Today, we're really going to dive into diabetes technology with primary emphasis on continuous glucose monitors. I'm hopeful that some of you got the opportunity to review our online enduring material. If you haven't done so, that has such a wealth of information, too much for us to cover today. We will go over kind of a high-level overview, but if you haven't had the opportunity to check that out yet, what we will do is provide you with a link at the end, and you can kind of register to do that module, too. So here's just kind of an overview of our online enduring module, where we really kind of dived into diabetes technology, and as many of you know, that comes in a number of different forms. So primarily, we'll be discussing continuous glucose monitoring today, but our online module also does talk about insulin pumps, connective devices, et cetera. So for those of you who may not be familiar, here's just a brief orientation to CGM. So CGM is our abbreviation for continuous glucose monitor, and every CGM device really has a few different components, so a sensor which transmits the glucose from interstitial fluid into a device that then transmits it on to a reader or a smartphone app. So you can see in the top right-hand corner of this screen, you may be familiar with this device if you use Freestyle Libre in your practice. The sensor currently looks about the size of a quarter. Its FDA-approved location is on the arm. There's two components that you screw together in order to kind of stamp that on the arm. It's super easy to use. It is considered an intermittently scanned continuous glucose monitor. Freestyle Libre 3 is out in limited market release right now, and that sensor is much, much smaller, about the size of a penny, and the applicator comes preloaded. So that will be even easier for your patients in the future. Bottom left, you may be familiar with Tuze, a Dexcom G6 device. Applicator looks a little bit more complicated, but it's still very easy to use. The sensor unit for that comes with a separate transmitter that you click into it. The sensor for the Dexcom lasts 10 days, whereas the Freestyle Libre lasts for 14. And finally, on the bottom right is the implantable CGM, which is the Eversense monitor. On the following slide, we'll be able to see kind of a brief review of the CGM comparisons, and this really dives into the type of CGM, whether they're real-time continuous glucose monitoring, meaning that the transmission of the glucose data is continuous, no matter if the patient is scanning it or not. It goes into the days of sensor wear. So again, Dexcom is 10 days, whereas Freestyle Libre is 14. And I'll be referring to those two devices most frequently during our discussions today, because those two are the most frequently widely used in clinical practice. You can see that most of these systems these days do have an alarm function, which is great, alerting the patient to either low- or high-blood sugar thresholds that they can set themselves, with the exception of critically low-blood glucose alarm, which cannot be manipulated. And then we do also have some integrations with pumps, which are available, too, with some of these devices, as well as most of them now do have smartphone apps. We can have patients share their data with either the office or loved ones. And some of the devices do also have separate receivers for those patients who may not have a smartphone compatible with the devices. Every device is water-resistant, meaning that patients can still swim, shower, bathe with them. And very few of them have interferences to the point where the devices are not going to be reliable. Most notably, vitamin C these days is important to note, because a lot of people take copious amounts of vitamin C, especially in the age of COVID. So we do know that vitamin C above the threshold of 500 milligrams per day is noted to cause falsely elevated sensor glucose readings in some instances. So it is important to note that for some of your patients. We can see on the next slide, if there's any one slide for you to take away from our talk today, I would like it to be this one. So A1C, while it's a great metric and a lot of times is the only metric that we have available in our practice for those without access to CGM, we know by no means is it a perfect lab value. So with it being kind of that, what we call a three-month measure of glycemia, we know that that doesn't tell the whole story, especially now that we have access to so much data. So we have patient A, B, and C here, which we can see all have A1Cs of seven. But when we look at their glycemia in regards to where they are in a target range of 70 to 180 milligrams per deciliter, we can see that patient A is in their target range all the time, the perfect patient, right, if one exists. But patient C is having hypoglycemic events 18% of the time and hyperglycemic excursions over 180, 58% of the time. So again, that A1C value, while very helpful when it's all that we have, if we can access more data, the better. And then I really like to show you this graph too, because it's important to note that even the most diligent patient who's checking blood sugars four times a day, we're going to miss things. And so you can see that this patient here is performing finger-sick blood glucose monitoring at home four times daily, looks to be in target range all the time, right? Well, if we overlay their CGM data, we can see that we're still missing glycemic excursions, both hypoglycemic and hyperglycemic. And why that's important when it translates to patient care is because if all we have is the data that we're provided, so if we have a fasting glucose and an A1C, you know, we really may make the inappropriate treatment decision. Through no fault of our own, we're only as good as the data we're provided. But we can see here that these patients A and B, we'll call them, so I think this one here, they both have an A1C of 7.8. But we can see that the patient who's having frequent hypoglycemia, which is on the gray line here, if all that we had on this patient is a fasting glucose and an A1C of 7.8, and all they were on was basal insulin, we may be tempted, if all we had was the fasting glucose and the A1C, to increase their basal insulin. But what we would be doing is contributing further to that hypoglycemia that's occurring in the early hours of the morning. So it can really be detrimental to the patient to really not have as much information as we need. So in addition of gathering more data, we can see that there's tons of benefits to CGM. I am a huge proponent of them in my clinical practice. I try and get as many patients on them as I can, not only because nobody likes sticking their fingers, you know, any times a day, but especially if I'm trying to get patients to do it more than twice a day seems to be a bit of a challenge sometimes. And I tell patients, you know, not only does this make things more convenient for you, but it really puts a lot of control in your hands. So it allows the patients to check in on their sugar way more often. If they're able to check pre and post-parengially, they start to really identify the glycemic impact of food choices, and that's very empowering for a lot of patients. So we can see it allows them to get insights into food, exercise, even illness, and kind of real-time management, no waiting, you know, three months to see where their A1C lands. The alarms are very helpful. The connectivity to the insulin pumps are helpful, and the connectivity with the office is important too. You know, oftentimes a patient may call in and, you know, be having difficulty with their blood glucose values, and being able to download and take a look at their CGM is great because it allows us to make much more educated decisions even to guide their management between office visits. So ultimately, we see an improvement in A1C. We see a reduction in hypoglycemia. We see reduced hospitalizations and really reduced costs eventually to the patients too. So our role here in initiating CGM, and this is in any practice, in endocrinology practice primary care, is just making it simple. So oftentimes a lot of these companies are happy to provide you with samples that you can house in your office. You can put one on initially. These devices are meant to be very intuitive for patients to apply, and so the same goes for our staff. Oftentimes our medical assistants or nursing support staff are able to kind of carry out that initial application and education with the patient. And then, you know, our role of the patient is really kind of guiding them on how to better self-manage their diabetes. So one thing I say to my patients a lot is, you know, I may see you once a month. I may see you once every three months, once every six months if you're doing fantastic, but you're living with this day in and day out. So we have to be able to give our patients a sense of self-management skills that they can kind of continue to harness at home. And then finally, none of this comes without reimbursement, which is great. I don't know that there's a whole lot of other clinical practices that get reimbursed for reviewing data. So I mean, I know cardiology. I don't think that they can bill for reviewing a blood pressure log at a visit, but we can with CGM. We can't with manual blood glucose logs, but we can with continuous glucose monitors. And so these are just Medicare allowable examples for the state of Florida, and I'm sure that we have participants from elsewhere in the country as well. But it may not be a lot, but it adds up. You know, if I see 10 patients a day that they all have CGM, I'm able to recoup, you know, an extra $30 a patient, and that's above and beyond what their E&M office billing code is. So this has been, you know, kind of really great as far as being able to get reimbursed some too. So, you know, what do we do next? So we've applied the CGM for the first time. The patient is using it. We've educated them on when to check it, and now they're coming back into the office, and we're really helping to guide the patient's management with the CGM information. So we're going to go into interpreting the AGP, which is an abbreviation for Ambulatory Glucose Profile, which is a segment of the CGM report. So we're going to kind of go through some steps that we look at when we're evaluating that. So first, we're going to look at how much data is captured. Ideally, we want the data to have captured at least 70% of the information, and that just tells us that the patient is utilizing the CGM properly, that they're wearing it correctly, that they're not, you know, going days and days without either scanning or in between their sensor changes. And then we're going to start reviewing the metrics. So the first metrics that we look at is the time in range. So the TIR stands for time in range, and then the time below range. So time below range represents frequency of hypoglycemia. So that's definitely one of those things that we want to address first. Then we'll look at the mean glucose, the glucose management index, which is the GMI, and then the glycemic variability. So you'll see GMI on the data download as represented by a percentage. So that is somewhat equivalent to an A1c, but there's not a perfect science there. The closer they are, the better, because obviously the A1c should be somewhat equivalent. But if there is some discordance, then we can kind of chat about that a little bit too. And then finally, we're going to look at the graph to identify any patterns of hypoglycemia and hyperglycemia. And even for those patients with really good control and no really super alarming metrics, we can really still kind of finesse their self-management sometimes just in looking at that graph. And then of course, we're going to talk about it with the patient on what it means and then how to make an impact. So we use this yes, I can approach. So yes, we're going to emphasize the positive points. We're going to identify issues. We're going to get to the bottom of it together. And then we're going to collaborate with our patient on coming up with an action plan. So really ACE, last year when they, was it last year or the year before? My goodness, time is flying. No, I think it was last year when they put out their Diabetes Advanced Technology and the Management of Persons with Diabetes Guideline, really gave us a great systematic approach to looking at a patient's glucose monitoring technology report and how to kind of analyze that in a way that makes sense. So this is just directly from the recommendations from the guidelines. So we want to use again, that systematic approach. We want to review the overall glycemic status. There's that time and range again, super important time below range and time above range. And then looking at that glucose profile to identify problem areas. And we really want to address problem areas that have the highest impact first. So I always tell my patients, you know, hypoglycemia that's occurring more than 4% of the time is going to trump everything else. So we've got to get rid of the lows and then we address the highs because the lows are really that what's can be in a lot of folks, especially in our older population, the most life-threatening. So when patients are having hypoglycemia more than 4% of the time, we really want to dive into their kind of history and talking with the patient. Are they missing meals but still giving mealtime insulin? Are they on a sulfonylurea? Does that need to be reduced? Are they on medications with high risk for hypoglycemia? Do we need to reduce their insulin doses? Is their kidney function worsening? What alcohol are they consuming? So all of those things are things that we need to think about when we're seeing prevalence of hypoglycemia. And then when we're seeing time and range less than 70 and really 70% and above is our goal for time and range. When we see that we're not meeting that goal, we want to talk about adherence. So is the patient taking their medication consistently? Do we need to see if something is dosed twice a day? Is there an extended release formulation that we can dose once a day if that's going to be easier for the patient? Do we need to add or escalate their medication management? Do we need to think for other alternate pharmacotherapies and kind of change some things up? What we don't want to do is get into this pattern of just inertia and, okay, well, you got to work on this without any kind of clear guidelines. And then sometimes, you know, we have to adjust things like mealtime dosing or carb counts that can help there too. So we're going to dive into a case report here. So this is Lee. Lee is a 48-year-old man with multiple medical concerns, anti-cardiolipin antibody syndrome with complete occlusion of IVC, opioid dependency, portal hypertension, fatty liver, and WAMI, newly diagnosed diabetes with a baseline A1C of 10.2. So Lee is managed quite appropriately by primary care. And his primary care doctor said to Lee, you know what, let's implement CGM. Let's see where you're at currently. So Lee started using CGM. This was his initial kind of report after 14 days. So you can see in the top right-hand corner here, and I'm going to try and use my little laser pointer tool here. So hopefully you can see what I see. So we can see that this captured 14 days' worth of data. His CGM was active for 60% of the time within that 14 days. Average glucose in that timeframe was 265, which was equivalent to a glucose management indicator approximately 9.6. We flip over here to the metrics that review his time in target range was 13%. He had 0% time below range. He was high between 181 and 250, 33% of the time, and over 250, 54% of the time. So when we jump down here to his AGP graphical analysis, we can see he is just high pretty much all the time. So let's kind of talk about this. So we kind of answered some of these questions already. So how often is Lee achieving target range? And so you can actually see it circled on this paper here, but 13% of the time. And when Lee was diagnosed, his A1C was 10.2, and on this report here, we can see his glucose management indicator was 9.6. So they correlate fairly reasonably with each other. So based on this, you know, we obviously need to implement some pharmacotherapy in addition to counseling regarding lifestyle, right? That's first and foremost. I tell my patients, even if you can get off medications, you're never going to get to that point that we don't talk about diet and exercise, right? So of course, we want to address those lifestyle components and implement some pharmacotherapy as well. So let's see what we did with Lee. So his intervention, patient counseled on lifestyle interventions referred for formal education. Perfect. Since his A1C was greater than 10, he was implemented on some basal insulin. So we chose Traceeba for him at 20 units daily, and then we chose GLP-1 with Victoza at 0.6 milligrams daily for Lee. So after four weeks, we saw Lee back in the office, at which time his GLP-1 was escalated and his Traceeba was tapered down. And here's his before and after. So in just a really short amount of time, so about two months time, he went from a GMI of 9.6% down to 5.4%. He's in his target range 98% of the time. He's not having any high glucose readings. He is having 2% low readings. And if this was my patient, I would probably at this point in time have him back off even further, if not discontinue the Traceeba entirely. We know that GLP-1 receptor agonists, of course, have a really low risk for hypoglycemia. So if any hypoglycemia is occurring in somebody on GLP-1 with basal insulin, it's the basal insulin that's the culprit for the hypoglycemia, not the GLP-1. So anyway, needless to say, CGM was a huge component in this, not only for us to be able to assess the data in a shorter interval of time, but really to empower Lee on making those decisions and guiding that management at home. So really, we can apply technology to really achieve those goals in these patients, moving beyond that A1C like we talked about. Gathering more data, more data is empowering for patients, but it's also helpful for us as clinicians to guide appropriate management with patients. As we can see here on this patient on the right-hand side of the screen, even though an A1C may be right around eight percent on this particular patient, we got a lot of work to do. I'll just talk through what I see looking at this AGP reports. It's unfortunately we're not in a format that we can be interactive here, but I'm just going to talk through what I see. I have a 14-day report here, and really 14 days is the minimum that you want to run one of these reports. We just check to make sure our patient is utilizing their CGM appropriately, and we can see the time this patient's CGM is active is 95 percent of the time. In that 14-day window, I'm capturing pretty much all of the glycemic data for this patient. Their average glucose is 197, equating to a glucose management indicator or approximate A1C of around eight percent with 30 percent glycemic variability. When I jump over here to our time and ranges, we can see we're having no hypoglycemia, so that's not a problem we need to address. But what we do need to address is that we're only in our target range 42 percent of the time and are high the remainder of the time. When we're looking at this ambulatory glucose profile here, what is most notable to me, well, there's a couple of things. What's really noticeable to me is this rapid decline in the blood sugar that's happening from 6 AM to 9 AM, and then this huge spike that's happening probably in the 7 to 7.30 to 8 o'clock window here. This gives us some problem areas to really work on. I tell my patients a lot, I'm like, if you're going to bed at a better number, but you're still doing whatever it is you're doing here, which is probably some short-acting insulin if I had to guess, although I'm not sure whose patient this is, but just looking at it here. If you go to bed at a better number, these good numbers here are going to start being too low. For this patient, I would address whatever's going on here, but we definitely need to be mindful of what's happening here too. Let's talk about another patient. RT is a 53-year-old man. He has type 1 diabetes. He's using basal bolus insulin and a continuous glucose monitor. Perfect. Every patient with type 1 diabetes should be utilizing some form of diabetes technology. RT is having a difficult time with post-meal glucose excursions. About 25 percent of all post-meal glucose levels are above 180. Sometimes he over-corrects with additional rapid acting, and then that results in hypoglycemia. His A1c is 6.7. We hear an A1c of 6.7 and we think, great, the patient is doing wonderful. But when we talk to the patient, we can see that he's having some highs and then some lows. His current regimen is 30 units of Traceeba a day, and then Humalog is his short acting, and he does that with one unit per eight grams of carbs with breakfast, one unit per 12 with lunch and dinner, and then uses a correction factor of one unit per 30 milligrams per deciliter over 120. When we look at RT's glucose profile here, and this report you can see looks slightly different. That's because this one is Dexcom, whereas the other ones that we looked at so far are Libre, have all of the same metrics though. We can see this person's sensor usage is 100 percent, which it really should be with a Dexcom that gives us real-time glucose data. It doesn't rely on the patient to scan the device in order to capture it. 100 percent of the data, we actually crop the top of this report here, but it would tell you the number of days, and that's what this 30 over 30 means here. It's a 30-day report. Over that time, RT's average glucose was 154 milligrams per deciliter, equates to a GMI approximately 7.0 percent equivalent to an A1c. A1c, as you can recall, was 6.7, so we're very similar there as far as the glucose goes. But you can see he's having three percent lows, one percent very low, and then he's 62 percent in range. 31 percent high, three percent very high, which we can see here in the middle. What's unique about RT as well is that he has modified his target ranges. You can see here in the daytime, his target range is 70 to 180, which I really would encourage you to pretty much default to with your patients. Anything below 70 is too low, anything above 180 is really too high even for a postprandial reading. When we're analyzing this report, we have to take into account that these time and ranges is based on this patient's individualized target ranges. When we analyze the graphical patterns, we can see what RT was talking about in regards to those postprandial rises here. But again, dropping down a little bit sometimes at night when he gives himself some additional short-acting insulin and he's stacking a little bit. This is an example of someone who's not doing terribly, but we really need to fine-tune it. Not really too many big, huge, huge changes, but really just fine-tuning at this point. Per the ACE guidelines, our targets for time below range would be less than four percent. Here are some strategies for achieving those. We could reduce the basal insulin. We could be making sure that we're counseling the patient that we're giving it at a good time. We want to review our target levels and we want to talk about not stacking. Then really ideally, 70 percent or more should be within a target range of 70-180. Again, that mealtime insulin is what's key here for RT. Then we want to make sure that we're reducing the amount of glycemic variability. When we see a lot of glycemic variability, oftentimes that comes from dietary differences. Not everyone's going to eat exactly the same thing, exactly the same day, exactly the same time. Sometimes we need to give patients a small, medium, and large meal settings and things like that. We really got to dig in with that history. Going back to when we're all in MP school, most of the diagnoses that we make is based on obtaining a really good history. The same goes with diabetes management. Let's talk about targets for RT. We really want him to be 70 percent time in range and he's not there. But his titer glucose target overnight will influence that like we talked about already. We really don't want him to be over 25 percent time above range. Because he's exceeding that postprandially, that's really going to be key here. Then we don't want him to be low more than four percent of the time, which he's right at four percent, but we want to be mindful when we're making adjustments for RT. Currently, his carb ratio at lunch and dinner was 1-12. We adjusted that to 1-10 just to give him a little bit more with his meals in that second half of the day. Talked with RT about not stacking short-acting insulin doses. Really, in a patient with type 1 diabetes, they shouldn't be given correction at night unless their sugar is over 200. We want to make sure that we're reinforcing that short-acting insulin with meals should be given about 15 minutes prior to eating as long as we're using something like a Novolog or Humalog. Obviously, if it's more of the newer fast-acting agents like Fiasp, or a Pedra, or Lumegev, we want to make sure we're giving it right at the start of the meal. Then also, we want to make sure that RT is being safe. We want to make sure that his low and his high alarms are activated. But overall, he's doing pretty well again, which is fine-tuning there. I don't have an after to show you on RT, but we can imagine with those changes that we would get him to where he needed to be. We'll jump into the next patient here. JM is a 58-year-old female, past medical history, type 2 diabetes, hypertension, CAD, multiple TIA, CKD, and heart failure with reduced ejection fraction. This is like our pretty typical diabetes patient. JM's had diabetes for seven years. Her current A1C is 8.1 percent, so definitely something needs to change here. She's currently taking Jardian's 10 milligrams daily, and then Levomir 45 in the morning and 35 at night. She's using a Freestyle Libre 2. This is her ambulatory glucose profile. Again, just not to be overkill here, but we're looking at these metrics. We're seeing that she's using this 81 percent of the time, which is fairly reasonable. Average glucose is 192, which equates to estimated A1C around 7.9 based on the GMI, having a lot of glucose variability right here, over 51.6 percent. Then we're jumping over here to the right, and there's lots of things that we need to work on here. JM is having low glucose readings between 54-69, with very low readings less than 54-3 percent of the time. She's only in her target range 36 percent of the time, and the rest of the time, she's either high or very high. This brings my mind back to that slide that we talked about way in the beginning that not all A1Cs are created equal. Even though JM's A1C we know is high, so it's not in that seven percent range, we could still have somebody with an A1C of eight that is hitting most of their metrics, but look how prevalent hypoglycemia and hyperglycemia are for JM. So lots of work for us to do together here. So this just reinforces what we just walked through. So percentage of the time that CGM is collecting the glucose data is 81. Average time over the selected range, which we've cropped out in this report, so I don't have the range, but again, at least 14 days is a good idea for a report, and then the time and range, and then that GMI. So again, this is just patterns to consider. So actual time and range versus goal. So we're time and range 36 percent of the time. Remember, our goal is 70 percent or more based on the ACE guidelines. The GMI versus time and range, so 7.9 percent is understandable when we're only hitting our time and range 36 percent of the time, and there's that glucose variability. So again, this is highly variable glucose. And this pattern here just kind of, excuse me, this slide here just kind of reviews those ACE guidelines as far as people with diabetes and the goals, and when they should be adjusted. So that's important too. So I just want to highlight here for older patients who are in a higher risk category, regardless of whether they have type 1 or type 2 diabetes, we do kind of loosen up those goals a little bit, right? And just like we would loosen up an A1C goal a little for those patients, we loosen up the goals for time and range. You'll see here that we want our time below range to be less than 1 percent in these folks, remembering that that compensatory mechanism for hypoglycemia just really reduces with age. So for those older folks, we really don't want any hypoglycemia if we can avoid it. And so because of that, we tend to be a little bit more liberal with our goals. Their time and range goals should be greater than 50 percent as opposed to greater than 70 percent in the majority of the population. And then their time above range should be less than 10 percent whereas we're a little more stringent with the rest of the population. So this is a really good kind of summary of goals as far as the ACE guidelines go. And so just kind of jumping back to where to start on that range. So those two metrics that we talked about, that we've been talking about, time and range and time below range should really be the starting points here. For this patient here, definitely this time below range is just 12 percent cumulative. It's just way too prevalent. And so we've talked a little bit about this GMI along the way and how we, you know, I keep using this terminology, estimated A1C, and that's how I kind of really talk to my patients about it too because they're like, well, why is my A1C on my CGM different than my GMI? And remember that that A1C, you know, is based on that glycolization of the red blood cells. We know that red blood cells on average have a lifespan of about three months. So that's why we tell patients A1C is about a three-month average of the glucose. But really, 50 percent of that is based on what happens in the four weeks prior to testing. So it can be a little bit skewed as well as those patients that may have anemia, kidney disease, liver disease, or a plethora of other problems that can make an A1C unreliable anyway, especially things like hemoglobinopathies. So again, there may be a little bit of discordance. If there is a huge amount of discordance, then we really need to be thinking about why. And the ADA standards of care really has a great kind of paragraph that talks about that in there, about falsely high or low A1Cs that I would definitely encourage you to review as well. But we can see here in the bottom part of this slide, end-stage renal disease, anemia, hemoglobinopathy, pregnancy, liver disease. So all the things we talked about that may affect that red blood cell turnover can really impact the A1C. So especially in those folks, the A1C sometimes becomes completely unreliable. You know, here at Mayo, we see a lot of transplant patients, and in particular, our liver transplant patients, we notice a huge discordance. I had one patient once whose average glucose was way over 300, and he came in looking so proud. He's like, I don't even know why they're having me see you. My A1C is five. And I looked at him, and I looked at his point-of-care glucose that we did in the office, as well as his trend of the glucose readings on lab, not the A1C, that were always over 300. And I said, well, I hate to break it to you, but your A1C, you may as well throw it out the window. So what did we do? CGM. And so he came back a couple of weeks later, and we reviewed the report together, and he said, I had no idea. I had no idea. And so it's really important that we're thinking about that. I'm gonna skim through just a little bit here, but I want to get to this one because the blood glucose variability is super important. So we do expect a little bit of variance in our glucose every day. Again, we're not gonna eat the same thing at the same time every single day, but this amount of variability warrants some additional investigation. So it's very difficult when we're having this amount of variability to have an accurate A1C, because of that continuous up and down, it's not gonna be reflected in the A1C that we can see, but we can see it on CGM. And then every CGM report gives you the option of looking at a daily glucose log. So you can really start digging in. I'm gonna kind of skim through here a little bit. You can kind of start assessing patterns here too. So you can see that when the blood sugar is really high, then we end up with a crash, same thing happened here. So really need to be thinking about what's causing those and how do we troubleshoot it? So in the end with JM, we reduced basal insulin doses to minimize the recurrent hypoglycemia. We started GLP-1 and up titrated. So we can see baseline on the left here and then on the right, so much, much better. So we know in summary, it's cost-effective. We know that it's about equivalent, if not less cost for a patient than finger sick glucose monitoring. We know that it has outcome benefits too. So complications like retinopathy, nephropathy, neuropathy decreases with additional increase in time and range. Here's some studies and these slides are gonna be available to you too. So I'm gonna leave you with this thought. So this is Chuck, he's a real world patient, 62 year old man, type 1 diabetes for 20 years. He's not on a favorable regimen. He's on NPH and regular, but that's okay. Sometimes we do what we gotta do, but he's never really had formal education. He had an MI two years ago. He doesn't even bother with finger sticks anymore because he said no one even looks at it with him. In the last two months, he's had four hospitalization, he's had, excuse me, 10 hospitalizations over four different hospitals, all with confusion, difficulty walking, weakness and chest pain. Fortunately, he's not had a stroke, but would he benefit from CGM? And I think that would be a big yes. So I'm gonna leave it there and open up to some questions and answers. And thank you for bearing with me. I know I'm going past the two o'clock timeframe, but I wanna give you back the opportunity to spend some time talking about questions here. So I see, excuse me, I see a question from Connie in the Q and A, how is insurance coverage for patients in obtaining CGM? So this is a great question, Connie. And for the most part with commercial insurance, CGM is very well covered for patients with type two diabetes even sometimes patients with pre-diabetes. For Medicare and the government funded programs, usually the patient needs to be on some form of insulin in order to get their CGM covered by insurance. But typically they're affordable for most folks. I will tell you here in Florida, the Freestyle Libre devices for patients without insurance coverage tend to be the most affordable. Currently I have patients who self pay for them just for convenience and their insurance won't cover that pay about $70 a month for two sensors at the Freestyle Libre. So some patients feel that the return on investment for that is great. So sometimes we'll do it even for a short period of time, just for educational purposes with folks. And again, a lot of these companies will do sample programs with you guys too. So definitely would reach out to your reps in the area. Dexcom is the name of the company who manufactures Dexcom and Abbott is the company who does Freestyle Libre. So, we don't see any other questions right now. I do see that our facilitators have put the link in the chat here with the link to the copy of the slides. And I believe you can also visit the online enduring materials register for that through that website. If you haven't had the opportunity to look at that, I'm also gonna type in here, if I can multitask, my email address in the chat. So if anybody has any questions, feel free to reach out to me. I'm gonna stop my screen sharing here cause that was the end of that. So feel free to reach out to me at any point in time. If you have any questions or want to kind of review any information, I'm happy to be a resource for you. So you can be a resource for your patients. And I just thank you so much for your time and your attention.

diabetes technology

continuous glucose monitors

CGM

A1C levels

hypoglycemia

patient empowerment

treatment plans

insurance coverage