COMMENTARY

CGM in Primary Care: Too Much Information or Excellent Tool?

Jay H. Shubrook, DO; Davida F. Kruger, MSN, APN-BC, BC-ADM

Disclosures

July 28, 2017

Jay H. Shubrook, DO: Hello. I am Jay Shubrook, a family physician and diabetologist at Touro University California College of Osteopathic Medicine in Vallejo, California. Today we continue our series on practical insulin use in primary care. I am speaking with Davida Kruger, an advanced practice nurse who is board certified in advanced diabetes management. Ms Kruger is from the Henry Ford Health System Division of Endocrinology and Diabetes. Good morning.

Davida Kruger, MSN, APN-BC, BC-ADM: Good morning, Jay.

Dr Shubrook: Today we are discussing continuous glucose monitoring (CGM), an important topic both today and as we look into the future of diabetes care. What is CGM?

Ms Kruger: CGM is a device, and quite a marvelous and geeky opportunity. I have been in the diabetes field for 35 years, and now that we have CGM available, the idea that we used to practice without it is stunning.

I am going to talk primarily about professional use of CGM by the healthcare provider. We place the small CGM device on the patient and leave it for anywhere from 5 to 14 days. It records more than 200 blood sugar levels a day. By the time the patient comes back to see the healthcare team, we have all kinds of data to help us make adjustments in that patient's lifestyle, medication, insulin, or whatever program the patient is on. It provides visuals and graphs to make those decisions.

Dr Shubrook: That sounds exciting and complicated. Please tell me a little more about what you mean by "professional." I believe you are comparing "professional" and "personal," and I need to understand what that means.

Ms Kruger: "Professional" means that the clinician places the device, owns the device, and the patient is only going to wear it for a defined period of time. "Personal" means the patient owns the device. I have 800 people in my practice who own the device they wear continuously. What I was referring to initially is professional use. Before CGM, when patients came to see me and I looked at their A1c results, even those patients with good A1c levels, I was not able identify whether they were having lows and highs, because the A1c is an average. The CGM gives me every blood glucose level at almost every minute of the day so that I can see exactly what is happening to the patient at a given time. I can see what is happening when the patient is sleeping; we are all very concerned about hypoglycemia when patients are sleeping. The fewest number of daily blood sugar measurements is about 220 that I can graph out.

It is a very simple, uncomplicated device that is waterproof. We place it on the patient, the patient wears it, comes back or mails the device to me, and then I plug it into a computer and the algorithm in the computer provides these beautiful pictures that allow me to then make clinical judgements.

Dr Shubrook: Is this something that can be used in primary care?

Ms Kruger: Absolutely. Typically, the patient in primary care does not bring a meter or a log book, and we are stuck looking at an A1c and trying to adjust medication based on that reading. So many patients have diabetes, and we all know that the primary care world sees the majority of the patients, not the specialist. CGM has provided the patient and provider a lot of information about glucose management. You can easily have a member of your office staff place the device. You can bill for the placement of the device, and then the patient can bring it back or mail it back, and you can bill for the interpretation of the data and make very good clinical judgements. There is no reason why the primary care physician or nurse practitioner on the team cannot use CGM.

Dr Shubrook: If I am interested in CGM, what do I need to have in my practice?

Ms Kruger: If you are interested in CGM, the first thing is to decide whether to use one company, two companies, or three companies. We chose to use two companies. The companies come in and set up the system. The outlay is the cost of the sensor, but that is built into the startup, so it really does not cost you anything. We had the companies come in, get it started, and set up the icons on our computers; our medical assistants download the CGM results when the patient comes in, and we put the results directly into our electronic medical records system. As the healthcare provider, I then take the data and give the patient a copy, and then make some decisions with the patient.

Dr Shubrook: It sounds like I need another person in my office, to place the devices and download the results.

Ms Kruger: For 10 years we did it without another person, but our program is so big now that we have a staff member dedicated to this 3 days a week. Your nursing staff or a medical assistant can take care of this, depending on the device. This morning, one of my patients showed up a day early, and before I even started clinic I was able to place it on her—literally within 3 minutes. I instructed her that all you have to do is wear it and mail it back to me. You really can streamline the process. What I usually tell providers is that the first five patients are the most difficult, until you figure out what is going on in your clinic. After that, it pays for itself--it actually more than pays for itself—and you get data that you otherwise would not have. Almost anyone in your office can place it. Data must be interpreted by a physician, nurse practitioner, or physician assistant in order to bill for it. The patient can come back for a visit or you can discuss results over the phone. In that case, you can bill for the interpretation over the phone, but not the visit.

Dr Shubrook: In my practice, I typically do not get enough information from my patients. Now you are telling me that I will get 220 readings or more? That sounds like too much information. How is this organized?

Ms Kruger: The beauty of it is that the download is put into graphs for you. The graphs are quite straightforward. This year, the American Association of Clinical Endocrinologists came up with the idea of incorporating the ambulatory glucose profile (AGP). This means that all of the downloads will look the same, regardless of the device. Results will be provided in a two-page document. You will be able to look at the document and say, that is the graph, those are the dailies, I can make a decision. Some of these are also going to help the primary care provider. The companies are also being very sensitive to the primary care world and providers who do not see this every single day of their lives, as I do. The companies provide directions in terms of saying, this is trending here or that is trending there. Right now each of the three companies has its own distinct downloads that are very easy to read, but in the next year or so you will see everyone using the AGP, so no matter which device you are using, you will get the same type of download.

Dr Shubrook: It really is an exciting time in the field of diabetes. If I wanted to start today, what are the first few steps? What are the three companies and how do I get started?

Ms Kruger: The devices are the Dexcom G4, FreeStyle Libre Pro by Abbott, or the iPro by Medtronic. Whichever company the provider is most interested in will come in to the office and get them going. A primary care office may be most interested in the Abbott Libre Pro because there is no investment in hardware, just software. You buy the sensors and place them on the patients. If you have patients on insulin, you may also want to look at the Dexcom G4 or the iPro. In my practice we use the Dexcom G4 and the Abbott FreeStyle Libre Pro. We probably place 10 or 12 a day.

Dr Shubrook: This is quite exciting, and it sounds like an area where we could really do some exploration. Thank you for sharing your expertise with us today.

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