WASHINGTON — Users of continuous glucose monitoring are a surprisingly diverse group.
That conclusion, from a survey conducted by researchers at the Rocky Mountain Diabetes Center, Idaho Falls, Idaho, suggests that different educational approaches may be needed for different types of patients, said Becky Sulik, R.D., a certified diabetes educator who works at the center.
The 26 men and 28 women had an average age of 45 years; 19% were older than age 60 years. Most (85%) had been trained to use the CGM by a certified diabetes educator who was employed either by the center or by the device manufacturer. Three-fourths of the patients came in for at least one follow-up visit after receiving their training, but only 41% of the group had downloaded the information from their receiver to a computer. Of those who did download, 75% discussed the results with the educator or physician.
In the context of formal education, patients ranged from those having several advanced degrees to those who dropped out of school in the eighth grade. “It wasn't just the highly educated patients” who used CSM, Ms. Sulik noted at the annual meeting of the American Association of Diabetes Educators.
Both staff and patients were initially very excited about real-time CGM technology when it first became available in 2006, but over time a more realistic picture has emerged. Although the technology does provide valuable information about glucose trends and warnings of highs and lows, it's important for patients to be told at the outset that they will still need to do finger sticks, and that those finger-stick values will be different from those of the sensor. Otherwise, they will perceive the discrepancy as an accuracy issue, she cautioned.
Patients also need to be prepared for the annoyance of the alarms going off at inconvenient times. And overall, they need to know that “it's not going to fix everything. … It only provides information. Judgment is still needed,” Ms. Sulik said.
Good candidates for CGM will have taken the time to learn about the technology and how it works; they are already testing at least four times a day as well as when they are suspicious about how they feel, and they are committed to working with their health care providers. Ideally, they also have computer access for downloading the data, and have either good insurance coverage or disposable income to pay for the technology.
When educating patients, diabetes professionals should tailor terminology to the patient's level of understanding, as words such as “calibration,” “interstitial,” or “initializing” may be unfamiliar. To explain the calibration process and why it's necessary, Ms. Sulik shows patients a picture of a roller coaster, with the plasma glucose represented as the first car and the interstitial glucose as the caboose, lagging behind. She uses the terms “tissue sugar” instead of “interstitial,” and “warm up” instead of “initialization.”
And, although diabetes professionals tend to use the word “sensor” to refer to the entire CGM system, it's important to explain to patients that the CGM actually includes three separate parts: the sensor, the transmitter, and the receiver.
As with all diabetes education, CGM training must be tailored to the individual patient. However, Ms. Sulik described the following several broad patient “types” that she and her colleagues have identified over time, and the educational approaches that might work best for each:
▸ “Deer in the Headlights.” These patients are overwhelmed with the amount of data yielded by the CGM and may feel helpless and frightened. Such patients are often older and not as comfortable with technology. They may even become immobilized and end up doing nothing with the data.
For these patients, the key is to start simple. It may take more than one visit to teach them how to use the device, with several follow-up visits to reinforce the skills. Get them to practice the basics of pattern management, and build their confidence by focusing on small successes, Ms. Sulik advised.
▸ “The Analyzers.” These patients “really like the data” and may become so preoccupied with individual readings that they miss overall trends. They are often quick to make multiple changes without waiting to see the effect of one change before making more. Sometimes it's the parent or spouse who is the analyzer, Ms. Sulik said.
With these patients it helps to focus on pattern management. Tell them to “experiment” with cause and effect before making more changes. Prioritizing the changes is also key. For example, reducing insulin doses at certain times to correct low blood sugars may take precedence over correcting highs. “Patients should make a change and then wait and watch,” she advised.