continuous glucose monitoring part 1 · continuous glucose monitoring (cgm) in conjunction with...

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CONTINUOUS GLUCOSE MONITORING

PART 1

Veronica Brady, PhD, FNP- C, BC-ADM, CDEUniversity of Nevada, Reno School of MedicineJuly 20, 2017

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COURSE OUTLINE(4- 40 MINUTE SEGMENTS)

1. What is CGM professional personal

2. Identification of appropriate candidates for CGM pre-DM, T1 or T2DM patients not at goal hypoglycemia unawareness

3. Interpretation of data review downloads from 3 available devices

4. Billing and coding cost of professional device ROI billing codes

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OBJECTIVES1. Define continuous glucose monitoring

(CGM)2. Identify the different types of CGM devices3. Identify appropriate candidates for the use

of CGM4. Verbalize understanding of data

interpretation5. Have a beginning knowledge of billing for

CGM insertion and interpretation

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WHAT IS CGM? Sensor composed of microelectrode coated with glucose

oxidase beneath biocompatible membrane, which converts glucose in the interstitial fluid into an electronic signal proportional to amount of glucose present.

Provides BG readings every 5 minutes (288 readings/day)

Lag time= 5 minutes

Requires finger stick BG at least q12 hours for calibration

Accurate for BG 40-400mg/dL

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CGM AT A GLANCE.

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TYPES OF CGM

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CGM CATEGORIES AND DEVICES

GlucoWatch – 1999

Current devices DexCom G4 Platinum DexCom G5 Medtronic Guardian REAL-Time MiniMed Paradigm REAL-Time MiniMed 530G with Enlite FreeStyle Libre Pro

Two categories: Professional- Medtronic iPro2, FreeStyle Libre or DexComG4

Platinum Professional Personal

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PROFESSIONAL USEBlinded

Medtronic i-Pro2 FreeStyle LibreDexcom G4 Patient does not get to

view blood glucose readings No alarms/warnings

Unblinded

DexCom G4 Patient can view readings

–and has opportunity to change behaviors based on readings Alarms/warnings

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AVAILABLE CGMDEVICES

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DEXCOM G4

Receiver-displays sensor BG readings (range up to 6 meters)

Sensor-measures glucose levels q 5 minutes

Transmitter- wirelessly sends BG readings to receiver

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MEDTRONIC IPRO2.

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FREESTYLE LIBRE PRO.

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LIBRE PRO SENSOR.

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SITE SELECTION AND SIZE OF TRANSMITTER

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SENSOR INSERTION.

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COMPARISON OF PROFESSIONAL DEVICES

Device Warm up period

Calibrations Days of Wear

Restrictions MultiplePatient Use

Free Style Libre

No None 14 No scans No

DexcomG4

2 hours 2x/day 7 No scans Yes

MedtroniciPro2

No None 6-7 Water proof for 30 minutes

Yes

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REMOTE APPLICATIONS

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DEVICES WITH REMOTE CAPABILITY

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THERAPEUTIC CGM: DEXCOMG5

Approved by FDA to use CGM values to make treatment decisions (replace blood glucose meter)

Currently only “therapeutic” CGM system on the market

Covered by Medicare

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AACE, ACE AND ADA RECOMMENDATIONS

FOR USE OF CGM

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AACE & ACE CONSENSUS ON CGM 2015

CGM usage has improved clinical diabetes outcomes by reducing hypoglycemia (1).

CGM is recommended in all patients with type 1 diabetes and should be available to all type 2 diabetes on multiple insulin injections, basal insulin, or sulfonylureas.

CGM should also be used in all patients who are at risk for hypoglycemia and/or have hypoglycemia unawareness (10).

CGM in type 2 diabetes can be useful in identifying and correcting postprandial glycemic excursions (11,12).

Intermittent use of CGM (usually 1-2 weeks) in patients with type 2 diabetes might be more effective than daily glucose fasting glucose in guiding the need for medication adjustment or advancing to new medications.

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AACE & ACE CONSENSUS 2017

CGM is recommended for patients with type 1 diabetes who have a history of severe hypoglycemia, hypoglycemia unawareness, or frequent hyperglycemia.

There is insufficient evidence to recommend CGM among patients with type 2 diabetes at this time.

Data on CGM during pregnancy are unclear.

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ADA STANDARDS OF CARE 2017

Continuous glucose monitoring (CGM) in conjunction with intensive insulin regimens is a useful tool to lower A1C in selected adults (aged ≥25 years) with type 1 diabetes.

Although the evidence for A1C lowering is less strong in children, teens, and younger adults, CGM may be helpful in these groups. Success correlates with adherence to ongoing use of the device.

CGM may be a useful tool in those with hypoglycemia unawareness and/or frequent hypoglycemic episodes.

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ADA STANDARDS OF CARE 2017 (CONT)

Given the variable adherence to CGM, assess individual readiness for continuing CGM use prior to prescribing.When prescribing CGM, robust diabetes

education, training, and support are required for optimal CGM implementation and ongoing use.People who have been successfully using CGM

should have continued access after they turn 65 years of age.

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BENEFITS OF USE CGM

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DETECTION OF HYPER/HYPOGLYCEMIA

CGM provides a “movie” of BG readings as opposed to a “snapshot”. Grunberger, 2015

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BENEFITS OF CGM (DIAMON D S TUDY, ADA 2 016)

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SUMMARY

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WHAT CGM DOES/DOES NOT DO

What CGM does: Tells if glucose is rising or falling—indicating need for

treatment Provides immediate feedback on impact of diet, exercise &

insulin Alarm if glucose is too high or too low Improves glycemic control (reducing A1c) with decrease risk of

lows

What CGM does not do: Replace finger sticks if blood glucose <40 or >400mg/dL Replace need for training in DM management

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TAKE HOME MESSAGECGM is useful for detecting hypoglycemia

especially in patients with reported “hypoglycemia unawareness”.

CGM is a useful tool to determine glucose fluctuates in patients who are difficult to get to target

CGM can be used with or without an insulin pump

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NEXT 3 COURSES1. Appropriate candidates for CGM2. Interpretation of data3. Billing and coding

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