Type 2 Diabetes Management in Primary Care: The Role of Retrospective, Professional Continuous Glucose Monitoring
- Maneesh Shrivastav1,
- William Gibson Jr.2,
- Rajendra Shrivastav3,
- Katie Elzea4,
- Cyrus Khambatta5,
- Rohan Sonawane1,
- Joseph A. Sierra1 and
- Robert Vigersky1
- 1Medtronic, Northridge, CA
- 2Diabetes Assessment and Management Center, Shreveport, LA
- 3Community Hospital of Staunton, Staunton, IL
- 4HealthEast Diabetes and Endocrinology, St. Paul, MN
- 5Mangoman Nutrition and Fitness, LLC, San Francisco, CA
- Corresponding author: Maneesh Shrivastav, maneesh.a.shrivastav{at}medtronic.com
Article Figures & Tables
Figures
- FIGURE 1.
Case 1 P-CGM reports: A) initial overlay, B) breakfast overlay, and C) P-CGM overlay ∼18 months after initial evaluation (February 2017).
- FIGURE 2.
Case 2 P-CGM reports: A) initial P-CGM overlay (October 2014) and B) post-DiAMC program P-CGM overlay (February 2015).
- FIGURE 3.
Case 3 P-CGM reports: A) initial P-CGM overlay (October 2014) and B) 30-day follow-up P-CGM overlay (November 2014).
- FIGURE 4.
Case 4 P-CGM reports: A) initial P-CGM overlay (October 2016) and B) recent P-CGM report (February 2017).
Tables
- TABLE 1.
Comparison of P-CGM Systems by Manufacturer (7,8)
Medtronic iPro2 P-CGM Dexcom G4 Platinum Abbott FreeStyle Libre Pro Duration of use (days) 6 7 14 Insertion site Abdomen Abdomen Upper arm Number of components 2 (sensor and recorder) 3 (transmitter, sensor, and receiver) 2 (sensor and reader) Minimum number of calibrations per day 2 2 0 Reading frequency (min) 5 5 15 Operational temperature (°F) 36–86 36–77 50–86 - TABLE 2.
Reasons for P-CGM Use in Primary Care
• Mitigation of hypoglycemia unawareness • Mitigation of nocturnal hypoglycemia unawareness • Provision of insight into nocturnal blood glucose patterns • Initiation of basal insulin (when necessary) • Understanding of when to initiate mealtime (prandial) insulin • Aid in adjusting the insulin-to-carbohydrate ratio for people with insulin-dependent diabetes • Understanding of how food affects blood glucose (i.e., how meals with various macronutrient ratios affect blood glucose profiles over the course of 24 hours) • Understand of how high-fat foods increase blood glucose over the course of 4–24 hours after ingestion • Increased patient accountability, which in turn improves patient self-care behaviors • Evaluation of the magnitude of the dawn phenomenon (i.e., early morning increase in blood glucose) and how it changes over time with lifestyle intervention • Reduction of medication and insulin use as patient’s insulin resistance or sensitivity changes - TABLE 3.
Two-Visit P-CGM Workflow for PCP Clinic
Visit 1: P-CGM Initiation Visit 2: P-CGM Report Review 1. Discuss CGM basics with the patient.
2. Set up and deploy P-CGM device on patient.
3.Describe requirements for calibrating the device using a blood glucose meter.
4. Reinforce the need for log-keeping (food, medication, and activity) and provide a log sheet or explain how to use a mobile app log (patient’s choice).
5. Schedule a return visit to maximize device utility (typically 7–14 days of P-CGM wear, depending on the specific device’s approved duration of use).1. Remove the sensor from the P-CGM recorder and download data.
2. Set preferences for individual target values and generate reports.
3. Interpret reports and provide recommendations to the patient.
4. Inform the patient about the effects of food, activity, and medications on blood glucose levels.
5. Provide the patient with a take-home copy of reports as an educational tool. - TABLE 4.
Work Breakdown for CGM CPT Codes
Code Workflow May Be Performed by:* Face-to-Face Meeting Required? 95250: CGM placement, training, downloading, and report generation Sensor insertion Physician, nurse practitioner, or physician’s assistant or licensed staff within scope of practice or under direct supervision of provider Yes Patient training Yes Meter instruction Yes Removal of transmitter Yes Downloading of data No Entering blood glucose readings No Generating printed reports No 95251: interpretation of CGM data Provider analysis of reports Physician, nurse practitioner, or physician’s assistant No ↵* Staff may provide services if they meet the Medicare “incident to” rules for reimbursement of services rendered incident to a physician’s professional services.
In this Issue
August 2018, 31(3)
Type 2 Diabetes Management in Primary Care: The Role of Retrospective, Professional Continuous Glucose Monitoring
