Effect of Professional CGM (pCGM) on Glucose Management in Type 2 Diabetes Patients in Primary Care

Development of a Continuous Glucose Monitoring Service by Clinical Pharmacists in a Medically Underserved Population

Background: Continuous glucose monitoring (CGM) is an evolving technology that provides a wealth of information to aid in managing diabetes. Professional CGM (ProCGM) is recommended when personal CGM is not desired or available. Patients in medically underserved areas may have limited access to personal CGM devices, thus ProCGM devices can be used for short-term monitoring and medication adjustment. Clinical pharmacists are well-positioned to help set up and establish personal and professional CGM management services. Objectives: To determine the effect of ProCGM in patients with persistently uncontrolled type 2 diabetes in a medically underserved population (MUP). Methods: Pre-post intervention analysis of a single cohort of patients in a public health center. Patients with persistently uncontrolled (A1c > 9%) and taking at least one daily dose of insulin were included. Included participants wore a ProCGM sensor and met with the clinical pharmacist at least once for ProCGM data interpretation and education. The primary analysis evaluated patients who achieved an A1c <9% 1-6 months after intervention. The change in A1c was also evaluated. Participants completed a pre- and post-survey about their experience. Results: Twenty-two patients were included in the final analysis. Ten patients achieved an A1c <9% (45%). The mean A1c pre- and post-ProCGM was 11.0% and 9.8% respectively, with a decrease of -1.2% (p=0.055) overall and a decrease of -1.7% for patients who wore the sensor for at least 10 days (p=0.012; n=15). Using the CGM data 91% of participants had a change to their medication regimen and 45% achieved an A1c <9%. Six participants experienced hypoglycemia per the CGM report, but only two were aware of it. After reviewing their glucose report with the pharmacist, 95% of the respondents agreed or strongly agreed to feeling more knowledgeable about blood sugar patterns after reviewing the report with a pharmacist. Conclusion: Almost half of the patients in the study achieved an A1c <9%. This study demonstrated glycemic benefit in patients in a MUP who wore a ProCGM for at least 10 days and met with a clinical pharmacist. Data from ProCGM enabled patients to better understand glucose patterns in those with persistently uncontrolled type 2 diabetes.

7. Diabetes Technology: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Roadmap to the Effective Use of Continuous Glucose Monitoring by Diabetes Care and Education Specialists as Technology Champions

This article describes the implementation of a diabetes technology educational program targeting continuous glucose monitoring (CGM) adoption that significantly increased utilization of CGM in the Division of Pediatric Endocrinology at the University of Florida. The author proposes that diabetes care and education specialists (DCESs) are uniquely positioned in the health care ecosystem to serve as diabetes technology champions. The article provides a step-by-step roadmap that DCESs and clinicians can use as they lead efforts to expand CGM adoption and durable use.

Expanding the Role of Continuous Glucose Monitoring in Modern Diabetes Care Beyond Type 1 Disease

Application of continuous glucose monitoring (CGM) has moved diabetes care from a reactive to a proactive process, in which a person with diabetes can prevent episodes of hypoglycemia or hyperglycemia, rather than taking action only once low and high glucose are detected. Consequently, CGM devices are now seen as the standard of care for people with type 1 diabetes mellitus (T1DM). Evidence now supports the use of CGM in people with type 2 diabetes mellitus (T2DM) on any treatment regimen, not just for those on insulin therapy. Expanding the application of CGM to include all people with T1DM or T2DM can support effective intensification of therapies to reduce glucose exposure and lower the risk of complications and hospital admissions, which are associated with high healthcare costs. All of this can be achieved while minimizing the risk of hypoglycemia and improving quality of life for people with diabetes. Wider application of CGM can also bring considerable benefits for women with diabetes during pregnancy and their children, as well as providing support for acute care of hospital inpatients who experience the adverse effects of hyperglycemia following admission and surgical procedures, as a consequence of treatment-related insulin resistance or reduced insulin secretion. By tailoring the application of CGM for daily or intermittent use, depending on the patient profile and their needs, one can ensure the cost-effectiveness of CGM in each setting. In this article we discuss the evidence-based benefits of expanding the use of CGM technology to include all people with diabetes, along with a diverse population of people with non-diabetic glycemic dysregulation.

The Association of Glucose Variability and Dementia Incidence in Latinx Adults with Type 2 Diabetes: A Retrospective Study

Latinx adults with both cognitive dysfunction and type 2 diabetes mellitus (T2DM) are significantly more likely than Latinx adults with diabetes alone to have complications such as cardiovascular disease. Glucose variability may be a risk for dementia, but the course of glucose variability in the time before a dementia diagnosis for Latinx adults with T2DM has not been examined. We used a 10-year retrospective cohort of medical records of Latinx patients with T2DM who had at least one use of a continuous glucose monitor. The objective was to examine how glucose variability was associated with future dementia diagnoses. A total of 116 charts were included. Mean of daily differences and mean amplitude of glycemic excursions were more strongly associated with dementia diagnoses than other variability indices (p < .01). Understanding the relationships between cognitive function, glucose variability, and barriers to health care can translate into improved interventions to enhance diabetes care.

7. Diabetes Technology: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

A Team-based Training for Continuous Glucose Monitoring for Diabetes Care: An Implementation Pilot in Primary Care Practices (Preprint)

BACKGROUND

The American Academy of Family Physicians (AAFP) develops and maintains continuing medical education that is relevant to modern primary care practices. One continuing medical education modality is AAFP TIPS, which are comprised of resources designed for family medicine physicians and their care teams that aid in quick and accessible practice improvement strategies, with actionable steps. Evaluating physicians' use of and satisfaction with this modality's content and implementation strategies has not been prioritized previously. Continuous glucose monitoring (CGM) plays an increasing role in the treatment of diabetes; uptake occurs more rapidly in endocrinology settings than in primary care settings. To help address such differences in CGM uptake and diabetes care, AAFP TIPS on Continuous Glucose Monitoring (AAFP TIPS CGM) was developed, using published evidence and input from content experts (family medicine faculty; AAFP staff; and an advisory group comprised of other primary care physicians, patients, a pharmacist, and a primary care practice facilitator). A pilot implementation project was conducted in 3 primary care practices.

OBJECTIVE

To evaluate AAFP TIPS CGM in primary care practices, the research team assessed use of and satisfaction with the content and assessed barriers to and facilitators for strategy and workflow implementation.

METHODS

In total, 3 primary care practices participated in a mixed methods pilot implementation of AAFP TIPS CGM between June and October 2021. Practice champions at each site completed AAFP TIPS CGM and baseline practice surveys to evaluate practice characteristics and CGM prescribing. They conducted team trainings (via webinars or in person), with the goals of implementing CGM into practice and establishing or improving CGM workflows. Practice champions and team training participants completed posttraining surveys to evaluate the training, AAFP TIPS materials, and likelihood of implementing CGM. Interviews were conducted with 6 physicians, including practice champions, 2 months after team training. Satisfaction surveys were also distributed to those who completed the AAFP TIPS CGM course via the internet during the study period.

RESULTS

Of the 3 practices, 2 conducted team trainings. The team training evaluation survey showed that practice staff understood their role in implementing CGM in practice (19/20, 95%), and most (11/20, 55%) did not have questions after the training. Insurance coverage for CGM was a remaining knowledge gap and potential barrier to implementing CGM in practice. Physicians and interdisciplinary care team members who took the AAFP TIPS CGM course via the internet, as well as those who attended in-person team training, expressed a high degree of satisfaction with the education, content, and applicability of the course.

CONCLUSIONS

This pilot implementation of AAFP TIPS CGM offers pertinent and timely information for primary care practices that desire to initiate or expand CGM use to best meet the needs of their patients with diabetes.

Continuous glucose monitoring in primary care - are we there?

PURPOSE OF REVIEW

In this review, we examine the expanding role of continuous glucose monitoring in glycaemic management in primary care.

RECENT FINDINGS

Improving technology and decreasing cost have increased the uptake of use of continuous glucose monitoring (CGM) for glycaemic management in primary care, wherein most diabetes is managed. Optimized use of this technology, however, will require a convergence of several factors. Availability of devices for people with diabetes, availability of data at the time of clinical interactions, and expertise in interpretation of CGM and ambulatory glucose profile (AGP) data, as well as optimization of therapies, will be required. Significant progress has been made in all three areas in recent years, yet creating systems of support for widespread use of CGM in primary care remains an area of active investigation.

SUMMARY

There has been significant uptake in the use of CGM in the management of diabetes in primary care. Optimized use, however, requires both access to CGM data and the expertise to use the data. Although promising strategies have emerged, the task of generalizing these strategies to the broad population of primary care in America is ongoing. CGM technology holds significant potential for improving glycaemic management in primary care, yet important work remains to leverage the full potential of this promising technology.

The Benefits of Utilizing Continuous Glucose Monitoring of Diabetes Mellitus in Primary Care: A Systematic Review

BACKGROUND

Continuous glucose monitoring (CGM) and intermittently scanned CGM (is-CGM) have shown to effectively manage diabetes in the specialty setting, but their efficacy in the primary care setting remains unknown. Does CGM/is-CGM improve glycemic control, decrease rates of hypoglycemia, and improve staff/physician satisfaction in primary care? If so, what subgroups of patients with diabetes are most likely to benefit?

METHODS

A comprehensive search in seven databases was performed in June 2021 for primary studies examining any continuous glucose monitoring system in primary care. We excluded studies with fewer than 20 participants, specialty care only, or hospitalized participants. The National Heart, Lung and Blood Institute and Grading of Recommendations Assessment, Development and Evaluation were used for the quality assessment. The weighted mean difference (WMD) of HbA1c between CGM/is-CGM and usual care with 95% confidence interval was calculated. A narrative synthesis was conducted for change of time in, above, or below range (TIR, TAR, and TBR) hypoglycemic events and staff/patient satisfaction.

RESULTS

From ten studies and 4006 participants reviewed, CGM was more effective at reducing HbA1c compared with usual care (WMD -0.43%). There is low certainty of evidence that CGM/is-CGM improves TIR, TAR, or TBR over usual care. The CGM can reduce hypoglycemic events and staff/patient satisfaction is high. Patients with intensive insulin therapy may benefit more from CGM/is-CGM.

CONCLUSIONS

Compared with usual care, CGM/is-CGM can reduce HbA1c, but most studies had notable biases, were short duration, unmasked, and were sponsored by industry. Further research needs to confirm the long-term benefits of CGM/is-CGM in primary care.

7. Diabetes Technology: Standards of Medical Care in Diabetes-2022

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.