Expert Voices: Enhancing Diabetes Outcomes and Clinical Workflow With Continuous Glucose Monitors (CGMs)
Video Transcript
Robin Loveday: Hello and welcome, everyone. My name is Robin Loveday. I'm a nurse practitioner, CDCES. And today, we're going to discuss the role of continuous glucose monitoring, or CGM, with managing diabetes. We're going to review benefits, challenges associated with this type of device, barriers to adoption, but also the unique benefits of this device in different subpopulations of patients living with diabetes. If you'll start us off and introduce yourself.
David Doriguzzi: Thanks, Robin. I'm David Doriguzzi. I'm a physician assistant. I’ve been working as a diabetes specialty PA for about 23 years. I am with a large medical group in Northern Los Angeles County in Lancaster, California. And it's a pleasure to be here today.
Dr Anita Swamy: I'm Dr. Anita Swamy. I'm a pediatric endocrinologist, and I specialize in diabetes. And I'm in the awesome city of Chicago, Illinois, and honored to be here today.
Dr Aaron King: My name is Dr Aaron King. I'm a family medicine physician in San Antonio. I've had an area of interest in diabetes now for about 20 years and enjoy taking care of full scope adults both with and without diabetes and also take care of type 1 diabetes.
Joy Ashby Cornthwaite: I'm Joy Ashby Cornthwaite, and I'm a registered dietitian and a certified diabetes care and education specialist. I lead a group of clinicians taking care of high-risk pregnancies in Houston, Texas.
Robin Loveday: So, the most recent American Diabetes Association, or ADA, guidelines now recommend CGM as the standard of care in adults with diabetes. CGM allows clinicians and patients to continuously monitor glucose levels, and this is making it easier to track glycemic variability. It's a critical piece of information because we know higher glycemic variability, it's associated with microvascular complications, nephropathy, neuropathy, retinopathy. Additionally, patients with diabetes using CGM frequently have greater glucose time and range, so 70 to 180 milligrams per deciliter, but also a corresponding improvement in A1C levels. So, how can missed glucose readings affect diabetes management but also help patients' outcomes?
Dr Aaron King: Well, Robin, I'd like to maybe address this first. So, one thing we see so commonly in primary care is that people really don't do their finger sticks like they're supposed to. We advise them to maybe try different times of day, and they struggle with that. Oftentimes, they just struggle to do it at all. And so, when they come in and we're trying to make a decision about their care, it's very hard to do so if we don't really have that information. And this is where CGM is really going to open things up and help us out. It reminds me a little bit of a patient I had recently. She was a little bit in the older population. She was in her 70s, and her A1C unfortunately was creeping up. So, she was initially in the 6s, moved into the 7s, and was most recently on two oral medications and had A1C over 8. And I asked her what her blood glucose was looking like at home, and she really wasn't testing very often.
So, I talked about different options to add maybe a third therapy, and she was very resistant to that. And I understand that, obviously already being on two medications. So, instead, we decided to put her on a CGM and see if maybe she could begin to modify some of her diet, exercise, and maybe be also more consistent with her medication. And I was a little bit hesitant, to be quite fair. I thought maybe this technology is not going to work for this person in her 70s. And, lo and behold, I was absolutely wrong. Turns out that she came in just 3 months later, and her A1C was already at goal. And we began discussing actually reducing one of her medications because her control was so good.
Fast-forward to just recently, I saw her back one year later. And I'm happy to report not only was her glucose values no longer in the diabetic range, but she actually was off all of her medications completely. And so, while this is not always what happens, it's just a powerful statement to how we can use that information both on the provider side but also on the patient side as well.
Robin Loveday: Yeah, I love it when our patients prove us wrong.
Dr Aaron King: Yeah.
David Doriguzzi: That's a great story. I'm reminded of a patient that I've taken care of for several years. Again, like your patient, she's an older lady. She's in her late 60s, and she has been type one diabetic longer than I've been alive. So, you can imagine just the journey that she's had and the changes that she's had to experience all along the way. I mean, her glycemic monitoring goes all the way back to where she had nothing more than just urine dipsticks. So, you can imagine that, for most of her time as a person living with type one diabetes, she's kind of been on her own having to just do whatever she had to do to make it work. So, she had very strong, developed ideas about what works, what doesn't, because that's what she made work.
As time went by, I started to introduce her to new options that might be beneficial to her, including CGM. And, initially, she was really resistant to it. She didn't want to do it. She said, "Look, listen, kid. I've got a way that I do this, and I do my finger sticks, and I do my injections." She never wanted a pump. She did her log books, and she just kind of made it work. And I never really pushed her that hard because her A1C was 6.4. So, I thought this is an option for you. I think this might help you. But, I mean, what can I say about your A1C? I can't argue with that.
Well, fast-forward a couple of weeks, and I get a call from her husband letting me know that she's in the hospital because he found her unconscious on the kitchen floor. And it turns out that she was having some pretty significant hypoglycemia events that we just never knew about because they weren't getting captured on her finger sticks. So, when she was released from the hospital, I finally convinced her just to try it. And come to find out that what was happening in between those glucose finger sticks—and what was not being captured by an A1C of 6.4, which is really just an average of everything—is that that was a very wide average of significant fluctuations in her glucose that were all taking place in between those finger sticks. And she was just so acclimated to those hypoglycemic events, and the unawareness that had set in was just profound. I was stunned to see just how significantly low she was getting. And it only took a slight decrease from the lows that she had been getting before to where it became a critical event where she's suddenly unconscious.
So, we started her on a G7, and she started to develop the ability to regulate her glycemic control in ways that she never was able to before because she was seeing what wasn't seen in the past. And she still maintained that target A1C, but now without those risks of the hypoglycemia events that she had become acclimated to in the past.
Joy Ashby Cornthwaite: And in pregnant women, so in women living with diabetes in pregnancy, oftentimes we are given—the first data that we receive is a glucose screening or a confirmatory 3-hour exam. Recently, we had a mom come in, 20 weeks, and she had a 1 hour of well over 200 milligrams per deciliter. And if we had sent her home with just the usual check four times, we may have had to wait two weeks in order to get any information back on how we should treat her. Instead, she left the clinic wearing a sample CGM, and within 2 days, we already knew that her values were on average very close to 200. And we could act immediately. And the important thing about missed data between the single glucose checks is, especially in pregnancy, the amount of growth and change for a baby that happens in a week, it's monumental. And now, we can get the data between the single BGM checks and act immediately.
Dr Anita Swamy: I think that's amazing. And I feel like, in pediatrics, my story to share is that children are very dynamic. They might go on a trampoline one minute. And then, unfortunately, get a virus and be bedridden the next day. So, it's really hard to keep up with all of these dynamic changes in their lives, their activity level, their growth. They do that thing called puberty. And so, it's critical for us to have a tool that helps us keep up with all of these changes. So, in that critical age group, I need those 288 data points. I need that every five minutes. I need that alert that tells me you're going to go low in 20 minutes. Not a check every eight to six hours, which is what we used to do. So, I think that those missed readings are where it's at for especially our pediatric population. I need those readings to do their care.
And I think the other way in which we've really utilized this is diabetes training camp. It’s a camp that we do for athletes with type one diabetes, both teen and adult. And I participate in the teen camp. And what we found is that the activity changes their glucose minute to minute—the type of activity, aerobic, anaerobic. Their preparation varies for this. Whether it's a practice or an actual game will affect their outcomes. None of these things did we know before we had a sensor.
Robin Loveday: So, let's talk about the clinician workflow perspective. CGM can also bring to light specific components of disease management that still require intervention. So, how have you seen CGM impact the way that you treat your patients with diabetes?
David Doriguzzi: Well, I can tell you that from my practice, my patient engagements are way more efficient than they ever used to be. A lot of what we spend doing in clinic is sort of trying to solve the mystery of what is going on in that patient's day-to-day life that's causing their A1C to be whatever it might be? What is causing elevations? What's causing hypoglycemia? And that mystery can be a lot more easily solved if we have the tracking available. And I've noticed that when I first started using CGM, I was kind of nervous that it was going to take a lot more time because more data, more information, more time, right? I think it's a natural assumption. But what I found is that I can actually accomplish more in a shorter amount of time. Because I can sit at my desk and—before I even go into the patient's room—I can open up their chart, and I can open up Clarity.
And I can see what's going on at a glance. I'm not teasing out numbers. I'm not tracing lines. I'm looking at a single picture. And without even really paying attention to a specific number, with colors and images, I can get a very quick idea of what's going on in that patient's glucose metabolism over the past 2 weeks or so. I can see where there's lows. I can see where there's elevations. I know what's going on with fasting. I know what's going on with postprandial glucose. And I can walk into that patient's room very, very informed knowing what we're up against, and that can help guide the conversation. We can speed up the mystery-solving part of it and go in knowing a little bit more about what we need to attack in terms of their challenges.
Dr Anita Swamy: And I would say that, just to piggyback, I completely agree. In our clinic, we have Clarity. And all of our patients are in Clarity, thank goodness. It's very easy to do. And so, we are able to see what's walking in an hour before clinic even starts. And, in my particular population, the underserved in the south side of Chicago, there's sometimes that there's other circumstances. They might not be able to afford supplies or there's other issues. And I can detect that on the download before I see the patient. And so, then I can call my social worker and say, "I really want you to be present for this patient," or my psychologist. I can detect burnout. We can see if the systems are working for them when we put them on AIDs. So, the way that CGM has impacted the way I treat my patients is it's made me a much better doctor and a much more involved doctor. And the interactions are far more meaningful than they ever were in the past.
Joy Ashby Cornthwaite: Yeah. And I would say that this applies very well to all of our patient care spaces. Clarity is a very important tool—as you mentioned, David—in removing the reactive, “How do I decipher this?” And it's a panic response in the moment because the patient has to bring you the data then and there. And then, you can't process it. They can't process it. And you're spending valuable clinical time trying to process it together versus having a really robust conversation on how are we going to, together, take care of these challenges?
The compare and contrast is one of my very favorite features in the Clarity app. I really love to sit with my patient, take a look at what we did last time and how that might have impacted the values this time. And, in that way, we can together decide what the best course for it is. But I can also cheer them on and say, "You have achieved XYZ," where we may not have been able to see the things that they succeeded in before. And maybe it wasn't exactly the goal that we set last time, but something else changed and something else improved. And we can really focus on that and let that motivate our path forward together.
Robin Loveday: Absolutely. Yeah, and I think it's nice, David, to your point, you kind of know what you're doing before you walk in. And it gives you time to be human and to have that relationship. But instead of necessarily diving straight in, you can say, "Hey, how's your family? How's life been?"
David Doriguzzi: And I love what Joy talked about, as far as the concept of togetherness—approaching this problem as a team rather than the conflict of provider versus patient. I mean, it really shouldn't ever be that, should it? It shouldn't be us against them. You beautifully described an idea of the team of that provider and patient working against the conflict of their own health and where they need improvements. And I think that sitting down with a patient and pulling up right on my tablet, showing them that same Clarity report that I just looked at, and we can investigate it together. And then, the patient starts to learn more about what's going on as well. And now, suddenly they're more equipped just like I'm more equipped to approach their diabetes as well.
Dr Anita Swamy: Yeah, absolutely. Encouraging.
Dr Aaron King: I want to add to that, David. I agree with what you said. We've been talking about using Clarity and how we all enjoy looking at all that data before we go in. And it's almost like taking one step back to take two steps forward. So many times in primary care where you're seeing patients every 15 minutes, you've got so many different problems to fit within that tight time space. It's very hard to stop and pause and say, “Okay, with the way that I'm flowing, the way I do things, is it worth it for me to do something different, to introduce a new technology or a new flow into my practice? Maybe I'll just keep doing it the way I'm doing it. It seems to be working.” But there is that moment where we need to, like I said, take a step backward, maybe take a few extra minutes, get comfortable with Clarity and learn how to integrate that. So then, when we go in, we can sharpen up our conversations and really be much more productive with that time in the room.
And you mentioned sometimes for those providers that aren't yet using Clarity, there is an option there where they can also just take the patient's smart device or the receiver, if they have one, and they can look on that and use that data to interpret. And then, as long as you're documenting that they're looking at adequate amounts of data and they're using that data to make decision-making within their note, that's a perfectly okay way of doing things.
But I think once providers begin to do that, they're going to realize that's somewhat inefficient also. You're taking that patient's phone, and you're asking for their permission, and then you're flipping through different screens. And one thing that Clarity has done that's really nice is you can go right into that app, as you know, and you can click on the Clarity Clinic tab and put in a code. And every provider can set up their own code. It can be just one simple word or maybe the name of your clinic or the name of you yourself. And then, you can put that in for all your patients, and it'll immediately link them back to Clarity. And I think once providers get to doing that consistently, they'll get comfortable with that and they'll find that to be very efficient.
David Doriguzzi: It really is. It was a lot easier to do than I initially thought it might be. And while having that on their phone is really convenient for people who aren't sharing or perhaps just we haven't set that up yet or providers haven't set that up. What you said a moment ago about taking that step just to invest the time into learning how to interpret an AGP, for example, how to use Clarity. It's really not that hard. And the idea of ongoing education, taking the time to continue learning, is something that we're all very familiar with. Nothing wrong with spending a little bit of time learning how to use a tool that will actually vastly speed up our patient interactions. It really does save me a lot of time. I would imagine you all probably have had similar experiences.
Dr Aaron King: Yeah, I feel like once you take that step, it's almost impossible to think about going backwards. If I have a patient not on CGM, I know that's going to be a longer, more difficult conversation around their diabetes than those patients on CGM.
David Doriguzzi: Way too much guess work involved.
Dr Anita Swamy: And I would say just in telehealth, so the world of virtual care has exploded. And I feel like I have to have them in Clarity in order for me to do a good service. I don't think I'm able to offer any assistance with a virtual visit if you can't see data. So, we're all so data-driven today, and I think that Clarity makes it very easy for us to hold these virtual clinics and help our patients between their in-person visits. Nobody wants to go in every three months. So, if you can facilitate that and have some assistance, even touch points every week, you can look at Clarity. It doesn't have to be a virtual visit. It can be a phone call with an educator to say, "I was struggling." So then, we can pull it up and take a look and say, "Oh, I see. Let's change this," is really powerful. We could never do that before.
Joy Ashby Cornthwaite: And in the pregnancy space, that insight between clinical visits is especially important because our visits are far more frequent. So, it can be every week, every other week, depending on the changing hormones and the changing glucose values. For many people, they're unaware that pregnancy is a moving target—faster than living with gestational diabetes outside of pregnancy. Every week that the placenta grows, I like to tell my patients it's like the baby has their own personal baby mafia. And so, the placenta hormones are increasing and gathering strength and determining where mom's glucose values are going. And that is a natural progression in pregnancy. But that means that we have to look and see those values weekly and then make clinical medication changes weekly if necessary. And with the data analysis that Clarity allows, you get that—data-gathering peace happens before the visit happens, and that saves you an extraordinary amount of time. And that time saved can be reinvested in conversation, decisions, and end with a shared decision when someone's going home. It's a beautiful thing honestly.
Robin Loveday: I love that baby mafia. Boss Baby is what I am picturing in my mind.
Joy Ashby Cornthwaite: Exactly.
Robin Loveday: Thank you all so much for your time and your expertise. This has been an absolute pleasure and thank you so much for joining us.