Getting the dominos to fall

Getting the dominos to fall

One of the more promising trends in diabetes management is the move towards device connectivity. Today there are several companies working on systems that transfer data from the various devices that patients use to manage their diabetes to a central location. This information can then be accessed by a patient’s physician, certified diabetes educator (CDE), insurance company or pharmacist. The basic theory is with this information easily accessible the patient’s healthcare team can better assist the patient in managing their diabetes.

While there are several different approaches, some companies use mobile or cellular technology to transmit data, others use the internet and email, while still others combine mobile and internet technology. No matter how the data is transmitted and how interventions or advice is communicated back to the patient what all these systems have in common is the reliance on the patient to capture data points.

The centerpiece of all this data comes from the patients glucose monitor.  Although the technology currently exists to transmit data from a patient’s insulin pump or continuous glucose monitoring system (CGMS) and soon this technology will exist for insulin pens, these interconnected patient management systems are mostly targeted at type 2 patients most of whom do not use insulin pumps or CGMS.

Perhaps the best way to illustrate how these news systems would work is take a look at what Sanofi-Aventis (NYSE:SNY) with their new iBGStar glucose monitor. The iBGStar is glucose monitor which can be attached to an iPhone. Like everything iPhone, the iBGStar seamlessly communicates with its own app. Each time the patient measures their glucose that reading is automatically sent to the app, which in turn can transmit the patient’s data to central database using cellular technology. The patients glucose readings along with any other data entered by the patient can then be seen by a “diabetes coach” who in turn can send text messages to the patient with tips on how they can better manage their diabetes.

Sanofi is also developing an insulin pen that communicates with the app, so in the future it’s possible the patients “diabetes coach” would not only see the patient’s glucose readings but also their carb intake plus when and how much insulin they take.

The general theory is with all this information the patient’s “diabetes coach” could help the patient better manage their diabetes. The payoff for Sanofi would come from the sale of insulin and test strips, with the potential for an even bigger payoff if they can demonstrate that patients using this system achieve better outcomes.

There are some who envision these interconnected patient management systems helping patients become more compliant with their therapy regimen. Although the technology does not yet exist to measure if patients on oral meds are taking their pills, the “diabetes coach” using the information gathered could see information that indicates the patient isn’t doing something correct and seek additional information from the patient which could reveal the patient is being non-compliant with their therapy regimen.

At its core the theory behind these interconnected patient management systems is all this information combined with expert advice will ultimately lead to better outcomes and ultimately lower healthcare costs. However, like all patient systems management systems the dominos will not to begin to fall if that first domino isn’t tipped over. And when it comes to these interconnected patient management systems the first domino is glucose readings. The central fact is glucose readings are the first domino that needs to fall if the rest are also to fall. Herein lies the problem with all of these systems, while the technology exists to collect and transmit data, no one has yet to figure out a way to get patients to monitor their glucose on a regular basis.

Consider with all the advancements in glucose monitoring technology, alternate site testing, smaller sample sizes, no-coding and faster test results patients on average test their glucose readings less than twice day. If these numbers are broken down by therapy regimen the numbers are even more telling. Leading the pact are insulin pump patients who on average test their glucose readings eight times each day, while at the other end of the spectrum you have non-insulin using type 2 patients who test less than once a day. It is this group, type 2 patients, who also happen to be the target for these interconnected patient management systems.

Even if you include type 2 patients who use insulin, the numbers aren’t much better. While these patients should be monitoring their glucose readings before they dose their insulin, this is not the case in the real world. As Diabetic Investor has noted in the past, many physicians dumb down insulin therapy for these patients. Rather than spend the time, time they don’t have, educating patients on insulin therapy, physicians, primary care physicians (PCPs) in particular (PCPs  treat 80% of the patients with diabetes),  provide their insulin using type 2 patients with simple dosing instructions.  A perfect example of this comes from the many patients who use both oral meds and the long acting insulin Lantus. To keep things simple the physician tells the patient to dose a set amount of Lantus each night and then makes adjustments to this dose based on A1C readings.

The same is also true for type 2 patients using an insulin blend or short-acting insulin. While it would be nice if these physicians could spend time educating patients on insulin dosing this is not something they are paid to do and as we noted earlier nor do they have the time to do this. To keep things simple and avoid hypoglycemic events the physician dumbs down dosing basically telling the patient to dose a set amount with each meal.

Physicians know that even if they tell these patients to test their glucose regularly it’s unlikely they will do so. As Diabetic Investor has been stating for years the reason the majority of patients do not test their glucose on a regular basis has nothing to do with the so-called pain associated with performing the test, rather that patients have no idea what the test results mean or how they use this information to better manage their diabetes. The reality is a patient on oral meds has little reason to test as no matter what the test results it won’t change when or how many pills they take.

The companies developing these interconnected patient management systems seem to believe that type 2 patients who have not been monitoring their glucose regularly will somehow magically change their behavior; that the patient who has not been testing will understand that this information is actually useful and that with the help of their “diabetes coach” they will actually benefit from collecting this information. While this may be true it flies in the face of how things work in the real world.

Let’s assume for a moment that these companies do somehow convince these patients who have not been testing regularly to start testing regularly. Will the patient actually see results or feel any better as a result? Will this behavior change yield a tangible result?  In theory the answer would be a solid yes, assuming of course the patient follow the advice provided their “diabetes coach”. The problem comes in when the patient does not see a personal benefit from all this work.

The real problem is that the companies developing these systems believe that managing their diabetes is central to the patient’s life. Diabetic Investor has said it a thousand times; the majority of patients with diabetes want to live their lives with their diabetes and not for their diabetes. They want their diabetes management to be part of their lives and not dominate their already busy and hectic lives.

This is not to say that Diabetic Investor is against this trend or does not see value to these systems, quite the contrary. There is no question that patients need help and that the more information the patient has the better. But it is equally true and there have been studies that prove this; that patients would sacrifice years off their lives rather than do all things necessary to properly manage their diabetes.

The bottom line here is that until these companies figure out a way to change patient behaviors and get them to test their glucose levels on a regular basis, the dominos won’t start falling.