Hello. Welcome to today's webinar, Strategies for Using Automated Insulin Delivery Devices in Your Practice. Before we start, the American Diabetes Association would like to acknowledge Medtronic and its support to bring this informative webinar to you today. The diabetes care team members with me today will discuss the various types of automated insulin delivery systems on the market today, share their experiences on effectively using them with patients, and as a group, we'll talk about strategies to optimize their use and effective clinical workflows to implement them. I'm Dr. Joseph Valois, and I'll be the moderator for today's discussion to share a little bit about myself. I'm currently at Wake Forest School of Medicine in Winston-Salem, North Carolina. I run the Diabetes Center there, and I've been doing clinical endocrine work and some clinical trial work in diabetes for over 25 years. I now have the privilege of introducing today's speakers. From left to right, Dr. Sean Oser. He's an associate professor at the University of Colorado Anschutz Medical Campus within the Department of Family Medicine. In the middle is Jennifer Scher. She's a professor of pediatrics and a pediatric endocrinologist with Yale Medicine, and Jenny Vata is a nurse practitioner with the Joslin Diabetes Center. This is a list of everyone's disclosures. Here are the objectives for today, and by participating in today's webinar, we hope that you'll be able to identify the various AID automated insulin delivery systems on the market, recognize ways to enhance accessibility, access, and usability of AID devices, give examples of how members of a healthcare team work to support the use of AID devices within a practice, and lastly, review workflow models that can be used in practice. I'm going to go through a couple of slides just to set the background in terms of some terminology we're all going to be using. So automated insulin delivery, some synonyms are the artificial pancreas, closed loop devices. The cartoon demonstrates a partially automated insulin delivery, which is why we use the word hybrid closed loop. What does that really mean? It means that the user generally needs to initiate a meal bolus or a meal announcement depending on the algorithm. So it requires input by the patient. If you think about a goal range of sensor glucose of 70 to 180, those are the upper and lower limits pictured in this graphic, and patients vary. We want to illustrate here the option in AID systems for a low glucose suspend, basal insulin is interrupted once the glucose crosses that threshold. In this example, 70 milligrams per deciliter. Another way of looking at this is you can have a predictive low glucose suspend where the algorithm's looking at the rate of change of glucose and will predict if you don't do something in the next 15, 20 minutes, you will cross that line. So that's what's meant by a predictive low glucose. Understand that hybrid closed loop, the sensor glucose data is fed to an algorithm within the pump and in some cases now within their smartphone. It adjusts insulin delivery via the pump, requires some information generally around meal time, but it's auto adjusting the basal insulin and sometimes some correction. This is a list of the available devices today. We're going to talk about them in detail. This is also, we'll have a link in the chat where you can access more detailed information about comparisons either in the ADA consumer guide or in the Panther program. But you can see across the spectrum of these devices, there's quite a bit of difference. So we're going to end with some question and answers. I'm going to start by opening up the discussion with a general question and I'm going to ask Dr. Sher to lead the discussion with this, but the perceived challenges regarding the accessibility and usability of AIDs can sometimes hinder their implementation or application within patients. So what strategies do you implement to implement the use of these devices in your practice? And then if others have some comments, we'll get to that too, but let's start with Jennifer Sher. Well, thank you so much. I'm excited to be here with you all today. So I think when we're thinking about implementing these types of technologies, it's important to think about what barriers can exist from the provider perspective and what barriers can exist from the person with diabetes perspective. So going from the provider perspective, I think sometimes people can be put off by how much there is to know. And so I'm grateful for those who are tuning in to learn more about these devices and to understand that the ADA standards of care say that AID systems should be offered for diabetes management to youth and adults with type one and other types of insulin deficient diabetes. And specifically in those individuals who are capable of using the device safely. The standards of care also highlight the choice of the device should be made based on the individual circumstances, preferences, and needs. So I think we all need to really just think about, we want to do the best for our patients. We know this technology is most going to mimic what our pancreas would be doing if it was working appropriately. And so we want to offer it to everyone. The other thing I want to highlight is as part of this session and ongoing education, there's practice considerations that have been developed from the ADA. And I believe it's going to be posted in the chat as well. And the thing that's really nice about this is it gives a whole breakdown talking about, you know, who should I be thinking about talking to about using AID? My opinion, anybody who's insulin using, this should be the conversation you're having, right? So sometimes we'll think, oh, motivation. Well, I can get anybody motivated, right? I'm going to talk to people about exercise. I'm going to talk to them about how best to get their glucose levels to target. I want to talk to everybody. I'm going to hope to inspire motivation over time. I'm going to talk to them about the fact that it may require some patients to get used to a new device, that we're going to go through a period of getting to know you, just like if you had previously started sensor or pump therapy, how do I integrate this into my care? And so I think it really just highlights some really important things to consider as we're talking to individuals. The other things that already mentioned are using some resources that we have that are potentially device agnostic, right? Comparison charts. How do I weigh the benefits of the various systems? What features are going to make it so that an individual with diabetes wants to use the device on a daily basis? Because we know that's going to be what drives outcomes. So again, I think that ADA consumer guide and the Panther program device comparison chart can be very helpful. On the alternate side of things, how do we talk to patients about using these devices? And so I think it's really important to set up expectations appropriately. What can devices do? What can't they do? What things do we need people to understand as they make this transition? And I always like to, when I'm talking to somebody who may be hesitant about using automated insulin delivery, I highlight a quote from that's been attributed to Einstein, who knows if he actually said it, but the quote says that insanity is doing the same thing over and over again and expecting different results. And my mentor Bill Tamburlaine told me years ago, pre-automated insulin delivery, insanity in type one diabetes is doing the same thing over and over again and always getting a different result. What do I mean by that? People with diabetes can do the same amount of exercise, eat the same meal, take the same amount of insulin, and every single night is a new adventure. And so what's so great about automated insulin delivery systems is that we're handing the variability from glucose over to the insulin delivery. And we're letting people have the opportunity to sleep and feel better. So I often ground my conversations in that concept. And when people come to my office to see me, I'm like, you know what I'm going to talk about. If you're not on AID, I'm going to bring it up. And they're like, yes, I know. And we go through the benefits. And I say, I just want to make sure you've heard it from me because I don't want you to come back and say, I didn't share this with you, right? That would be me doing very poor quality care. And so I think having that conversation repeatedly is very beneficial and talking about how things can benefit an individual's life. That's where really understanding what are the things that may be barriers to you using a system? Is it about, I don't want to wear a device? Well, you're carrying all this other stuff. Maybe it's going to be easier just to have the device on. Hey, you're taking five shots a day. You only have to change the infusion set maybe every three days or in some cases, every seven days. And maybe that's enough to get over that hump of trying something out. I also often will point out, I'm not shackling you to a system. I'm asking you to try it. This is not a ball and chain. We're just going to see how it goes, but the important thing there, and this is highlighted in that practice considerations document, give it some time. I tell people, I'm going to set up your initial doses. Some of the systems you just enter weight, but you've got to give it some time to figure out whether there needs to be adjustments or optimizations to settings or whether we need to change some behaviors. So what I like in the practice considerations is it highlights, we should tell people, plan to be in touch with us maybe three days after you start a system, seven days, 14 days, 30 days. And this can be a MyChart message. It could be a telehealth visit so that I can go ahead and have that face-to-face. I can bill potentially for having that visit with the individual, but it's going to allow us to hopefully enable persistence of device wear. And that's what we're after. So I think that while there could be many barriers perceived by multiple parties who are in the realm of individuals with diabetes, our job as providers is to help keep informing people and each other about how we can overcome these barriers. And I hope that answered somewhat of the question. I think if I was your patient, I'd be starting AIG tomorrow. Thank you. Jenny or Sean, do you want to add anything to that before you go to the next question? I was just going to say, I appreciate what you mentioned about quality of life and kind of talking to the patient about what's really challenging for you and how can we make that better? Because it's very stressful to have diabetes and taking insulin multiple times a day. And people's lives on a day-to-day basis can change. So I think that's a really good point about how can we help improve their quality of life? And a lot of these systems are going to help do that. I completely agree. And I'm grateful for your comments. I'd like to add too that representing primary care here as a family physician, I think it's important to remember that not all of these systems need to have every feature used in order to still be effective and to bring improvements for people in their efforts to reach their glycemic targets. I think a lot of my research background is in CGM for the last several years, and I see a similar evolution of the journey of AID through the ADA standards. So CGM used to be recommended as helpful or considered, and now it's recommended in the treatment of diabetes in so many situations, not because CGM has changed so much, but the evidence base has changed a lot. So it made a lot of reasonably obvious sense to start CGM research in type 1 diabetes, and it was clearly shown to be beneficial. And then it's moved into intensively managed insulin-treated type 2 diabetes, and now basal-only type 2 diabetes, and on and on. So I see this similar journey through AIDs where it's not that there's evidence that it's not effective, it's just that there's not evidence and some of these later applications doesn't exist yet. And it will come. So as we see movement into type 2 diabetes with AID also, right as Dr. Sher suggested, the standards recommend consideration of AID for other types of diabetes that are treated with insulin, not just type 1. It can be amazing to get, rather than a once a day or coming once a week basal insulin injection, which probably is sort of one size mostly fits, right, for most of the times of the day or days of the week, to have the dynamic insulin dosing ability that insulin pumps, even our older insulin pumps bring, but to have those be even more dynamic and react to CGM glucose readings and adjust up, adjust down as needed is really astonishing and takes a lot of the work away from the person with diabetes while they're seeing better glycemic results. I think those are great additions to the overall comments. And I think it is important to recognize, I think Jen Sher kind of pointed out that the frustration is you can do everything, keep everything stable, but the glucose is going to change. And I think this allows a reaction to it. And we first started using AID in our practice eons ago, you would see people suspending for up to, you know, 90 minutes overnight. And I was thinking, well, gosh, if I'm giving them basal insulin as an injection, you know, how do you account for that? So it gives a lot more flexibility to the patient and that sleep is not underestimated, right? For overnight hypoglycemia, this is a very nice solution. So moving on to sort of a different slice, in many cases, several team members play a role in this whole process. And a lot of times I hear in our groups that are referring patients, well, I don't have the support you have, or what do I really need to have? So what are some practical considerations for engaging members of the care team effectively to say, okay, this is what we're going to do in our practice for these patients. And Sean, I'm going to ask you to lead us off. Sure. Thank you, Joe. So as a primary care physician with experience in health systems and in clinical research, it really resonates with me, as I mentioned before, that Dr. Shearer mentioned considering AID for anyone treated with insulin, because in primary care, we treat 90% of type 2 diabetes and half of adults with type 1 diabetes. So this is really relevant now in primary care, whereas up until now, I'd say it has been more relevant, but not exclusively relevant to diabetes and endocrinology practice settings. But this is definitely now a primary care and endocrinology space. So there's this cliche we have basically in primary care that if you've seen one primary care practice, you've seen one primary care practice. I imagine the same thing is true for diabetes and endocrinology practice settings also. But the bottom line, I think, is really that one size does not fit all. So it really makes sense to make use of your resources that you have in your practice. And that largely includes the people that you have access to in your practice or system. But I would say it's important to look outside a little bit too. So in primary care, for example, we know that only 36% of us in primary care practice have access to a diabetes care and education specialist, even part-time, not just full-time, only 36%. Most of us have medical assistants or nurses or some combination thereof. Some of us have clinical pharmacists, care managers, and some other roles. And we've learned a lot about this in our very large CGM implementation project across over 60 primary care practices throughout Colorado. But how would that apply to AID, to automated insulin delivery also? And again, the bottom line is making use of who you have. So there are certain tasks that need to be accomplished, like talking with the patient and writing a prescription or an order. And that usually falls to the prescribing clinician, of course. But someone will need to handle prior authorization, getting insurance approval. And so think about who's best positioned to do that, whose scope of practice is it within and within their duties. So the practice guide that we mentioned already that was put in the chat, it goes over a number of tasks that are needed in how to get AID into your practice and how to get your patients using AID. And matching these to the right people in your practice can really help a lot with implementation. And then I mentioned considering outside resources also, right? Like the trainers from the AID manufacturers, they can save a lot of time and effort and resources from your practice. So make use of them. They're trained to get people up and running on the systems and on the devices. And in my practice, for example, where we don't have anyone like a CDCES who is really able to do that, it doesn't have the time to do it, it's a great resource to be able to have the manufacturer provide that training. That's what they're there for, make use of it. If you can outsource it, I think it's just an under-recognized and underused resource. And as I mentioned before, you don't need to use every feature of every system in every case. So think about what the training burden is going to be, how much actually needs to be gone into, and which people are in your practice that can do those things. So for example, we've had medical assistants who help with the parts that are within their scope, right? They're not practicing outside their scope, but to give people information on the CGM part of the AID system, maybe on other parts of the insulin delivery part of the AID system to gather the necessary information. We're lucky enough to have some folks who can work on prior authorization and have really gotten great at streamlining some of the paperwork. It's great if you have a diabetes practice champion, understanding in diabetes and endocrinology practices, that might be anyone, but in primary care, if there's someone who's more of a go-to resource, that can be really helpful. Standardizing language so that you know that the authorization process is going to be really easy and not having to always put the very unique specific information that is patient-specific into a note to get authorization, but just to have a macro or quick text or smart phrase or whatever your electronic health record uses that says that this patient meets the following criteria, and if you have one that requires that they, I don't know, that they, you know, I'm going back to old times when Medicare, for example, required insulin injections three times a day or more in order to cover CGM, you don't need to say that they test their blood glucose six times a day if that's the real answer. You just need to say more than three. So other examples exist in this space that you just need to make sure that people meet the minimum criteria to help ease the burden of getting the authorization across the line. So matching those tasks to the people and examples like that I think can be really instrumental and highly recommended if you want to do this with the least burden, without increasing burden in your practice. We know that we're all too busy to add more stuff if it's not going to make an important difference. And I think this is a place where we don't need to add unnecessary more stuff to do in order to make that difference. That's very thoughtful. There's lots of good tips in there. I'm going to ask Jenny, comment, if you have anything you want to add from the Boston experience. Yeah, so I work at a large specialty practice. So the team members that are involved in or play a role in helping to facilitate AID systems in our practice may look different than a smaller practice. But I think the key message is to identify who is the team member that can do that specific task, whether it is downloading the device or helping the patient connect to the cloud-based services that all of these systems have so that we can as clinicians access that data and utilize it. So who is best to do that? Who is on your pharmacy team or can help with the prior authorization and the paperwork associated with getting these devices covered? In my practice, we have a diabetes technology department. So it's a group of people that help to what DME company, what durable medical equipment company are we going to use that's approved by your insurance to get these devices to you. And one thing I wanted to touch upon too, I think you mentioned about the manufacturer trainers, which can be really helpful for provider education as well. So if you have a patient that's utilizing one of these systems and you're not really sure how to address a certain issue, or you've tried to troubleshoot something and it's not working effectively to reach out to those resources from the manufacturer to discuss a specific issue and to just get more education, especially as these systems are updating. So there's always more features. They're changing their products all the time. So just to get an update so you can be as up to date as possible. I think those are really good points. And I would just, for those people that aren't doing this nine to five, like any of the panelists are, there are electronic ways to do some of this DME, some of this ordering. The representatives, they're usually divided into sales and clinical and the clinical people are disconnected from sales. So you don't necessarily need to know how to change somebody from MDI. I mean, there's protocols for that. They can show you, they can walk you through it. So there's a lot of help outside of it. And since I'm talking, I'll finish one other thought and then ask Dr. Sher for her comments. But part of my job, ironically, is, like Tyshawn said, if you see one primary care pricing, I've been to three different institutions. They all practice differently. I'm currently in an environment where they do not want to manage insulin. So we've been training and we've been very successful. We have a designated MA that is the diabetes specialist in a couple of the offices. And he or she does a really good job of helping patients with their technology, getting downloads, knows who to connect. And that can, you don't have to do everything with the AID in other words. I mean, there's some very basic things that are relatively easy to access. And as Jenny mentioned too, for me, I love it when I can step out of the room and one of our CMAs can just make sure the patient's connected. Because after the patient's tried three passwords and I've got to move on. But once that's done, it's worth the effort. Because then you can touch, you can do remote patient monitoring. As I sort of foreshadowed, I'm part of where I'm at. We've got people that drive three to four hours to see us. And if they can skip a couple of those visits with remote patient monitoring, this lends itself to it very well. Dr. Sher, other comments on this? I would echo what you guys are saying completely. You know, using external folks, specifically again from the manufacturers, we ask them, they know our structure. They know our sick day plan. They know how to link people to our clinic account. That's huge, right? Because everybody should walk out of our practice having a sick day plan. Remind them to have pens ready in case issues occur. Make sure that we can see their data. And so utilizing those resources. I've been at Yale since my training, big name, small resources. So I feel like in the end, we try and get the most out of everybody we can. And even as we see Yale branch out into satellite practices, we're seeing MAs at one satellite, training MAs at another satellite about how to facilitate the diabetes visits and make it go easier. And it's great when it's that, you know, in the same level communication so that they don't feel completely like, oh, this is foreign. I have somebody else who I can contact and an ally to help me out. So lots of ways we can get over issues if they are. And if I can just quickly add, yeah, the outside resources, I'm really glad that you made the distinction between the clinical folks. Often they're also called medical science liaisons or MSLs, and they very definitely are separated from the sales side of things. And they're there to give scientific information to practicing professionals. The trainers and those resources, talking about scope, there's one thing that they can't do for sure, which is practice medicine, and they can't do any medical decision making, right? So if it's daunting to you to say, oh, I still have to figure out the initial settings to set up the system. Some systems don't actually require that at all, or at least one, and others require different amounts of it. But they have resources. If this is new to you, they have resources to suggest how to go through the calculations and set up those, make those initial settings decisions. They don't tell you what those decisions are, right? That's still up to you as the clinician. But it can really help make it more approachable and a lot less daunting, and it can be really helpful. Okay. Let's change topics just a little bit. Workflow models, which we've been talking about a little bit, serve as frameworks for organizing and managing tasks. In your experience, and this may, we may have covered this, but maybe go into more detail, what effective workflows have you encountered in your practice? We've already talked about a couple, but there's an opportunity for Jenny to lead us, and you can run with that. And actually, you know, I'll also say, throw in there, maybe each one of you, since I'm looking, we're good on time. One of the questions that's come up is, when you're assessing AID users, and you're talking to them, what are the patients saying about their self-care in terms of their expectation? So I'll remind people about that in a minute. But to the workflow question, Jenny, you want to lead us with? Yes. Yes. So I think it's really important when we're implementing these devices to think about the logistics of workflow. And it's going to vary from practice to practice, and that's okay. But there are some common themes that we can think about. The way I think about this is, you know, pre-consultation, what needs to happen before the appointment, the consultation, what you're doing with the patient when they're sitting in front of you, and post-consultation, what needs to happen and the logistics of after the appointment. So pre-consultation, at least at my practice, is when we make sure patients are connected to the cloud-based service for their device or are able to download their AID system before the appointment, because it's really crucial that the data from these devices are so valuable, and it's crucial that we have access to that during the appointment. So that needs to happen before the appointment and finding the key stakeholders in your practice of who can actually do that work before you see the patient. During the consultation phase, you're actually sitting down with the patient. I like to pull up the data and look at it together. And let's look and see, you know, what patterns are we noticing, what areas are there for improvement, etc. So that can happen during the appointment, talking about obviously, adjusting settings at that point if needed. And then the post-consultation, which we touched upon a little bit before about how do we make sure if a patient's already using an AID system, how do we make sure that they're getting their supplies, their supplies are affordable, which can be challenging. If there's any changes in insurance, you know, reaching out to pharmacy team, if you have access to that to figure out where they can get their supplies. And these themes, I think, translate really well to a telemedicine workflow. And for telemedicine, at least at my practice, the pre-consultation may happen on a different day. So we usually make sure the devices are downloaded and the patient's connected to the cloud-based service the day before the appointment. Then the day of the appointment, we can access the data together. We usually or I usually encourage patients to be connected to the practice. Some patients may or may not be comfortable doing that. But it's it's really valuable if a patient calls in, you know, after hours and there's an emergency, we can actually access their data in real time. If they have a severe hypoglycemic event, we can look and see kind of what happened and adjust their settings over the phone because we have access to their their glucose data and their pump data. So that's really important. But again, the workflow is going to change from practice to practice depending on your resources, and you can modify as as needed. So I don't know, Dr. Ossor, if you have any suggestions for primary care workflow, which may look a little different than, you know, a specialty practice. Yeah, and often, I think when when we're able to to have that phased approach, like the pre consultation during the consultation, that that's really helpful. Often, it just sort of comes up during a regular visit. And there, you know, most often, I'd say in primary care, we're not just, we're not just having diabetes follow up visits, we're doing follow up with diabetes and hypertension and CHF and hypothyroid, everything all at the same time. So the discussion may come up, and is usually maybe a little too long to have during that visit. So that might sort of serve as the pre consultation almost, right, is to bring up the idea of AID, spend a little bit of time talking about some of its what it involves some of its potential advantages, and then set up an opportunity to talk about it more later. And again, you know, having if you have clinical pharmacists, taking advantage of them is great, figuring out, like I said before, how to, how to make sure all the tasks are addressed, how they can all be apportioned, as long as they all get done. And within scope, it doesn't otherwise matter so much who, who does them as long as they get done. Dr. Scherer, anything from the AP's perspective, maybe a little different or not? You know, the only thing I'll say from the pediatric perspective is, you know, in our practice, especially, we have kids going on to AID within weeks of diagnosis, you know, there's not much lag time, you are an outlier, if you're not on AID, but we're going to keep talking to you about it each time we see you. And so there's, there's not as much transition upfront, it's more when we switch devices, making sure we remain connected to those devices, and then engaging with our nurse coordinators to go over sick day plans, speaking with school nurses, that's a huge part of what we do as pediatricians, there's lots of school nurse calls, we're creating education plans, and there's resources online that you can also provide some from device manufacturers, some from organizations that you can pull and provide to school nurses or other care providers, which in my head could complement the geriatric population as well, though I don't go there, right. So I think that, in the end, there's lots of resources and going to a specific device manufacturer asking if there's ways that caregiver guidelines could be provided to babysitters and other people. But we rely a lot on our nurse coordinators to help with that final bit of it, you know, now we're using it, what things do we have to keep top of mind. And I do want to say, Jenny, you said something that I so love, sitting in the visit, having the data in front of you, and talking about a particular instance, it's like light bulbs, right? I have had parents say, I told you, she knows everything you do. And I'm like, no, no, no, like, I'm not a spy. I'm just going to go through things. I'm like, I think you ate here and the bolus came in late. This is what's going on here. But I think it really grounds that conversation and grounds whether I'm going to make an insulin dose optimization, or I'm going to recommend a behavioral modification. And I feel like a lot of times, we're focused on behavioral modifications, because systems are doing so well. So, you know, taking that, you know, rich data set you have to really provide some, I take screenshots, and they're in the after visit summaries. And I'm like, this is the time you over treated the low, right? Remember this, this is why I say only treat with this much. And I think it just makes it better. Sorry, I go off topic. I'm so glad you brought that up. Because, yes, behavioral outcomes and how people are feeling is something that we I just think we always need to be paying attention to, we need to be better about paying attention to it more often. And I, it's having these reports available and having this data available has helped me tremendously. It's reminded me that I can always find something that's going well. And I always start with celebrating that. As a I didn't disclose, but I am a person with type one diabetes also. And I, I remember, you know, I think we've so many of us have heard stories of patients who say, Oh, I went to the to my appointment, and they just yelled at me for such and such. Or what did you what did you do 23 days ago, when your blood sugar was 357? I have no idea. That was 23 days ago. What were you doing 23 days ago? Right, but, and then, of course, in our training, professionally, I almost feel like we are trained to solve problems, right? We're trained to find problems and solve problems. And one of the problems with that, no pun intended, is that it's, it's, it's focused on problems, which are negative, right? So, so to start with what's going well, it is is paramount. And when all I had was an A1C, and possibly some finger stick records, not anything about about CGM records, not not the many more metrics that we get now about glycemia. Those are both from the CGM products, but also from the AID reports. It makes it so much easier to find that thing to start with. And to say this is this is going really, really well. And now, after we celebrate that, and I give someone credit and acknowledgement for that, right, then we can turn to where where we can focus our attention on what else can we change? What else can we focus on? Where can we spend our time and our efforts? And I try to avoid a lot of that negative language, right? That what's going I don't say what's going wrong, right? But but where can we spend those efforts? Where can we where can we put our attention? Because this other stuff is going great. We don't need to pay attention to that. Just keep doing that. Here's what else we can do. I like to use the phrase, we're trying to make good better. Sometimes when we're trying to hone in on some things, because people come in and they get very distraught when they say, you know, they know, right? Because they've been looking at their sensor, they're looking at their time. And here's what I'm going to do looking at time. And we've got about 10 questions in the Q&A. But I want to go back to the first thing. And I'm going to go sort of around the clock. And I'll go last. But so the first question I sort of prepped you for, I mean, what are your patients saying? In terms of what are their wishes around their diabetes self care? I mean, what are the and my screen is Jenny, Sean and Jennifer. All right, I will go first. So what are patients saying? So there's actually a diabetes distress scale that you can use for patients that are feeling overwhelmed or disengaged in their care. But you know, it's there's a lot of things about diabetes that is can be burdensome. And every single person is going to give you a different answer. But I think it's really important to listen to them about what part of their life do they feel is not the best quality, whether it's related to exercise, you know, I love to exercise, but I go low. So I'm nervous about doing it now not doing it. But it's really important to me. Or, you know, I am not sleeping at night because, you know, my blood sugar is higher, my blood sugar is low. So listening to them about what's going to motivate them. And then thinking about the systems that we have available and what system would really work well to address their concerns. And I think that all of these systems can work really well, but it's really individualized to, you know, what the patient really, really wants, you know, out of their diabetes care. Sure. Sean, anything to add to that? Yeah, I would say that this is another tenet of our training, right, which is, and sometimes we forget to do this, but ask the patient. And don't make assumptions. So I don't have a single answer for what are they asking about some of them want to take fewer shots or no shots. Some of them want to want to do less work in managing their diabetes. Some of them are motivated by that A1C and the A1C only some of them by some of the other glycemic metrics, which is where I try to turn attention to. But it's a very individualistic and personal answer usually. And that's probably what the single most important thing is, right? Whatever's important to the person sitting in front of you. That's what's important to be addressing. Jennifer? So I want to echo a couple things. I totally agree with what you guys have said. I definitely think understanding what's important to an individual as a pediatric endocrinologist, this will change over developmental stages. You know, I'm catering to a parent when I have a toddler in my office and I'm catering to the parent and the school system potentially and the child, you know, school-aged children. By adolescence, the kid may say, I don't wanna do anything with the system. And the parent's like, I really wish they would, you know, be more engaged with meal announcements. And in the end, we'll ground the conversation with, we're doing pretty darn good. So one of the things I love, Sean, I'm also a person living with diabetes. I never tell anyone they're A1C when they come to see me until they're walking out the door. And I say, because I need you to listen through the rest of the visit. And I remember as a kid, I would go in and I would hyperventilate, like, oh my God, did I do poorly? And I had the best endocrinologist in the world. He set it up so well for me, but I saw it as judgment. And so I try to hold those metrics back to the very end. I talk a lot about a 5% increase is really clinically meaningful in terms of our time and target range. So let's celebrate that every single time. And with some of these kids, you know, we see systems now that have the ability to do automated corrections. You know, I'll see a ton of automated corrections. I will see no carb entry. And I'll look at the parent and say, they're 65. We're 70% time and target range. I'm okay with this. And then I will provide historical perspective of what practice was like when I first came out of fellowship and that it wasn't too long ago, but we've changed so much. And I remind people when they think about the statistics we're told, I remember being told I would have complications. I don't have complications. It's because we're changing the course of the disease with systems like this. So I reassure people that, you know, we're gonna hit these targets. We're gonna get there together. We're all gonna have bumps in the road. And I think many people with diabetes, I'm gonna include myself in this. I remember the bad days much more than I remember the good days. And so highlighting those good days is really important and celebrating every triumph and recognizing at least in youth, the developmental stages, things that we need to focus on, empowering autonomy, getting kids ready to head off to college. There's a lot, it's a lot of fun to work with youth. Very rewarding, so. I like a lot of those comments. And actually earlier when you were speaking, another thing we're working on is actually what you identified. There is a lot of comparisons to patients entering the nursing home versus, you know, it's another situation where we're taking, we need somebody else to help manage the patient, particularly if there's going to a memory care and we need that sick day plan. And sometimes it's, depending on where you live, some of, many of our nursing homes here will not allow anything and from sensors to pumps, but there are some workarounds you can do. And if you have an engaged family member, as, you know, Sean and Beth and Jennifer sort of foreshadowed with a lot of these services, you can do many, many things with them blinded. You can lock out the pump and you can do is that seven day set. So if the caregiver can show up once a week, it's gonna frequently do, I hate to say better, but can frequently do better than what else is being offered. Another little barrier there for the geriatric population too, is a lot of these long-term care facilities will only get one dose of insulin a day. And it's finding a place for a person with type one diabetes or someone who needs multiple daily insulin injections. It's not all bad. I mean, there's lots of good things and actually, I don't know why I do the same thing as you do, Jen, but I always do, I save the A1C towards the end of this because I don't want it to be about a number. I mean, it's healthcare, but a lot of the patients are like, what's my number? What is it? And I'd be like, well, let's, we'll get, you know, anyway. I think if we can start, we've been doing the Q and A, but officially start the Q and A. So I think we're up to about 10 questions. I'm watching the time. We've got a good amount of time. So someone who is thinking about starting AID and her patients or his have limited health literacy and or limited social support. So a couple of points here, what's the minimum requirement that you think is going to target a patient who can be successful with AID? In other words, what sort of tasks do you require? And again, we can go in that same sequence, Jenny, Sean and Jen. So that's a great question. At my practice, it's just standard that we do a pump assessment. This usually takes place, a certified diabetes educator will do the pump assessment to assess the patient's knowledge and can they troubleshoot if this device fails? Because with any type of technology, there can be times where it doesn't work as intended or the device fails. So safety is the number one concern and making sure that they have the knowledge to address a significant safety concern. You don't need a certified diabetes educator to assess their readiness to use one of these AID systems. You as a clinician can do that. Talking about sick day management with them, talking about troubleshooting, if a pump fails, transitioning to multiple daily injections off of a pump if needed. So I think that would probably be the minimum requirement from my perspective is assess their ability to safely manage this device. And if they do have a spouse or another caregiver who is very involved in their management, that's fine as well, making sure that they're able to help manage the AID system. John? I agree, safety first. As long as we can be confident of safety, then I'm not sure there are any other strict minimums that I employ. It's more of an individual decision. So, you know, there's one system, unless something's changed in the last week that I don't know about, there's one AID system that has an FDA indication for type two diabetes, type two diabetes is very different than type one diabetes. I would urge people just not to think of it as intensively managed type two. It's very different than type one, including ability to still secrete more glucagon, for example, right in type two and endogenous glucagon than in type one. So safety comes down often to, can you take care of the device? Can you take care of the device? Can you load it with insulin, whichever form factor that's in, can you, and not too much air, right? Or ideally almost no air. There's plenty of training about how to minimize any air bubbles. And, you know, in general, since these are for people who are already on insulin, I would say, is the safety of the automated dosing regimen greater or less than once a day basal insulin or a few times a day short acting insulin, right? Because you mentioned like nursing facilities, for example, where there's, I would argue there's not even a dosing decision being made every day, right? That decision was made weeks or months ago and probably never revisited. And that's just what someone gets every day. But if, but these systems, if they're making a dosing decision, for example, every five minutes, we know that's almost 300 dosing decisions made every day in the moment, and they're driven by data, that's gotta be, I would think, safer than the way we're delivering insulin most of the time to most people. So as long as you can feed and take care of the device and keep it clean and working and everything, it's on the table. Good, anything different to add? Just a couple of things that I'll say. Minimum requirement, you need insulin. That's the only minimum requirement in my practice. I will definitely say, you know, if you're on a pump already, and now we have a pump that if you give too much insulin, it suspends, it's better than what they're doing. If they're on injection therapy and they're forgetting basal insulin, and all of a sudden they're getting basal insulin through an automated system, better than what they're doing. So in many ways, I can't find a situation where it's less safe to use AID. I have individuals, I have a family who's not followed specifically by me, but in our practice where both parents are blind, and we have been able to go ahead and start AID and do it safely. You know, when we think about, well, what about carb counting? How invested do they need to be? We can get over that, right? Some of these systems have automated corrections. One of them has a qualitative approach. If somebody doesn't have a qualitative approach to carb announcement, I tell people 20, 40, 60. 20 is a small meal, 40 your usual meal, 60, you're going to town. And it could be completely wrong, but it's still better than what we're doing. So I think all the parameters that we had in the past really have, you know, dropped away. And I think that even, you know, with limited numeracy, we can find ways to get around it. I agree. I would just add as a fellow, we all have biases, but we had a woman that's getting admitted frequently with DKA, and she had quite a few cognitive challenges. And I thought my attending was crazy putting this young woman on a pump, but she went from an admission every month to 18 months with no admission to hospital. I think, again, for the literacy and numeracy, when I talk about, I do know across the country, no one's trying to insult some diabetes centers. They require carb counting classes and six months of showing you can do with MDI before you give pump. I don't think that's necessary at all. And most of us eat 12 meals or less. I mean, you can work around it relatively easily. So here's an interesting question, which I don't have a good answer. I'll try and set it up. But it's phrased as, it says nurses, but some of our care team cannot bill for CGM interpretation. So does anyone on the panel use the 99457 code for us? He, she put in CGM management, but I think really blood glucose management. And I will tell you that we do not. And for some of our educators and our clinical pharmacists, we have a clinician to CGM and bill for it. Anyone else have experience with that or that's fine. So go ahead, Sean. I'll just say that that's a specifically a remote patient monitoring code, not specific to glucose, but obviously it would apply to glucose in this context. What we've done instead, those generally reimbursed far lower than the CPT codes that are specific to CGM. And although basically we just have, if we have a non, if we have an affiliated healthcare professional who is performing some of the data delivery, we leave the interpretation to one of the prescribers who can bill under it. And we just bill an incident too and make sure that they review it. And I guess maybe I may not be right on this, but that 99457, it's a 30 minute, or there's a time element that seemed excessive when I was looking at it. And most of my virtual visits average 16 minutes. To 12. So, all right. So here's one opinion about weight gain due to insulin therapy. Anonymous attendee. And I guess that opens up a whole bunch of issues. I will say, if you need, one of the slides I use in almost all my talks on diabetes is from Google images, looking at the first children that got insulin and making the before and after, making if you need insulin, you need insulin. And it's like air. You need as much insulin as it takes. There are some things that you can fast around that, but in general, patients on AID, their total daily insulin dose goes down in terms of some patients on MDI. So I think what I'm reading through here, if we give people insulin effectively, what about the weight gain? Other comments from the panel? Any strategies? You know, we're just tackling, there's a Webex coming up on, how do you manage obesity and type one diabetes? And everybody I'm sure is aware that a lot of our weight loss medicines, certainly for glucose control are not approved in the US for type one diabetes. So I think this is a question that has many levels to it, but I don't have a better answer. If anyone else does, please speak up. Sean first. Sure, I would say it goes back to what Jennifer was saying earlier that I think it's rare that it would be worse, right? I think it would be better in almost all cases. There are plenty of studies of these AID systems that pretty much show, I think, weight neutrality. Many of them do show lower total daily doses after the system adapts compared to the usual care dosing that participants enter the studies with. And I've seen that too in my patients who both are in studies and who are not in studies. Especially we tend to, when you focus on the type two part, we tend to start insulin late. We tend to have people on too much basal insulin and getting them back to a more physiologic balance that is made much faster and more effective by these systems produces generally lower total daily doses and therefore less weight gain, if any. There's a question in the group here about convincing adolescents to have something attached to them. So I- Are there any approaches to that? Or anyone really, but it was raised more towards adolescents. I spend a lot of time on this and we talk a lot about what you can see and what you can't see. And the sense that, you know, I've had kids go through, my own kids go through their teenage years. And I say, you know, you think everybody's looking at you all the time, but everybody's so in their own head, worried about everybody else looking at them. We're not looking at each other. And so some of what people are anxious about is the physical device. But I talk about how highs and lows can impact how we're acting, our dynamics in a group. And if we're having fewer excursions, our interactions with those around us can be improved. And again, that it's not a ball and chain, give me a chance, let's see what happens. And if you really don't like it, we can stop it. So I think that if you can just get people to try, and I usually say for at least one month, then tell me that you don't want the device on your body. Sometimes we'll have people, you know, have an infusion set placed with, you know, obviously take everything off. I'm just gonna put it here and we're gonna put the tubing in your pocket. Go home, see what that feels like. I'm gonna take a pod. I'm not gonna deploy it. I'm just gonna stick it to you. How does that feel? Just that physical sensation. And I think that when they realize the, you know, I'm sitting at the cafeteria and I'm bolusing with all my friends and I don't have to run somewhere because I don't wanna take a shot in front of all of them. And I'm in more targeted glucose levels. My conversation is better. I think we can reframe that. Perfect answer, I think. We've got two minutes. And so I'm gonna pop up one which may take all of that, but it's a good question. Is there any legal liability exposure, liability exposure with data from CGMs, particularly in insulin delivery devices, automatically delivered to the practice through the cloud such as Clarity or LibreView or CareLink? And since someone's looking at the data, who's responsible for that data? I will start by saying that in general, you're responsible when you look at it. And that doesn't help if there's a problem, but all those end user licensing agreements that everybody just clicks through, notifies them. But there's a couple of ways to attack this. The International Diabetes Center basically has a way to ask for the data download. And that's when they feel they become responsible for it. But other opinions, it's a very good question. And it's a stumbling block also. There's a question here about inpatient use of this, but that liability issue when somebody is an inpatient has a little more focus on it as well. Other thoughts about legal liability for data sitting in the cloud? I think we let families know we're not watching this all the time. We're very upfront. I have people who will call and say, well, this happened and you didn't reach out. Well, as a reminder, we're not sitting here with 800 screens or 800 views up. We need you to reach out to us. And I will say, I know last year, I was on a consensus document about interoperability and where things lay in terms of responsibility. And there's greater discussion going on about this. I think it's a topic that's gonna continue to evolve. But right now, I think we would be hard pressed to say, we're gonna go ahead and be monitoring all the time. That can't be the expectation, so. Really wanna take this opportunity to thank everybody who thought we'd run out of time. Dr. Zoser, Sharon Mota for a great discussion. And I wanna thank everybody on the WebEx for joining us. You helped make it interactive, the questions are good. Following the webinar, you will receive an email from the ADA Insights Team with a link to complete a brief survey. I would ask you to complete that survey. It provides feedback about today's program and also helps us construct future programs and offerings. Another announcement, you can mark your calendar for November 12th, optimizing AID systems case-based strategies for individualization as part of the Hands-on Tips to Improve Diabetes Care webinar series. You can hear case examples of all the AID systems. The registration link's in the chat box and you can get one CE for joining. If you need more information about the intersection of diabetes and technology, check out Making Diabetes Technology Work program during continuing CE. More about insulin pumps, CGMs, automated insulin delivery, apps. And there's also a link in the chat box. This concludes today's program on time. Thanks everybody for all the interactions and the questions. And we'll try and get back to some of them later if we can. Have a good rest of your day.

automated insulin delivery

AID devices

personalized care

glucose management

patient barriers

insulin-related weight gain

quality of life

legal liabilities

healthcare settings