How Individualizing Pump Therapy Can Result In Retention Rates

FROM THE EXPERTS

INSULIN PUMP THERAPY/CGM: THERE IS NO "ONE-SIZE-FITS-ALL"

In a recent issue of In the Know, Dr. Timothy Gilbert shared his valuable insights about insulin pump therapy (IPT) and patient selection. Dr. Gilbert especially piqued our interest when he shared his pump retention rate—an impressive 95%. We can all learn from a statistic like that, so we circled back with Dr. Gilbert and diabetes educator (DE) Olivia Blalock to uncover some of the secrets to their success.


How Individualizing Pump Therapy Can Result In 95% Retention Rates

HOW INDIVIDUALIZING PUMP THERAPY CAN RESULT IN 95% RETENTION RATES

BY TIMOTHY R. GILBERT, MD, AND OLIVIA BLALOCK, MS, RD, LDN, CPT

Over the years, our practice’s IPT/continuous glucose monitoring (CGM) prescribing and retention rates have increased significantly. We have a number of processes in place that have helped fuel this growth, but our structured education/training protocols tailored to each patient are the most important.

When it comes to IPT training and education, there is no “one-size-fits-all” model. We identify patients’ unique needs and learning styles and individualize therapy to make it work for them. This approach allows patients to focus on “living with diabetes, not for diabetes.”

Some best practices that contribute to our 95% retention rate include:

  • When starting IPT, we set expectations from the outset by telling patients: “You’re going to be here a lot.” Over time, we have figured out that intensive education, especially during the first 90 days, is crucial. The better educated patients are upfront, the better they do on IPT long term. We call this the 5 Ps: Proper Planning Prevents Poor Performance.

    We tell patients who are initially on the fence about IPT: “We need 90 days of 100% commitment. If you want to change therapy after that, we can.” However, that almost never happens—in fact, most patients end up saying they wish they had tried IPT sooner.

    Our training protocol for IPT/CGM, which is outlined in our previous article, includes a series of appointments for pre-pump training, pump start, pump follow-up, sensor/CGM start, CareLink® education, and system follow-up. We use these appointments to repetitively set the stage for patients and to ensure they know what to expect. We have found that this initial training protocol not only positions patients for success, it results in fewer questions later on in therapy.

    Once the initial training is completed, patients come in whenever they have an issue that needs to be addressed—generally at 90-day intervals, but only if needed.
  • Patients partner with us in goal-setting and trouble-shooting. When patients feel like they are in the driver’s seat, they get more excited about therapy. We talk to them about what they want to achieve, and how to fit IPT/CGM into their lifestyle—realistically.

    We offer proactive support and solutions that are individualized for each patient’s lifestyle. Common topics include when and how to calibrate, how to look for trends in blood glucose/sensor glucose (BG/SG), and helping patients understand why BG does not equal SG.

    If needed, we use simplified methods to help patients estimate carbohydrates consistently (consistency is key even if the counting isn’t perfect). We want them to use the Bolus Wizard®, which means we would rather see them enter fixed amounts of carbs versus exact numbers if that helps with adherence. We can always adjust the settings if needed. Flexibility—not perfection—is key to longer-term IPT success and retention.
  • We provide engaging, “anticipatory” education. We coach patients using real-world scenarios that help them anticipate and successfully manage nearly any situation they might encounter. For example, if a patient with a demanding job anticipates there will be times when she won’t have a chance to check her BG before lunch, we teach her how to bypass the BG entry into the Bolus Wizard and enter estimated carbohydrate counts. Patients get engaged with this process, and they often start coming up with scenarios of their own that we can walk through.

    While our education process is intentionally repetitive to reinforce key training messages, we also strive to keep it interesting and engaging. We use quizzes and interactive demonstrations, and our DEs have even been known to wear pumps themselves to show patients how easy they are to use.
  • We’re always there when patients need support. Someone from our office is always available when patients have questions, even if it’s through the answering service on a weekend. We explain to patients when to call the Medtronic helpline and when to call us.
  • Re-engage patients when needed. It’s critical to flag situations in which patients may appear to be losing motivation. For example, maybe they have done historically well, but all of a sudden their BG checking frequency is down, or their carb entries have tapered off. Our educators meet with these patients to help them regroup, refocus, and re-establish goals. Often we find the solution is something simple, such as revisiting carb-counting principles or suggesting a tool such as a smartphone app. By intervening early on, we are almost always able to re-engage these patients before they are on the brink of attrition.
  • Don’t use IPT as a “carrot.” Patient selection is important to us, but not in the way that one might think. We believe that if patients meet clinical guidelines for IPT/CGM therapy as well as our practice’s basic requirements, they will likely succeed. We have demonstrated it time and again—even previously nonadherent patients will step up to the plate if presented with the opportunity. For more on our philosophies about patient selection and how we position patients for success, see our first article.

SOURCES
Gilbert T. T2D and pump therapy: It’s time to redefine the “ideal” patient. In the Know [Medtronic Diabetes and Bayer HealthCare].. Accessed June 4, 2015.
Sensors & transmitters: Why sensor glucose does not equal blood glucose. Medtronic Diabetes. Accessed June 5, 2015.
Introducing the StartRightSM program for new insulin pump therapy and continuous glucose monitoring patients. Medtronic Diabetes. Accessed June 8, 2015.

Timothy R. Gilbert, MD, is founder and medical director of the Endocrinology Center of Southwest Louisiana (SWLA) in Lake Charles, Louisiana. The practice is a division of Imperial Health, the region’s largest physician-owned multi-specialty group. Dr. Gilbert has served as a primary investigator and sub-investigator for several diabetes studies. He is a member of the American Association of Clinical Endocrinologists, American Diabetes Association-Professional Section, the Endocrine Society, and the Louisiana State Medical Society, where he currently serves as a parish delegate on the state level. Dr. Gilbert speaks nationally on multiple diabetes-related issues, including utilization and management of insulin pump/CGM therapy.

Olivia Blalock, MS, RD, LDN, CPT, is a registered dietitian and certified product trainer for the Endocrinology Center of SWLA, where she is part of a team that includes endocrinologists, nurse practitioners (NP), and dietitians. Olivia is one of the office’s 2 pump/CGM trainers and works with the physicians and NPs to provide and manage pump therapy. She also provides diabetes education at all stages and for all ages. She supports the practice’s diabetes self-management education program, serves as a hospital consultant for in-patient diabetes education, and provides outpatient consults in medical nutrition therapy.