Diabetes care has tended to focus on achieving adequate glucose levels — but the real goal should be maintaining those levels over time, said Alex Abitbol, endocrinologist and assistant medical director of LMC Healthcare, during Benefits Canada’s 2021 Chronic Disease at Work conference in late February.
“Much of the guidelines, much of the discussions amongst practitioners is getting patients to targets. That’s very important, don’t get me wrong, but keeping people there is often forgotten.”
Poorly controlled diabetes not only presents a risk to employees’ on-the-job safety and reduces their productivity — especially when experiencing an episode of hypoglycemia — it also puts them at higher risk of long-term complications such as blindness, kidney disease and cardiovascular disease — all of which drive employer health costs.
That’s where digital monitoring — also known as continuous glucose monitoring — becomes important, Abitbol said. There are currently two types of digital glucose monitors: continuous glucose monitors and flash glucose monitors. Continuous glucose monitoring systems are typically body-worn or sometimes implanted, and they send an ongoing flow of data to users’ smartphones in real time, including predictive alerts if their blood sugar levels are too high or too low. Flash glucose monitors provide users with information right at the moment they’re “flashing” or accessing the data.
“Both for the individual but also for the population as a whole, . . . integrated real-time glucose monitoring in a virtual-care setting becomes essential to engage the patient and . . . for self-management.”
The monitors replace the traditional way of measuring and managing diabetes, with multiple finger-pricks per day and test strips to track blood sugar levels. The problem with this long-standing approach, Abitbol said, is these readings only capture a moment in time — and while patients are attempting to achieve a certain average glucose level, there are many ways to reach an average. An average glucose reading of 8.5 could be achieved by numbers consistently in that realm, or wild variations between two and 20.
“There wasn’t really a good way of recognizing that . . . [Readings] only tell you the blood sugar, it doesn’t tell you if it’s going up or down, it doesn’t tell you if the patient injected insulin, it doesn’t really add much information,” he said.
In contrast, he added, “[the monitors] don’t just give you a number anymore. They also give you the trend arrow. So being able to know where your sugar is, but also the direction it’s heading, is why flash and continuous glucose monitoring is making big differences in clinical outcomes.”
According to Abitbol, people with diabetes spend on average 160 hours per week managing their disease, and traditional endocrinological clinic resources — at full capacity — aren’t able to meet that demand. It’s something that was even further complicated by the pandemic, as doctors quickly shifted to virtual care.
Continuous monitoring coupled with other virtual health resources, such as digital coaching and telemedicine, could help to fill this gap. “Virtual coaching seems to be a hot topic among many aspects of chronic disease management — the idea being that the adherence piece gets maintained over time and of course [produces] better health outcomes. [And] remote monitoring [and] the predictive glucose alerts have . . . an established role in Type 1 and Type 2 diabetes when it comes to the reduction in hypoglycemia.”
Currently, about 22 per cent of Canadians with diabetes manage it with continuous glucose monitoring, Abitbol said. He estimated 60 to 75 per cent of his clinic’s patients have their monitoring devices covered by their benefits plan. “The majority of at least flash glucose monitoring and even real-time CGM tends to rely on private coverage today.”
While he noted digital monitoring systems can be expensive and drive up plan premiums if employers choose to cover them, Abitbol pointed out they can prevent other health-care expenses down the line. “Delaying or preventing someone’s eye disease, kidney disease, heart disease would, in my opinion, be at the forefront of why this technology needs to be [covered by benefits],” he said. “But you could also look at analyses [of] days of work lost, missed school days and you’ll quickly see the technology makes up for that when you’re looking at it on more of a cost basis.”