Personal continuous glucose monitors (CGMs) have been a salvation for many patients with diabetes, their caregivers, and their healthcare providers. They have introduced a world of glucose data that were previously unavailable via fingerstick monitoring and that can provide new insights. From a strictly technological standpoint, CGMs could help every person with diabetes improve their blood glucose control.
However, just like insulin pumps, some patients (at least initially) may not be suitable candidates for CGMs. Some of the criteria healthcare organizations use to determine who is or is not a suitable candidate for the use of insulin pumps, such as the patient’s level of understanding and engagement in their care, are also applicable to making decisions about whether a patient may or may not benefit from using a personal CGM.
Understanding a patient’s abilities and wishes in the following areas may increase the likelihood of success with a personal CGM and may indicate specifically which patients are not likely to be a good fit for CGM. These criteria are general and may not apply to all patients.
- Patients who are unable or unwilling to use the data to make decisions. There are many patients with diabetes who dutifully take their blood glucose readings day after day, as prescribed by their healthcare providers and who never give the numbers a second thought. In many of these patients’ minds, the blood glucose numbers have no relation to their intake of food, exercise patterns, or medication use. Education can help some of these patients if they simply do not understand what to do with the data, because teaching these patients the skills they need to manage their diabetes will make all the difference in how they approach their care. However, there is a subset of patients that regardless of their personal knowledge or education, generally prefer their treatment decisions be dictated by their healthcare provider(s). There is another group of patients that are unable to make use of the information without the support of a clinician, such as some patients with developmental delays, dementia, or limited math literacy. For these patients, a professional CGM may be called for, but a personal CGM will likely make no difference in their care and the daily demands that will be required for its proper use may lead to unnecessary frustrations for the patient.
- Patients who do not want to have a device attached to their bodies. A subset of patients will simply not want to be connected to any kind of device that is affixed to their body. These patients are bothered by the look or feel of the device, and no amount of information about its efficacy or benefits will overcome that personal resistance. This group is larger than most people think. In an article appearing in the January 2018 edition of Clinical Diabetes, 27% of respondents indicated that being attached to a CGM was a major barrier to its adoption. In addition, those patients who have extensive scar tissue and are having difficulty finding new places to inject insulin may find a lack of viable “real estate” for insertion a deterrent to using CGM.
- Patients who cannot afford the equipment or sensors. Although more insurance companies are covering CGMs, adoption still imposes a significant financial burden for many patients. For example, Medicare only covers CGMs for those who take multiple daily injections of insulin or use an insulin pump and who check their blood glucose at least four times a day. Even if covered by insurance, patients can still pay significant, out-of-pocket costs. Some may still think this is a worthwhile personal investment, but patients should be well informed about the potential costs, and for some, the costs will be a constraint.
- Patients for whom the device causes psychological distress. For some people, the ability to see their blood glucose numbers every few minutes becomes emotionally overwhelming. They might feel that they must watch the receiver constantly, and they may become upset when they see numbers that are out of range. Similar to patients who anxiously take fingersticks countless times a day without a therapeutic purpose, these patients can become obsessed with the tool. For patients who become overwhelmed, the psychological burden of the CGM may be too high in relation to its likely benefits. This is a different issue than when a patient becomes disgruntled by the frequency of alerts and alarms, a feature provided by the CGM that can predict the direction of blood glucose flow and forewarn patients of impeding hypo or hyperglycemia. In those scenarios, changing settings will often solve the problem.
- Patients for whom the burden of caring for the device is too high. Properly caring for CGMs includes the requirements of setting up and changing the device, skin irritation, and insertion pain. Although most of these issues can be resolved, for some patients, the additional information does not outweigh the added burden. This reinforces the need to provide clear instructions about these steps and the work needed to personally benefit from CGM use.
Choosing appropriate candidates for continuous glucose monitoring is vital to using CGMs to improve patient care and provide the best data possible for making treatment decisions. Taking the time to talk with patients to understand their view of the technology, their personal preferences, and to eliminate any misconceptions they might have, will help clinicians effectively identify those people for whom CGM is not a good fit right now.
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Nora Saul is a Registered Dietitian and Certified Diabetes Care and Education Specialist. Nora has more than 25 years of experience in the field of diabetes education, consulting for the Joslin Diabetes Center and other industry partners. Nora leads content development for Silver Fern’s diabetes products and training.