Dennis P. Scanlon, PhD: When we’re talking about these treatments in therapies, we always want to be conscious of subpopulations and whether there are differences (whether it’s by age, disease duration, demographics, or such). Mary Ann, you work with all kinds of patients. Your thoughts on that?

Mary Ann Hodorowicz, RDN, MBA, CDE: Yes, I do. When you get into considerations about age and disease, the older patient has more difficulty with self-monitoring because it’s intermittent, the data can be incorrect, or they forget their logs. With personal continuous glucose monitoring (CGM), you can rely on the data. There’s no forgetting to do it, and that helps diabetes educators and physicians with medication adjustments and lifestyle changes for patients. So, it’s more reliable, solid, accurate, and ongoing data.

With the pediatric population, it’s wonderful because parents are so involved with their children’s control, especially of type 1 diabetes. So, with that data, they can make more timely medication adjustments, identify the hypoglycemic and the hyperglycemic events before they get symptomatic and cause a hospitalization, make changes in their lifestyle interventions, diet, and exercise with the young children. There’s audible alerts if they’re going into hypoglycemia, which then, could be circumvented. Hypoglycemia doesn’t occur with symptoms.

For the very aged, or the very young, there’s clear benefits, and payers are starting to recognize that. Again, as I said before, it’s not just for type 1 diabetics, but also for type 2 patients on multi-daily insulin doses. Nine out of 10 patients have type 2 diabetes, and 30% to 40% of them will be on insulin injections or pumps, where CGM is critically important.

Neal Kaufman, MD: To me, one of the things that I would like to add is, yes, it’s very important that we have devices that are able to give information to individuals, but those individuals have to be ready to use that information to feel activated, engaged, and to have what’s called “self-efficacy”—the confidence and competence that they’re able to manage their life, and manage their emotions when they have a chronic condition, and manage their relationship.

When you do that, and when educators are involved, they’re able to not only teach the content, the hard science, of what it means when your sugar goes up and down, but also, how do you overcome some of those barriers? How do you make it so that an individual not only knows what they need to do, but wants to do it?

So, for example, there’s a program out of Stanford University called the Chronic Disease Self-Management Program (30 years in the making, in-person). There also is a digital version that we’ve been involved with for the last 8 or 9 years. And it basically has been able to demonstrate (in individuals with type 2 diabetes, as the largest study ever done in a self-management program with over 1300 subjects, a thousand of whom were on a digital version), that if your A1C (glycated hemoglobin) was above 9%, (this is type 2), it went down by .93% at 6 months, and 1.27% at 12 months, with a 6-week intervention. So, you’re able to transform. Someone said, “How could that work? Six weeks? How does it work a year later?”

It works because people change their lives, they change their emotions, and they change their sense of well-being and, therefore, they were able to follow the doctor’s or nurse’s orders better. That becomes critical in anything that has to do with self-management.

Dennis P. Scanlon, PhD: That’s Dr. Kate Lorig’s work, in part, right?

Neal Kaufman, MD: Correct.

Dennis P. Scanlon, PhD: A lot of peer-to-peer interaction as well?

Neal Kaufman, MD: It’s peer-to-peer support, where 2 individuals (in-person or digitally), who have a chronic condition, have been trained to facilitate a group meet with, in-person, 10 to 15 people, or online with 20 to 30 people. The online is asynchronous. People come on as often as they want to for about an hour-and-a-half a week for 6 weeks. The in-person is for two-and-a-half hours a week at the same time, let’s say, every week. And those results have been replicated in many, many different studies (both the in-person and the digital).

Dennis P. Scanlon, PhD: Do we think these technologies change the conversation between patients and providers, and break down some barriers a little bit because of the data availability and the constant monitoring?

Robert Gabbay, MD, PhD, FACP: I think they have the potential to. I think that’s just beginning to be tapped. I think continuous glucose monitoring certainly helps. Even the simple ability of downloading blood glucose meter data and then looking at that with a patient, I think, is really helpful. But, I think there is a piece that we’re not quite there yet with.

One would imagine somebody where you could use glucose monitor on, something that’s tracking their activities, something that’s measuring all sorts of things and what they’re doing, and then that data is fed back to their provider.

Well, most providers don’t want all that data. It’s too much data. So, having some intelligent decision support tools that could analyze that data and flag individuals that need help is the piece that’s happening at the margins. But, certainly, that’s the next revolution.

Neal Kaufman, MD: The revolution after that is being able to assess it in the moment and give feedback to an individual in the moment.

Robert Gabbay, MD, PhD, FACP: In the moment, absolutely.

Neal Kaufman, MD: And allowing them to see this little change that’s happened. So, I’d add emotions into that because, clearly, emotions make a difference.

Robert Gabbay, MD, PhD, FACP: Absolutely, yes.

Neal Kaufman, MD: So, if you have physical activity, emotions, glucose, considerations about what you just ate, what activity you’re about to do, it gives you in-a-moment advice. “You know, you should think about doing this.” It can’t tell them to do that, but it could certainly make a huge difference if they’re ready to do it.

Mary Ann Hodorowicz, RDN, MBA, CDE: Yes, I call that an Avatar. They need that digital Avatar, (health coach) to interpret their lifestyle issues into the data and then interpret that data into changes in lifestyle. We have to have Big Brother in the ozone doing this for us.

Neal Kaufman, MD: The reason this is so hard is that individuals with diabetes and other chronic conditions, in which self-management is important, have micro decisions that they make every day—not one of which is important, but the sum of which determine their outcome. It’s so much easier if you just had to do 1 thing, but because of your entire life, that’s the first challenge. The second challenge is that the more I make you use my device, the more you’re upset with me because you’ve got diabetes. You don’t want to think about it.

So, the perfect device, the perfect intervention, is one that requires no time (from) you and helps make it happen. That doesn’t work. It does if we start talking about automatic insulin delivery, but if you really talk about all the other aspects, the individual has to make multiple choices every day. How do you make the healthy choice and easy choice for them so that they don’t have to spend a lot of time managing their diabetes and they can get on with their life? Because that’s what people really want. They don’t want to be managing their diabetes.

Kenneth Snow, MD, MBA: And the question is, will this technology, or can this technology, result in the equivalence for our patients of alarm fatigue? We know it happens in the hospital where nurses (well-intentioned, well-trained), stop paying attention to alarms because there are so many of them. It just becomes the background noise. Do we have so many tools for folks with diabetes—monitoring their activities, monitoring the diet, monitoring their blood sugar, monitoring everything else—that they begin to tune out from it because it’s impossible to be engaged because it just gets in the way of living?

Using Technology to Help Data Make Sense in Diabetes

Robert Gabbay, MD, PhD, FACP; Mary Ann Hodorowicz, RDN, MBA, CDE; Neal Kaufman, MD; Dennis P. Scanlon, PhD; and Kenneth Snow, MD, MBA, explain that the use of tools in diabetes care requires a partnership between good technology and a patient who is ready and willing to use it, and the next phase will involve technology that gives patients feedback from data at the point of care.
Published Online: June 09, 2017


Dennis P. Scanlon, PhD: When we’re talking about these treatments in therapies, we always want to be conscious of subpopulations and whether there are differences (whether it’s by age, disease duration, demographics, or such). Mary Ann, you work with all kinds of patients. Your thoughts on that?

Mary Ann Hodorowicz, RDN, MBA, CDE: Yes, I do. When you get into considerations about age and disease, the older patient has more difficulty with self-monitoring because it’s intermittent, the data can be incorrect, or they forget their logs. With personal continuous glucose monitoring (CGM), you can rely on the data. There’s no forgetting to do it, and that helps diabetes educators and physicians with medication adjustments and lifestyle changes for patients. So, it’s more reliable, solid, accurate, and ongoing data.

With the pediatric population, it’s wonderful because parents are so involved with their children’s control, especially of type 1 diabetes. So, with that data, they can make more timely medication adjustments, identify the hypoglycemic and the hyperglycemic events before they get symptomatic and cause a hospitalization, make changes in their lifestyle interventions, diet, and exercise with the young children. There’s audible alerts if they’re going into hypoglycemia, which then, could be circumvented. Hypoglycemia doesn’t occur with symptoms.

For the very aged, or the very young, there’s clear benefits, and payers are starting to recognize that. Again, as I said before, it’s not just for type 1 diabetics, but also for type 2 patients on multi-daily insulin doses. Nine out of 10 patients have type 2 diabetes, and 30% to 40% of them will be on insulin injections or pumps, where CGM is critically important.

Neal Kaufman, MD: To me, one of the things that I would like to add is, yes, it’s very important that we have devices that are able to give information to individuals, but those individuals have to be ready to use that information to feel activated, engaged, and to have what’s called “self-efficacy”—the confidence and competence that they’re able to manage their life, and manage their emotions when they have a chronic condition, and manage their relationship.

When you do that, and when educators are involved, they’re able to not only teach the content, the hard science, of what it means when your sugar goes up and down, but also, how do you overcome some of those barriers? How do you make it so that an individual not only knows what they need to do, but wants to do it?

So, for example, there’s a program out of Stanford University called the Chronic Disease Self-Management Program (30 years in the making, in-person). There also is a digital version that we’ve been involved with for the last 8 or 9 years. And it basically has been able to demonstrate (in individuals with type 2 diabetes, as the largest study ever done in a self-management program with over 1300 subjects, a thousand of whom were on a digital version), that if your A1C (glycated hemoglobin) was above 9%, (this is type 2), it went down by .93% at 6 months, and 1.27% at 12 months, with a 6-week intervention. So, you’re able to transform. Someone said, “How could that work? Six weeks? How does it work a year later?”

It works because people change their lives, they change their emotions, and they change their sense of well-being and, therefore, they were able to follow the doctor’s or nurse’s orders better. That becomes critical in anything that has to do with self-management.

Dennis P. Scanlon, PhD: That’s Dr. Kate Lorig’s work, in part, right?

Neal Kaufman, MD: Correct.

Dennis P. Scanlon, PhD: A lot of peer-to-peer interaction as well?

Neal Kaufman, MD: It’s peer-to-peer support, where 2 individuals (in-person or digitally), who have a chronic condition, have been trained to facilitate a group meet with, in-person, 10 to 15 people, or online with 20 to 30 people. The online is asynchronous. People come on as often as they want to for about an hour-and-a-half a week for 6 weeks. The in-person is for two-and-a-half hours a week at the same time, let’s say, every week. And those results have been replicated in many, many different studies (both the in-person and the digital).

Dennis P. Scanlon, PhD: Do we think these technologies change the conversation between patients and providers, and break down some barriers a little bit because of the data availability and the constant monitoring?

Robert Gabbay, MD, PhD, FACP: I think they have the potential to. I think that’s just beginning to be tapped. I think continuous glucose monitoring certainly helps. Even the simple ability of downloading blood glucose meter data and then looking at that with a patient, I think, is really helpful. But, I think there is a piece that we’re not quite there yet with.

One would imagine somebody where you could use glucose monitor on, something that’s tracking their activities, something that’s measuring all sorts of things and what they’re doing, and then that data is fed back to their provider.

Well, most providers don’t want all that data. It’s too much data. So, having some intelligent decision support tools that could analyze that data and flag individuals that need help is the piece that’s happening at the margins. But, certainly, that’s the next revolution.

Neal Kaufman, MD: The revolution after that is being able to assess it in the moment and give feedback to an individual in the moment.

Robert Gabbay, MD, PhD, FACP: In the moment, absolutely.

Neal Kaufman, MD: And allowing them to see this little change that’s happened. So, I’d add emotions into that because, clearly, emotions make a difference.

Robert Gabbay, MD, PhD, FACP: Absolutely, yes.

Neal Kaufman, MD: So, if you have physical activity, emotions, glucose, considerations about what you just ate, what activity you’re about to do, it gives you in-a-moment advice. “You know, you should think about doing this.” It can’t tell them to do that, but it could certainly make a huge difference if they’re ready to do it.

Mary Ann Hodorowicz, RDN, MBA, CDE: Yes, I call that an Avatar. They need that digital Avatar, (health coach) to interpret their lifestyle issues into the data and then interpret that data into changes in lifestyle. We have to have Big Brother in the ozone doing this for us.

Neal Kaufman, MD: The reason this is so hard is that individuals with diabetes and other chronic conditions, in which self-management is important, have micro decisions that they make every day—not one of which is important, but the sum of which determine their outcome. It’s so much easier if you just had to do 1 thing, but because of your entire life, that’s the first challenge. The second challenge is that the more I make you use my device, the more you’re upset with me because you’ve got diabetes. You don’t want to think about it.

So, the perfect device, the perfect intervention, is one that requires no time (from) you and helps make it happen. That doesn’t work. It does if we start talking about automatic insulin delivery, but if you really talk about all the other aspects, the individual has to make multiple choices every day. How do you make the healthy choice and easy choice for them so that they don’t have to spend a lot of time managing their diabetes and they can get on with their life? Because that’s what people really want. They don’t want to be managing their diabetes.

Kenneth Snow, MD, MBA: And the question is, will this technology, or can this technology, result in the equivalence for our patients of alarm fatigue? We know it happens in the hospital where nurses (well-intentioned, well-trained), stop paying attention to alarms because there are so many of them. It just becomes the background noise. Do we have so many tools for folks with diabetes—monitoring their activities, monitoring the diet, monitoring their blood sugar, monitoring everything else—that they begin to tune out from it because it’s impossible to be engaged because it just gets in the way of living?
View More From This Discussion
Episode 1 Intervention for Diabetes Prevention
Episode 2 The Challenges of Diabetes Prevention Programs
Episode 3 Diabetes: Role of Payers Versus Role of Technology
Episode 4 Clinical Rationale for CGM in Diabetes
Episode 5 Using Technology to Help Data Make Sense in Diabetes
Episode 6 Which Technology Merits Payment in Diabetes Care?
Episode 7 Evaluating Factors for FDA Approval of Diabetes Devices
Episode 8 The Change in the Device Coverage Landscape
Episode 9 The Future of Diabetes Prevention and Management
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