Diabetes And Technology Robert J. Rushakoff, MD Professor of - PDF document

3/17/16 ¡ Diabetes And Technology Robert J. Rushakoff, MD Professor of Medicine University of California, San Francisco robert.Rushakoff@ucsf.edu Disclosures n None 1 ¡

3/17/16 ¡ "Each ¡blind ¡man ¡perceived ¡the ¡elephant ¡as ¡something ¡ different: ¡a ¡rope, ¡a ¡wall, ¡tree ¡trunks, ¡a ¡fan, ¡a ¡snake, ¡a ¡ spear..." ¡ ¡ Telemedicine ¡ Medica9on/ Wearable ¡ Central ¡ Automa9on ¡ Monitoring ¡ Apps ¡ insulin ¡ Devices ¡ inpaCent/outpaCent ¡ Personal/central ¡ Pla/orms ¡ Delivery ¡ ¡ ¡ 2 ¡

3/17/16 ¡ Diabetes And Technology n Journals n JOURNAL OF DIABETES SCIENCE AND TECHNOLOGY n DIABETES TECHNOLOGY & THERAPEUTICS n National/International DM technology meetings n International Inpatient DM meetings 3 ¡

3/17/16 ¡ Diva: Romeo and Juliet Romeo a six-ounce, hand-held device that n resembles a pocket calculator. Glucose Monitor n n Programmed to beep at set times as reminder when to test blood sugar, take insulin, eat meals and exercise 3 month storage n n Records blood sugar n With push of button, records insulin doses, amount of food eaten, intensity of exercise done and the times at which all those activities took place Juliet device produces printouts n n Can send data to provider using a telephone modem. Robert Ratner, MD: It's not perfect for everybody. It's a lot of work, a lot of effort, and a lot of patients are unwilling to do that. And, frankly, for a lot of patients, it's not necessary. Patient’s MD: Those who benefit most those whose diabetes is out of control and those who are newly diagnosed and need to become aware of how different things affect them. Most people can use the system, for several months and then "graduate" to using just a diary and a simple blood sugar monitor. Those who want to, can buy their own system - hospitals lend or rent them to patients - but the system is expensive and not always reimbursable by insurance. Romeo costs about $495; Juliet, $275. 4 ¡

3/17/16 ¡ • The treatment with DIANET vs conventional showed a better metabolic control • lower before breakfast: 87 +/- 6 vs 104 +/- 4 mg • Lower before lunch: 85 +/- 5 vs 104 +/- 4 mg • Lower after dinner: 102 +/- 5 vs 124 +/- 6 mg) • These results were associated with higher insulin doses in the DIANET vs conventional treatment, and a significant reduction of hypoglycemic reaction in both group 5 ¡

3/17/16 ¡ Diva: Romeo and Juliet n Chemstrip bG n When strip gone - - device worthless 6 ¡

3/17/16 ¡ Diva: Romeo and Juliet n Chemstrip bG n When strip gone - - device worthless n Technology limited to single device (expensive and was not covered by insurance) n Time consuming n ? Who really needed it n Who will pay Diva: Romeo and Juliet Now 2016 Has anything changed since 1988? 7 ¡

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3/17/16 ¡ Requirements for Successful “technology” Use n Make stuff easier to do n For the patient; For the MD/Nurse/Pharmacist n Integration n Supports normal Workflow n Scalable n Sustainable n Cost effective 9 ¡

3/17/16 ¡ General Concerns with Data n Numbers, numbers and more numbers: n Potential to overwhelm patients, clinicians or other care givers n ? How to actually interpret all the data and actually make real time use of the information Key Issues n While new technology is cool - - n Have to show some improved outcomes n Not short term studies 10 ¡

3/17/16 ¡ Glucose Meters n Generally - - still have to prick finger n You get glucose value n ? Remains on value for patients not on insulin n Patients on insulin - - more is better Glucose Meters n Numbers have to be in the context of what you’re eating and doing n The patient would love to have something they could beam onto the food to figure out how many carbs, to figure out how much insulin to give. n The key is trying to integrate numbers into action, so the devices are trying to become smarter, to give some sort of narrative with the data. So . . . . . . . 11 ¡

3/17/16 ¡ Glucose Meters: Accu-Chek Aviva Expert Works like pump for calculating doses n calculates the amount of insulin needed based on: n the test result n expected carbohydrate intake n past bolus doses, often referred to as “insulin on board.” Glucose Meters: Abbot Freestyle Flash • Measures glucose every minute in interstitial fluid through a small (5mm long, 0.4mm wide) filament that is inserted just under the skin and held in place with a small adhesive pad. • No finger prick calibration • Disposable, water-resistant sensor can be worn on the back of the upper arm for up to 14 days • A reader is scanned over the sensor to get a glucose result painlessly in less than one second. • Scanning can take place while the sensor is under clothing 12 ¡

3/17/16 ¡ Glucose Meters: Abbot Freestyle Flash Insulin Pumps n Newer pumps more user friendly n Some integration with CGM n Touch screen, small n BUT - - still just pumps and requires a user who really knows how to interpret data, make changes, input correct information. 13 ¡

3/17/16 ¡ Stupid stuff n Wrong time on meters n Wrong time on pumps Continuous Glucose Monitoring n CGM devices continue to improve, with interfaces that wirelessly transmit data to smartphones or a cloud-based system. As an example, the Dexcom G5 mobile CGM helps caregivers to monitor their family members with diabetes and also allows physicians to monitor several of their patients at once 14 ¡

3/17/16 ¡ Smart Continuous Glucose Monitoring SmartGuard™ • low glucose suspend feature Medtronic Pumps/CGM • two different • suspension of insulin delivery when the glucose levels are predicted to hit the low limit in the next 30 minutes • Suspension set to when the glucose levels hit the low limit. • can automatically suspend insulin infusion for a maximum of 2 hours when sensor glucose (SG) levels are predicted to approach a pre-determined threshold and, without intervention, will resume basal insulin delivery to its pre- set rate. Reviewing Data Type 1 DM n EVER download data from one or more devices n Adults: 31% n Caregivers: 56% n ROUTINE reviewer of Data n Adults: 12% n Caregivers: 27% n ROUTINE reviewer HbA1c vs no review n Adults: 7.2% vs. 8.1%; P = .03 n Children: 7.8% vs. 8.6%; P = .001 Ever Download: black Routine Download: Striped Routine Review: white Wong JC, et al. Diabetes Technol Ther. 2015 15 ¡

3/17/16 ¡ 2014 Survey of Diabetes Apps Arnhold M, et al. J Med Internet Res. 2014. Review of top 6 apps in 2011 EndoGoddess: gone Bant: .99 too much 3 others gone 1 still there - -out of date info 16 ¡

3/17/16 ¡ mySugr Diabetes Logbook 17 ¡

3/17/16 ¡ Some Current Diabetes Apps n Diabetek n Diabetic Connect n Diabetes Pilot Pro. Food database n Diabetes Tracker n BG Monitor Diabetes n OnTrack Diabetes n Diabetes in Check n Carb Counting with Lenny Diabetes tracker 18 ¡

3/17/16 ¡ Diabetes tracker BG Monitor Diabetes 19 ¡

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3/17/16 ¡ Smartphone apps for calculating insulin dose: a systematic assessment 46 calculators that performed simple mathematical operations using planned carbohydrate intake and measured blood glucose. 59% (n = 27/46) of apps included a clinical disclaimer n 30% (n = 14/46) documented the calculation formula. n 91% (n = 42/46) lacked numeric input validation, n 59% (n = 27/46) allowed calculation when one or more values were n missing 48% (n = 22/46) used ambiguous terminology n 9% (n = 4/46) did not use adequate numeric precision n 4% (n = 2/46) did not store parameters faithfully. n BMC Medicine 2015 13:106 Smartphone apps for calculating insulin dose: a systematic assessment 67% (n = 31/46) of apps carried a risk of inappropriate output n dose recommendation that either violated basic clinical assumptions (48%, n = 22/46) or did not match a stated formula (14%, n = 3/21) or correctly update in response to changing user inputs (37%, n = 17/46). Only one app, for iOS, was issue-free n No significant differences were observed in issue prevalence by n payment model or platform. majority of insulin dose calculator apps provide no protection n against, and may actively contribute to, incorrect or inappropriate dose recommendations that put current users at risk of both catastrophic overdose and more subtle harms resulting from suboptimal glucose control. BMC Medicine 2015 13:106 21 ¡