AACE Podcast Episode 51: Clinical Conversations in Diabetes Technology

Date: August 5, 2024
Host: AACE
Guests: Maria Mogollon, FNP & Dr. Jeff Unger, MD
Theme: Exploring the clinical practice, benefits, and real-world impact of diabetes technology, particularly continuous glucose monitors (CGMs), on patient care and workflow.

Episode Overview

This episode delves into the transformative role of diabetes technology—especially CGMs—in modern endocrinology practice. Host Maria Mogollon, NP, and expert guest Dr. Jeff Unger bring practical experience, patient anecdotes, and updated guidelines to illuminate how CGMs can optimize diabetes management for both providers and patients. The conversation covers candidate selection, onboarding, financial considerations, barriers, primary care roles, and the nuances of interpreting CGM data.

Key Discussion Points & Insights

1. Broadening Access: Who Should Use CGM?

• Dr. Unger's Recommendation: All people with diabetes should be considered for CGM, not just select patients.
  • “Anyone with diabetes deserves CGM.” (02:23)
• Fingersticks are impractical compared to CGMs, which provide continuous, actionable data.

2. Addressing Financial Barriers & Misconceptions

• Cost Comparison: CGMs are more cost-effective than frequent fingersticks.
  • “One finger stick cost $1.15...but CGM reading cost .008 cents.” (03:30)
• The expanded information provided by CGMs outweighs their cost and enhances patient outcomes.

3. CGM in Primary Care and Patient Education

• Universal Prescribing: All primary care physicians should prescribe CGMs when possible.
  • “Everybody that has diabetes needs to be on CGM.” (05:07)
• Patient Fears: Open conversations help patients overcome anxieties about complications.
  • “What scares you the most about diabetes?...Nothing’s going to happen to you on my watch.” (06:16)

4. Onboarding Patients: Time and Workflow Solutions

• Time Commitment: Onboarding is quick—putting the sensor on takes seconds; education about five minutes.
  • “Takes about a tenth of a second to put the sensor on... five minutes to onboard.” (07:32)
• Team Approach: Training staff and even utilizing manufacturer resources can streamline onboarding.
• Personal Touch Matters: Doing setup in-office vs. referring patients to tech support is preferable for most.

5. CGM for Special Populations

• Patients on Dialysis: CGMs provide more reliable glucose metrics than A1C due to red blood cell turnover. Use GMI (Glucose Management Indicator) instead.
  • “A1C is not reliable in dialysis; what you've got to do is put these people on sensors.” (11:13)
• Hypoglycemia Risk: Sensors’ alarms are invaluable for elderly and high-risk patients.

6. Challenging Resistance & Stigma

• No “Bad” Candidate: Dr. Unger asserts virtually everyone can benefit, even those with prediabetes or those resistant to technology.
  • “I don't know of anybody that's not a good candidate.” (13:10)
• Dealing with Resistance: Empathy, education, and real-life role modeling in the community help reduce stigma.

7. Case Studies: Transformative Patient Stories

• Refractory Patient: A patient with years of poor control (A1C >12) and repeated hospitalizations stabilized within 67 days after starting CGM. (09:13)
  • “It took 67 days to go from time in range 0% to 76%...A1C dropped from 12 to 7.2.” (09:13)
• Soccer Mom Example: CGMs provide trend data, crucial for safety decisions (e.g., driving after insulin use).
  • “The sensor is going to detect if the glucose level is trending up, down, or...straight across.” (16:26)
• Enthusiastic Learners: Even tech experts get excited, analyzing CGM data to better understand their response to interventions.
  • “Did you know that when you exercise your blood sugar goes down?” (23:01)

8. Interpreting CGM Reports

• First Priorities:
  • Time in Range (“green zone”): >70% between 70–180 mg/dL
  • Time Below Range: <4% (may reduce to 2% in older/frail patients)
  • GMI: Algorithm-predicted A1C
  • Glucose Variability: <33% desirable; “flat lines” are good (in contrast to other specialties)
    • “Diabetologists like flat lines...what do cardiologists do when they see a flat line?...they get really nervous.” (19:20)
• Ease of Use: The AGP (Ambulatory Glucose Profile) report is simple for clinicians and patients to interpret.

9. Billing and Compensation

• Reimbursement Available: Providers can bill for onboarding and interpreting CGM data (monthly downloads), including via telemedicine.
  • “We can be compensated...not doing this for nothing...in exchange for our time, we can bill for it.” (20:35)

Memorable Quotes & Moments

• On CGM Cost Benefit:

  “It's a lot cheaper to use CGM than it is to use finger sticks. And that's why I tell people...they get so much more information.”
  — Dr. Jeff Unger, (03:30)

• On Patient Fears:

  “Nothing’s going to happen to you on my watch. I’ve got your back.”
  — Dr. Jeff Unger, (06:16)

• Defining “Who Needs CGM?”

  “I don't know of anybody that's not a good candidate...even for prediabetes we use it.”
  — Dr. Jeff Unger, (13:10)

• On CGM as Empowerment:

  “Look how excited people are, Maria, with this technology. And look how we could stimulate them to do the right thing.”
  — Dr. Jeff Unger, (23:02)

• On Flat Lines in Diabetes:

  “Diabetologists like flat lines. Very, very important. What do cardiologists do when they see a flat line? Well, they get really nervous.”
  — Dr. Jeff Unger, (19:20)

Notable Timestamps

| Segment | Timestamp | |-----------------------------------------------------|-------------| | Opening, introductions | 00:05–01:10 | | Who is a good candidate for CGM? | 02:23 | | CGM vs. fingersticks: cost, data, patient benefit | 03:30 | | Primary care role and patient fears | 05:07–06:16 | | Onboarding workflows and staffing tips | 07:32–08:19 | | Special populations: dialysis, hypoglycemia risk | 11:13 | | Resistant patients and stigma | 14:30 | | Soccer mom (type 1) case study | 15:49 | | Interpreting AGP report: time in range, variability | 17:23–20:10 | | Billing, remote visits | 20:35 | | Bob the rocket scientist: patient engagement story | 21:43–23:02 | | Final encouragement and closing | 25:10–25:36 |

Final Recommendations & Takeaways

• Embrace CGM as a universal tool for diabetes management—including in primary care, for elderly, and for dialysis patients.
• Onboard patients effectively—dedicate a few minutes, use your staff, and prioritize a supportive in-person experience.
• Understand and leverage reimbursement—bill for onboarding and interpretation, including via telemedicine.
• Interpret AGP reports with focus—time in range, time below range, GMI, and glucose variability.
• Empower your patients—CGM creates informed, engaged, and healthier diabetes management.

Summary compiled by [AACE Podcasts] – Episode 51: Clinical Conversations in Diabetes Technology.