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Evidence-Based Diabetes Management September 2017

Conference Coverage: ADA, AADE

Christina Mattina, Mary Caffrey
Coverage of technology developments at the 77th Scientific Sessions of the American Diabetes Association (ADA) and the annual meeting of the American Association of Diabetes Educators (AADE).
  Polonsky said the idea that patients with T2D might not use CGM because doctors are too busy, “makes me very sad.”

--Mary Caffrey

AADE 2017

For Diabetes Educators, Technology at Every Turn

From the enthusiastic crowd at the keynote address, “Let’s Get Digital,” to an exhibit floor where device makers consumed more real estate than drug companies, there was no missing technology’s rise in diabetes management. And there’s more to come, along with policy questions, said speakers at the annual meeting of the American Association of Diabetes Educators (AADE), held August 4-7, 2017, in Indianapolis, Indiana.

Digital health attracted $450 million in venture capital and continuous glucose monitoring (CGM) grabbed another $250 million in 2016, according to Christopher J. Bergstrom, MBA, an associate director at Boston Consulting Group, who spoke on August 6. Technology’s role in both treating and preventing diabetes is crucial, notwithstanding CMS’ early decision to leave digital providers out of the 2018 launch of the Medicare Diabetes Prevention Program.

“There’s one thing I know,” Bergstrom said. “Digital will be part of it. Why? There [are] 84 million people with prediabetes!”2

He noted the alliances that have formed between startups and medical device mainstays, and between tech giants, like Google’s Verily and pharmaceutical giant Sanofi. The marriage of healthcare and data will bear dividends that have yet to be fully understood. “The new data sets are the patient-centered data sets,” he said. 

  What can insurance companies learn about diabetes and depression from scanning 30,000 social media posts? Companies like Medtronic are asking, “How do we go beyond the pill?”

Role of Diabetes Educators

Diabetes educators are the foot soldiers who teach patients to use blood glucose meters, CGM systems, and digital tools that let patients track their personal data or share it with providers. The era of population health—and accountability for patients’ glycemic control—made for a standing room-only crowd at Abbott’s presentation on the FreeStyle Libre Pro, which lets an educator or physician collect 2 weeks’ worth of data with no effort from the patient. FreeStyle Libre Pro won FDA approval 1 month after last year’s AADE meeting, just one of many technology developments over the past year.3

  Also at the meeting, many educators wanted details on how to bill Medicare for Dexcom’s G5 continuous glucose monitor—and why CMS won’t let patients use their smartphone.4 And on August 7, MannKind Corp, maker of inhaled insulin Afrezza, announced at the meeting it would be part of a clinical trial with One Drop, the digital device platform, evaluating its effectiveness in combination with the management tool.5   Not every digital health tool can serve every purpose, but various ones on the market can:

  • Track patient data, which clinicians can use to make medication adjustments • Offer reminders to take medication • Offers AADE’s curriculum through a smartphone,6 such as what WellDoc’s BlueStar system can do. • Provide real-time feedback for patients managing their disease.

Digital Health and the Triple Aim

On Sunday afternoon, Kevin Clauson, PharmD, associate professor of Lipscomb University, addressed how diabetes educators can harness the potential of digital health. As digital tools become smaller, less expensive, and better connected to health systems, they have the potential to improve self-care, deliver a better patient experience, and lower costs. The catch, he said, is that patient data will become a commodity.

Clauson said educators must be mindful of this when their patients have opportunities to use free or low-cost options. He reviewed more up-and-coming technological tools, many of which could improve medication adherence. Proteus Digital Health, which received attention throughout the meeting, can include a digestible sensor in a pill, which offers the first fool-proof way of measuring adherence. Type 2 diabetes and hypertension are high on its list of target conditions.7 Apple, he said, also is working on another step: “middleware” will let health systems connect all of the data from thousands of apps and wearables into usable information that can be integrated into an electronic health record.

 However, the questions here are not just technical. Health systems are concerned about being overwhelmed with patient data and being held liable if they fail to act on something that lands in patient record. 

As Bergstrom said in his morning talk, the ethical and policy questions will come faster than anyone realizes. The next generation of tools is at the doorstep. “There’s going to be a tipping point, right before we know it,” he said. 

--Mary Caffrey

References, Artificial Pancreas

1. Mattina C. Infographic: hybrid closed-loop insulin delivery systems—outcomes and outlooks. The American Journal of Managed Care® website. ajmc.com/newsroom/infographic-hybrid-closed-loop-insulin-deliverysystems-outcomes-and-outlooks. Published June 16, 2017. Accessed July 21, 2017.

  2. Del Favero S, Boscari F, Messori M, et al. Randomized summer camp crossover trial in 5-to 9-year-old children: outpatient wearable artificial pancreas is feasible and safe. Diabetes Care. 2016;39(7):1180-1185. doi: 10.2337/dc15-2815. 

  3. Stewart ZA, Wilinska ME, Hartnell S, et al. Closed-loop insulin delivery during pregnancy in women with type 1 diabetes. N Engl J Med. 2016;375(7):644-654. doi: 10.1056/NEJMoa1602494.

  4. Garg SK, Weinzimer SA, Tamborlane WV, et al. Glucose outcomes with the in-home use of a hybrid closed-loop insulin delivery system in adolescents and adults with type 1 diabetes. Diabetes Technol Ther. 2017;19(3):155-163. doi: 10.1089/dia.2016.0421.

  5. Kovatchev B, Peiyao C, Anderson SM, et al. Feasibility of long-term closed-loop control: a multicenter 6-month trial of 24/7 automated insulin delivery. Diabetes Technol Ther. 2017;19(1):18-24.
doi: 10.1089/dia.2016.0333.  

References, CGM Debate

1. Medicare announces criteria covering Dexcom G5 Mobile CGM for all people with diabetes on intensive insulin therapy [press release]. San Diego, CA: Dexcom; March 24, 2017. https://www.dexcom.com/news/medicareannounces-criteria-covering-dexcom-g5-mobile-cgm-for-all-people-withdiabetes-on-intensive-insulin. Accessed July 20, 2017.

  2. Beck RW, Riddlesworth T, Ruedy K, et al; DIAMOND Study Group. Effect of continuous glucose monitoring on glycemic control in adults with type 1 diabetes using insulin injections: the DIAMOND randomized clinical trial. JAMA. 2017;317(4):371-378: doi:10.1001/jama.2016.19975.

  3. New study shows adults with type 1 and type 2 diabetes on multiple daily injections (MDI) benefit from CGM [press release]. San Diego, CA: Business Wire; June 9, 2017. http://www.businesswire.com/news/home/20170609005161/en/Study-Shows-Adults-Type-1-Type-2. Accessed June 11, 2017.

  4. Manning JP, Halford J, Sulik B, Sulik M, Parkin CG, Liljenquist DR. Use of continuous glucose monitoring is acceptable and potentially beneficial in older T2DM patients treated with basal insulin therapy: a pilot study. Infusystems Intl. 2014;13(4):35-42.

References, Technology at AADE

1. Caffrey M. Rule would limit digital providers to makeup sessions when Medicare launches DPP in 2018. The American Journal of Managed Care® website. ajmc.com/newsroom/rule-would-limit-digital-providers-to-makeup-sessions-when-medicare-launches-dpp-in-2018. Published July 14, 2017. Accessed August 8, 2017.

2. Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2017. CDC website. cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf. Published July 18, 2017. Accessed August 8, 2017.

3. Abbott receives FDA approval for the FreeStyle Libre ProSystem, a revolutionary diabetes sensing technology for healthcare professionals to use with their patients [press release] Abbott Park, IL: PR Newswire; September 28, 2016. prnewswire.com/news-releases/abbott-receives-fda-approval-for-the-freestyle-libre-pro-system-a-revolutionary-diabetes-sensing-technology-for-healthcare-professionals-to-use-with-theirpatients-300335325.html. Accessed August 8, 2017.

4. Caffrey M. Medicare issues rules for CGM coverage—no smartphones allowed. The American Journal of Managed Care® website. ajmc.com/newsroom/medicare-issues-rules-for-cgm-coverage-no-smartphones-allowed. Published March 28, 2017. Accessed August 8, 2017.

5. MannKind and One Drop partner to launch the A-ONE clinical trial [press release]. Valencia, CA, and New York, NY: Globe Newswire; August 7, 2017. globenewswire.com/news-release/2017/08/07/1081103/0/en/MannKindand-One-Drop-Partner-to-Launch-the-A-ONE-Clinical-Trial.html. Accessed August 8, 2017.

6. WellDoc, American Association of Diabetes Educators (AADE) partner to Incorporate AADE diabetes self-management education curriculum into the BlueStar digital therapeutic platform [press release]. Columbia, MD: Globe Newswire; January 4, 2017. globenewswire.com/news-release/2017/01/04/903158/0/en/WellDoc-American-Association-of-Diabetes-Educators-AADE-Partner-to-Incorporate-AADE-Diabetes-Self-Management-Education-Curriculum-into-the-BlueStar-Digital-Therapeutic-Platform.html. Accessed August 8, 2017.

7. Proteus Digital Health website. proteus.com. Accessed August 8, 2017.
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