Use of technology in diabetes: a practical case study
Diabetes technologies, such as continuous blood glucose monitoring (CGM), are well-established in diabetes care, and can improve care given to patients in general practice, but it is essential that general practice nurses learn how to use them to their best advantage
CGM is a device that measures glucose in the interstitial fluid (the fluid between cells), rather than capillary blood glucose levels from finger-prick testing, via a sensor inserted through the skin. The information allows trends in glucose levels to be seen, and alarms can alert patients if their blood glucose levels are too high or too low.
Currently, more than 4.4 million people are living with diabetes in the UK, with 3.2 million at increased risk of developing the condition. The direct and indirect costs of diabetes showed that just over 40% of costs are related to diagnosis and treatment, with the rest, at just over £6 billion, relate to excess costs of largely preventable complications.2 With increasing prevalence, the cost of treating complications can only rise.
General practice nurses (GPNs) are best placed to educate people about both their risks of developing diabetes and to support people living with diabetes.3 The complexity of the task of providing diabetes care has grown, partly because of the greatly expanded range of medications, and partly because of the increasing prevalence of frailty among older people with diabetes.
NICE has recommended CGM for patients with type 1 diabetes, and selected patients with type 2 diabetes since 2022, and considers the technology to be cost-effective.4 It can help patients understand their blood glucose readings, self-manage their condition, and improve blood glucose control. It can be particularly useful to replace 3-6 monthly follow-up appointments to monitor HbA1c after a treatment change – which also requires commitment from patients, and can be especially helpful for those patients who are difficult to reach or have restrictions on their time due to other responsibilities.
However, optimal use of these technologies is necessary to obtain benefits and crucially depends on diabetes education and training of both clinicians and users. Glennie and colleagues5 report that the benefits of CGM include improvements in patient’s quality of life, work productivity, and savings to the health system. Helping people to live well with diabetes is key to engagement, reducing the health burden of potential micro- and macrovascular complications. However, GPNs also need to develop their own skills in using CGM technology.
SELF-EDUCATION
In this article, I will detail my personal experience of self-education for the use of the technology, understanding how to use the data to improve care, and demonstrating the real time benefit of developing care plans with people with diabetes to improve glycaemic control. I hope this can be used by other practice nurses and those undertaking diabetes management who are considering the use of the technology in their practice.
NICE NG28 suggests offering CGM to those with type 2 diabetes on multiple daily insulin injections that would require at least eight tests a day or those who require support from carers to undertake blood glucose monitoring, have impaired hypoglycemia awareness or at risk of severe hypoglycemia.4
Different brands of CGM are available, including FreeStyle Libre 2 and Dexcom, but FreeStyle Libre 2 (Abbott) is one of the systems available in my local area (Bristol, North Somerset and South Gloucestershire [BNSSG]).
I undertook a short training needs analysis to understand my knowledge and required learning. This helped to develop awareness of my current skills and where further knowledge was required. I asked the local diabetes specialist team, who recommended the manufacturer-specific training as a starting point. Care should be taken when choosing this type of training to maintain a level of independence. However, it was appropriate in this instance as Libre Sensor was the preferred formulary choice.
After self-directed training offered on the Abbott website and a support session from the local representative, I felt confident in training patients on the device's application and using the data. The LibreView website allows CGM data to be shared with a practice for remote review. A reader is available for those without a smartphone, and a report is downloaded to a computer. While the reader could be seen as an inferior approach, in my experience, it is a way for people who are not technically minded or without a smartphone to engage in the CGM, facilitating access.
Online group training by a specialist nurse from Abbott to understand the data and how to structure a consultation using these data to support the person was crucial for developing my practice. Without adequate training, there is a risk of poor-quality consultations.
UNDERSTANDING THE DATA
An ambulatory blood glucose (AGP) report provides an agreed presentation of data by a consensus of clinicians.6 The AGP report has three main aspects: identifying hypoglycemic events, time in range (TIR), and predicted Hba1c, which can be used to help structure the consultation. Fear of hypoglycaemia constitutes a barrier that impairs the patient’s ability to reach glycaemic control,7 so the priority is to use the data to identify potential or actual hypoglycaemic events to promote safety. The use of the technology can improve control and reduce the fear of low blood glucose, and patients report how reassuring it is to be able to know the direction of travel of their blood glucose, and to be able to act on it. Alarms are set on the app or reader to alert the user of potential hypoglycaemic events. This is especially useful for those people who live alone or have poor hypoglycaemic awareness. Hypoglycaemia has a significant negative impact on patient outcomes, healthcare resource use – it is estimated that the average length of hospital stay for severe hypoglycaemic events in type 2 diabetes was 5 days, with a mean cost of hospital admission of £1,034, and the total average per-patient cost for patients who experienced a hypoglycaemic event in hospital was £2,235.8
Prevention of hypoglycaemia through CGM is key, and CGM has improved patients’ confidence of working within an agreed range and preventing hypoglycaemic events, demonstrating the use of CGM can prevent both costly admissions and support better control of diabetes
Assessing TIR, i.e. how long an individual is between 3.9 and 10 mmol/l in a time frame is an internationally agreed mechanism for assessing diabetes control.9 Each 10-percentage point increase in %TIR correlates with a reduction in HbA1c percentage of approximately 0.8%.9 This gives the person using the technology a simple goal of keeping their blood glucose in range.
In my view, the ability to focus on an updated HbA1c is the most powerful of the data sets. An HbA1c test shows the average amount of glucose attached to haemoglobin over the past three months. It's a three-month average because that's typically how long a red blood cell lives. The delay in monitoring changes in treatment can lead to ongoing high readings and therefore change management is slow. However, 14-day AGP has been shown to accurately predict the anticipated glucose control profile for up to 30 days under typical everyday conditions. In my experience, this is particularly helpful for those with poor control who need faster evidence of improvement, such as those awaiting surgery. A recent patient had an HbA1c of 84mmol/mol and was precluded from knee surgery. By adding a sulfonylurea to the patient’s regimen, and by using CGM data,10 we were able to see a change in predicted HbA1c of 65mmol/mol within four weeks. While this is an unusual case, and the CGM was not available on the NHS at the time, it demonstrated to the surgical team and the patient that changes to diet and medication use were possible. The surgery went ahead, and recovery is currently underway.
Understanding the data and being able to communicate the results to the patient was a revelation to me. While I had been used to booklets with individual readings, often there was little context in the readings; for example, illness can increase blood glucose readings (as can celebrations!) The continuous data and trends over days and weeks led to fruitful conversations in consultations about ‘treats’. Congratulating the patient on even small achievements encourages persistent change: the data provided information to enable this to happen.
Individual readings from continuous monitoring can give insight into trends and help the person understand their patterns and change their behaviour.
The following case study demonstrates the value of CGM, especially in people who have found managing their diabetes difficult.
CASE STUDY
Joanne, aged 31, with type 2 diabetes, had an HbA1c of 103 mmol/mol. This had been consistently high for the past 4 years, and although she was not experiencing any osmotic symptoms, she was struggling with her diabetes control and asked for support. As she was taking basal/bolus insulin, with five injections a day and required testing at least eight times a day, Joanne met the local criteria for initiation of CGM. Joanne had recently experienced a hypoglycaemic event requiring external support. This added to her eligibility for CGM.
After demonstrating the technology, including application, changing, and reviewing her readings, she agreed to share her data via LibreView. After two weeks of using the technology, we discussed how it was working for her. She had warnings of low blood glucose, and she was able to act on them to avoid a hypoglycaemic event. We stayed in contact over the next 8 weeks by text and phone to assess how she managed. Over this time, she managed to reduce her predicted HbA1c to 80 mmol/mol, developing better eating habits and understanding the value of smaller meals in managing her blood glucose variability. After using CGM for 6 months, Joanne understood her diabetes better and has been able to reduce her insulin needs because she has lost weight and decreased her food intake. Her HbA1c is now 58 mmol/mol, within range. Joanne attributes these improvements to CGM.
While the benefits in practice are undeniable, there are challenges with CGM. One patient had looked at his readings over 150 times in one day. When I asked him about it, he admitted he was obsessed with CGM and felt it was controlling his day. We spoke about the anxiety that was provoked by additional information and discussed strategies to address it. After 6 weeks, despite implementing these strategies, we were unable to maintain his anxiety to an acceptable level and, therefore, discontinued the CGM. There is limited research on this, and it will undoubtedly be a developing area.
CONCLUSION
Using specialist diabetes services is a way for clinicians to learn aspects of using digital technologies. My local services provide a wealth of knowledge, and while I am developing my skills, I am still referring patients who are out of my scope of competence.
Therefore, while GPNs are best placed to deliver patient-orientated and focused strategies to improve diabetes care, opportunities for development need to be available. Digital improvements need to be consistently used so they become standard practice. I believe a primary care network-based service for complex patients who do not require specialist input but need enhanced general practice care would be ideal.11
My overall experience has been that using CGM leads to reducing HbA1c and improving engagement to support people to develop a better understanding of their diabetes. While implementing CGM is encouraged, we need more resources to support GPNs to develop the skills to manage the data and help patients. With the increasing complexity of diabetes management and the increase in prevalence, support to GPNs with both time and education is needed if CGM is to have maximum impact.
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