Becton, Dickinson and Company · NYSE:BDX
Becton, Dickinson and — Investor Presentation (2022)
116 slides from Becton, Dickinson and's investor presentation, 2022
Slide 1: Practical Aspects of Pharmacy-Based Implementation, Reimbursement, and Integration of CGM-Based Care
Practical Aspects of Pharmacy- Based Implementation, Reimbursement, and Integration of CGM-Based Care Across the Full Spectrum of Persons ; with Diabetes: A Year 2022 Update for the Managed Care Pharmacist Prime me Rances Very High 250 mgt) High (181-20 m9)
Slide 2: The Emerging Foundational Role of Sensor-Based CGM for Managing Diabetes
From Clinical Trials to the Front Lines of Diabetes Care The Emerging Foundational Role of Sensor-Based CGM for Managing Diabetes in the Managed Care Pharmacy Setting Diana Isaacs, PharmD, BCPS, BCACP, CDCES, BC- ADM, FADCES, FCCP Endocrine Clinical Pharmacy Specialist CGM and Remote Monitoring Prog
Slide 3: Welcome and Virtual Symposium Overview
Welcome and Virtual Symposium Overview CE/CME-certified virtual symposium jointly provided by the University of Massachusetts Medical School and CMEducation Resources, LLC Commercial Support: Supported by an educational grant from Abbott Diabetes Care
Slide 4: Program Faculty
Program Faculty Diana Isaacs, PharmD, BCPS, BC-ADM, CDE – Program Chair Clinical Pharmacy Specialist/CGM Program Coordinator Department of Endocrinology, Diabetes & Metabolism Cleveland Clinic Diabetes Center Cleveland, OH Susan Cornell, BS, Pharm.D., CDCES, FAPhA, FADCES Associate Director of Exper
Slide 5: We Kindly Request That You…
We Kindly Request That You… PLEASE COMPLETE THE ONSITE or ONLINE COURSE SURVEY AND EVALUATION FORM to receive CE/CME credit for this program
Slide 6: Continue Learning With Us
Continue Learning With Us Access Enduring Materials from This Virtual Symposium ► This entire virtual symposium, and additional diabetes CE/CME offerings, will be available as a Clinical Excellence WebCAST on multiple clinical websites, including www.DiabetesCAST.com ► PowerPoint slides from this pr
Slide 7: The Current State of Diabetes
The Current State of Diabetes ► 37.3 million people have diabetes (11.3% of the US population, 14.7% of all US adults) ► 96 million aged 18 and older have prediabetes (38% of the adult US population) ► In 2018, approx. 17 million Emergency Department visits for diabetes ► In 2018, a total of 8.25 mi
Slide 8: Most Are Not Meeting Treatment Goals
Most Are Not Meeting Treatment Goals ► 23.8% met the recommended goal of at least 150 minutes/week of leisure-time physical activity Preventing Diabetes-Related Complications | Diabetes | CDC 8
Slide 9: There is a Need to Try Something Different…
There is a Need to Try Something Different… Diabetes care that relies on quarterly visits with A1C checks neglects the reality of life with • Impact of lifestyle on glycemic diabetes that is continuous management • No visibility on their response to interventions Using A1C alone may not be very help
Slide 10: Introducing CGM
Introducing CGM ► Measures glucose from interstitial fluid (ISF) every 1-5 mins and records glucose every 5-15 mins (up to 288 readings/day) ► Includes 3 components: transmitter, sensor, receiver/reader Skin The sensor Interstitial filament is <0.4 fluid mm thick Cells Glucose For illustrative purpo
Slide 11: BGM vs CGM: Experience the Difference
BGM vs CGM: Experience the Difference Undetected hypoglycemia = glucometer readings Undetected hyperglycemia
Slide 12: Why CGM? At Least 42 Factors Affect Glucose
Why CGM? At Least 42 Factors Affect Glucose Behavioral and Food Medication Activity Biological Environmental decision making 20. ↑ Insufficient sleep 15. →↓ Light 21. ↑ Stress and illness 34. ↑ Expired 39. ↓ Frequency of 1. ↑↑ Carbo- exercise 22. ↓ Recent insulin 10. →↓Dose glucose checks hydrate 16
Slide 13: CGM Provides Real-Time Data
CGM Provides Real-Time Data Take action quickly with highs, treat lows before they happen
Slide 14: A1C Alone is Just Not Enough
A1C Alone is Just Not Enough https://diatribe.org/time-range.
Slide 15: The Evolution of CGM
The Evolution of CGM It’s evolved a ton in the last 5 years, to be the new standard of care Personal CGM Playbook. Available at: personal-cgm-playbook.pdf (diabeteseducator.org) 15
Slide 16: CGM Offers Many Benefits
CGM Offers Many Benefits ► Lower A1C ► Reduce time spent in hypoglycemia ► Reduction time spent in hyperglycemia and severe hyperglycemia events ► Increased time in target glucose range ► Improved overall quality of life and well-being ADA Standards of Care 2022
Slide 17: The Managed Care Pharmacist's Important Role in CGM
The Managed Care Pharmacist’s Important Role in CGM Overcome Cost/ Access Therapeutic Coverage Inertia Address Improve Health Optimize Diabetes Disparities Care Stats in Use
Slide 18: Practical Aspects of Pharmacy-Based Implementation, Reimbursement, and Integration of CGM-Based Care
Practical Aspects of Pharmacy- Based Implementation, Reimbursement, and Integration of CGM-Based Care Across the Full Spectrum of Persons ; with Diabetes: A Year 2022 Update for the Managed Care Pharmacist Prime me Rances Very High 250 mgt) High (181-20 m9)
Slide 19: Clinical Evidence, Rationale, and ADA Guidelines for Incorporating Sensor-Based CGM
From Clinical Trials to the Front Lines of Diabetes Care Clinical Evidence, Rationale, and ADA Guidelines for Incorporating Sensor-Based CGM to Optimize Diabetes Management in the Managed Care Setting Susan Cornell, PharmD, CDCES, FAPhA, FADCES Associate Director of Experiential Education Professor
Slide 20: Faculty Disclosures
Faculty Disclosures Susan Cornell, PharmD, CDCES, FAPhA, FADCES, has the following relevant financial relationships with commercial interests to disclose. Advisory Board member and Speaker Bureau for Novo Nordisk, Inc Advisory Board member for Sanofi Advisory Board member for Bayer
Slide 21: National Diabetes Statistics Report – 2022
National Diabetes Statistics Report – 2022 • New diabetes cases have decreased in the last 10 years, except in people < 20 years of age. • 37.3 million Americans (11.3% of population) have diabetes. • 96 million American adults (38% of population) have prediabetes. • New diabetes cases were higher a
Slide 22: National Diabetes Statistics Report – 2020
National Diabetes Statistics Report – 2020 Key Point: For people with diabetes - There is much room for improvement in preventing diabetes complications. 89.0% were overweight or had obesity (body mass index (BMI) of ≥ 25 kg/m2). 27.6% were overweight (BMI of 25.0 to 29.9 kg/m2 ). 45.8% ha
Slide 23: Summary of Revisions: Standards of Medical Care in Diabetes 2022
Summary of Revisions: Standards of Medical Care in Diabetes -2022 Section 6: Glycemic Targets Time in range fully incorporated into glycemic assessment
Slide 24: What is the best way to monitor blood glucose?
What is the best way to “monitor” blood glucose? Glycemic control is assessed by: 1. A1C measurement average BG over the past 3 months does not provide a measure of glycemic variability or hypoglycemia. 2. Continuous glucose monitoring (CGM) using either time in range (TIR) and/or glucose ma
Slide 25: Daily Glucose Tracings of Patients With T2D and A1C of 6.5%
Daily Glucose Tracings of Patients With T2D and A1C of 6.5% What do you think of these patients’ glucose 360 control? Euglycemic range defined as 70 to 180 mg/dL 270 Glucose (mg/dL) 180 90 0 12AM 2AM 4AM 6AM 8AM 10AM 12PM 2PM 4PM 6PM 8PM 10PM Reproduced with permission from Kohnert Clock time KD et
Slide 26: Time in Range
Time in Range Diabetes Type Glucose Range Recommendations (% of readings; time per day) <54 mg/dL <1% (<15 min) <70 mg/dL <4% (<1 h) 70-180 mg/dL >70% (>16 h, 48 min) Type 1/type 2 diabetes >60% for individuals <25 years old (>14 h, 24 min) >180 mg/dL <25% (<6 h) >250 mg/dL <5% (<1 h, 12 min) <70 mg
Slide 27: Standardized CGM Metrics for Clinical Care
Standardized CGM Metrics for Clinical Care Number of days CGM is worn Recommend 14 days Percentage of time CGM device is Recommend 70% of data from 14 active days Glycemic variability (%CV) Target ≤36%* Time above range (TAR) % reading & time >250 mg/dL Level 2 hyperglycemia Time above range (TAR) %
Slide 28: Information / Data from CGM
Information / data from CGM Glucose statistics Ambulatory Glucose Profile (AGP) (mg/dl) Daily Glucose Profile
Slide 29: CGM Data: Glucose Statistics and Time in Range
CGM Data: Glucose Statistics and Time in Range Glucose Statistics and Targets Time in Range Jan 6, 2021 – Jan 18, 2021 13 days % Time CGM Is Active 99.9% Very High (>250 mg/dL) ..……20% (4 h, 48 min --------------------------------------------------------------------- Glucose ranges Targets [% of rea
Slide 30: Correlations of TIR and A1c
Correlations of TIR and A1c Time in Average A1c Range (%) (%() 40 8.1 50 7.7 60 7.3 70 6.9 80 6.5 Bergenstal, RM. Continuous Glucose Monitoring Data as an Adjunct to A1C. Role of Continuous Glucose Monitoring in Diabetes Treatment. American Diabetes Association. 2018 Aug: 19-20.
Slide 31: Classifications of Hypoglycemia
Classifications of Hypoglycemia Glycemic criteria / description Level 1 Glucose <70 mg/dl and ≥ 54 mg/dl Level 2 Glucose < 54 mg/dl Level 3 A severe event categorized by altered mental and/or physical status requiring assistance for treatment of hypoglycemia American Diabetes Association. 6. Glycemi
Slide 32: CGM as a Standard of Care
CGM as a Standard of Care • CGM is rapidly improving diabetes management. • A 14-day CGM assessment of TIR and GMI can serve as a surrogate for A1C in clinical management • The use of CGM-derived TIR and GMI may provide more timely treatment changes • New data support increased TIR correlates with t
Slide 33: CGM as a Standard of Care
CGM as a Standard of Care • Standardized reports, such as the AGP provide visual cues and may help the patient (and provider) better interpret the data to guide treatment decisions. • CGM can be useful to guide: • nutrition therapy • physical activity • prevent hypoglycemia • support medication mana
Slide 34: Conclusion
Conclusion • The role of the pharmacist continues to evolve • Especially in diabetes care models • Monitoring glycemic control is more than A1C • Use of CGM technology can • Provide better data on glucose “time in range” • Improve glycemic variability • Improve diabetes management • Pharmacists can
Slide 35: Practical Aspects of Pharmacy-Based Implementation, Reimbursement, and Integration of CGM-Based Care
Practical Aspects of Pharmacy- Based Implementation, Reimbursement, and Integration of CGM-Based Care Across the Full Spectrum of Persons ; with Diabetes: A Year 2022 Update for the Managed Care Pharmacist Prime me Rances Very High 250 mgt) High (181-20 m9)
Slide 36: Practical Strategies for Incorporating CGM into Managed Care Pharmacy Practice
From Clinical Trials to the Front Lines of Diabetes Care Practical Strategies for Incorporating CGM into Managed Care Pharmacy Practice Diana Isaacs, PharmD, BCPS, BCACP, CDCES, BC-ADM, FADCES, FCCP Endocrine Clinical Pharmacy Specialist CGM and Remote Monitoring Program Coordinator Cleveland Clinic
Slide 37: CGM Cost and Access
CGM Cost and Access ► Lowest-cost CGM option: $75 per month without insurance ► Historically, insurance plans limited access to people with type 1 diabetes, but now there is a ton of data on the benefits in people with type 2 diabetes ► Commercial insurance is plan specific, coverage often through
Slide 38: Medicare Access to CGM
Medicare Access to CGM ► Medicare and others have expanded to include type 1 and type 2 diabetes, but have multiple requirements: Multiple daily injections or insulin pump therapy Insulin treatment regimen requiring frequent adjustments Ongoing visits to assess adherence Only covers non-adju
Slide 39: Medicare Improves Access
Medicare Improves Access ► As of July 18, 2021, CMS no longer requires beneficiaries to perform 4x BG tests to qualify for CGM ► This removes a major barrier to CGM access including inconvenience/pain of testing and cost of test strips Medicare typically only covers 3 test strips/day ► Insulin als
Slide 40: Medicaid Access to CGM
Medicaid Access to CGM ► Some plans require either documented hypoglycemia unawareness or evidence of multiple severe low BGs (<50 mg/dL) ► Many require 30-day log showing >4 finger sticks per day required for most plans A Guide to CGMs and Medicaid Coverage Differences by State – T1 D Exchange
Slide 41: CGM Coverage: Pharmacy vs. DME
CGM Coverage: Pharmacy vs. DME Asks Send for Prior to pharmacy Authorization Prior Authorization Rejected Was supposed to go through DME
Slide 42: Managed Care Pharmacists Can Ensure Optimal Access
Managed Care Pharmacists Can Ensure Optimal Access ►Knowledge of DME vs. pharmacy benefit ►Prior authorization criteria ►Documentation requirements ►Creative solutions to access
Slide 43: Creative Solutions to Access
Creative Solutions to Access ► Intermittent use of “Periodic use of rtCGM or isCGM or use of professional personal CGM CGM can be helpful for ► Many ways to CGM: diabetes management in Wear 7-14 days prior to circumstances where continuous use of CGM is not office visit appropriate, desired or W
Slide 44: Overcome Health Disparities in CGM Use
Overcome Health Disparities in CGM Uee ► 65% of Black and Hispanic compared with 79% of White beneficiaries knew that Medicare helps pay for diabetes testing supplies and self-management education. ► A retrospective chart review showed that 30.5% of Black and 32.5% of Hispanic patients initiated CGM
Slide 45: Introducing the Identify, Configure, Collaborate (ICC) Framework
Introducing the Identify, Configure, Collaborate (ICC) Framework ► The ICC framework has been adopted by ADCES for integrating any technology tool into diabetes clinical care ► The Managed Care Pharmacist can use the ICC framework to ensure optimal access to CGM and overcome health disparities
Slide 46: Strategies to Identify
Strategies to Identify ► Many people with diabetes have never heard of CGM ► They assume they wouldn’t qualify to have one ► They may have concerns about a device being attached to their body – lack understanding of how it works, ease of use ► Make sure your patients are aware of their choices and h
Slide 47: How to Identify
How to Identify ► Assess needs and goals to determine the right technology for the right person at the right time ► Areas to assess: Current use of technology Readiness to adopt new technology Physical and cognitive conditions Financial means to access technology Digital health literacy
Slide 48: Strategies to Configure
Strategies to Configure ► Ensure open discussion regarding individual needs and preferences ► Provide person-centered education ► Configure the options • Ex. alerts on/off, alerts at different thresholds, glucose targets, time in range goals ► Determine a plan for communication with the team to reco
Slide 49: CGM Education and Training
CGM Education and Training “When prescribing a device, ensure that people with diabetes/caregivers receive initial and ongoing education and training, either in-person or remotely, and regular evaluation of technique, results and their ability to use data.” American Diabetes Association. 7. Diabetes
Slide 50: Simply wearing the devices may not automatically translate to health benefits
“Simply wearing the devices may not automatically translate to health benefits.” Camille was given a CGM but not educated on her glucose targets. She has been wearing it for 3 months!
Slide 51: Collaborate
Collaborate ► Collaboration includes 2-way discussion about data using shared decision making ► Supports behavior changes and/or medication adjustments to halt the cycle of therapeutic inertia and improve health outcomes ► Evaluates user engagement and ongoing use of technology ► Check for potential
Slide 52: Review of Continuous Glucose Monitoring (CGM) - DATAA
Review of Continuous Glucose Monitoring (CGM) - DATAA Isaacs D, et al. The Diabetes Educator. 2020;46(4):323-334.
Slide 53: The Cleveland Clinic Experience: How We Use Pharmacists in CGM Services
The Cleveland Clinic Experience: How We Use Pharmacists in CGM Services ►Professional CGM service led by pharmacists • Insertion/education/billing/interpretation • CGM Shared Medical Appointments ►Personal CGM service led by pharmacists • Identify, configure, collaborate • Medication adjustments thr
Slide 54: The Cleveland Clinic Experience (cont.)
The Cleveland Clinic Experience (cont.) ► Pharmacists and pharm techs help with prior authorization process at Cleveland Clinic pharmacies ► CGM interpretation pool Pharmacists interpret CGM reports sent by providers Generate revenue through facilitating the billing of CPT 95251 72 hour turnar
Slide 55: Summary
Summary ► Insurance coverage has been expanding to include more people with type 2 diabetes with less stringent requirements ► The Identify, Configure, Collaborate (ICC) framework is a tool that relies on shared decision making and can help address health disparities in CGM use ► There are many ways
Slide 56: Practical Aspects of Pharmacy-Based Implementation, Reimbursement, and Integration of CGM-Based Care
Practical Aspects of Pharmacy- Based Implementation, Reimbursement, and Integration of CGM-Based Care Across the Full Spectrum of Persons ; with Diabetes: A Year 2022 Update for the Managed Care Pharmacist Prime me Rances Very High 250 mgt) High (181-20 m9)
Slide 57: How To Implement CGM into Practice to Improve Cardiovascular Risk Reduction in Type 2 Diabetes
From Clinical Trials to the Front Lines of Diabetes Care How To Implement CGM into Practice to Improve Cardiovascular Risk Reduction in Persons with Type 2 Diabetes Christie Schumacher PharmD, BCPS, BCACP, BCCP, BC-ADM, CDCES, FCCP Professor, Pharmacy Practice Director, PGY2 Ambulatory Care Residenc
Slide 58: Learning Objectives
Learning Objectives 1) Describe the different between professional- and personal-use CGM. 2) Discuss how to initiate CGM services including best practices in patient selection, clinic integration, documentation, and reimbursement. 3) Design a patient-centered diabetes treatment plan considering cont
Slide 59: Cardiovascular Disease and Diabetes
Cardiovascular Disease and Diabetes Aggressive modification ~$37.3 of CV risk billion in CV- factors • Diabetes Leading related • • HTN Dyslipidemia cause of spending • CKD • Smoking morbidity per year cessation and associated mortality in with diabetes diabetes American Diabetes Association. Diabet
Slide 60: HF and T2D: The Stats
HF and T2D: The Stats 50% • Half of patients with T2D may develop HF 2X • Risk of developing HF is more than doubled in the presence of T2D 8% • Increase in risk for HF for every 1% increase in A1C • Patients with both T2D and HF have a nearly doubled mortality rate 2X compared to HF patients withou
Slide 61: 2022 ADA Standards of Care
2022 ADA Standards of Care FIRST-LINE = metformin1 + comprehensive lifestyle modifications (e.g., weight management and physical activity) 1 May consider initial combination therapy if A1C levels ≥1.5–2.0% above target Indicators of high risk or established ASCVD, HF or CKD? YES NO Consider independ
Slide 62: ASCVD or Indicators of High Risk
ASCVD or Indicators of High Risk 1 GLP-1 agonist with EITHER SGLT2 inhibitor with /OR proven CVD benefit2 proven CVD benefit2 For GLP-1 receptor agonists, strongest For SGLT2 inhibitors, evidence mostly stronger evidence for for: • liraglutide (LEADER) 1. empagliflozin (EMPA-REG OUTCOME) • dulagluti
Slide 63: 2022 ADA Standards of Care
2022 ADA Standards of Care FIRST-LINE = metformin1 + comprehensive lifestyle modifications (e.g., weight management and physical activity) 1 May consider initial combination therapy if A1C levels ≥1.5–2.0% above target Indicators of high risk or established ASCVD, HF or CKD? YES NO Consider independ
Slide 64: Heart Failure
Heart Failure Empagliflozin • EMPA-REG OUTCOME (HHF ↓ 35%) • EMPEROR-REDUCED (HHF ↓ 31%) • EMPEROR-PRESERVED (HHF ↓ 29%) 27%) Particularly HFrEF (LVEF <40%) Canagliflozin • CANVAS + CANVAS-R (HHF ↓ 33%) • CREDENCE (HHF ↓ 39%) Dapagliflozin SGLT2 inhibitor with • DECLARE-TIMI 58 (HHF ↓ 27%) • DAPA-HF
Slide 65: Using CGM to Optimize Antihyperglycemic Medication Use
Using CGM to Optimize Antihyperglycemic Medication Use
Slide 66: CGM Overview
CGM Overview CGM systems are either owned by the user (personal-use) or the health system (professional-use) Require the insertion of a thin filament under the skin which measures interstitial glucose every 1 to 5 minutes A small sensor connects to the filament and sends readings via a wireless tran
Slide 67: Guideline Recommendations
Guideline Recommendations CGM in T1D • Should be considered in all children and adolescents with type 1 diabetes • To lower A1C and/or reduce hypoglycemia in adults who • Are not meeting glycemic goals • Have hypoglycemia unawareness • Have episodes of hypoglycemia CGM in T2D • Recommend real-time C
Slide 68: Guideline Recommendations
Guideline Recommendations Professional-use CGM • Not using personal-use CGM • Recommend in addition to diabetes self-management education and medication therapy management to improve glycemic management in persons with T1D or T2D • May be helpful in identifying and correcting patterns of hyper- and
Slide 69: Why routine use of sensor-based CGM to increase Time In Range is important
Why routine use of sensor- based CGM technology to increase Time In Range is important: What do we know?
Slide 70: The Impact of Flash Glucose Monitoring on Glycaemic Control
The Impact of Flash Glucose Monitoring on Glycaemic Control as Measured by HbAIc: A Meta-analysis published online: 31 October 2019 of Clinical Trials and Real-World Observational | Diabetes Ther Studies Mark Evans - Zoé Welsh - Sara Ells - Alexander Seibold _https://doi.org/10.1007/s13300-019-00720
Slide 71: Effect of Continuous Glucose Monitoring on Glycemic Control, Acute Admissions, and Quality of Life
Effect of Continuous Glucose Monitoring on Glycemic Control, Acute Admissions, and Quality of Life: A Real-World Study J Clin Endocrinol Metab, March 2018, 103(3):1224-1232 Sara Charleer,'? Chantal Mathieu,' Frank Nobels,? Christophe De Block,* Regis P. Radermecker,° Michel P. Hermans,® Youri Taes,”
Slide 72: A nationwide cost reduction during the RESCUE trial period
A nationwide cost reduction of € 345,509 during the RESCUE trial period
Slide 73: Professional- vs. Personal-use CGM Systems
https://provider.myfreestyle.com/compare-products.html Professional- vs. Personal-use CGM https://provider.dexcom.com/products/dexcom-g6-pro/how-it-w Systems
Slide 74: What is a Professional-Use CGM?
What is a Professional-Use CGM? Purchased and owned by the clinic or practice • Used intermittently by the patient and the health care team to help facilitate diabetes management Data collection can be either blinded or unblinded • Requires clinicians to retrospectively review data of glycemic patte
Slide 75: Which Patients May Benefit from Professional-Use CGM?
Which Patients May Benefit from Professional-Use CGM? Insurance does not cover personal-use CGM Discordant A1C and SMBG When health care providers need more data Lack of SMBG data - not testing as frequently as recommended A1C >9% Frequent hypoglycemia or hypoglycemia unawareness Post-prandial hyper
Slide 76: Professional-Use CGM
Professional-Use CGM Abbott FreeStyle Dexcom G6 Pro Libre Pro • Disposable sensor/transmitter • Disposable Components • Receiver for data sensor/transmitter display/storage, which is owned • Receiver for data and kept at the health care display/storage, which is clinic owned and kept at the health •
Slide 77: Professional-Use CGM
Professional-Use CGM Dexcom G6 Pro FreeStyle Libre Pro Maximum wear time 10 days 14 days Approved sites Abdomen Back of upper arm Calibrations required 0 0 Data Software Clarity LibreView Alarms for high/low Yes, in unblinded mode No Salicylic acid and ascorbic Interfering substances Hydroxyurea aci
Slide 78: Commonly Cited Barriers to Professional-Use CGM
Commonly Cited Barriers to Professional-Use CGM Barriers Integration Results Lack of funding for start-up 46% spend less than 10 min at costs (66%) each visit 25% spend 11 - 20 min Lack of sufficient reimbursement (57.5%) 76% follow-up within 2 weeks Unpredictable patient follow-up (48%) Lack of tim
Slide 79: Integrating CGM into Clinical Practice
Integrating CGM into Clinical Practice How many interventions will you need to make? What is your availability? • Can you schedule a follow-up visit(s) during the wear period to review results? Can place during regularly scheduled visits • Takes less than 5 min unless setting up unblinded mode and c
Slide 80: Billing for CGM Services
Billing for CGM Services CPT 95249 CPT 95250 CPT 95251 • Any trained health care • Any trained health care • A physician or licensed non- professional professional physician provider as outlined • e.g., nurses, certified • Incident-to requirements are by their scope of practice in diabetes care and
Slide 81: CGM Billing Timeline
CGM Billing Timeline Next Provider Follow-up ≥72 Appointment Appointment Sensor hour Download data, Placement Download data, provide and review s provide disease AGP report CGM system set- state management up, training, and collaboratively education Bill CPT 95249 or with provider 95250 incident-to
Slide 82: Tips for CGM Integration
Professional-use CGM orders • Readers are one-time purchase • Consider purchasing 2, one as a back-up • Order sensors based on need • Start with with a small number, 6-8 sensors, until Tips for workflow established • Consider sensor expiration dates CGM • Establish ordering and inventory process Int
Slide 83: Trouble Shooting Tips
Trouble Shooting Tips Sensor adhesion • Products that help prevent adhesive failure: • Bidirectional adhesives make the skin “stickier” Skin Prep, Skin TacTM Adhesive patches or tapes Tegaderm HP, product-specific adhesive patches • Check with manufacturer prior to use Skin irritation • Fluticas
Slide 84: Endorsements
Endorsements American Diabetes Association (ADA) International Society for Pediatric and Adolescent Diabetes (ISPAD) Juvenile Diabetes Research Foundation (JDRF) American Association of Diabetes Educators (AADE) Foundation of European Nurses in Diabetes (FEND) American Association of Cli
Slide 85: Guidance on targets for assessment of glycemic control: Type 1 / Type 2
Guidance on targets for assessment of glycemic control: 1% of the day is ~15 minutes Type 1 / Type 2 and Older / High-Risk Individuals Time Below Range Time Above Range Time in Range (TIR) Diabetes (TBR) (TAR) Group % of Target % of Below % of Above readings Range readings Target readings Target tim
Slide 86: Guidance on targets for assessment of glycemic control: Pregnancy
Guidance on targets for assessment of glycemic control: 1% of the day is ~15 minutes Pregnancy Time Below Range Time Above Range Time in Range (TIR) Diabetes (TBR) (TAR) Group % of Target % of Below % of Above readings Range readings Target readings Target time/day time/day Level time/day Level <63
Slide 87: Standardized CGM Metrics for Clinical Care
Standardized CGM Metrics for Clinical Care >250 mg/dL Level 2 hyperglycemia Number of days CGM is worn Time above range 14 days is recommended >180 mg/dL Level 1 hyperglycemia (TAR) Percentage of time CGM is active 70% of data from 14 days is recommended Mean glucose Glucose management 70-180 mg/dL
Slide 88: Ambulatory Glucose Profile
Ambulatory Glucose Profile Ambulatory Glucose Profile (AGP) Report • 3 components Key Metrics and Time in range Ambulatory glucose profile (AGP) Daily profiles
Slide 89: CGM Targets
CGM Targets Older/High-Risk: Pregnancy: T1D & T2D T1D & T2D T1D >250 mg/dL Target time Target time Target time (13.9 mmol/L) <5% >250 mg/dL <10% (13.9 mmol/L) >180 mg/dL >140 mg/dL (10.0 mmol/L) <25% <25% (7.8 mmol/L) >180 mg/dL <50% (10.0 mmol/L) Target Range: >70% Target Range: 70-180 mg/dL 63-140
Slide 90: CGM Interpretation and Training Resources
CGM Interpretation and Training Resources Innovating Decisions and Empowering Action (IDEA) in Diabetes Management • Available from: https://nf01.diabeteseducator.org/eweb/DynamicPage.aspx Association of Diabetes Care and Education Specialists (ADCES) Personal Continuous Glucose Monitoring Implement
Slide 91: Patient Case: Meet RV
Patient Case Meet RV Using CGM in discordant A1C and SMBG 91
Slide 92: Meet RV
Meet RV ► CC: RV is a 71-year-old year old Hispanic man presenting for a follow-up visit for chronic disease management for T2DM, HTN, HLD, cirrhosis, PVD, and smoking cessation. ► PMH: type 2 diabetes, hypertension, tobacco use, previous cocaine abuse, severe PVD, alcoholic liver cirrhosis (now abs
Slide 93: Meet RV
Meet RV • Self-reported SMBGs • Only checking FPGs upon wakening at 6 am • 135, 126, 119, 86, 83, 94, 115, 111, 64 mg/dL • Reports he “feels low” when he wakes up Date A1C Fasting Plasma Glucose 8/11/2020 8.8% 114 mg/dL 3/9/2020 8.5% 85 mg/dL 12/24/2019 8.0% 125 mg/dL
Slide 94: Meet RV
Meet RV Medications for Type 2 Diabetes Metformin 1000 mg twice daily Glipizide 10 mg twice daily Insulin degludec (Tresiba) 55 units daily Subcutaneous semaglutide (Ozempic) 1 mg weekly Empagliflozin (Jardiance) 25 mg daily *Resistant to adding mealtime insulin because he is low when he wakes up
Slide 95: What adjustments would you make to RV's medication regimen?
What adjustments would you make to RV’s medication regimen? What lifestyle modifications would you recommend?
Slide 96: Patient Case RV
Patient Case RV AGP Report GLUCOSE STATISTICS AND TARG TIME IN RANGES August 21, 2020 - September 3, 2020 14 Days % Time CGM is Active 100% Very High >250 mg/dL Ranges And Targets For Type 1 or Type 2 Diabetes P| Glucose Ranges Targets % of Readings (Time/Day) = Target Range 70-180 mg/dL Greater tha
Slide 97: Patient Case RV
Patient Case RV IBULATORY GLU E PROFIL (GP) AGP is a summary of glucose values from the report period, with median (50%) and other percentiles shown as if occurring in a single day. 350mg/dL 95% 2505 75% (~ 180: 50% 25% Target Range LL, 5% 12am 3am 6am 3am 42pm 3pm 6pm Spm 12am
Slide 98: Patient Case RV
Patient Case RV DAILY GLUCOSE PROFILES Each daily profile represents a midnight to midnight period with the date displayed in the upper left comer. Friday Saturday Sunday Monday Tuesday Wednesday Thursday 250 27
Slide 99: Patient Case RV
Patient Case RV Q Glucose 9 Average Glucose . AVERAGE mga GLUCOSE 187 no. % above target 49» % in target a7 480 % below target 4 aes 70 10th to 90th Percent: ° 2am 6am 12pm 6p 2am Low Glucose Events 100 LOW GLUCOSE EVENTS 7 oo Average duration 105 0-1 70 oe el 40
Slide 100: What adjustments would you make to RV's medication regimen?
What adjustments would you make to RV’s medication regimen? What lifestyle modifications would you recommend?
Slide 101: Patient Case RV
Patient Case RV 01 02 03 Start mealtime Decrease basal Taper off insulin 4 units insulin glipizide at before each future visit meal
Slide 102: Patient Case: Meet SM
Patient Case Meet SM Using CGM to Optimize Medication Therapy 102
Slide 103: Meet SM
Meet SM • HPI: SM is a 78-year-old man presenting for an initial visit for chronic disease management for T2DM, Parkinson’s disease, CAD s/p PCI • A1C was 8.0% one month prior to initial visit • Self-reported SMBGs • Testing 2 times daily • 90-110 mg/dL upon awakening • Reports he wakes up every nig
Slide 104: Meet SM
Meet SM Medications for Type 2 Diabetes Metformin ER 750 mg 2 tablets daily Insulin glargine (Lantus) 14 units daily Insulin lispro (Humalog) 10 units TID with meals
Slide 105: Patient Case SM (Visit #1)
Patient Case SM (Visit #1) 01 02 Decrease insulin Order FreeStyle glargine to Libre 2 CGM 10 units daily
Slide 106: Visit #2 Daily Graph
Visit #2 Daily Graph 106
Slide 107: What adjustments would you make to SM's medication regimen?
What adjustments would you make to SM’s medication regimen? What lifestyle modifications would you recommend?
Slide 108: Visit #2 Plan
Visit #2 Plan 01 02 03 04 Stop insulin Decrease Start Continue glargine 10 insulin lispro empagliflozin metformin units daily from 10 to 8 10 mg daily ER 750 mg 2 units with tablets daily meals
Slide 109: Visit #3 (~1 Week Later)
Visit #3 (~1 Week Later) www.freestylelibre.us
Slide 110: Visit #3 Plan
Visit #3 Plan 01 02 03 Continue Decreased insulin Continue empagliflozin lispro from 8 units metformin ER 750 10 mg daily to 4 units with mg 2 tablets daily • Only 1 week on therapy meals • No basal insulin at this • Counseled on time carbohydrate consumption to reduce post-prandial glucose excursio
Slide 111: Visit #4 (~2 Weeks Later)
AGP Report GLUCOSE STATISTICS AND TARGETS IME IN RANGES May 27, 2021 - June 8, 2021 14Days % Time CGM Is Active 10% Very High 2 wo 2% con anges Ana ge Pr yn Tp aa High ve -200 moe 19% ore a Targa otto no pores Oa ne ae earns Soe 70 mot Lan nan 6 ng ow 4 rot aman 1 4) — aR Target Range 70-ssomya 87%
Slide 112: What adjustments would you make to SM's medication regimen?
What adjustments would you make to SM’s medication regimen? What lifestyle modifications would you recommend?
Slide 113: Visit #4 Plan
Visit #4 Plan 01 02 03 Discontinue Increase Continue insulin lispro empagliflozin to metformin 750 25 mg daily mg 2 tablets every morning
Slide 114: SM is a 78-year-old man presenting for chronic disease management
SM is a 78-year-old year old man presenting for chronic disease management for T2DM, Parkinson’s disease, CAD s/p PCI Current T2DM Medications: Metformin ER 750 mg 2 tablets daily Empagliflozin 25 mg daily Repeat A1C: 7.1%
Slide 115: Thank You
THANK YOU Christie Schumacher PharmD, BCPS, BCACP, BCCP, BC-ADM, CDCES, FCCP Professor, Pharmacy Practice Director, PGY2 Ambulatory Care Residency Program Midwestern University College of Pharmacy, Downers Grove Campus (CPDG) Clinical Pharmacist, Advocate Medical Group Chicago, IL
Slide 116: Practical Aspects of Pharmacy-Based Implementation, Reimbursement, and Integration of CGM-Based Care
Practical Aspects of Pharmacy- Based Implementation, Reimbursement, and Integration of CGM-Based Care Across the Full Spectrum of Persons ; with Diabetes: A Year 2022 Update for the Managed Care Pharmacist Prime me Rances Very High 250 mgt) High (181-20 m9)
Becton, Dickinson And Company — Investor Presentation (2022) on 6ix