By Arnold Saperstein, MD, FACP, Chief Medical Officer, Cecelia Health, Inc.
I wanted to share the case history of a patient – I’ll refer to him as Stephen – that we were caring for in Cecelia Health’s Virtual Clinic. Stephen, a 62-year-old man with Type 2 Diabetes, was poorly controlled and required insulin therapy. Stephen’s diabetes care is managed by his primary care physician who has been his physician for over 15 years. Over the course of several months Stephen’s hemoglobin A1c continued to rise and his fingerstick glucose values were consistently high. His physician attempted to control his diabetes by raising his insulin dose at each visit, but there was no evident progress.
Stephen was then referred to Cecelia Health’s Virtual Clinic for an evaluation and assistance with chronic disease management to include access to an endocrinologist and a certified diabetes care and education specialist (CDCES) via telemedicine. As part of this patient’s care, he was prescribed a continuous glucose monitoring (CGM) device to provide for ongoing assessment of his glucose values. Given that CGM collects numerous glucose levels throughout the course of a day, we are able to measure a value called time in range (TIR), or the percentage of time Stephen’s glucose level was within a normal range. The American Diabetes Association (ADA) guidelines indicate that a moderately well-controlled patient should be in range at least 70% of the time, or approximately 17 out of every 24 hours. The startling finding was that Stephen was nowhere close to the 70% time in range, but instead measured in range only 4% of the time! Moreover, the CGM data indicated no obvious effect from insulin dosing.
During a video visit with Stephen, we learned that he followed his diet closely and appropriately and lived a moderately healthy lifestyle including a daily walking regimen. When discussing Stephen’s frequent insulin dose increases, the Cecelia Health CDCES asked him to demonstrate how he administers his medication. The root of the problem was immediately revealed: Stephen was using his Insulin pen incorrectly. He was only removing the outer cap, but never removed the inner cap, so effectively he was not getting any medication!
In a very calm fashion, our CDCES explained the issue to Stephen, and most importantly explained that he should not take the full dose. The CDCES explained the importance of starting with a very low dose and how to adjust based on his CGM results. Over the next three months, Stephen’s time in range gradually increased from 4% all the way up to 98%.
I am so thankful that Stephen followed our advice and is on a path to improved health. In our work, it has become clear that patients are increasingly confused about how to appropriately use the devices and therapies they are prescribed. In Stephen’s case, the confusion could have been life threatening if for some reason he discovered the cap and gave himself a full dose. We have clearly seen that provider offices, device manufacturers and suppliers provide some level of training, but the level of support is insufficient for most of the population with diabetes.
My clinical recommendation is to ensure that all patients have access to a well-trained CDCES who can devote the time needed to provide the training and support required to empower each patient to gain the maximum benefit from the devices they have been given and to avoid unnecessary morbidity. This type of support should be provided in a timely manner to the point of care soon after any device is prescribed and before the patient attempts to use it on their own. This can be in collaboration with a provider’s office or even better with a pharmacy or device supplier to immediately follow dispensing. I look forward to a day when effective virtual clinical support is the norm in diabetes management as opposed to the exception rule.
About the Author
Dr. Saperstein began his career in managed care in 1992 and joined MetroPlus Health Plan in 1995 initially as Chief Medical Officer and then as President and CEO from 2006 until 2019. MetroPlus Health Plan is a managed care organization that, under Saperstein’s leadership grew from 40,000 members to over 500,000 members with an estimated 32,000 participating providers. Saperstein has spent the majority of his career developing programs that ensure the highest quality of care. During his tenure at MetroPlus, it ranked as one of the highest scoring plans for quality of care as measured by the New York State Department of Health Medicaid Incentive Program and by the Medicaid Consumer Guide for New York City. Under his leadership, MetroPlus rose to the forefront of Value Based Purchasing. Programs he developed included groundbreaking quality incentive pay for performance programs across the entire MetroPlus network.