Introduction
The past few decades have seen an unprecedented advance in technology available for the management and treatment of diabetes. Novel devices have made living with diabetes both easier and safer. It is important for the health care professional to have a good working knowledge of these resources to effectively meet patient needs. Being able to provide individualized recommendations can make a significant difference in a patient’s experience living with diabetes. This chapter focuses on the current tools that can improve both patient and clinician experience in diabetes care.
CASE QUESTIONS
1. How do you interpret the glucose logs?
View Answer
1. The patient is putting in a lot of work to monitor her diabetes. It is important to let her know that you recognize her efforts. Affirm her for the effort she is making to manage her diabetes and record her blood sugars. Despite this work, several questions still remain.
What is the timing of her fingersticks? Specifically, are these readings taken before or after her meals? Her log indicates she is having some lows. We need to understand at what glucose level she feels the need to respond, and how she chooses to do so. This might be an opportunity to review the rules of 15s (
Chapter 5). She is also having significant hyperglycemia. How is she managing these? Once we understand the landscape in terms of glucose checks and actions, we can go into more depth regarding her awareness of possible trends.
Many clinicians like to have logs available prior to entering the exam room. It can take approximately 5 to 7 minutes to review glucose logs and to determine patterns, trends, and mean values throughout the day. This is a necessary step for insulin management but requires time that, unfortunately, many clinicians do not have. The following sections address additional strategies to help make a diabetes visit more efficient.
It is great that this patient is checking her glucose regularly. These readings are necessary for her to be able to determine her dose of insulin at each meal. The logs as presented to us may be a bit less useful. Given that she is checking her glucose before taking mealtime insulin, we might assume that these readings are before breakfast, before lunch, and before dinner.
Specifically for this patient, I would recognize all of the work she is doing to manage her diabetes and document this to help us to help her. Her morning readings are relatively stable reflecting the basal insulin and her nighttime schedule, but the daytime readings vary widely. We will need to learn more about that.
2. How can patient glucose data be assessed more efficiently?
View Answer
2. Many patients bring a glucose meter to the office visit for review and the clinician scrolls through readings with the patient. This is time consuming and not an effective way to establish trends. Fortunately, the great majority of glucose meters have the capacity to interface with computers, so data can be downloaded, and individualized reports can be generated. Previously, each product line required proprietary software to do so. There are now universal platforms such as Glooko
1 and Tidepool
2 that help clinicians retrieve data from devices. To use these, the provider or a staff member creates accounts with either Glooko or Tidepool and downloads the software to a computer. Meters that have downloadable capacity come with a cable to plug directly into a computer. You will have to remind your patients to bring this to their visits. I recommend setting up a download station in your clinic and assigning a staff member to oversee the process (see more below). This saves time and lets the clinician view glucose data more efficiently.
While it is not addressed in this case—this is a great scenario to consider using a continuous glucose monitor (CGM; either professional or personal version) to get 10 to 14 days of data to see her 24-hour glucose profile. We will discuss more about CGM in the upcoming cases in this chapter.
Here is an example of a downloaded glucometer report. The report reveals specific information indicating when glucose is being measured, making it easier to identify trends. This is a powerful tool to help tailor patients’ treatment regimens.
Home Blood Glucose Log.
3. What other practices can make visits more efficient?
View Answer
3. Helping people manage their diabetes can be time- and labor-intensive. Below are strategies to help make our visits more efficient:
Create and use an office download station
Utilize a point-of-care HbA1c machine
Utilize a written instruction sheet template
Avoid the need for fasting lab work
Have dedicated diabetes-only visits
4. What tools are available to help patients and clinicians assess basal and bolus insulin regimens?
ANSWERS AND EXPLANATIONS
1. The patient is putting in a lot of work to monitor her diabetes. It is important to let her know that you recognize her efforts. Affirm her for the effort she is making to manage her diabetes and record her blood sugars. Despite this work, several questions still remain.
What is the timing of her fingersticks? Specifically, are these readings taken before or after her meals? Her log indicates she is having some lows. We need to understand at what glucose level she feels the need to respond, and how she chooses to do so. This might be an opportunity to review the rules of 15s (
Chapter 5). She is also having significant hyperglycemia. How is she managing these? Once we understand the landscape in terms of glucose checks and actions, we can go into more depth regarding her awareness of possible trends.
Many clinicians like to have logs available prior to entering the exam room. It can take approximately 5 to 7 minutes to review glucose logs and to determine patterns, trends, and mean values throughout the day. This is a necessary step for insulin management but requires time that, unfortunately, many clinicians do not have. The following sections address additional strategies to help make a diabetes visit more efficient.
It is great that this patient is checking her glucose regularly. These readings are necessary for her to be able to determine her dose of insulin at each meal. The logs as presented to us may be a bit less useful. Given that she is checking her glucose before taking mealtime insulin, we might assume that these readings are before breakfast, before lunch, and before dinner.
Specifically for this patient, I would recognize all of the work she is doing to manage her diabetes and document this to help us to help her. Her morning readings are relatively stable reflecting the basal insulin and her nighttime schedule, but the daytime readings vary widely. We will need to learn more about that.
2. Many patients bring a glucose meter to the office visit for review and the clinician scrolls through readings with the patient. This is time consuming and not an effective way to establish trends. Fortunately, the great majority of glucose meters have the capacity to interface with computers, so data can be downloaded, and individualized reports can be generated. Previously, each product line required proprietary software to do so. There are now universal platforms such as Glooko
1 and Tidepool
2 that help clinicians retrieve data from devices. To use these, the provider or a staff member creates accounts with either Glooko or Tidepool and downloads the software to a computer. Meters that have downloadable capacity come with a cable to plug directly into a computer. You will have to remind your patients to bring this to their visits. I recommend setting up a download station in your clinic and assigning a staff member to oversee the process (see more below). This saves time and lets the clinician view glucose data more efficiently.
While it is not addressed in this case—this is a great scenario to consider using a continuous glucose monitor (CGM; either professional or personal version) to get 10 to 14 days of data to see her 24-hour glucose profile. We will discuss more about CGM in the upcoming cases in this chapter.
Here is an example of a downloaded glucometer report. The report reveals specific information indicating when glucose is being measured, making it easier to identify trends. This is a powerful tool to help tailor patients’ treatment regimens.
Home Blood Glucose Log.
3. Helping people manage their diabetes can be time- and labor-intensive. Below are strategies to help make our visits more efficient:
Create and use an office download station
Utilize a point-of-care HbA1c machine
Utilize a written instruction sheet template
Avoid the need for fasting lab work
Have dedicated diabetes-only visits
Create and Use an Office Download Station
As mentioned earlier, the use of a glucose meter (or CGM) download station can save 5 to 7 minutes per patient visit. Downloaded reports allow clinicians to quickly analyze glucose readings and, thus, more efficiently develop a coordinated patient plan.
Here are a few suggestions to optimize the process:
Identify a specific staff person to be the “device manager.” This person will make sure patients bring their devices to visits and oversee data capture.
Consider creating a download station in the waiting room for patients to utilize themselves.
Implement data downloads as part of the check-in process.
Some devices (like CGMs) will upload to the web. A staff member or the provider can review the data online and generate a report prior to or at the time of the visit. In my own practice, a designated MA (medical assistant) downloads reports from the web on the morning of patient appointments.
Utilize a Point-of-Care HbA1c Machine
For many patients, coming for blood draws in advance of office visits often proves challenging.
Despite established protocols for previsit planning, many patients come to visits without having completed labs. As a result, the visit agenda must be postponed until blood work is completed. This either leads to extra work for clinician and staff to communicate results and discuss regimen changes or a delay in addressing results until the next scheduled appointment.
Having point-of-care (POC) testing within the office considerably improves the efficiency of patient visits. Available options include POC HbA1c, POC UACr, and POC lipid assays. Most devices are CLIA waived, which simplifies implementation. The machines are small and easy for staff to use. Some companies/services will provide these devices at no cost with an agreement for the ongoing purchase of test cartridges. Having access to the results at the time of care provides a “teachable moment” with the patient and allows for timely recommendations and interventions. Most practices bill directly for testing and the service is reimbursable, which can maximize profitability.
Primary care research has supported the use of HbA1c machines in practice. One study completed in the primary care setting found that a POC HbA1c machine reduced therapeutic inertia.
3 Another Canadian Health System study found that the use of POC machines were cost-effective.
4 Another primary care-based study found that POC HbA1c was associated with increased frequency of care intensification and improved patient HbA1c.
5 Patients who received POC testing reported greater patient satisfaction and an enhanced relationship with their health care professional.
6
Utilize a Written Instruction Sheet Template
I find that much of the advice and guidance I provide is repeated from patient to patient throughout the course of the day. I also know that I am often presenting a great deal of instruction and/or education, which can overwhelm patients and family members. Providing patients with written instructions improves both retention and adherence. In my own practice, we provide written templates that have worked well.
Attached is a copy of our office instruction template. The first page identifies glucose, blood pressure, lipid, and antiplatelet goals, and provides insulin dosing instructions. The second page reviews common diabetes medication classes and titration schedules. The third page serves as a reminder of the quality-of-care metrics needed for excellent diabetes management. The fourth page provides rationales for specific medication selections.
Typically, we provide patients with the first two pages to reinforce dosing and self-monitoring instructions. We use page 3 to help inform patients about best-practice guidelines for comprehensive diabetes care. This helps assure that patients are aware of the recommended preventive services and understand the processes of care. This template was designed specifically for our practice; it may not translate well to yours. Using the template has helped alleviate my workload and patients do seem to appreciate having a bigger picture of their diabetes care.
Diabetes Management Today’s Visit Date
Starting Diabetes Medications
Diabetes Process-of-Care Check-Off Sheet (American Diabetes Association)
Avoid the Need for Fasting Lab Work
Requiring fasting labs can delay care and may cause unnecessary risk to the patient. As mentioned in this case, the patient experienced hypoglycemia attempting to get fasting lab work on at least two occasions. Historically, fasting results were thought necessary to help guide glucose management. This is no longer the case as patients now provide us with fasting glucose readings via self-monitoring and with multiple data points. We no longer require fasting lipid levels either. Current guidelines emphasize intensity-based statin therapy as opposed to treating to LDL targets. Of note, our practice finds the use of nonfasting triglycerides to be useful in measuring insulin resistance.
Have Dedicated Diabetes-Only Visits
A person with diabetes lives with the condition for 8760 h/y. Devoting 1 to 2 h/y to clinical management should be a bare minimum. Yet, accomplishing this can be a real challenge in the primary care setting where people often present with multiple
complaints or chronic conditions they want to address. If I have a patient who was originally scheduled for a diabetes recheck but presents with additional concerns, I will ask them which they want to focus on today Rather than try to address both issues, I may recommend that we focus on the patient’s concern and reschedule their diabetes visit. I tell the patient that their concern and their diabetes management are both very important. Trying to address both in a single visit will result in neither getting the attention they deserve.
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