Better education, preparation can optimize patient use of CGM
SAN FRANCISCO — Several potential barriers can impede the regular use of continuous glucose monitoring for patients with diabetes, and providers must confront issues of cost, insurance and burdensome paperwork “like preparing them for a trip to the DMV,” according to a speaker here.
CGM use has steadily risen over time, as more devices are FDA approved and the technology improves, Rebecca L. Longo, ACNP-BC, MSN, CDE, a nurse practitioner specializing in adult diabetes and medical weight loss at Lahey Hospital and Medical Center in Burlington, Massachusetts, said during a presentation at the American Diabetes Association Scientific Sessions. Regular CGM use is associated with improvements in multiple diabetes outcomes, including a reduction in HbA1c, less hypoglycemia, more time spent in the recommended glucose range and better quality of life metrics, she said. However, recent T1D Exchange data suggest that, over time, CGM use declines, particularly among adolescents.
“Regular use is key,” Longo said during her presentation. “We can prescribe the CGM, but we need to have patients wearing it. When you combine [data] from several of the major trials, 80% adherence seems to be the marker where patients see the optimal benefit.”
Recent T1D Exchange survey data revealed several reasons patients report not wearing CGM, Longo said. Respondents reported reasons ranging from expense, insurance issues, device discomfort, pain, possibility of infection or unfamiliarity with the device.
“When looking at the 14% of patients who discontinued continuous glucose monitoring use, really homing in on these factors is important,” Longo said. “Accuracy, insurance coverage, false alarms ... many of these are modifiable factors.”
JDRF survey data revealed similar patient-reported barriers, Longo said, including expense, problems with insertion, persistent alarms (alarm fatigue), accuracy issues and adhesion problems.
“Cost is still No. 1,” Longo said. “They’re expensive. Each individual company has different subscription programs, out-of-pocket policies, and it’s impossible to find out what the actual price of the CGM is.”
Longo noted that for Medicare patients, criteria for covered CGM is strict; patients must perform self-monitored blood glucose monitoring at least four times daily, need at least three insulin injections daily or be on pump therapy, and must be seen by a health care provider every 6 months to assess the patient’s CGM regimen and diabetes treatment plan. In most cases, Longo said, Medicare patients must obtain their CGM from a durable medical equipment company — not a pharmacy.
“I can’t tell you how many phone calls I get that say, ‘The doctor did not submit the paperwork,’” Longo said. “I know full well I submitted that paperwork, in fact I faxed it myself the week before. Then after 30 minutes on the phone with the device company, you figure out that the patient hasn’t been seen in 6 months, and the insurance requires they have at least 6-month visits.”
To avoid confusion and cost surprises, Longo said, insurance education for patients is key.
“It can be difficult to get into the requirements of the insurance company, and it takes a lot of perseverance by the patient,” Longo said. “Like preparing them for a trip to the DMV, let them know that this can be burdensome, require a lot of paperwork and be time-consuming, but with better education, they can have realistic expectations to get a device.”
Longo said prescheduling visits can also be helpful, as well as education about reordering supplies like test strips and batteries. Additionally, providers should educate patients on sensor placement, rotation of placement and proper cleaning of the site to avoid skin irritation and infection. Accuracy should also be discussed, noting that there might often be a difference between a reading from a blood glucose meter vs. a CGM.
To avoid so-called CGM alarm fatigue, which can interrupt sleep and lead to distress, Longo recommend considering what a patient can handle. If a patient has significant hypoglycemia, for example, higher glucose targets may help. However, high targets may not best serve patients who experience a sense of anxiety or failure with multiple alarms. Newer devices allow for customizable alarms for nights vs. days, Longo noted.
“It is important to remember that, despite the device, diabetes-related distress is prevalent throughout diabetes,” Longo said. “CGM, non-CGM, pump or [multiple daily injections]. Discuss distress with the patients and their family and use the psychosocial interventions we can do for diabetes distress.”
Many CGM devices come with software that allows patients to view customizable reports similar to what a health care provider can view in-office, Longo said. Providers should educate patients on how to best use these reports to track glycemic patterns and set goals when appropriate.
“Engage the patient in more than just the day-to-day blood sugar, so they can see the effect over time of their different choices,” Longo said. “Use the customizable alerts.”
For some patients, remote CGM monitoring via smartphone can help alleviate diabetes-related burden or anxiety, Longo said, with the caveat that education must happen within the family, particularly regarding older adults who experience more glucose variability.
“Education is key,” Longo said. – by Regina Schaffer
Longo RL. Motivating patients to wear continuous glucose monitors. Presented at: American Diabetes Association 79th Scientific Sessions; June 7-11, 2019; San Francisco.
Disclosure: Longo reports no relevant financial disclosures.