Bringing Patients the Latest CGM Smart App Technology for Real-Time BG Readings and Insulin Adjustments

As the rates of diabetes mellitus (DM) continue to rise, health systems and providers are being challenged to meet the demands of high-quality, high-value care, especially for those patients at highest risk. This is occurring while new tools for managing diabetes are being introduced to providers and patients at an exponential rate.

Continuous glucose monitoring (CGM) is among the most innovative of the technological advances now available and represents the future of diabetes technology. CGM devices generate nearly continuous blood glucose (BG) data and provide useful information regarding BG variability.

Patients experiencing problems with their diabetes management often require additional time and expertise, which presents challenges in a busy clinic setting.

This information is available not only to health care providers, but also to patients and their families. CGM data can be used to identify BG trends and patterns to assist with insulin and other treatment adjustments, and to alert users when BG is out of the desired target range. Improvements in CGM technology, and changes that apply to users, are being made at a rapid pace that includes remote monitoring capabilities and transmission of data to personal electronic devices, such as phones, computers, and tablets. The U.S. Food and Drug Administration (FDA) recently expanded the approved use of a mobile CGM system to allow for replacement of fingerstick BG testing for diabetes treatment decisions in people 2-years-of-age and older with diabetes. This is the first FDA-approved CGM that can be used to make treatment decisions without confirmation from a traditional fingerstick test.¹ These devices are the foundation for the first hybrid closed-loop insulin delivery systems^2,3.

Insulin delivery is now possible through the use of continuous subcutaneous insulin infusion (CSII) insulin pumps. Programs now allow insulin pump and CGM devices to connect and send information through devices (some the size of a car key fob) to smartphone applications. With this technology, patients can quickly view their BG information. Furthermore, some of these devices display BG trends associated with food and activity levels. This creates opportunities for real-time adjustments in insulin delivery, allowing for quick responses to situations or environments in which BG levels change rapidly. Technologies that aid in the acquisition and processing of glucose information to a person with DM can be shared with their diabetes care team and have the potential to prove invaluable,⁴ but health care systems need to be prepared to handle all of the additional data that is becoming increasingly available.

Additionally, hybrid closed loop systems combine the ability of CGMs to send information automatically to insulin pumps which can they use internal algorithms to help the patient maintain optimal glycemic control via automatic adjustments in the insulin therapy being infused into the patient.⁵

Diabetes Management in Health Care Systems

While all of these innovations are life-changing for the patients and their families, training patients on the skills necessary to use these tools, and learning to interpret all of this available data, requires a prepared diabetes care team. The complexity of diabetes management requires that health care providers support their patients with the appropriate amount of time and education that are necessary for effective self-management and adherence. Patients experiencing problems with their diabetes management often require additional time and expertise, which presents challenges in a busy clinic setting. As diabetes therapies and technology are quickly advancing, health care systems need to be prepared to help patients use these tools and translate information for positive health outcomes.

The Multidisciplinary Diabetes Clinic was conceived in collaboration with the diabetes education specialists at the Falk Center for Diabetes and Endocrinology at UPMC. Faculty and staff recognized limitations in providing the necessary care and time required for high-risk patients with glycemic management problems. Although the benefits of our highly-trained team members — which includes diabetes educators and dietitians — are numerous, their services for care and education, like many programs, are underutilized.^6-8 Through a review of our patient database, we realized that although there were on-site educators and dietitians, for a variety of reasons patient visits to team members “fell through the cracks.” Referral was not done in a systematic way, and care and education delivery were fragmented.

The Multidisciplinary Diabetes Clinic was designed to proactively identify patients experiencing challenges with glycemia, e.g., high hemoglobin A1C, recurrent unplanned care, hypoglycemia unawareness, new comorbidities and/or therapies, special needs related to diabetes technology, and other issues. These patients were scheduled for a visit that included multiple members of the Multidisciplinary Diabetes Clinic team. Using a patient-centered approach, members of the team have an opportunity to meet with the patient to individually assess, and collaboratively organize a treatment plan that attends to all of the complex elements of diabetes care, including nutrition, medication management, and psychosocial, and behavioral issues. Ongoing patient follow-up is provided by a familiar member of the clinic team.

Diabetes Technology at UPMC

The UPMC Division of Endocrinology and Metabolism offers a full range of DM technologies to assist patients with diabetes in achieving their optimal glycemic control and overall improved health. Technologies offered in our program include professional CGM and interpretation, CSII initiation, real-time CGM initiation, and use of hybrid closed loop systems. Additionally, the Division offers potential opportunities for patients to use the latest in smart phone apps and other diabetes technologies through clinical research opportunities.  Conveniently, these services are offered through telemedicine encounters that allow for access to patients in their own home or setting most comfortable for them.  

Through the combined efforts of our physicians, certified diabetes educators, advanced practice nurses, and staff, we have a comprehensive diabetes care and self-management education program that utilizes and integrates these technologies with lifestyle, physical activity, and dietary choices to help patients begin to understand the complex nature of glycemic management and obtain optimal glucose control. With all of the innovative tools and technology being introduced in diabetes care, the Multidisciplinary Diabetes Clinic is being used to accommodate all of these rapid advances in diabetes care, and it is ready for all of the innovations ahead.

References

1. U.S. Food & Drug Administration (FDA) News Release. FDA Expands Indication for Continuous Glucose Monitoring System, First to Replace Fingerstick Testing for Diabetes Treatment Decisions. Dec. 20, 2016.

2. Garg S. The Future of Glucose Monitoring. Diabetes Technol Ther. 2016; 18(2): S2-iv-S2-2.

3. Bergenstal RM, Garg S, Weinzimer SA, et al. Safety of a Hybrid Closed-loop Insulin Delivery System in Patients With Type 1 Diabetes. JAMA. 2016; 316 (13):  1407-1408.

4. American Diabetes Association. Strategies for Improving Care. Diabetes Care. 2016; 39 (Suppl. 1): S4-5.

5. Brown SA, et al.  Six-Month Randomized, Multicenter Trial of Closed-Loop Control in Type 1 Diabetes.  N Engl J Med.  2019; 381:  1707-1717

6. Rui L, Sundar S, Lipman R, Burrows N, Kolb L, Rutledge S. Diabetes Self-management Education and Training Among Privately Insured Persons With Newly Diagnosed Diabetes. The CDC Morbidity & Mortality Report. 2014; 63(46): 1045-1049.

7. Duncan I, Ahmed T, Li QE, Stetson B, Ruggiero L, Burton K, Rosenthal D, Fitzner K. Assessing the value of the diabetes educator. Diabetes Educ. 2011 Sep-Oct;37(5):638-57. doi: 10.1177/0145721711416256. Epub 2011 Aug 30.

8. Ruppert K, Uhler A, Siminerio LM. Examining Patient Risk Factors, Comorbid Conditions, Participation, and Physician Referrals to a Rural Diabetes Self-management Education Program. Diabetes Educ. 2010; 36(4): 603-12.

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