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The Rise Of Glucose Monitoring Among Non-DiabeticsContinuous glucose control -
Continuous glucose monitoring — CGM systems use a sensor to measure the level of glucose in the fluid under the skin. The sensor is attached to a transmitter placed on your skin, which is held in place with a sticky patch figure 1. It wirelessly transmits results to a small recording device no larger than a cell phone or to a smartphone or other smart device.
In some cases, it transmits the information directly to an insulin pump figure 2. You can attach the recording device to your clothing, carry it in a purse or bag, or place it near you eg, on a bedside table. If you use a CGM system, you will need to remove the sensor and replace it on a different part of your body approximately once every 7 to 14 days.
Different CGM systems are available; one implantable sensor can last up to days, but it needs to be inserted and removed by a physician, nurse practitioner, or physician assistant. FREQUENCY OF GLUCOSE TESTING. Studies have proven that people with diabetes who maintain normal or near-normal blood glucose levels reduce their risk of diabetes-related complications.
Checking your glucose levels can play an important role in achieving your glucose goals and reducing the risk of complications. See "Patient education: Preventing complications from diabetes Beyond the Basics ".
Type 1 diabetes — For people with type 1 diabetes, frequent glucose testing is the only way to safely and effectively manage blood glucose levels. People with type 1 diabetes may use blood glucose monitoring BGM with fingersticks and a glucose meter, or continuous glucose monitoring CGM.
In people with type 1 diabetes, CGM is generally used if available and affordable. See 'Methods of glucose monitoring' above and 'Continuous glucose monitoring' below and "Patient education: Type 1 diabetes: Overview Beyond the Basics ".
Most people with type 1 diabetes who use BGM alone need to check their blood glucose level at least four times every day. If you use an insulin pump, give yourself three or more insulin injections per day, or are currently pregnant, you may need to test as many as 10 times a day or more.
See "Patient education: Care during pregnancy for patients with type 1 or 2 diabetes Beyond the Basics ". This way you will be able to access your testing equipment wherever you are, making it easier to manage your blood glucose.
Glucose monitoring is useful for people with type 2 diabetes who take insulin or certain medications that can cause hypoglycemia. It is generally unnecessary in people who manage their diabetes with diet alone or who take medications that do not cause hypoglycemia, especially if they have reached their glucose goals.
Your health care provider can help you determine how frequently to check your glucose based on your situation. Most people with type 2 diabetes who perform glucose monitoring use BGM. For people taking insulin, CGM may be used if available and affordable. See 'Who should use CGM?
How to check your blood glucose — The following steps include general guidelines for testing blood glucose levels. However, because the instructions can vary between devices, it's best to check the package insert for your glucose meter or talk with your health care provider.
It's important to never share monitoring equipment or fingerstick devices, as this could lead to infection. Lancets that are used more than once are not as sharp as a new lancet and can cause more pain and injury to the skin. Alternate sites are often less painful than the fingertip.
However, results from alternate sites are not as accurate as fingertip samples. This should not be a problem if you always use the same site. However, when your blood glucose is rising rapidly eg, immediately after eating or falling rapidly in response to insulin or exercise , it's more accurate to use the fingertip, as testing at alternate sites may give significantly different results in these situations.
If you have difficulty getting a good drop of blood from your fingertip, try rinsing your fingers with warm water and shaking your hand below your waist.
This can help get the blood flowing. The results will be displayed on the meter after several seconds. Blood glucose meters — There is no single blood glucose meter that is better than others. Your health care provider or pharmacist can help you choose a meter based on your preferences as well as other factors like cost, ease of use, and accuracy; it should be one that is approved by either the International Organization for Standardization or the US Food and Drug Administration FDA.
Medicare also covers costs of BGM. Accuracy of home BGM — Blood glucose meters are reasonably accurate. However, there can be some variability between meters, so it is always wise to use caution and common sense. If you get a result that does not fit with how you feel for example, if it says your blood glucose is very low but you don't have any symptoms , take a second reading or use an alternate method for testing your blood glucose such as a different meter.
Blood glucose meters are least accurate during episodes of low blood glucose. See "Patient education: Hypoglycemia low blood glucose in people with diabetes Beyond the Basics ". The accuracy of BGM can be affected by several factors, including the type of blood glucose strip and meter.
Inaccurate readings can be caused by the use of expired strips, improper storage of strips exposure to high temperature and humidity , inadequate cleansing of your skin, and ingestion of vitamin C and acetaminophen. It's a good idea to check the accuracy of your blood glucose meter occasionally by bringing it with you when you have an appointment to get blood testing.
This way, you use your home monitor to check your blood glucose at the same time that blood is drawn and compare the results. If the results differ by more than 15 percent, there may be a problem with your meter or other equipment; your provider can help you figure out what's going on and how to correct the problem.
Help for people with vision impairment — People with vision impairment a common complication of diabetes sometimes have difficulty using glucose meters. Meters with large screens and "talking" meters are available. If you have impaired vision, you can get help from the American Association of Diabetes Care and Education Specialists ADCES at Continuous glucose monitoring CGM is a way to monitor your glucose levels every 5 to 15 minutes, 24 hours a day.
Because of reliability issues, warm-up periods, and the need to calibrate some of the devices, CGM does not eliminate the need for at least occasional fingersticks. CGM systems are described in detail above see 'Continuous glucose monitoring' above.
Who should use CGM? CGM systems are most often used by people with type 1 diabetes. Periodic use of CGM can also help you and your health care provider determine when your glucose is low or high and how to adjust your medication doses or food intake to prevent these fluctuations.
Devices that combine an insulin pump with a CGM system are also available. See "Patient education: Type 1 diabetes: Insulin treatment Beyond the Basics ". Advantages — There is evidence that people with type 1 diabetes who use a CGM system consistently and reliably rather than blood glucose monitoring [BGM] have modestly better managed blood glucose levels.
The "real-time" CGM devices automatically display your glucose level every five minutes, using numbers, graphics, and arrows so you can easily tell if your level is increasing, decreasing, or stable figure 3. The receiver recording device can also be set to trigger an alarm if your glucose level gets above or below a preset level, which can be especially helpful for people who cannot feel when they have low blood glucose also known as "impaired awareness of hypoglycemia".
Most CGM systems permit real-time "sharing" of your CGM readings with others eg, family members or caregivers. Some, but not all, of these intermittently scanning CGM devices are able to alert you of low or high glucose readings.
You can download glucose results from the CGM system to your computer, tablet, or smartphone, allowing you to see glucose trends over time. If you take insulin, your health care provider can help you figure out how to use this information to adjust your insulin dose if needed.
Drawbacks — CGM systems may show lower glucose values than blood glucose meters, especially when blood glucose levels are rapidly rising. In addition, the costs associated with CGM are greater than those of traditional glucose meters.
Not all continuous glucose meters and supplies are covered by commercial health insurance companies. Glucose testing — The results of glucose testing with blood glucose monitoring BGM or continuous glucose monitoring CGM tell you how well your diabetes treatments are working. Glucose results can be affected by different things, including your level of physical activity, what you eat, stress, and medications including insulin, non-insulin injectable medications, and oral diabetes medications.
To fully understand what your glucose levels mean, it is important to consider all of these factors. When keeping track of your results, you should include the time and date, glucose result, and the medication and dose you are taking.
Additional notes about what you ate, whether you exercised, and any difficulties with illness or stress can also be helpful but are not generally required every day.
You should review this information regularly with your health care provider to understand what your results mean and whether you need to make any changes to better manage your glucose levels.
Need for urine testing — If you have type 1 diabetes, your health care provider will talk to you about checking your urine for ketones. Ketones are acids that are formed when the body does not have enough insulin to get glucose into the cells, causing the body to break down fat for energy.
Ketones can also develop during illness, if an inadequate amount of glucose is available due to skipped meals or vomiting. Ketoacidosis is a condition that occurs when high levels of ketones are present in the body; it can lead to serious complications such as diabetic coma. Urine ketone testing is done with a dipstick, available in pharmacies without a prescription.
If you have moderate to large ketones, you should call your health care provider immediately to determine the best treatment. You may need to take an additional dose of insulin, or your provider may instruct you to go to the nearest emergency room.
Meters that measure ketone levels in the blood are also available, but due to their cost, urine testing is more widely used. ADJUSTING TREATMENT. Checking your glucose either with blood glucose monitoring [BGM] or continuous glucose monitoring [CGM] provides useful information and is an important part of managing your diabetes.
Medtronic also offers a monthly subscription program that features unlimited sensors and insurance verification services.
But the Medtronic device's glucose numbers are also blinded to the patient, and it requires three finger-stick glucose numbers to be entered daily in addition to the data gathered by the sensor. The three devices also have different data analysis software.
We recommend reviewing your organization's policies about cloud-based software and internet firewalls with an IT specialist before selecting a device, to ensure you will be able to download CGM data without purchasing new technology.
Representatives of device manufacturers are able to provide information about technical support, customer service, and implementation. Meeting with all three device vendors before purchasing one may be helpful.
Get administrative buy-in. Administrative support is one of the key elements for successfully implementing a clinic-owned CGM program. Administrators will need to understand the challenges of treating diabetes and the benefits of CGM.
Mapping out the billing and reimbursement process, staffing needs, and projected use before purchasing CGM systems can make administrators more likely to buy in. Designate a staff champion. Another key to a successful CGM program is identifying a staff champion within the clinic.
This role can be filled by a medical assistant, licensed vocational nurse, dietitian, or diabetes educator. The main qualifications are enthusiasm for new projects and good patient education skills.
The staff champion will be trained to select patients for the CGM program see more on that below , use and maintain devices, insert sensors and provide instructions to patients, download and disseminate the results, and bill and code for services. Device manufacturers can provide training videos and educational materials for staff.
Training a backup staff member may be helpful for when the champion is unavailable. Select patients. Physicians and staff will need to learn to identify appropriate patients for CGM.
Good candidates include those with uncontrolled diabetes, lack of hypoglycemia awareness, discordant A1C and finger-stick readings, dawn phenomenon, postprandial hyperglycemia, nocturnal hypoglycemia, suspected medication nonadherence, and special populations e.
A spreadsheet with the names of potential CGM candidates should be distributed to all clinic physicians. Establish a standardized workflow. The first step in the workflow is to obtain prior authorization before patients can have the sensors inserted. Coverage is instead determined by local Medicare contractors, and prior authorization criteria can vary between contractors.
Patients who are pregnant, starting insulin for the first time, or starting an insulin pump are also usually approved. Most private insurers cover professional CGM for specific patient populations, often based on their type of diabetes and level of control. Check the written policies of payers in your area for their specific coverage criteria.
Once you have prior authorization from the patient's insurance carrier, you may insert the CGM sensor on the same day as an office visit or at a separate appointment. The insertion is a simple process using an auto-applicator. Trained staff can do the insertion and instruct the patient to keep a detailed food and activity record, all of which requires approximately 10 to 15 minutes of face time with the patient.
When the sensor's wear time expires, after six to 14 days, patients can easily remove the sensor by peeling off the adhesive. The patient then returns it to the clinic, either in person or via mail, for data downloading.
All manufacturers offer cloud-based software to make the data upload and storage simple. Data reports can then be printed or sent electronically to the ordering physician for interpretation and therapeutic decision making. The patient should have a second office visit either in person or virtually to review and explain the reports.
This could occur on the same day the sensor is returned or at a later date. Professional CGM device manufacturers have tried to make CGM reports easy to understand and interpret. Some of the devices also report hourly glucose statistics, mealtime insulin analyses, and other daily details.
The summaries contain insights and suggested solutions based solely on the data, but reviewing the results with the patient can lead to better understanding of what they were doing at various times that might have affected glucose levels and enable meaningful conversations about how to improve glucose control.
Developing a systematic or step-by-step method of reviewing the data will make interpretation more efficient. Adding details such as typical mealtimes to correlate the glucose peaks and valleys can be especially useful.
We also recommend asking patients about exercise habits or any other lifestyle factors that could affect the data. Write in the medications patients take and note the timing of insulin doses. Look for patterns of low glucose levels. Try to determine if these are outliers or common occurrences, and seek the patient's input on potential causes.
Assess overnight glucose control. Take note of consistent areas of hyperglycemia or peaks and whether they occur pre- or post-prandially.
Point out areas of consistently good glucose control, and help the patient recognize the source of these successes. Once your observations are complete, develop an action plan with patients based on the problem areas identified.
Make adjustments to their medication regimen or diet as needed. Give patients a copy of the report and add it to the electronic health record as well. Repeat the process as frequently as once a month to evaluate interventions. Here are three examples of how CGM data can lead to interventions that improve patients' health outcomes.
Patient 1 is a year-old male with an initial A1C of 9. Data: CGM identified glucose level was higher than in the period from midnight to 6 a. and had a large variance — during the day. This indicates poor food choices and evening snacking. Interventions: The physician added a glucagon-like peptide-1 GLP1 to his medication regime, and the dietitian increased education about portion size and carbohydrates.
The patient was also able to identify and correct his low-fiber diet. Patient 2 is a year-old female with initial A1C of Discussion with the patient revealed she was consuming too many carbs, such as an eight-ounce glass of orange juice, to correct for feeling low.
Interventions: The dietitian counseled her to eat lunch earlier and include protein, and provided education on a carb-controlled diet. The physician suggested adding five units of insulin lispro at dinner.
She is taking 75 units of insulin glargine twice daily and eight units of insulin aspart three times daily with meals. Data: CGM showed highs after breakfast and dinner, indicating large portions and poor food choices.
Interventions: The physician increased mealtime insulin and provided counseling on appropriate food choices. The initial costs of adding CGM to a practice depend on the device. Code is for training the patient, startup and calibration, sensor removal, and data download in a professional CGM program.
This code may be billed by any qualified health professional QHP. Code is for training and startup of personal CGM, in the same way you would bill for professional CGM. Code may be billed by a physician or QHP for the interpretation of the CGM report. This can be done with or without the patient in the office, but a face-to-face or virtual office visit is recommended to review the results and make therapy adjustments.
This allows a practice to quickly recoup startup costs and generate revenue. Professional CGM advances the care of diabetes and generates revenue for a clinic. The increased data compared to finger-stick readings provides a helpful roadmap to guide discussions on dietary choices and to plan medication changes.
A motivated and well-trained health care team will ensure the successful launch of a program. Vigersky R, Shrivastav M. Role of continuous glucose monitoring for Type 2 in diabetes management and research.
J Diabetes Complications. Beck RW, Riddlesworth T, Ruedy K, et al. Ann Intern Med. Ida S, Kaneko R, Murata K. Utility of real-time and retrospective continuous glucose monitoring in patients with Type 2 diabetes mellitus: a meta-analysis of randomized controlled trials.
J Diabetes Res. Longo R, Sperling S. Personal versus professional continuous glucose monitoring: when to use which on whom. Diabetes Spectr.
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