Hello, and welcome to Time and Range, Reducing Barriers. My name is Lucia Novak, and I will be moderating today's webinar. I am an adult nurse practitioner, board certified, also in advanced diabetes management, and I am president of Diabetes Consultant Services, working out of various offices in North Bethesda, Maryland, Camp Springs, and Silver Spring, Maryland. I am so excited to be here today. None of this would be possible without the guidance of the American Diabetes Association's Time and Range Advisory Group. And I would like to thank the members and for all their hard work that went into developing today's program. We are also very grateful for the support of Abbott and LifeScan, who have made this program a possibility. So let's see who we have joining us on today's program. If you could, please let us know where you are joining us from. If you would like to type into the chat box, perhaps the organization and the state that you are joining from, that would be great. Looks like I have some folks from Maryland joining. I know that I have sent this out to my NP group. We have someone from Vanderbilt University, Lindsey Mayberry from Nashville, Tennessee. Welcome. Anyone else out there that wants to introduce themselves? We have Dr. Ali Anjum from Bruin. We have Sarah Franklin from the Johnson Diabetes Center in Boston, excellent. Someone from Wichita, Kansas is joining us, Mary Heibert, and many, many folks. So thank you all for joining us. Want to get started with today's program. We do have a lot to go over today. So thanks for joining today. So I'd like to start by encouraging all of you to become a member. If you're not already members of the American Diabetes Association, the membership will provide you opportunities to network as well as grow professionally. The ADA memberships include a variety of professional member benefits, including sharing best practices, such as being in on this particular webinar. You get to share interesting articles, expand your network, and also be able to browse some of the information that we have available for you today. So time and range wants to hear from you. There's going to be some links that are going to be uploaded in the chat box. I'm going to ask you as we progress through today's program that you enter in your questions in the Q&A chat. I will be monitoring that so that I can make sure that we get to all of your questions and answers. But I would also like to encourage you, once you become members of ADA, to join the newest online collaborative, which is the Time and Range Online Collaborative, and you'll be able to join the discussion. And for more information, I encourage you to visit professional.diabetes.org forward slash time and range. Time and range has a new home. You can access all content on the ADA's Institute of Learning. You will be able to view recorded webinars, podcast episodes, practice PEARL videos, and infographics. Use the link to access the content after the webinar. And again, those links are being posted for you in the chat box. The Time and Range Initiative provides resources for clinicians to increase their knowledge on time and range to enhance uptake within your clinical practice. We will spend today's program by following the agenda on the screen. Please note that today's presentations will be followed by a Q&A session. And if you have your questions as we've moved through them, please type them in the Q&A box. I will be answering, along with Dr. Peters and Peak, as many questions as we can at the end of both presentations. Now, I'm very excited to introduce to you our first speaker today because she brings a unique perspective to our discussion. That would be Dr. Ann Peters. Dr. Peters is a professor of medicine at the Keck School of Medicine of the University of Southern California and director of the University of Southern California Clinical Diabetes Programs. Her research has focused on testing new approaches for diagnosing and treating diabetes and developing systems of care to improve outcomes in diabetic populations. Dr. Peters has published over 200 articles, reviews, and abstracts, and three books on diabetes. She has been an investigator on over 40 research studies and has spoken at over 400 programs throughout the U.S. as well as internationally. We are excited to have Dr. Peters presenting on time and range challenges. And with that said, let's get started. Dr. Peters. All right. So hello, everybody. And for those of you who don't know me, I try to look at things from more than one perspective. And today when I'm speaking with you, I'm looking at time and range challenges from the challenges I find in the clinic I work in in East Los Angeles, which is part of the County of Los Angeles Safety Net Program, and our patients are all under-resourced. And I can tell you one of the things I'm most proud of in my whole life is that all of us here in California got together and made it so that all of our patients who have type 1 diabetes can get CGM. And as I'm going to discuss, I've made it so that all of my patients on anything can get CGM. And so we use a lot of CGM in my clinic. And I want to show you or teach you some of the barriers, both from providers accepting it as well as to patients. So this really just comes from my experience, even just from the last couple of weeks. So these are my disclosures of potential conflicts of interest. And let's just start from the beginning. So I thought that when I brought CGM into my clinic, that everybody around would jump up and down with joy. We have CGM, we have so much more data, we can really help our patients better. But that was the exact opposite reaction. I even was banned from using CGM by the person who's in charge of subspecialty care because they thought it would make too much extra work for the staff. So this was not something that was embraced. So then I thought, well, what are my providers asking me for? Well, they want to help their patients control their diabetes just like I do. But they want it to be simple and they want it to fit in to their really busy days. And the patients that we see are sick. They have all sorts of other comorbidities than just diabetes. They're dealing with homelessness, they're dealing with food insecurity, they're dealing with just so much stress that they really want this diabetes piece to be simple. They understand NA1C. They may not know all the nuances, but they're used to it. And it's hard for them to separate from this. And I don't want them to entirely, right? I don't want to give them too much more. But I know, and you know, that an NA1C doesn't tell you how to manage a patient. It tells you that a patient needs management. Our providers do prescribe blood glucose monitoring, and they're kind of used to it. But we know the limits to that. And I think anybody who thinks about it does as well. I think that time and range is a useful concept, but not all by itself. Because as I'm going to show you, I teach a lot more about time below range than I teach about time in range, because at first I have to reduce the time below range to make people safe. So what do we tell people about CGM? Well, this is from Roy Beck and Rich Bergenstahl. And they say that a time and range of 70 to 180 of 70% corresponds to an A1C of approximately 7%. And every 10% increase in time and range is associated with a 0.5% improvement, meaning reduction in A1C. Well, teaching this as a concept becomes difficult, because they're used to an A1C that should go down. And now we're saying a time and range should go up. And that begins this sort of conflict, like, they turn me off now because they don't want to look at this and think of it this way. So I've separated A1C from time and range. I talk about them as though they're two completely unrelated issues. And I just talk about time and range is this, A1C is that. Because if I try to correlate them, I run into issues in terms of understanding. So I really like teaching about time and range in context. And we all know, looking at this graph, and this is from Rich Bergenstahl, that green is good. But what we really think when we look at this is that red is bad. Now, I'm not supposed to say good and bad, I know, but for purposes of this, I am. But red is what we don't want. Now, this does confuse people with red-green color blindness, I might add. But if you see that below the line, that's what we want clinicians to focus on. And in fact, looking at this graph, if you give more pre-dinner insulin to bring the glucose levels down, then what you're going to get is even more hypoglycemia. So what I teach my providers is not just time and range, but looking for time spent low, time below range. And then this lovely thing happened to me. A foundation called the Hanke Foundation decided that they wanted to give me money to let everybody in my clinic, in my comprehensive health center, who has type 1 or type 2 diabetes, have access to CGM, free CGM. And they wanted me to help patients and their providers use it. So the goal is to take CGM and put it on anybody who wants it and any patient who's referred by their providers. And then I look at the data and I send back a report to the primary care providers. And we have thousands of patients who actually need CGM. I can't monitor thousands of patients, but I do and increasingly am getting hundreds of patients and looking at their printouts. And it's surprising to me the variability in what I see in these patients who are not really pre-selected. It's anybody a provider wants to send me or any patient who wants a CGM. The sensors were all donated by Abbott, to whom I am very grateful. And the foundation also funded a bilingual staff who's actually from the community around my clinic in East LA, who can teach and remotely follow each patient as often as they need to be followed. And they can even do daily follow-up if a patient needs it. And we then have the patients follow us and we're doing it observationally. So in the very beginning, I do a blinded CGM to see where patients start, and then we track them so that we're going to get data on this as well, observationally, of course, but to see what we learned from doing this with our patients over time. This is the form that I created that I send back to the primary care providers. And at the top, it has a patient identification. And then I put CGM data because I'm trying to train them on understanding what we're talking about. So I send them, what's the GMI? What's the time and range, time below range, time above range? And then I give them a interpretation. And then I give them suggestions. So this patient's below range a lot. They're on a sulfonylurea agent, which I suggest reducing. And I say that's in response to too much time below range. And then I say how much time till I get another follow-up tracing. And in this time, I wanted it every other week. So this is the kind of exchange. And I send them the CGM tracing so that they can see how I figured this out. But I want them to get a sense of time and range, because here, the time and range is fine at 78%, but the time below range is not. Now we have a lot of challenges. So using the device, well, I had to get the providers to accept that we weren't going to make their lives worse. Then we have to convince patients to wear a device if there are patients who were referred. And there's all sorts of physical factors that make this hard, because my patients aren't sitting at work in a desk in a comfortable room. They're out there. They're doing construction work. They're doing fieldwork. They're working in people's homes. They're doing all sorts of things that make them hot and sweaty. They get skin reactions. The devices fall off. It's really hard to wear these devices in the circumstances under which my under-resourced patients work. And they also don't have the kind of work environment where they can take time off for meals or snacks or to look at their blood sugars. These are tough lives. And then if I want them to get over bandages and skin prep and do all sorts of things to make it so that CGM sticks, those actually are out of pocket, because when I prescribe CGM, I can't get those things. So there's a cost, and I don't want my patients to incur a cost. Then the alarms are unsettling, and you really can't have people alarming, and a lot of the jobs where my patients are working. It's embarrassing to them. It makes them feel like they're broken or flawed. These people are ostracized at work. They may lose their jobs if there's too much buzzing and beeping going on, or they may live in crowded apartments and houses where there are several people in a room, and nobody likes to be woken up by an alarm in the middle of the night, and especially if it's a false alarm. So there's a lot more noise issues and alarm issues with my population who's under-resourced than a setting where people can deal with this in a way that's more effective. And then data analysis, which I'm going to talk more about, but it's a challenge even for me. Sometimes I just can't even figure out what's going on with these patients. So I'm going to show you examples now. So this is a patient who's on glipizide, metformin, pioglitazone, and dulaglutide, and in my system, you go through the generic agents first. So metformin, then a sulfonyl reagent, then pioglitazone, then you can use a GLP-1 receptor agonist. So this is blinded CGM. And if I'm just teaching the provider that the time and range works, you look at this, and the time and range is above 70%. There's a lot of green, and the patient's doing great. But if you look at the whole picture, and this is why I teach time below range so much, there's persons below range way too much. And this is somebody who's obviously on too much glipizide. And I actually have learned not to completely stop the glipizide, because sometimes then they rebound up really high, but I'll cut it back to just a quarter of the dose they're on and make sure that we then follow them again in a week or two to see that these numbers have come up. But I see a lot of sulfonyl reagent-induced hypoglycemia. But here's another tracing, and this is from a blinded CGM. And in case you haven't seen this before, this is what happens when something dislodges the CGM sensor under the skin but doesn't pull it out. So this is a patient who works in construction. He banged into it. He decided that the thing was going to come out, so he put more tape over it. So he didn't pull out the sensor completely, so it didn't stop sensing, but it gave me this report. Well, when I got this report, I went a little bit insane, because I thought, you know, how can this patient be alive? There's so much hypoglycemia. But it turns out that the patient was at the same time actually wearing a real-time CGM, so he knew his data was fine. So when my study coordinator called and said, what's happening? He said, I'm fine, I'm fine. I guess I must have done something to the blinded CGM when I changed it. But I've seen this happen only on blinded CGMs where you get a ton of lows that aren't real lows, that had something to do with the sensor jiggling under the skin. So you don't want to get too alarmed with that. Here's a patient, and this is a really classic patient that I see. They're on metformin, Lyspro, and Glargine, and their timing range is too low. And this is what I say over and over again, add in a GOP1 receptor agonist. Now in my clinics, we can add in a GOP1 receptor agonist if the patient is obese or overweight, has cardiovascular disease, or CKD. And so in this case, I could add in somaglutide and try to get this person off of the Lyspro, which is the hardest thing for my patients to give, and keep them on basal insulin. So I do feel like one of the real benefits to CGM is so that I can see these patterns. I can see that the prandial insulin isn't really working because the person isn't really giving it correctly with their food. So I can add in a GOP1 receptor agonist. And frankly, I think that's a real benefit in these patients because we have these agents available to our patients, and they're just not prescribed often enough. This is that patient that I told you where I don't know what to do. This is a patient with type 1 diabetes, and she's always reacting to something. She's either higher, she's low, if she's low, she drinks tons of juice. She goes high, then she treats. This is really hard on this individual. And we've worked with her for a long time and not gotten too far with her, except she's not going into DKA. But this is somebody where I can't wait till I have a pump that I just put on her and it does everything without her having to do much fiddling around with it, because it's really hard on her life to be up and down like this. Now, I'm going to show you two blind patients, because these are the kind of patients I see. This is a patient with, he's 50, he has type 2 diabetes, he's homeless, he's blind, he's had a CVA, he's had an MI, and he's on dialysis. Now, these are really complicated patients to have. And he has a lot of food insecurity being homeless. And he was actually on 42 units of insulin that was given three times a week when he went to dialysis. So he was getting Degladec three days a week. And this is what the tracings look like. And obviously what I do is I markedly reduce the insulin. And finally, to the point where he's basically on almost no insulin, and he may not need any insulin. He might need insulin again if he starts eating more. Again, he's got a lot of food insecurity issues, but he also might do really great on a DPP-4 inhibitor. But I have to see if I can get that for him. But this is the data that we got from the professional Libre so that we could see what was happening to him. And then the next patient is an older gentleman, and he's also blind or nearly blind. He has a little bit of vision. He's got type 2 diabetes, and he's on glomepiride and linagliptin. And he basically can't be on any other meds, including insulin, because he can't reliably give a shot every day. He has a spouse who takes care of him. You can see on the left that his time and range is pretty low. And this was during the pandemic, and he was really depressed and just sitting around and eating. And rather than do anything, I put him on real-time CGM, and his wife worked with him in terms of what he could eat. And I taught the wife about time and range, and I taught her about how to look for the green and how to keep him in the lines. And she did great and brought his A1C down to the low sevens. And this is perfect. And I think that this case here, the CGM really helped with the dietary changes that needed to happen and helps him and his wife help him do better with his diabetes. This is a patient. She's a developmentally disabled adult. She's in her fifties. When I put a CGM on her, she has type one diabetes. It completely overwhelmed her. She hadn't been in the hospital for DKA or severe hypoglycemia in years. As soon as I put the CGM on her, she was in and out of the hospital every other week, and I couldn't figure what was going on. And of course, what was happening is that every time she saw she was high, she was giving insulin and giving way too much insulin. And then she'd go too low, and then she'd get scared again. And then she decided not to give any insulin. And so her reactions to this, and this was repeated on multiple occasions, I just couldn't get her to not overreact to the numbers, to the way the scan was. So I just put a professional CGM on her from time to time and have her do finger sticks and so reliably do finger sticks. And she does much better on finger sticks. She hasn't been in the hospital again since I put her on finger sticks. These are two patients with type one diabetes where the big issue obviously is they're not really giving their insulin. And this is a psychosocial issue more than an education issue. Both of these patients have had a lot of education and both of these patients just give enough insulin to more or less keep out of DKA. So these are hard and these are really low, obviously time and range patients. These are the stresses my patients face commonly and not insignificantly. Many of them are off taking care of a sick family member so they don't take care of themselves. They're going through a divorce, death of a loved one, eviction, deportation, homelessness, loss of a job, theft or robbery, injury, abuse, legal issues, prison, food insecurity, disability, mental illness, just to name a few. And these are things that I see every single time I'm in clinic. These aren't just theoretical. These are stressors that make it really hard for people to treat their diabetes. This is a patient who had recurrent DKA. She has significant psychological issues and refuses care. But when she was up here all the time, she was giving some insulin and she said she had to go on Ozempic. And I said, you don't need to go on Ozempic, you need to give more insulin. And she said, but when I give more insulin, I get more hungry and I'm hungry all the time. And if you put me on Ozempic, I won't be hungry and I won't eat and my sugars will be better. So I actually did it and her sugars got a whole lot better. Now, this is not to say that these sugars are exactly where they should be, but you can see that she's actually coming into a close to normal range. And so giving her Ozempic, listening to her, has actually really helped me help her because she doesn't feel that insatiable hunger from being hyperglycemic all the time and I've been much more successful. And then before I close, I wanna say that it is my team that does all this hard work with me and gets all these CGM tracings and tries to teach everybody they can about how to use CGM. And I'm really grateful to be able to work with such wonderful people. And then in conclusion, obviously technology, CGM, time and range is not a panacea, but it really can be helpful. But I think the onus is on us to teach it well so that providers and patients can use it. And I think that we also have to really be mindful about individualizing recommendations and being mindful of whether or not we're helping a patient or hurting a patient and figure out the patient's circumstances and say to ourselves, how can we help this person the most? And the answer won't be the same to every person, but I think we can do a really good job if we do it in this way. So thank you. Well, thank you so much, Dr. Peters. I always learn so much from you every time I listen to you and your experiences are just so real. I'd like to take this opportunity now to introduce Dr. Monica Peek. And she's just gonna continue us on our journey with trying to understand how to utilize time and range. So Dr. Peek is an associate professor at the University of Chicago where she provides clinical care. She teaches and she does health services research with a focus on health disparities. So again, understanding how these social determinants of health really impact our patients. Dr. Peek is the associate director of the Chicago Center for Diabetes Translation Research, the executive medical director of community health innovation and the director of research and associate director at the McLean Center for Clinical Medical Ethics. Her diabetes translation research focuses on developing and evaluating multi-level interventions to improve outcomes among racialized minorities, promoting equitable doctor-patient relationships among racial minorities and integrating the medical and social needs of the patient. Dr. Peek has authored over 100 peer-reviewed research papers and publications and has served as the principal investigator of multiple grants from institutions such as the NIH, the National Institute of Diabetes and Digestive and Kidney Diseases, the Robert Wood Johnson Foundation and the Merck Foundation. We are so excited to have Dr. Peek with us today. So without further ado, Dr. Peek, I turn it over to you. Great, thank you so much for having me. It's wonderful to come after Dr. Peters because I'm essentially gonna be saying the same story, just telling it in a different way. So I framed mine as helping physicians help patients with the idea that we are ultimately trying to think about social determinants of health of our patients and how we can address those. First, so on my agenda today is to talk briefly about time and range, then social determinants of health and then potential solutions. And again, Dr. Peters has already done all of the hard work for me, so I can just sort of slide through my slides. So I'll start with time and range. And as Dr. Peters noted, there are many things that CGM provides for us, not only time and range, but time above range and time below range, hyper and hypoglycemia, which are also really important measures to know. But it's great to know how much the person is in range. And that's a nice compliment value to know in addition to the A1C. And so we have two kinds of continuous glucose monitors, real-time scanning and intermittently scanned CGM. And the better scanners are the real-time and that's what most people are using nowadays. I'm gonna start by talking about two studies that came out in JAMA last year that I wrote an editorial, co-wrote an editorial for, because they really were sort of watershed moments in how we are thinking about type 2 diabetes and CGM. And bless you, Dr. Peters, for opening up the access for people with type 2 diabetes to CGM and making sort of that happen for people who don't exclusively have type 1 diabetes. So I'll start with a study called the Mobile Study that was a randomized trial that had patients with type 2 diabetes. And they found that those who were on basal insulin in primary care settings benefited from the use of CGM. These patients that were in primary care were seeing subspecialists for their CGM care. But they were still managed by primary care physicians. What they found is that there's several sort of important things about this study. One is that the study population was extremely diverse. There was a lot of racial and ethnic diversity, a significant amount of the patients were low income as evidenced by their use of Medicaid as a government insurance. Many of them, again, for income correlated with a high school or less than high school diploma. And what they found is that the use of real-time CGM significantly reduced their A1C by 0.4%. And that was statistically significant. And then it also increased the amount of time in range by about four hours per day. So it was three hours and 50 minutes. And so then the second study was done by Kaiser and it was an observational study that looked at patients for about five years. And they looked at patients who had type 1 and 2 diabetes. Most of the patients had type 1 diabetes. And they looked at those who had just as part of routine care were initiated with CGMs versus those who were not initiated. And then looked at their outcomes over time. Those who had initiated the use of real-time CGM found that they, like the randomized control trial, had a 0.4 reduction in their A1C over time. And that interestingly, the benefits were greatest in patients with type 2 diabetes as opposed to type 1. They also looked at other measures like whether or not they had hypoglycemia that was significant enough to warrant going to the emergency room and or being hospitalized. That was also reduced in this patient population by 53%. And so the take-home messages from these two studies that were published in the same issue of JAMA was that the use of CGM in primary care and usual care settings is something that's very feasible, that it's possible for use in type 2 diabetes patients that are on doses or regimens of insulin that aren't super complicated. So not, you know, three and four times a day where they're checking their sugars five times a day, that they can be used in diverse patients like the one in the mobile study, also actually in the Kaiser study also, as far as racialized or ethnic minorities, low-income patients, those with low numeracy. And importantly, the mechanism of action for the studies was felt to be patient engagement. So increased adherence to medication, to the insulin, lifestyle changes, so that sort of in response to what they were seeing as far as the numbers in CGM, because the amount of total insulin actually remained unchanged. And so it wasn't that the physicians were seeing the CGM and then adjusting the insulin doses. And so that's a really important story in that we can see, despite many of the challenges that the social determinants of health, the community settings that people are living in, that they have, and Dr. Peters listed so many of them that she sees all the time in practice, that I see all the time in practice. I worked on the South side of Chicago, that this can, these can be overcome when patients and providers and study settings are really sort of focusing on these issues. Now the question is, are we gonna focus on these issues? Are we gonna try to make the efforts to overcome them? So now we're gonna talk a bit more about some of these social determinants of health. How do we get here? So just to level set, so we have a common definition. So these are the structural, economic, environmental and social forces that drive health and wellbeing throughout our life course. There are factors that impact health, where we live, learn, work, play and provide care. There are policies and procedures that shape differential access to goods and services. Examples include food insecurity, unstable housing, exposure to violence and barriers to healthcare. I'm just, okay, sorry. Okay, and then, so I'm just gonna define another term. So we, again, our level setting around some of our terminology and that is structural inequities. And so this has some overlap in the language for social determinants of health. And so these are policies, laws, procedures and norms that differentially limit the access to goods, services, opportunity and or risk. I didn't have the risk in there, but so good things and potentially bad things. And so when this, and this may be on the next slide, I can't remember. But when these, I'll say that these structural inequities don't sort of randomly occur in the population. They occur along fault lines based on social identities. And we all have social identities where they're based on our gender, our age, our race, ethnicity, whether or not we're an immigrant to this country or not, our native language, all of these different factors, our sexual orientation and whether or not any given identity is associated with more power or less, whether it's valued more in our country or valued less. And so the people who have stacked identities that accumulate power have more access to goods, services and opportunities. Those who have stacked identities with less power have a lot less opportunity, a lot less access to goods, services and opportunity, a lot more access to risks. And so examples include segregation of schools, racialized residential housing, discrimination in banking and lending practices, unfair criminal justice policies, unequal access to basic human needs like food, shelter, housing, clean air and water, we think about the Flint lead crisis in water, et cetera. All right, and so we know that these structural inequities are not just sort of like bad things, but they're also associated with poor health outcomes like the, so I'm a primary care physician, I'm not an endocrinologist. And so a lot of the things that I see day-to-day in practice are not just diabetes, but they're also hypertension, chronic lung disease, cardiovascular disease, asthma. All of these things have been associated with various kinds of structural inequities in the community. And this is the slide about how structural inequities and social identities are aligned. So let's take one example and that's education. So in 1954, there was Brown versus the Board of Education. Everyone's happy and celebrating, saying segregation is no longer the law of the land. And so that technically black children should have the same access to high quality schools that had previously been limited to only white children. But what we see is that today, black children are still separate and unequal. They're five times as likely as white children to attend schools that are highly segregated by race and ethnicity. They're more than twice as likely as white children to attend high poverty schools. And that has implications in that the performance of students, of black students suffer when these students attend these high poverty schools because these schools have less resources and for a number of other reasons associated with those schools. So a high poverty school has less money for teacher to school, sorry, teacher to student ratios, less money for all the bells and whistles that we think about when we think about great schools as far as extracurricular activities, things that the students can be exposed to. And so you see lower performance. And so when we begin thinking about things like health literacy or digital literacy or e-literacy that's needed for things like CGM or other kinds of technology that we need for health, we have to then think, well, how did that happen? It's not just a coincidence or like a random thing of nature and these are the result of policies that we have made as a society to say that some people don't deserve to be literate. And so that's something that we have to address. That was something we tried to address in 1954. And then there were all these workarounds when we created, that's when all these private schools came into play and that a lot of schools are funded based on housing. And so people who have better housing, that's what's funding the schools. And so there's just all of these workarounds that happen to try and keep the status quo. And so we see the continuation of many of the problems that have persisted over time. So then we'll think about another issue, and this is just a model that I helped to sort of develop that sort of thinks about diabetes outcomes. It's a simple version of it, but the things in the social environment and the built environment that ultimately can lead to poor health. And so one example of that is, I had mentioned before, residential segregation. That's a result of residential redlining. And so people have probably heard of redlining. It still is a policy that began in the Depression area where Black neighborhoods were, this is a map, were put in red and considered high risk. White areas were put in green and considered low risk. The high risk areas were areas that would not be given loans and where Black people would really not be allowed to move out of. Those are the same areas that the government would then not invest in as far as infrastructure and technology and other things like that. And so now when we look at areas that have access to broadband in the home, these align tightly with historic neighborhood risk classification. So when we try and figure out, okay, who's got broadband? Who has internet access? That's going to line up with those previous red lines around housing that the government and homeowners and realtors decided Black people should stay in versus around white and Black neighborhoods. So again, this is not random things in society like, huh, I wonder why that person doesn't have access. These are policies. These are choices that we made as a society that certain people don't deserve certain things and now they don't. And so when we're asking that people have technology or they're downloading things on their computer, can they do that? And so one of the things that we noticed is that housing instability exacerbates the digital divide. And so increasingly over time, we've seen that Black or African-American households have increasingly faced systemic obstacles with building wealth. And so wealth is related to, we mainly build wealth through housing. That's how we build wealth and that's how we pass wealth on intergenerationally. And so we think about internet and broadband use and other kinds of technology. The groups that we are most likely to worry about are, this group right here at the top of the list are racial and ethnic minorities. So that's just, I'm just going to give us a couple examples. So we think about literacy, we think about housing. Now I'm going to think, have us think about within the clinical context, a patient provider decision-making. I think a lot in my work, I do research around shared decision-making. And so we normally think about clinical context for shared decision-making, treatment options, the kinds that are there and the patient context around, is there family support for making that decision? Are there resources for enacting that treatment plan? And this here is a friendly looking doctor who looks very much like one of the doctors I had when I was in medical school. What we frequently don't think about for this friendly looking doctor is that he has a lot of the stacked social identities that are associated with a lot of power around race, gender, assumed sexual orientation, high SES, documented citizen, primary languages, likely English, the official language of the country. And when he is interacting with patients who have the opposite of those, there's going to be a lot of discordance and exacerbation of the power imbalance that may lead to triggering or exacerbation of implicit biases that may result in worse care. And so we have to begin thinking about some potential solutions, all of this sort of related to time and range, but time and range just being as one example of the kind of care delivery or care that's happening in the home, in the clinical setting that we want people to have. So potential solutions. Project ECHO, which has been used in settings, all kinds of clinical settings in the country, has also been used in diabetes. And here at the University of Chicago, this is a poster session that we just had at the ADA was to, I'll just read the title, Improving Translation of Diabetes Management Practices in Community Primary Care. And it was specifically for the management of medically and socially complex diabetes patients. So we talked a lot about CGM and some of the new medications, but we also specifically talked about managing the socially complex patients, the ones with that long list of problems. And so how do you try and get that complicated care to complicated patients? And so that was the challenge for that ECHO course. And we found that the providers had a lot of increase in self-confidence, self-efficacy at the end of the program. They also increased their knowledge by a significant amount. So we can improve providers' knowledge. This is a paper that Lindsay Mayberry, who is on today's webinar, was the first author for that was looking at mobile and internet interventions for disadvantaged and vulnerable populations. It was in current diabetes reports a couple of years ago. And a couple of the take-home messages were that, one, it can work for marginalized populations with improvements of things like diabetes distress, self-confidence, quality of life, diabetes knowledge, et cetera. But one of the things that we have to address is usability and accessibility into the interventions, the study designs, and those have to be described in the study methods. And there are digital universal precautions that exist. And so these are just some examples around identifying opportunities, making health literacy and numeracy standards for what we do, thinking about the readability level, using various kinds of media, can we use videos, providing means for access, encouraging patient participation in the process, asking for patient feedback, all of these things. And there's also digital literacy training for patients that can be free and provided with kiosks in the clinic. People can go to the library, et cetera. The use of human capital. We are all sort of thinking about community health workers, peer navigators as a way to bridge a lot of the social care that we're now trying to incorporate into medical care. And the digital interventions alone may be unlikely to sufficiently address the needs of patients who have a lot of social determinants of health. And that's one of the things that Dr. Peters noted is that they were using a lot of additional personnel for some of the high-risk patients. And so this combination of human capital with technology may result in the optimal use of some of that technology. And so this is an NPO that I helped co-run here in Chicago that integrates social care with medical care for sites across the country. And one of the things that the sites rely heavily on is the use of community health workers. And so they do that for social screening needs and referral, but also with the idea of developing cross-sector partnerships for larger structural issues. So not just the individual level food insecurity of that person, but thinking about food insecurity of that neighborhood, for example. So in summary, some of the potential solutions can be training providers, training up primary care providers, specialist co-management, addressing digital literacy, thinking about the use of human capital with community health workers, or training the medical assistants in your practice. And then obviously specifically addressing some of the social determinants of health. And these are some of the sites on the campus where I work. And I will just also say that I'm actually now a professor of medicine. So my apologies for sending an outdated bio to you. And that's it. Wow. All I can say is wow. These have been phenomenal presentations by both Drs. Ann Peter and Monica Peek. Thank you both so much. I think if anything I've learned again, and I reinforce this with other healthcare providers, is there really is no such thing as a non-compliant patients. Patients don't choose to not do what's best for themselves. There's always something underlying. And now I feel like I have to go back to school and restudy history, especially knowing the policies that are involved with creating a lot of these social determinants of health. So at this point, I'd like to open it up to our question and answers. And if you haven't done so, please do submit your questions to the Q&A box. One question that was asked by Sarah Franklin, a nurse practitioner out there, is with the rollout of the Freestyle Libre 3, and again, as technology improves, but this particular device is not going to have a reader device. It's going to require a pretty advanced smartphone to be used as the receiver and wanted to know how that's going to impact access. And I do know that the Freestyle Libre 2 is not going away for that particular reason. And we also have another, the implantable Eversense also is only phone mobilized, but maybe Dr. Peters, do you have anything to add on any limitations with Freestyle that you're aware of? Well, let's see. I think it's discriminatory and I think it limits it because a lot of my seniors, and I don't care what their socioeconomic status is, they don't want to deal with smartphones. They can't deal with smartphones. It's harder and they love the reader. I think that everybody in diabetes should strive to give the most options. And the reason that I really love the Libre 3 is it's so frigging tiny, but also because they don't have to swipe. And so some of my non-swipers are the ones who aren't going to have smartphones and then I can't use the Libre 3 because they don't have a smartphone. So, and I wish that came with the reader. I just, it really gets me that it doesn't, but I don't have strong opinions. One thing that I will say is that for a long time, there is a digital divide around smartphone use for racial and ethnic minorities. That has since closed. So while before, so initially years ago, I did a texting intervention and specifically avoided smartphones because of that divide. And the intervention was specifically for African-Americans. But now racially that gap has closed, but you're right. And that older populations, I still have people using, like they're trying to make flip phones sexy again. I see the advertisements for them, but I have patients that are still using the old flip phones. And you know, so I'm like, they still make those, you know? He's like, no, no, they don't. I've had this for like 20, I'm like, oh, so you're right that there are, you know, and I can tell already, I'm going to be one of those people, you know what I'm saying? Not keeping up with technology and all that stuff. So. But in our population, it hasn't, it hasn't gone away in terms of having smartphones because our population in East LA, there's still at least 30 to 40% of the people who don't have smartphones and we try to give them smartphones. But as you talked about all the redlining and everything else, I mean, the cell phone, the internet's not good enough and they get stolen. I've had, you know, we tried everything to try to bridge that divide and it's a tough one and it's not unbridgeable, but, and I took notes from what you said, by the way, I loved your talk. But I really want to start doing more teaching of digital literacy, because you say I can train people and maybe I need to add that to what I do is, our staff tries to train them, but I mean, formal training, that would be really cool. I think this is such an engaging and such an important aspect. And Sarah, thank you for asking that question, because there is a lot of discrimination involved with diabetes management. We already are trying to get past the shame and blame. And now we got to make sure that they have the access that they need. So I have a question by someone by the name of E. Rumley and is asking specifically about time and range. So if time and range and the true time and range is 70 to 180, why do we have the guideline for fasting blood glucose levels of 80 to 130? Do we need a guideline for fasting sleeping time and range versus daytime time and range? And I think, Anne, you mentioned some of this was trying to get people to get away from blood sugar and A1C and more into what the time and range is, if you'd like to take that one. Well, time and range is meant to just look at pre and post-prandial. So it doesn't give you a time and range by day. It just wants to say that if you want to be in a more or less normal, but not really normal for non-diabetic, but what is considered a reasonable range for somebody with diabetes at 70 to 180. And that correlates with an A1C if you're 70% or more of 7%, but you're correct. The time post-prandially should be different, but the ADA, when they write those guidelines, they're talking about finger sticks before eating and after, but you could do something really complicated, but you can't really do that because you don't know when people are going to eat or not. But obviously the goal is to keep them down before they eat and not go too high after eating. And somebody without diabetes really doesn't go much above 140. So I think it's just to give you a broad bucket that then correlates with what the A1C is. And I have patients who don't want that. They shrink their time and range. They are pickier than the 70 to 180. And I also have patients who have hypoglycemia unawareness where I raised the bottom up to a hundred. So I will, and then pregnancy, obviously, but I'll change the time and range as much as is necessary to work with that individual patient. And that's a great point. It's still all about individualizing care for our patients. And so where the average person with type two or type one diabetes non-pregnant has that time and range of greater than 70% in that 70 to 180, for those that we are concerned about, we want that time and range to be maybe 50%, but we're even more strict with how often they can go below that 70 milligrams per deciliter. So thank you for that answer. And thank you for that question. Dr. Peek, I have a question, particularly about for you, about for practices that don't have access to community health workers or even patient educators. How can the principle of using cultural bridges apply for marginalized patients? Yeah. So every practice has unfortunately a natural hierarchy within the clinic based on education that usually falls also around racial and ethnic lines. So the physicians are disproportionately white and the staff are disproportionately non-white and usually come from the communities that they're serving, be it Latino, Asian, or black. And so this is a ready population. And you may see, if you observe that sometimes they'll know the patients that are coming in, you know, they may, you know, go to church with them or whatever, depending on how large the community is. And so training up your MAs to work at the top of their license is something that is, you know, part of how we think about team-based care. I do a lot of quality improvement, but it's also a way of thinking about optimizing your social capital within your human human capital and having these this particular population be able to do things before and after visits, between visits, like a community health worker, but they're already sort of part of your team that other team members may not be able to as effectively do because they're not sharing the same lived experience. Excellent. We have about a minute left and I'd like to just say thank you. I want to make sure there weren't any other questions out there. Anything that you might want to add just because it's burning and you'd like to get that out to the, to the audience, either one of you, 30 seconds or less. Thanks for listening. I was just going to say, thank you for having us. I think this is a really important discussion. It's a really important thing to think about, like not just the technology, but like the barriers, the social barriers to that. So thank you ADA and Time and Range, you know, team for acknowledging that this is something important to address. Absolutely. Thank you all. Thank you both for presenting and for the audience. So this concludes today's program. Again, we thank our presenters. I would also like to say thank you again to AVID and LifeScan for their support and every one of you for joining. Time and Range will be launching additional resources. So please be on the lookout for upcoming webinars, podcast episodes, and of course, practice pearl videos. Upon conclusion, you will receive an email to complete a brief survey. Please provide us feedback on today's program. Thank you again for your time. And we look forward to connecting with you at the next Time and Range webinar.

diabetes management

time and range

social determinants of health

continuous glucose monitoring

A1C levels

digital literacy training

individualized recommendations

blood glucose levels

social determinants of health in patient care