Enhancing Patient Engagement
Tools for meaningful patient-centered conversations and informed decision-making techniques for implementing continuous glucose monitoring in primary care
The importance of “why”
CGM reports provide clinicians with an intimate and close-up view of the patient’s glucose levels, exposing their diabetes management “wins” as well as the challenges and roadblocks they have faced along the way.
As we review our patient’s glucose data, it is important to do so in partnership with our patients, to understand the “why” behind the numbers, to use non-judgmental, non-accusatory, and empathic language and tone, and to focus on identifying practical and feasible solutions rather than assigning responsibility or blame.
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Uncover positives
An empathic tone starts by identifying positives, so begin by recognizing your patient’s efforts and successes, even if they are partial.
"I’m so glad you’ve been wearing your CGM more throughout the week! This shows that you had the CGM on and working 70% of the time over the past 2 weeks.
What were you able to do these last two weeks to use the CGM more consistently than before?"
Recognize awareness of barriers
Patients often have good insights into the barriers they face implementing treatment recommendations. Before diving into potential solutions, describe the benefits of using a CGM and ask your patient what their experience has been and what they think would help them better adhere to treatment recommendations.
"There are many benefits to using a CGM.
- It alerts you when your blood sugars are dropping so that you can detect and treat a low blood sugar event before it gets severe.
- It can show you patterns in blood sugar levels to help us adjust your medications.
- It shows you, and us, how your body reacts to different kinds of foods and physical activity. Studies show that people who use their CGM more, benefit more from it.
What can we do to help you use your CGM even more?"
Pinpoint specific barriers
After patient’s share their perspective, probe for other common factors impacting CGM wear:
Patient does not have enough sensors. This can be due to:
- Not picking up a sensor prescription due to not knowing it is waiting for them at the pharmacy, problems with a durable medical equipment supplier, not ordering the sensors or financial difficulty affording sensors.
- Prior sensor fell off or had to be removed, and the patient was unable to pick up the next set early.
Patient does not remember to put the sensor on
Patient has difficulties with sensor site. This can be due to:
- Sensors not staying on or falling off.
- The site where the sensor was attached became irritated, and the patient is worried about more skin issues.
These factors can be addressed with person-centered education and providing additional resources and support. Consider engaging a Certified Diabetes Care and Education Specialist (CDCES) or clinical pharmacist to work with the patient and overcome these challenges.
Dealing with sensor difficulties
Identify routines
In order to interpret the AGP, it is essential to understand the patient’s daily routine. As you review the AGP together, ask your patient:
Discern daily trends
"These are your blood sugar levels over the course of the day. It’s really helpful to see them like this since we usually only see blood sugars at a single point in time and not how they change throughout the day.
We would like all of your blood sugars to be between these two green lines. What are your thoughts looking at this? Are these numbers what you had expected to see?"
As your patient reflects on the AGP tracings, a few probing questions can help:
[if there is high glycemic variability]
“Did you know your blood sugars change so much during the day? What do you think causes this?”
[if TIR is high]
“You see how most blood sugar levels are between the green lines, that is exactly what we want to see! Blood sugars staying in a safe range, without highs or lows, throughout the day. Even when you eat, blood sugars go up, but then come down just as they should.
This is an especially important point to make because patients may try to get their glucose levels to never rise, even post-prandially, potentially resulting in overtreatment or fear of hyperglycemia.”
[if glucose levels rise substantially after a meal]
“Are these your meals? Do you recall if you might have forgotten to take your insulin before eating? Did you take it after eating or not that time? How many days a week do you miss an insulin dose?”
Correlating data to motivate
Many patients like knowing how their real-time glucose values correlate with hemoglobin A1c, since they are much more used to hemoglobin A1c measuring their glycemic levels than time in range or even real-time glucose.
It is important to note that the glucose management indicator (GMI) is an estimate of hemoglobin A1c, but is not the same thing. Since hemoglobin A1c is influenced by other factors outside of glucose levels (for example: the hemoglobin level in the blood and other factors not related to diabetes). That is why the GMI is likely different from the A1c test the patient may have had at the same time.
It is also much more recent; GMI is based on glucose levels over the prior 14 days, while A1c reflects glucose levels over the past 3 months.
This can be used to motivate patients if they recently made dietary or behavioral changes to improve their glycemic control, which would be reflected in a lower GMI than A1c.
Language matters
Early morning hypoglycemia
Just like nocturnal hypoglycemia, early morning hypoglycemia is one of the most important pieces of information to detect on an AGP and discuss with your patient.
“I see you had a low in the early hours of the morning.”
“Were you awake when it happened?”
“Did you feel any symptoms?”
“What do you remember about the night before this event?”
These questions can help shed light on impaired awareness of hypoglycemia and potential causes of the hypoglycemic event. Other possible questions to ask may include:
“Is the basal dose of insulin too high? Did the patient eat a larger than usual meal and overestimate the amount of rapid-acting insulin to be given at that time? Did the patient snack at bedtime and maybe take insulin to cover it?”
Daytime hypoglycemia
Asking patients in an empathic and normalizing way about missed, forgotten, or delayed mealtime insulin doses; worry about hypoglycemia with preemptive or compensatory behaviors to prevent it; and overtreatment of hypoglycemia is important if not first volunteered by the patient.
This is also a good time to ask patients about cost-related barriers to obtaining glucose-lowering medications, food insecurity, and insulin rationing.
Daytime Hyperglycemia
If hypoglycemia occurred during the day, it is helpful to understand what was happening before. Ask your patient about their day, what they recall happening during these times, and how they respond to these events.
“Did you miss a meal or eat a smaller than usual portion?”
“Did you administer insulin after, not before, the prior meal?”
“Did you have unplanned or greater than expected physical activity?”
“Were you stuck in traffic without anything to eat?”
Identifying day-to-day changes
It is helpful to also review the individual days that make up the 14-day CGM report. This is especially important in situations where one or more of the days is different from the others.
Consider asking your patient:
Reviewing this information with patients is a great opportunity for focused self-management education and contingency planning.
Consider asking the patient about any strategies for:
Taking diabetes medications when sick.
Fasting for tests, religious, or other reasons.
Preparing to go on a long drive or being stuck in traffic.
Engaging in exercise.
Engaging a CDCES if the patient has many "one-offs" with resulting dysglycemia is very important.
Gaps in glucose data
It can be helpful to point out areas without glucose data, which correspond either to times when the patient wasn’t able to wear a sensor or – for intermittently scanned CGMs that use a reader to upload glucose data – when the patient wasn’t able to scan the CGM every 8 hours. Identifying the reason why the gaps are there is important for troubleshooting access to and usability of the CGM.
Sharing data
One of the many helpful features of a CGM is the ability to share glucose information with other people. I always ask my patients if they would be OK sharing their glucose data with me so that I can see it even when they are not in the office. That way, I or a member of my team can connect with them in between appointments to troubleshoot any problems, questions, or mishaps that may have happened in real-time.
I also ask if they would like a family member or care partner to see their data and even get alerts in real-time. This is especially helpful for patients who have cognitive or functional impairments, as well as patients with impaired awareness of hypoglycemia or frequent hypoglycemia, because it can get them help for hypoglycemia right away.
Make sure you don’t miss this!
Use empathic language to recognize your patient’s efforts and successes, even if they are partial
Allow patients to share their perspective then probe for other common factors impacting CGM wear.
Identify routines, daily trends, and day-to-day changes by asking probing questions to evaluate causes or events.
Reviewing data with patients is a great opportunity for focused self-management education and contingency planning.
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References
- Chun JH, O’Neill MS. Optimizing diabetes care with the standardized continuous glucose monitoring report. Clin Diabetes. 2020;38(2):194-200. doi:10.2337/cd19-0066
- ElSayed NA, Aleppo G, Aroda VR, et al. Glycemic targets: standards of care in diabetes–2023. Diabetes Care. 2023;46(Suppl 1):S97-S110. doi:10.2337/dc23-S006
- Dickinson JK, Guzman SJ, Maryniuk MD, et al. The use of language in diabetes care and education. Diabetes Care. 2017;40(12):1790-1799. doi:10.2337/dci17-0041
- PANTHER Program. Skin Solutions. Accessed February 27, 2024. https://www.pantherprogram.org/skin-solutions
- Fang M, Wang D, Rooney MR, et al. Performance of the Glucose Management Indicator (GMI) in Type 2 Diabetes. Clin Chem. 2023;69(4):422-428. doi:10.1093/clinchem/hvac210