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 1. How to Make Your Diabetes Office Visits More Efficient
“How can I possibly do all of these things?”
A 68-year-old woman comes in to discuss her diabetes. She has had type 2 diabetes for about 20 years. She was supposed to have fasting labs done before this visit. She does not drive and must take the bus to get to the office for her blood work. She tried coming for her previsit lab work twice before, but each time she experienced symptoms that prevented her from making the journey. She had to eat to feel better, and since she knew the labs were supposed to be fasting, she just stayed home.
Managing her diabetes has been hard. She thought she had a system that worked for her but lately, she feels as though she never knows what her glucose will do on any given day. She tries to be carbohydrate consistent and might take more insulin if she is going to eat more.
Med HX: type 2 diabetes, hypertension, dyslipidemia, knee and hip osteoarthritis, chronic kidney disease (CKD), nonproliferative diabetic retinopathy, peripheral sensory diabetic neuropathy
Medications: metformin 1000 mg bid, insulin glargine 48 units per day, insulin glulisine 12 units with breakfast, and 10 units with lunch and dinner unless she is sure of the carb content of the meal and then she uses a 1:5 carb ratio. She also takes glulisine for correction with 2 units for every 50 mg/dL above 200 mg/dL, atorvastatin 80 mg daily, valsartan/HCT 160/25 mg daily, gabapentin 300 mg po tid.
Allergies: none
Family Medical History: type 2 diabetes in mom and sister, dad—coronary artery disease, brother—heart failure
Social History: lives with her spouse; retired; likes to do things with her social club
Physical Exam: Ht. 5′7″, Wt. 187 lb, BMI 29.3, P 66, R 17, BP 132/68
GEN: overweight female with truncal obesity, in no distress
HEENT: normal including thyroid exam
CV: normal
RESP: normal
Extremities: normal peripheral pulses, normal sensation to monofilament exam, bunions noted to both first toes, callus formation on the ball of the foot
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?
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 Glooko1 and Tidepool2 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.
Before Breakfast
2 h After Breakfast
Before Lunch
Before Dinner
Bedtime
Mon
81
127
234
92
Tues
128
203
78
281
167
Wed
123
170
375
Thurs
93
Fri
45
153
177
253
Sat
135
95
Sun
87
107
123
Mon
58
163
200
83
132
Tues
113
160
136
335
102
Wed
156
143
Thurs
118
104
Fri
74
115
158
202
315
Sat
267
160
163
210
180
Sun
156
124
3. What other practices can make visits more efficient?
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 Glooko1 and Tidepool2 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.
Before Breakfast
2 h After Breakfast
Before Lunch
Before Dinner
Bedtime
Mon
81
127
234
92
Tues
128
203
78
281
167
Wed
123
170
375
Thurs
93
Fri
45
153
177
253
Sat
135
95
Sun
87
107
123
Mon
58
163
200
83
132
Tues
113
160
136
335
102
Wed
156
143
Thurs
118
104
Fri
74
115
158
202
315
Sat
267
160
163
210
180
Sun
156
124
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
How Often Should I Check My Blood Sugar? __________Times per day
__X__ First thing in the morning before you eat or drink and at bedtime
_____ Before lunch or dinner
__X__ Whenever you feel that your blood sugar is low (experiencing symptoms)
__X__ Always check before injecting a dose of insulin
My basal insulin is ________________. My dose is ______units at _______________time.
My mealtime and correction scale insulin is _________________. I take _______ units for my food _____ minutes or right BEFORE breakfast, lunch, dinner (circle time and meals).
My correction scale is:
____ units if less than 150
____ units if glucose 151-200
____ units if glucose 201-250
____ units if glucose 251-300
____ units if glucose 301-350
____ units if glucose greater than 351
I also take:______________________________________________________________ ____.
Blood Sugar Goals
A1C
Less than 6.5% 7% 7.5% 8%
Average blood sugar over 3 months
Blood sugar before eating
80-130 mg/dL or _______________mg/dL
Blood sugar 2 hours after a meal
Less than 180 mg/dL or
_______________mg/dL
Other Treatment Goals
Blood pressure
Less than 130/80 mm Hg or 140/90 mm Hg
Aspirin
Secondary prevention: diabetes and history of ASCVD
(75-162 mg/d)
Primary prevention: may consider if have diabetes, increased CV risk and low bleed risk, ages 40-59 but not recommended for 60 years or older
Statin
High intensity
(based on age and risk of heart attack and stroke in the next 10 years and LDL level)
Moderate intensity
None
Starting Diabetes Medications
Class
Agent
Instructions
GLP-1 Receptor Agonists
Victoza (liraglutide)
Week 1: 0.6 mg daily
Week 2: 1.2 mg daily
Week 3 and thereafter: 1.8 mg daily
Trulicity (dulaglutide)
Weeks 1 and 2: 0.75 mg weekly
Week 3 and thereafter: 1.5 mg weekly
*Can increase to 3.0 and 4.5 mg if needed
Ozempic (semaglutide)
Weeks 1-4: 0.25 mg weekly
Rybelsus (oral semaglutide)
Weeks 5-8 (or longer): 0.5 mg weekly
*Can increase to 1 or 2 mg weekly if needed
3 mg daily on empty stomach and 4 oz of water for 30 days, then 7 mg daily
*Can increase to 14 mg daily if needed (after 30 days of 7 mg)
Bydureon (exenatide—weekly)
2 mg once weekly at any time of day
Byetta (exenatide—twice daily)
5 mcg twice daily before meals within 60 minutes
*Can increase to 10 µg twice daily after 1 month of 5 µg
Dual GLP/GIP Receptor Agonists
Mounjaro (tirzepatide)
2.5 mg weekly
*Can increase 2.5 mg/wk every 4 weeks if needed
SGLT-2 Inhibitors
Jardiance (empagliflozin)
Once daily
Invokana (canagliflozin)
*Pay attention to UTI symptoms and keep yourself hydrated
Farxiga (dapagliflozin)
Steglatro (ertugliflozin)
DPP-4 Inhibitors
Nesina (alogliptin)
Once daily
Onglyza (saxagliptin)
Tradjenta (linagliptin)
Januvia (sitagliptin)
Insulin
Insulin N (NPH)
Basal/background insulin ______ units
Toujeo (glargine)
Can be taken at bedtime OR in the morning
Tresiba (degludec)
Basaglar (glargine)
Lantus (glargine)
Semglee (glargine-yfgn)
Levemir (detemir)
Insulin R (Regular)
Bolus/mealtime insulin ____ units
Novolog (aspart)
Inject 15 or 30 minutes before a meal (one to three times daily)
Humalog (lispro)
Apidra (glulisine)
Fiasp (aspart)
Bolus/mealtime insulin ____ units
Lyumjev (lispro-aabc)
Inject right before OR within 20 minutes of a meal (one to three times daily)
Feet should be assessed at each diabetes care visit
Annual Eye exam
Yes
No
Date:
Subsequent examinations for type 1 and type 2 patients with diabetes should be repeated annually by an ophthalmologist or optometrist.
Annual Lipid Screening
Yes
No
Date:
Annual Liver (LFT) Screening
Yes
No
Date:
NASH Screening (Fib-4 score)
Yes
No
Date:
Every 3 years or if present with symptoms
Annual Test for Kidney Function
Yes
No
Date:
Urine albumin (UACr) and eGFR in patients with diabetes and/or comorbid hypertension at diagnosis
How often should I get my A1C checked?
6 mo
3 mo
Date:
A1C within set goal or <7%, then check every 6 mo
A1C not at goal or ≥ 7%, then check every 3 mo
Routine Blood Pressure Readings
Yes
No
Date:
Blood pressure should be measured at every routine diabetes visit.
Medications
Should I be on aspirin therapy?
Yes
No
Consider aspirin therapy (75-162 mg/d) as a secondary prevention in patients with type 1 or type 2 diabetes AND history of atherosclerotic cardiovascular disease
Consider as primary prevention in those with diabetes, increased cardiovascular risk, after comprehensive discussion with patient (benefits vs risk of increased bleed risk)
≥40 years of age, CVD, or CVD risk factors include dyslipidemia, high blood pressure, smoking, and overweight/obesity, a family history of premature coronary disease, CKD, presence of albuminuria
20-39 years of age with additional ASCVD risk factors
Vaccinations
Annual Flu Vaccine
Yes
No
Date:
≥6 months of age
COVID-19 Vaccine (List below)
Yes
No
Date(s):
Pfizer-BioNTech—age 6 months to 5 years old: administer 3-dose series
Pfizer-BioNTech—age 5 or older: administer 2-dose series (21 days apart); booster(s) as needed
Moderna—age 12 or older: administer 2-dose series (28 days apart); booster(s) for ≥18 years old as needed
Janssen—age 18 or older: administer 1 dose; booster indicated 8 weeks after dose 1
Pneumococcal Vaccine
Yes
No
Date:
Age 2-5: complete 4-dose series of pneumococcal conjugate vaccine 13 (PCV13) if not done by 15 months old
Age 6-18: administer 1 dose of pneumococcal polysaccharide vaccine 23 (PPSV23)
Age 19-64 with diabetes: if not previously vaccinated or unknown history, administer Prevnar 20 or PCV15 followed by PPSV23 a year after. *If previous PPSV23, may administer PCV15 or PCV20 a year after. **If previous PCV13, administer PPSV23 (8 weeks apart) then another dose PPSV23 (5 years apart).
Age ≥ 65 years of age: if not previously vaccinated or unknown history, should receive pneumococcal conjugate vaccine (PCV15 or PCV20). *If PCV15, dose of PPSV23 8 weeks (if immunocompromised) to 12 months after initial vaccination is recommended. **If PCV20, PPSV23 not indicated unless HCP deems necessary. Age ≥65 years of age: if previously vaccinated with PPSV23, should receive a follow-up ≥12 months with PCV13.
Hepatitis B Vaccination
Yes
No
Age 19-59: administer hepatitis B vaccination (2- or 3-dose series) to unvaccinated adults with diabetes.
Age 60 or older and at increased risk for hepatitis B, then you and your provider may decide if needed.
DM Complications/Comorbidities Management
Major Complications/Comorbidities
History of ASCVD or High ASCVD Risks
Heart Failure
Chronic Kidney Disease With Albuminuria
Chronic Kidney Disease Without Albuminuria
First line
GLP-1 receptor agonists or SGLT-2 inhibitors
SGLT-2 inhibitors with proven benefits
HFpEF: Jardiance
HFrEF: Farxiga, Jardiance
+SGLT-2 inhibitors with primary evidence of reducing CKD
+Invokana (if urine albumin excretion >300 mg/d)
+Farxiga (adjunctive therapy if UACr >200 mg/g)
Kerendia (finerenone) (may initiate if eGFR ≥25 mL/min/1.73 m2; must monitor potassium prior to initiation and during therapy)
SGLT-2 inhibitors with primary evidence of reducing CKD
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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CASE QUESTIONS
ANSWERS AND EXPLANATIONS
