Medtronic Technology & Therapies Symposium Summary
Real World PLGM Performance
Dr Kaufman shared the latest results from the recently published paper reporting the real world performance of the SmartGaurd™ technology Suspend Before Low function as compared to previous low glucose suspend technologies. The real world data of nearly 5,000 users using the currently available MiniMed 640G and Enlite™ glucose sensor, totalling 286,149 user days of data showed that not only did the suspend below low function reduce time spent less than 3.9 mmol as compared to LGS, but users also spent less time above 13.3 mmol. Importantly the real world data is also showing that in a similar outcome to clinical studies that the suspend before low function avoids the low limit being reached approximately 75% of the time. The full paper can be accessed http://online.liebertpub.com/doi/abs/10.1089/dia.2016.0216
Future of Data
Dr Kaufman shared that systems are getting smarter and that more analytics will increasingly become available to assist in the management of diabetes. Currently the landscape of data for diabetes is predominantly descriptive (how am I doing), however we are moving into the age of predictive (how will I be doing) and then to prescriptive (what should I be doing). It sounds like the not too distant future will hold technology that can recall the glucose results from previous similar meals and suggest alterations to dosing based on past performance.
Successful Transition Clinics
Dr Jane Holmes-Walker shared insights into successfully transitioning patients from the paediatric to the young adult clinics and what techniques and systems have proved to be most successful. Dr Holmes-Walker shared that the ACI Transition Care Network has a set of seven principles for managing transitions. Successfully completing the first two consultations in the young adult clinic is important to ensure reduced chances of subsequent drop out, but ongoing SMS text reminders and recall systems are important. We learnt that age of transition does not have an impact on clinical outcomes and that insulin pump use is associated with better glycaemic control during the transition. https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0011/251696/Key...
Neuroimaging and hypoglycaemia
Dr Choudhary shared he has a special interest in hypoglycaemia and with good reason. He stated that logic would suggest that if nephropathy is screened for routinely when incidence at 20 years post diagnosis is less than half of the prevalence of hypo unawareness1, then clinics need to be routinely screen for hypoglycaemia. Kings College hospital uses the Gold Score to screen for hypoglycaemic unawareness every visit
He also shared how some new neuroimaging research has shown that people with impaired hypoglycaemia awareness may not have the same negative response to a hypoglycaemic event as those who have awareness, indeed some patients may even have a pleasurable response.
He also touched on the paper that he recently worked on in which CareLink data of MM640G users was mined and it showed that SmartGuard was preventing the user from hitting the low limit over 70% of the time. http://online.liebertpub.com/doi/abs/10.1089/dia.2016.0216
Lessons to be learnt from the UK
During this session Professor David Simmons highlighted that whilst every system has its challenges the NHS do at least two things for people with diabetes that are lacking here in Australia. Firstly they provide publicly funded insulin pumps, based upon health economic analyses. They also provide CGM for those with great need (eg at risk of severe harm from nocturnal hypoglycaemia). Whilst locally 68 pumps are funded publicly this only scratches the surface of the need. We also learnt that NICE national audits provide a good framework for identifying challenges and data for presenting the rationale to change current practice.
Dr Choudhary presented a routine used to interpret CareLink reports in less time. He highlighted the importance of:
- Having a pre-test hypothesis derived from looking at the key statistics
- # of BG tests per day
- Basal/Bolus Ratio
- Separate behavioural and structural issues
- Behavioural issues: blousing post meal, missing boluses, over-rides, set changes, chaotic lifestyle
- Structural issues: TDD, basal rate, ICR, ISF
His final point was that it doesn’t make sense to try and address behavioural issues making structural changes.
Integrating psychology into consultations
Dr Choudhary shared insights and concepts around diabetes distress and the psychology of patients developed with Dr Chris Garrett, the diabetes psychologist at King’s College Hospital, and how implementing these concepts has changed consultations. Telling patients they need to work on reducing their A1c, measure more, etc has probably been discussed with that patient multiple times, so repeating that advice without first understanding the driving force behind their behaviours is unlikely to produce the desired results.
We first need to provide patients with the education (eg DAFNE), beyond that, implementation of the education / knowledge is a behavioural issue that needs to be addressed with behavioural interventions.
He shared that adjusting your style to the patient and spending time understanding what is going on (Pandora’s box) generally creates an environment where the patient is more open to a candid discussion and more likely to act on any information provided in the consult.
Optimising CSII & CGM
Dr Choudhary shared that at the start of his consults sometimes he tells his patients that there are different levels of care that they can receive at Kings (Bronze, Silver or Gold) ,but achieving gold takes more commitment than silver or bronze. How it is important to ensure that the patient understands that they will likely be able to achieve a low A1c, but that it will require the patient putting in the required effort.
We also learnt that data from King’s patients showed that patients with A1c <7.5% on average had approximately 60% time in range (4mmol-10mmol), 7.5%-8.9% was approximately 50% and >9.0 was approximately 40%. The King’s experience is that sharing this information with their patients helps reduce anxiety about measurements done that are out of range.
Golf analogy: With a bolus being the tee off and the objective to land 60% of readings on the green, and 10% of the time you overshoot into the bunker and 30% of the time you only make the fairway and need another shot to get onto the green.
His opinion regarding CGM set up is that there is no point setting up an alarm for a condition that the patient will not act upon. His tip that I particularly liked was to look at a CareLink download and identify the post meal peak glucose values and set the high limit just above the peaks. This means that if the user gets a high alert and they are not sick or had carbs without insulin they need to treat this alert as a set failure and change the set.
What business are we in?
Professor Steven Boyages shared that healthcare professionals are essentially in the sales business, which requires the persuasive selling of better outcomes to patients. That patient expectations of their healthcare professional are only increasing and with the ever growing access to information and data it is increasingly important for healthcare professionals to be up to date with the latest technology. He also shared some very interesting background on the hype-cycle whereby new products usually have an over-estimation in their ability to address needs until they reach the market whereby the challenges typically sets in and we reach the trough of disillusionment. After this however, we reach the slope of enlightenment (pump and CGM) and progress into the plateau of productivity.
Running efficient clinics
Dr Choudhary shared that at Kings, they have weekly meeting that runs for 2 hours in which each patient’s download is reviewed by the full team allowing for knowledge transfer between all participants. This also allows for hand-over of care, and for group input to a care plan – especially for complex cases.
Kings have also recently implemented a patient survey to be filled out in the waiting room to collect information on what the patient would like to focus on in the consult, their comfort with carb counting, hypoglycaemia unawareness and diabetes distress. These forms and a guidebook are all available at http://www.hin-southlondon.org/clinical-areas/diabetes/resources
Guardian Connect is a stand-alone CGM system which will allow for users to view their CGM values directly on their iphone/ipod and allow them to upload their data in real time allowing for up to five friends/family to view the data in real time. The system also allows those friends/family to opt in for SMS alerts based on the glucose values of the primary user. Information about this system including the pricing is available https://hcp.medtronic-diabetes.com.au/guardian-connect
1 N Engl J Med 2011;365:2366-76.] [The albumin excretion rate was 30 mg or more per 24 hours in 19.4% of the participants who had been in the DCCT intensive-therapy group and in 22.6% of those who had been in the DCCT conventional-therapy group] compared to > 46% of those with long standing diabetes who develop IAH ] Diabetic Medicine, 27, 666–672