3 Key Learnings from ADA 2016
It was exhilarating to attend the American Diabetes Association’s 76th Scientific Sessions with more than 18,000 participants from across the globe. My multi-disciplinary training allowed me to absorb and appreciate the broad range of information presented at this event. It was not easy to distill my top three takeaways from the myriad of presentations, but here are the findings that had the biggest impact on me and will influence my work:
1) Titration of Basal insulin therapy is wrought with challenges
A) An online survey of 942 adults with T2D, conducted by Peyrot et al. (787-P), found that:
1) People Stop Basal Insulin Therapy for Many Reasons: More than half of the patients who interrupted and restarted basal insulin therapy and patients who discontinued basal insulin therapy selected more than one reasons for their actions.
2) Persuasion by HCP: The most important reason for interrupting and restarting basal insulin therapy was persuasion by healthcare providers (HCP) to restart insulin therapy. Also, patients who discontinued basal insulin therapy stated that if their HCP persuaded them, then they would most likely restart basal insulin therapy.
3) Difference in symptoms experienced: Patients who interrupted basal insulin therapy experienced significantly greater hyperglycemia, hypoglycemia symptoms, and weight gain compared to patients who continued basal insulin therapy. (p<0.05)
B) Another online survey of HCPs and patients with T2D on basal insulin therapy, conducted by Berard et al. (972-P), found that:
1) Not Reaching Target A1c: Out of 106 US respondents, 59% of patients had not reached target HbA1c and 41% were self-titrating.
2) Physician Perceived Barriers: US HCPs stated that perceived barriers to achieving HbA1c target among self-titrating patients were patients’ fear of hypoglycemia, low patient motivation and involvement, and patients’ reluctance to increase insulin dose if they didn’t experience any symptoms of poor glycemic control.
3) Patient-Reported Barriers: On the other hand, US patients who have not reached HbA1c target mentioned that fear of weight gain, the perception that increasing insulin dose meant worsening of diabetes, and frustration with the long time it took to reach their goal as top three reasons for not achieving a glycemic target.
These two poster presentations support our hypothesis for developing Glooko’s mobile insulin dosing system (MIDS) demonstrated at the ADA. Our hypothesis is that providing tools to the patients to help them with self-titration may help to optimize basal insulin dose titration and intensification. In addition, timely access to a patient’s persistence pattern will allow HCPs to initiate a conversation with their patients thereby addressing reasons for interrupting basal insulin therapy and persuading them to restart insulin therapy.
2) Patient satisfaction and perception is an important driver for investing in diabetes programs
The definition of health should not be restricted to clinical outcomes, but should take into account outcomes related to other aspects of the patient experience. In an oral presentation by Andrea L. Cherrington MD, MPH, I learned that effectiveness of a diabetes intervention should not be hinged on the change in HbA1c alone but also take into account the impact of the intervention on the social and emotional well-being of the patients. In a poster presentation by Howard Wolpert, MD and Sanjeev Mehta, MD, endocrinologists at Joslin Diabetes Center, (726-P) 61% of patients in the care management group (CM) of a 6-month clinic-based quality improvement project completed baseline and follow-up diabetes-related surveys (Self-care Inventory-Revised, Problem Areas in Diabetes, and Diabetes Distress Score). These patients also evaluated their experience of health care delivery using the Patient Assessment of Care for Chronic Conditions (PACIC). Patients in the CM group received usual care along with remote care management. Patients shared their blood glucose readings from their blood glucose meter using the Glooko Mobile App and the Glooko MeterSync Blue with their care management team, who reviewed the uploaded blood glucose readings weekly. The care manager contacted patients by phone/email to share treatment recommendations. At the end of the project, patients in the CM group reported a significantly higher perception of adherence to diabetes self-care recommendations (p = 0.03); lower diabetes-related emotional distress (p = 0.002) and an enhanced experience of healthcare delivery (p = 0.005). These findings support the idea that patient-provider communication in between clinic visits can improve patient’s experience of care and empower patients to manage their blood glucose.
3) Challenges with In-Between Visit Reimbursement Remain
At the session on risk-based contracting many physicians, administrators, and certified diabetes educators shared with the panelist that providers are not reimbursed adequately for communicating with patients with diabetes in between clinic visits. This sentiment was shared by Mary Voelmle, MS, FNP, CDE, who shared her experience of remotely monitoring women with gestational diabetes using Glooko, Tidepool, and Medtronic CareLink. She shared that although remote monitoring made it easier to adjust insulin, improve clinic workflow and use reports as teaching tools, the reimbursement for reviewing the reports was limited. She used CPT code 95251 in her practice as it is applicable for non-face to face service, but most payers limit the number of times per year this CPT code is covered. It is evident that providers and patients derive value from remote access to blood glucose readings from blood glucose meters, insulin pumps, and continuous glucose monitors but the reimbursement challenge is a significant hindrance to the adoption of remote monitoring by providers.
Pharmacological therapies, diabetes technology, diabetes education, lifestyle intervention combined can not help patients manage their diabetes if tools that facilitate effective communication with care providers are not present. Health systems and payers have to adopt solutions that facilitate delivery of information to HCP who can then engage patients in a meaningful conversation in a timely manner.