Clinical Diabetes Technology Meeting 2008
The fourth annual Clinical Diabetes Technology Meeting was held in Orlando on April 11th and 12th, 2008. In attendance were hundreds of clinicians, scientists, and engineers from government, industry, academia, and clinical practice. During the two days of sessions, speakers shared information on a variety of topics, including issues affecting accuracy in home blood glucose monitoring, many aspects of continuous glucose monitoring, glycemic variability, reimbursement issues, tools for managing diabetes in pregnancy, and pumps in school, just to name a few. Here is a summary of some of the sessions:
- Barry Ginsberg, MD, presented Factors Potentially Affecting SMBG. Dr. Ginsberg explained the difference between accuracy and precision and what those differences mean specifically for patients using home blood glucose monitors. While the best meters today are very, very good, with 5% errors easily achievable even by home users, he answered the question, "Why aren't strips more accurate?" Factors include small but important variability in manufacturing, temperature and altitude (which impact different strip technologies differently), hematocrit level, contamination by food on the fingers, and coding errors, just to name a few. These errors can combine to yield results that are significantly off.
- Howard Wolpert, MD, presented Overview of Continuous Glucose Monitoring Technology. Dr. Wolpert presented a brief review of glucose sensing technologies and noted that continuous glucose sensing is in a similar phase of adoption as blood glucose monitoring was around 1980. After reviewing the differences between blood glucose and CGM, including the physiological lag, Dr. Wolpert offered advice on alarm level setting to help reduce the risk of patient burnout. He also made a very important point -- patients and health care professionals must realize that CGM data is just data, it's not a grade.
- Jen Block, RN, CDE, in Continuous Glucose Monitoring as a Behavior Modification Tool, picked up where Dr. Wolpert left off. Beginning with a summary of some recent studies on CGM, Jen noted that it doesn't take long for CGM technology to make a difference. She noted that patients in a nine-day study of an early DexCom system showed significant improvements (21% reduction in time spent < 55 mg/dl, 23% reduction in time spent > 240 mg/dl, and 26% increase in time spent between 81 and 140 mg/dl). A similar study using the FreeStyle Navigator® showed equally impressive results. The clear message: continuous glucose monitoring technology works if you use it. Like Dr. Wolpert's closing message, Jen also reminded the audience of health care professionals that using continuous glucose monitoring exposes a patient's "naked diabetes" -- all their data is there to see. This exposure can make some patients feel vulnerable and defensive, and as such health care professionals must be very careful never to be judgemental. Jen spoke about talking about "what is working" and "what is challenging." (Good advice for parents also.)
- Darrell Wilson, MD, presented Glycemic Variability, a topic that has been discussed and which has come under increased scrutiny lately (see report from Diabetes Technology Meeting 2007, first bullet). Dr. Wilson explored the challenge of "facticious euglycemia," or "the log book data doesn't match the HbA1c," something seen by many teams who treat teens. After a brief review of the concept of Average Daily Risk Range, Dr. Wilson noted that highly variable blood glucose readings predict extreme highs and lows in the clinical setting. He also noted that "variability is an enemy practically," and, even more importantly, that variability tends to drive parents, and patients, crazy. Offering advice on helping to reduce variability, especially post-prandial spikes, Dr. Wilson reiterated the importance of pre-bolusing for meals. In response to an audience question about the use of an iPort, Dr. Wilson thought that it could help if it made pre-meal injections easier to do.
- Bruce Buckingham, MD, shared part of a new, online teaching tool about continuous glucose monitoring that is under development and nearing publication. The tool covers continuous glucose monitoring systems from Abbott Diabetes Care, DexCom, and Medtronic Diabetes. Dr. Buckingham used an audience response system to try out questions on various topics associated with CGM, including calibration and dealing with alarms. The audience response was very positive, and Dr. Buckingham lamented that none of the questions were "voted off the island." He jokingly noted that his talk should have been titled, "Are You Smarter Than A Fifth Grader With Type 1 Diabetes?"
- Lois Jovanovic, MD, a (if not the) leading expert on diabetes in pregnancy, examined the potential impact of CGM for women with diabetes who want to have a baby in her talk entitled Technology for Monitoring and Managing Pregnancy and Diabetes. To set the stage, Dr. Jovanovic noted that women with type 1 diabetes who receive no special care during pregnancy have babies with a 9% risk of major malformations, while those who receive special diabetes care have babies with just a 2% risk -- the same as the general population. This is incredibly good news for women with type 1, but it does show the importance of rigorous pre-conception diabetes management.
- In the final session on Friday, Paula Jameson, MSN, ARNP, and Irina Nayberg, RN, led the Patient Panel: Living with Continuous Glucose Monitoring. The panel consisted of six people using sensors from each company. The adults in the panel agreed that continuous sensing was transforming for them, giving them significantly more insight into their bodies and allowing them to achieve better diabetes management while reducing the risk for low blood sugar. Stealing the show was young Gregory, who brought his mom, Wendy. Gregory did great in front of the large audience. When asked if his teacher would know what to do in response to a CGM alarm, he simply said, "Of course not," resulting in a round of loud laughter. His mom did follow up and note that his teachers and school were very supportive and in general knew what to do.
- Lori Laffel, MD, spoke about Insulin Pumps in the Schools. After presenting general demographic data, including that about 15,000 children are diagnosed with type 1 each year, Dr. Laffel reviewed studies that show that children using pumps are more likely to have significantly better control than those who use multiple daily injections. Dr. Laffel reviewed her practice (Joslin in Boston), with a large patient population with pump users spanning all age groups. While praising the new "smart pumps," Dr. Laffel noted that "it's the people who use the pumps that have to be smart." On the issue of school, Dr. Laffel noted that children spend 20,000 hours at school from Kindergarten through 8th grade. Clearly, attentive diabetes care during that time is essential to both the short term and long term health of the child. Dr. Laffel mentioned the ADA's Safe at School program, which offers excellent guidance for parents and schools.
- Ruth Weinstock, MD, presented Telemedicine for Managing Diabetes, reporting on a school program utilizing telemedicine for children in grades K-8 who have type 1 diabetes. Kids in the intervention group were given a school glucose meter and a home glucose meter which was downloaded from school every month. Pump users also downloaded pump information to the health care provider from the school site. The monthly tele-visits consisted of an on line video interaction with the student, parent, school nurse and CDE and provided each subject with treatment recommendations for optimal diabetes management. After six months of data collection, the intervention group reported increased health related satisfaction for families, lower HgA1c, and a reduction in urgent calls to the diabetes clinic.
Barry Ginsberg, MD, PhD, presented the first session about issues affecting accuracy in home blood glucose monitoring
Jen Block, RN, CDE, spoke about the power of continuous glucose sensing to help with positive behavior change
Bruce Buckingham, MD, shared an online education tool about CGM, currently under development, and asked for audience feedback on several questions
Lois Jovanovic, MD, reminded us about the importance of good control during pregnancy
Gregory and his mom Wendy (members of the patient panel) shared their experiences with the DexCom Seven continuous glucose monitoring system