You’re listening to Podcast to Practice, brought to you by Springer Healthcare IME.

Podcast to Practice brings you expert led independent medical education discussions inspiring healthcare professionals to maximize their learning and make measurable changes in their own clinical practice.

This podcast is part of an independent medical education program entitled, “techniques for implementing continuous glucose monitoring and primary care”, and is supported by an independent educational grant from Abbott.

My name is Dr. Eugene Wright, and I hold an appointment as consulting associate in the Department of Medicine of Duke University Medical Center and currently serve as the medical director for performance improvement at the South Piedmont Area Health Education Center or AHEC here in Charlotte, North Carolina.

I’d like to welcome you to this independent medical education program on CGM device updates, which we’ll share with you a couple of exciting innovations, advancements and discoveries in continuous glucose monitoring that were presented at the ADA or American Diabetes Association 84th Scientific sessions held in Orlando, Florida between June 21st -June 24th, 2024.

While there were many intriguing sessions at ADA this year, I’ll focus on just a few key sessions in particular which I feel will impact your practice the most.

In the opening address, titled “The Dissociations Between Technology Advances and Health Outcomes for Diabetes in the US – What Should We Do Differently?”, FDA Commissioner, Dr. Robert Califf argued that “Technologic advances aren’t fulfilling their promise for improving diabetes or overall health outcomes in the U.S.”.

Dr. Califf pointed out CGM technology as not always reaching those who might benefit the most. “Technology has brought incredible advances in diabetes, notably continuous glucose monitoring and pumps that make life more manageable for patients.” However, Califf pointed to a truism Ed Yong wrote in The Atlantic, “Technological solutions tend to rise into society’s penthouses, while epidemics seep into its cracks.” 

New Technology—Equity and Access

In a Day 1 panel discussion regarding new technology equity and access included thought leaders from across several disciplines discussing the implications for technology equity and access.

Dr. Ramzi Ajjan of the University of Leeds in the UK noted that Black individuals with diabetes have greater hospitalizations for hypoglycemia, perhaps due to over treatment of elevated measured A1c values compared with average glucose related to red blood cell biology.[1]

In their study, they used CGM and bi-monthly A1c collected in a 26-week study of adults with T1 or T2 diabetes across different racial groups. They noted a clinically significant A1c, and average glucose derived A1c, discordance, particularly in black individuals with A1c levels being measured higher than average glucose derived A1c. This suggests that CGM metrics may be better than A1c for assessing glycemia in Black patients.

In another presentation from this session by Dr. Medha Munshi Director of the Joslin Geriatric Diabetes Program, discussed the implications for CGM use in long-term care facilities.[2] In her study, of 65 residents with a mean age of 65 years and 50% female, 14% of the cohort was on a SU medication and 68% were on insulin.

The CGM data showed 26% of the cohort with >1% time spent in hypoglycemia or below 70 mg/dl. A larger burden of hyperglycemia was seen in 54% of the cohort spending > 10% of the time above 250 mg/dL, 37% spending > 25% time above 250 mg/dl and 14% spending > 90% above 250 mg/dl.

Fingerstick reading frequency was 2 or fewer times /day in 74% of the cohort, 3 times/day in 13% of the cohort and 4 or more times a day in only 13%. On average this cohort had 13 comorbidities with 85% having functional disabilities. The A1c’s in this group were: 45% had A1c <7%, 27% were between 7%-8% A1c, 12% were between 8.1%-9% A1c, and 16% > 9% A1c.

Her conclusions from the study were that patients with Diabetes living in long-term care facilities have a high burden of both hypo- and hyperglycemia despite fair control of A1c. More consistent use of CGM would help identify glycemic excursions to improve therapeutic decision-making.

The Role of the Interdisciplinary Team in Technology Onboarding in Primary Care

On day 2, Dr. Eden Miller of Bend, Oregon in her presentation showed data and evidence that CGM helps not only patients on insulin therapy but also patients on non-insulin therapy. This was presented previously as a poster.[3] More recently the incremental A1c benefit of adding CGM to patients on GLP 1 RA’s was demonstrated in a real world observational study of a large US claims database. That study showed adding CGM to GLP 1 RA provided additional A1c reduction. After FSL acquisition, average HbA1c decreased from 9.8 ± 1.5% to 8.3 ± 1.6%, in patients on GLP 1 RA with the last prescription 90 days prior to FSL prescription. In another study starting a CGM (within 30 days) with a GLP1 RA compared with GLP 1 RA without CGM, had a greater A1c reduction at the first A1c within 60-300 days post CGM (2.43% with CGM vs 1.73% with GLP 1RA alone). These studies provide evidence for the benefit of adding CGM in patients on GLP 1 RA therapy.

New Technology- Glucose Monitoring and Sensing

Throughout the meeting several posters and presentations demonstrated the value of CGM for the primary care practitioner. Poster 1927-LC by Dr. Satish Garg et al., used Optum’s de-identified Market Clarity data of >79 million people to evaluate CGM use in 74,264 people with type 2 diabetes who were treated with non-insulin (NIT; n=25,788), basal insulin (BIT; n=25,292), and prandial insulin therapy (PIT; n=23,184).[4] The primary outcomes were changes in all-cause hospitalizations (ACH), acute diabetes-related hospitalizations (ADH), and acute diabetes-related emergency room visits (ADER) during the 6- and 12-months post-index period.

The results were striking in all categories. The non-insulin therapy, the basal insulin therapy, and the prandial insulin therapy showed significant improvements in all cause hospitalization, all cause diabetes related hospitalizations, and all cause diabetes related emergency room visits. Furthermore, these reductions were sustained during a six to 12 month for all groups.

The results were striking in all categories. The non-insulin therapy, the basal insulin therapy, and the prandial insulin therapy showed significant improvements in ACH, ADH, and ADER. NIT (14%, 32%, 30%), BIT (25%, 57%, 37%), PIT (25%, 54%, 36%) respectively. Furthermore, these reductions were sustained during 6-12 months: NIT (10%, 31%, 30%), BIT (23%, 56%, 34%), and PIT (19%, 49%, 36%) respectively. Again and all were statistically significant (p<0.0001).

The conclusions were that the use of CGM in real-world across different therapeutic regimes in people with type 2 diabetes was associated with significant reductions in all-cause hospitalizations, acute diabetes-related hospitalizations and ER visits.

New Technology—Continuous Glucose Monitoring

Ms. Valerie Ruela of USC presented six-month outcomes from the Hankey Project, which provides free CGM and remote monitoring for one year to people with diabetes from under-resourced backgrounds in Los Angeles.[5] Participants were provided an Abbott FreeStyle Libre 2 CGM and followed via LibreView – additionally, data from blinded CGM were obtained at baseline, six months, and one year. AGP and clinical data were sent to the principal investigators as clinically indicated (weekly, monthly, quarterly), which then allowed the HCPs to make CGM-based recommendations based on the LA County algorithms for diabetes management. Project staff reviewed LibreView daily and participants were contacted with diabetes education if glucose values were <70 mg/dL or ≥250 mg/dL more than 5% of the time. 195 participants completed six months.

Non-insulin users saw a 3.6 hour/day improvement in Time in Range, from 53% at baseline to 68% at six months (p<0.001). Insulin users also saw improvements, from 47% at baseline to 59% at six months, resulting in +2.9 hours/day in Range (p<0.001). Non-insulin users saw a 2.2% reduction in A1c, from 9.7% to 7.5% at six-months (p<0.001), and insulin users saw a 1.3% reduction in A1c, from 9.3% to 8% at six-months (p<0.001). Ms. Ruela explained that these improvements were sustained to 12 months. Importantly, diabetes distress significantly decreased in both groups.

Due to CGM remote monitoring, there was significant uptake of GLP-1 RAs in the cohort. In non-insulin users (n=72), GLP-1 RA use increased from 14% at baseline to 39% at six months. The insulin cohort (n=123) saw an even greater increase, from 24% at baseline to 69% at six months. Ms. Ruela noted that while there was great increase in incretin uptake, only two participants in the non-insulin group began insulin post baseline. 

Dr. Peters, the PI, noted that CGM uptake has been “incredible” in this population. While this remote monitoring model requires a significant time commitment, the researchers hope remote monitoring systems will improve in the future to expand this work. Ms. Ruela shared that the study will complete in February 2025.

CGM Implementation in Primary Care Practices

To expand this work, Dr. Thomas Grace presented his data that showed that a collaboration between a primary care practice and the local public health department to improve CGM access, could favorably impact diabetes outcomes.[6]

In his study, CGM systems (Dexcom G6 and G7) were provided to eligible participants with T2D who were ≥18 years of age, CGM-naïve, and did not have health insurance coverage for CGM. Outcomes included changes in A1C and CGM metrics from baseline to one year.

The results showed that participants (n=177) were (mean ± SD) 59.1 ± 12.0 years, 41.2% female, BMI 35.5 ± 8.5, duration of diabetes 11.1 ± 9.3 years. After one year, A1C decreased from 9.4% ± 1.6 to 7.1% ± 1.3 (-2.3% ± 1.9, p<0.001). The proportion of participants meeting the ADA target of A1C <7.0% increased from n=1 (0.6%) at baseline to n=91 (51.4%) at one year. Those meeting the HEDIS target of A1C <8.0% increased from 19.2% at baseline to 85.9% at one year. CGM outcomes (n=109) after near-continuous use included an increase in TIR of 9.9% ± 29.4 (p<0.001) and a large increase in TITR (p<0.001, Table).

His conclusion was that self-guided use of CGM by primary care patients with T2D for one year was associated with clinically meaningful improvements in A1C and TIR.

What was striking about this study is that the patients received limited education on diabetes or CGM.

On Monday in Oral presentations on New Technology-Continuous Glucose Monitoring, Dr. Sean Oser of the University of Colorado described his PREPARE 4 CGM study that described the strategies for implementation of CGM in primary care practices.[7] He spoke about the different resources and tools to assist with implementation to include the AAFP CGM implementation modules through the AAFP TIPS and the Virtual CGM Implementation Services (VirCIS) platforms. He noted that DCES’s have the potential to be the technology champions for the busy PCP and be integrated into the multidisciplinary team in primary care. His toolkits and platforms are suited for the PCP that is eager to implement technology but uncertain how to go about getting started.

I think the key take away points are that continuous glucose monitoring is an incredibly powerful tool in clinical practice to help our patients better understand and manage their diabetes. It can help guide nutrition choices, enable timely and effective medication management on the part of the HCP and the patient, and help prevent the harms associated with hypoglycemia.

Implementing CGM in primary care practices is feasible and improved glycemic outcomes as well as reduced diabetes distress, however, is best done with a team-based approach.

There are a number of available resources to help clinicians and practices get starting using CGM in their practice. I hope you check out Springer Healthcare IME’s CME-accredited interactive infographics and Tweetorials where I, along with Dr. Rosalina McCoy and Dr. Jennifer Green, dive deeper into the most important considerations for CGM use in primary care.

Thanks for listening to this podcast update! Stay tuned for the next podcast where we will continue talking about recent updates in the CGM field.

Thank you for listening to Podcast to Practice brought to you by Springer Healthcare IME. For more information on our educational programs available, visit ime.springerhealthcare.com.

REFERENCES

[1] Ramzi Ajjan, Timothy Dunn, Yongjin Xu, Pratik Choudhary; 142-OR: A1C and Average Glucose Discordance—Personalized A1C Improves the Discrepancy, Particularly in Black Individuals. Diabetes 14 June 2024; 73 (Supplement_1): 142–OR. https://doi.org/10.2337/db24-142-OR

[2] Christine Slyne, Kirsten Roberts, Colin D. Conery, Haley Brabant, Noa Krakoff, Elena Toschi, Medha Munshi; 145-OR: Assessing the Current State of Diabetes Care in Long-Term Facilities Using Continuous Glucose Monitoring. Diabetes 14 June 2024; 73 (Supplement_1): 145–OR. https://doi.org/10.2337/db24-145-OR

[3] Eden Miller. Is Primary Care the Best Place for Continuous Glucose Monitoring (CGM) Initiation?. Poster presented at ADA; June 21^st-24^th, 2024; Orlando, Fl.

[4] Satish K. Garg. Impact of Continuous Glucose Monitoring Use on Hospitalizations in People with Type 2 Diabetes—Real-World Analysis. Poster presented at ADA; June 21^st-24^th, 2024; Orlando, Fl.

[5] Valerie F. Ruelas, Anne L. Peters; 358-OR: Remote CGM Monitoring in People with Type 2 Diabetes (T2D) in an Under-resourced Setting. Diabetes 14 June 2024; 73 (Supplement_1): 358–OR. https://doi.org/10.2337/db24-358-OR

[6] Thomas Grace, Jennifer E. Layne, Christian Hicks, Courtney R. Green, Tomas C. Walker; 982-P: The Dexcom Community Glucose Monitoring Project for People with Type 2 Diabetes—One-Year Outcomes. Diabetes 14 June 2024; 73 (Supplement_1): 982–P. https://doi.org/10.2337/db24-982-P

[7] Sean Oser, Kimberly T. Wiggins, Tristen Hall, L. Miriam Dickinson, Kristin Crispe, Perry Dickinson, Tamara Oser; 359-OR: CGM in Primary Care—Practice Characteristics and Choice of CGM Implementation Strategy in PREPARE 4 CGM. Diabetes 14 June 2024; 73 (Supplement_1): 359–OR. https://doi.org/10.2337/db24-359-OR