at two in the morning to check a finger stick. And I mean, the things, it just gets rid of that whole piece. And sometimes there's a discovery about what's happening on pizza night when they go out and seeing that, gee, that's contributing an awful lot to my A1C. So it can uncover a lot of mysteries when you're stuck with somebody who's taking all their medicine, but not a goal, or if they're a goal and having hypoglycemia or on hypoglycemic unawareness that I become aware of when I do the CGM, particularly for my patients that are over whatever age limit we're going to say is old. Yeah, I think for most people with type two diabetes who are on long acting insulin, I can say I haven't actually ever put a CGM on one of them and not found nocturnal hypoglycemia. It's never happened. They're always over-treated at night. And there's a lot more Don phenomenon than we realized. Once I started really looking at CGM, boy, people's glucose rises at 3 a.m. a lot, and people are under a lot of significant stress in their life, and they don't realize that that is a factor in their increased blood glucose. And some people assume that when they exercise, their blood sugar goes down, and then you put a glucose monitor on them and you find that your marathon runner is just putting out sugar while they exercise and that they need to maybe do something a little bit differently with their physical activity. So it does really bring to light a lot of nuance in blood sugars that we just don't have access to with a finger stick. Someone in the chat wrote that you can actually get one free, any patient can get one free sensor from a company by either Dexcom or Abbott. I believe both of them, if you write, if you just ask for it, they'll send you a free one. And that can often get people started at least to see if they want to try and pursue getting more of them through their insurance or pay for it out of pocket. Except for if you're on Medicare. Yeah. Oh, that's right. They won't give it to you if you're on Medicare. Is that right? Government assistance, yeah. Or main care. No free sensors for you. Yeah. There's the pro sensors. You guys want to talk a little bit about what the pro sensor is? The Abbott Libre Pro. I don't use it. We don't use it. I used to use them in research, but we don't usually use it in clinical practice anymore. It's a sensor that the patient can't see the numbers on, but you only see the numbers when they bring the sensor back to you and you read it with your meter. And it's sort of the old way that CGM used to work. And it's also the way we sometimes do it in research if we don't want the patients reacting to their glycemia for sort of a placebo effect. But it's really not that great for what we use CGM most of the time for, which is helping patients understand and learn about how their diet, exercise, and medication is changing their glycemia, giving that instant feedback. It sort of defeats the entire purpose of a CGM most of the time. But for patients who have limited technology comfort and for patients who don't have internet access or a phone, sometimes it's the best way just to get a glimpse of what's going on with their glycemia. I use it in eating disorder patients if tracking is a trigger for their disorder. Sometimes it will help me very much see what their glycemia is, but they don't need to, I don't use the Pro version. I just use a blinded sample, maybe on their significant other's phone. You know, they'll never see it. So it's a question of whether you need to keep checking, keep doing the near field or the Bluetooth connection or not. The Pro, you don't have to do anything. Do you just put it on? And when they bring it in, you can read the whole thing. So that's helpful. But somebody in the chat says they put a Pro on 12 different patients a quarter of the year and I saw a 25% decrease across the board. I assume that's an A1C, just with a Pro sensor. So the patient didn't even get to see the numbers. They know they're wearing something, that's monitoring them. So, and somebody else says Medicare patients can get a free sample, at least with the freestyle, Abbott Freestyle Livery. And that's somebody who only works with Medicare patients. So maybe there's some way to get that. And then somebody mentioned that the Dexcom Pro has a switch that you can turn on the blinded or unblinded mode, which is correct as well. So that could be, so the Abbott Freestyle Livery Pro doesn't have the ability to be seen by, unblinded by the patient, but the Dexcom does. And how long do patients typically wear the Pro for? That's 14 or 10 days, same as the regular sensor, right? Correct. Correct. And again, we're just using them largely in research as you pointed out, Dr. Richardson. Because they can mail them back to us. We have a gestational diabetes meal program and they get it placed at discharge and they mail the CGM back. So it makes it convenient for that type of stuff. Great. All right, so I think we're running out of, we are out of time. In fact, we are out of time. So later today, you're gonna get a post test in an email. If you complete the post test, you get your continuing education credit. And the webinar is being recorded. So you can either let someone else see it or watch it yourself. And it will be available until October of 2025. I think that's all we've got for today. Thank you for joining us.

Continuous Glucose Monitors

diabetes management

real-time glucose data

patient engagement

glucose trends

nocturnal hypoglycemia

postprandial spikes

self-management

remote monitoring

patient empowerment