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Part 2: The Blood Glucose Monitor

Editor’s Note: This is the second installment in Scott Ehrlich's multi-part series, What's a Diabetic to Do? Join us as he shares a first-hand account of his experiences as he moves along his treatment journey after having been diagnosed late this summer. Click here to read his first article on this subject.

A few months ago, I went for a blood test and found out my A1C was over 10%. This, combined with an unexplained weight loss of about 30 pounds, lead doctors to the obvious conclusion that I had joined the ranks of about 30 million Americans who had diabetes. At this point, the two major questions were which type of diabetes, and how can I treat it? Because it came on suddenly and quite severely, my doctors suspected type 1. I, knowing my diet and physical activity regime over the last 30 years, suspected type 2. I decided to detail my experience as a newly diagnosed diabetic and the challenges I have faced, having spent so much of my time on the marketing side, to now be on the patient side.

In this article, I detail my experiences with the blood glucose monitors. My future articles will deal with the medications available and the overall consumer experience of being a newly diagnosed diabetic.

After going to my GP with my initial blood results, I went to an endocrinologist for a follow-up. I was sent home with an Accu-Chek Aviva Plus meter. However, my insurance prefers OneTouch meters, so I acquired one of those, a OneTouch Verio. I also received an offer for a free Abbott FreeStyle meter, which I took advantage of as well. Lastly, I took a trip to Europe and was able to acquire an Abbott FreeStyle Libre wearable monitor, which isn’t yet available in the United States. My impressions of all of these monitors are detailed below.

Accu-Chek Aviva Plus

The Accu-Chek Aviva Plus monitor was my first experience using a blood glucose monitor. It looked similar to a stopwatch and had some pretty good functions on it that allow you to mark when you did your test, get averages, and transfer to a computer. It takes 0.6 µL of blood for a successful test that go into a strip from the front. You know you have enough blood when the strip sucks it up. All in all, upon first glance, it didn’t seem that difficult.

My actual experience with the monitor itself was far less pleasant. It took me quite awhile to figure out how to use it properly. The biggest issue I had was that it would often flash that too much time had passed from when I inserted the strip to putting blood on it, and that I had to try again. This meant I had to prick myself again AND waste another testing strip (which weren’t cheap), even when I knew I had done the test promptly. It was only after a few weeks that I learned that this message really meant that there wasn’t enough blood on the strip.

While 0.6 µL didn’t seem like that much blood, compared to some older and cheaper monitors that took 1 µL, it was often more than I got from a single finger prick, meaning I had to do lots of squeezing or additional pricking to get enough blood for a sample. And once you put blood on a strip, if there wasn’t enough, you couldn’t add more blood, so that strip was lost. I wasted probably 1 out of every 2 strips at first and even after a few weeks, I was still wasting 1 out of every 4 or so. That’s a lot of money on wasted strips.

Another thing I disliked was how it transmitted your data. It came with a wireless way to connect and transfer data to your cell phone, for storage and further analysis, which I thought was great. It was only when I tried it that I learned the wireless wasn’t compatible with my Droid phone so all of that functionality was out the window and I could only import some raw numbers via USB.

Between the strips' issue and cost, the large amount of blood needed for testing relative to other current meters, the lack of alternate site testing, and the mediocre interface, this was my least favorite meter I used. I still have it for emergencies, in case something happens to one of my others, and it's certainly functional, but I didn’t find anything on it that was comparatively excellent and it definitely had many shortcomings.

OneTouch Verio IQ

The next meter I tried was a OneTouch. My insurance said they preferred OneTouch so I was allowed to get one of a variety of meters for no cost. I opted for a OneTouch Verio IQ. This meter was advertised as only needing 0.4 µL of blood and had some alternate site testing. It also had an analysis program that you could do through computer. And, since my insurance worked closely with the makers of OneTouch, I thought the strips would be very affordable.

On some accounts, this meter was all that it advertised. Taking it out of the box, it was by far the slickest looking meter, looking like a modern iPod, with a full color interface. It had the best graphics and definitely looked like a modern monitor should look. It also took less blood to work, which was nice. The blood, however, was inserted into the side of the strips (which were much smaller than the Accu-Chek strips); I found that to be easier after a few tries. It was a promising meter but it did have a few shortcomings.

Firstly, it wouldn’t turn on when I took it out of the box. I realized it has a rechargeable battery, unlike the rest, and needs to be charged before use. That’s not a big issue, but can be a problem if you need to test right away or frequently and don’t remember to charge it regularly. Another issue is that the alternate site testing was somewhat limited. Think your palm or sides of fingers but not other places on the body, if that matters to you. Finally, it only came with ten strips and, despite being the preferred (and, in fact, only covered meter) by my insurance, they still wanted nearly a dollar a strip, considerably more than I was paying for the Accu-Chek. Because of this, I opted not to continue use past the ten included strips. For the limited time I used it, it seemed like a quality monitor and if someone really needed a lot of analytics on their blood tests and tested frequently, it could be very useful, even if it still left some things to be desired.

FreeStyle InsuLinx

The final monitor I tried was the Abbott FreeStyle InsuLinx. I received this through a coupon I found on the Abbott FreeStyle website. While the coupon has proven incredibly difficult to use (more on this in a future article), I found the trouble to be worth it with this monitor. I was excited about it because it only required 0.3 µL of blood and allowed testing in many sites. When I first used it, I was hoping it would make my testing, which I had done quite frequently at that time, much easier. It's nice to see I was proven correct.

Firstly, it required only half the blood as the Accu-Chek monitor and about 75% as much as the already low amount needed by the OneTouch. Secondly, you can test nearly anywhere you like. So if you are getting sore or have an aversion to testing on your fingers, you can use forearms, upper arms, wherever. And finally, my favorite part, if you don’t get enough blood on the strip when you test, you have 60 seconds to add more. This gives you plenty of time for one or two additional pricks if need be, meaning you almost never have to waste a strip. The strips themselves are also tiny and allow you to put blood in from either side, giving a lot of flexibility that way as well. From a simple testing standpoint, this is by far the best monitor of the three in every way.

This is important because the in-monitor features, at least the ones I’ve found, are minimal. You can only do a small bit of labeling, analytics are pretty much none existent, and I have not found out how to do any sorts of averages on the monitor itself. The interface is also nothing special, with the ability to choose a background image the most advanced thing I have found.

Still, analytics aren’t that important to me as I just need to stay in a fairly wide range of sugars and don’t have to treat often with insulin or other meds throughout the day. So for me, simple functionality with little blood and little wasted strips is paramount. And to that end, this monitor is by far the best of the ones I have used.

Continuous Glucose Monitors

Despite that, I still felt there had to be something more. Pricking your finger, testing a few times a day, getting a few snapshots of blood sugar readings. All of these things seemed very archaic with today’s technology. So, in researching for something better, I found two continuous blood glucose monitors. These were wearable devices that would give you your blood sugar on a fairly constant basis without finger pricking or strips. The first, which is currently available in the United States, is made by Dexcom. This is a device you can wear on your arm for seven days and get consistent blood sugar readouts. Unfortunately, the cost of $700 or so for the initial device and its lack of coverage by insurance made testing it a bit out of my reach.

Another device I had seen was the Abbott FreeStyle Libre. This device, at a cost of $80 for a wearable patch and another $80 for the scanning device, along with a wear time of 14 days, was much more in my wheelhouse. When I found out that you can use an app on your cell phone instead of purchasing the reader, bringing down the cost of trying it even further, I was even more intrigued. There was one hitch, however; this device has yet to be submitted to the FDA for approval and is therefore not available in the US. In fact, you can’t even access the website or apps from a US computer.

This was quite discouraging. As luck would have it (or as lucky as someone can be when having diabetes), I was headed to Germany for an extensive vacation around this time, where it was for sale, so I made some arrangements to procure a single pod for trial. I was curious to see how my newly diagnosed body would hold up to the diet of beer and pretzels I planned on feeding it, as well as how my blood sugar reacted outside of my normal testing hours or while I was sleeping.

After getting my device and downloading the app, I watched YouTube videos on how to set it up. Seeing the size of the needle I would need to put into my skin to “install” it, however, made me quite queasy (although seeing six-year-olds putting it in themselves without even flinching both put me at ease and made me realize how big of a baby I was). Still, after a copious dose of liquid and pretzel courage, I had my wife put it into the fatty part of my left arm. To do this, you put the pod (about the size of a quarter) in an applicator-type object, push down almost like a stapler, and take it off. Shockingly, not only did it not hurt, I didn’t even feel it go in. And yet there it was, on my arm. I initialized it with the app and took the first reading on my phone. I then checked it against my blood glucose monitor. They were nearly identical.

I was enthralled with this device, how it could be there, attached to my arm and I could just wave a phone over it to get my blood sugar, cursing that this wasn’t available in the US. I checked my blood sugar over and over, amazed at this new technology. Oddly, though, my sugar readings dropped, first to slightly low, then very low, then to the point where I would be in a hypoglycemic coma, then to the point I would be dead. I confirmed on my blood sugar monitor that I was not, in fact, dead at that point, nor were my readings even low, and thus I began to see a flaw in my new toy. Further research told me it could take 1-3 days to calibrate the device. With only 14 days of use and it being basically useless for the first few, I became less enthralled. Furthermore, my wife noticed a fairly massive (albeit painless) bruise forming from the insertion site, taking up most of my upper arm. Perhaps technology wasn’t as great as I thought it would be.

After toying with removing the device, I waited out the few days and it did, in fact, calibrate. The results would deviate from my blood sugar monitor, sometimes by five points, sometimes as much as 20. I read that because this was measuring your sugar through fluid in your skin rather than blood, the readings wouldn’t be as current as finger testing and weren’t to be used if your sugar was rapidly changing, such as after eating or if you needed it for insulin doses. This was a fairly severe limitation of the product. I am not sure if this calibration time or inaccuracy was a result of the device itself or the third party app I used to read it, but it is definitely an issue.

Still, this device was amazing. I could swipe my phone over my arm for a few seconds and get an instant reading. I could test as much as I want, wherever I wanted, in seconds. I could have, at a glance, all my results for days, including during when I was sleeping. I could see my highs and lows, when I was rising and falling, what really caused my sugar to spike and drop. It was very instructive and I could see this sort of device is the future.

After 12 days (and another few beers), I took it off. It peeled off fairly simply and painlessly, and the bruise itself started to go away. I don’t feel the need to get another device because of the trouble involved in procuring one and the lack of support once I had it, as well as the fact that it is also a bit cost prohibitive now since it is a cash payment. I do, however, think that when Abbott submits this to the FDA in 2017 or 2018, assuming it's approved, I would definitely consider using it again, maybe even as a replacement for my other device. Right now, at $80 every 14 days, I am not sure the value is there. But cut that to $10-$20 with insurance and improve the issues with calibration, this could cause testing compliance to skyrocket. Improve the life to 30 days and this device would really take off. As much as I find my other Abbott FreeStyle InsuLinx to be useful, it's obvious that a wearable CGM, integrated with apps and analytics on common cell phones, is the future of testing.

In recent years, as a result of advances in technology, expansion of channel reach and increased focus on patient outcomes, the Point of Care channel has grown to be a more important part of brand marketing strategies – most notably for healthcare marketers. Campaigns at POC have been successfully fueled by data-driven targeting and a high degree of consumer engagement with relevant content, but what has made POC most attractive to marketers can be summed up in one word… measurability.

POC has offered marketers the unique opportunity to track the consumer journey from the healthcare provider visit (at the doctor’s office, hospital, or pharmacy) to the point of sale. And now, with heightened focus on understanding outcomes on every campaign, measurement design has become equally as important as the campaign design itself.

To best position yourself for success – as well as get the most accurate read on your campaign’s performance – it’s important to recognize both the benefits and limitations of measurement. Below are three key questions to ask yourself before finalizing your measurement plan:

1. Is my campaign large enough to measure?

Not every campaign is large enough to measure – statistically speaking.

A campaign (often in the form of a “test campaign”) may be too small in scale to allow you to detect a more immediate and/or statistically significant impact. This doesn’t mean your campaign isn’t working. Rather, it suggests that you need to adapt your measurement design to account for the size of your campaign. For example:

• Conduct a feasibility study to understand if statistical significance can be achieved given size of sample, timeframe for measurement, and assumptions around magnitude of impact;
• Use insights captured via primary research (qualitative or quantitative) versus transactional purchasing to obtain earlier indicators of program success;
• (If married to secondary analytics) Analyze transactional purchasing over a longer period of time to increase the size of the sample subject to study.

2. Do my research metrics align to my campaign’s objectives?

ROI is not the only indicator of campaign success – though it is of course among the most important. 

Marketers have a variety of metrics at their disposal to understand campaign performance – from ad awareness and message recall captured via primary research to purchase lift and brand adoption captured via transactional-level analyses. Using pharmaceutical marketing as an example, product life cycle will have a considerable impact on key performance indicators of a campaign. Marketers of brands entering growth and maturity will focus on new patient starts, impact on market share, and return-on-investment; whereas, launch marketers may expand KPIs beyond new patient starts to increase in brand awareness, consumer message recall, and adoption of the brand among non-prescribing physicians.

Communicate your brand’s objectives up-front so that all key performance indicators are addressed in your measurement plan.

3. When should I look to first measure my campaign… and how frequently should I track performance?

Campaigns take time to resonate. 

It’s hard to wait to evaluate the performance of a campaign. In the pharmaceutical industry, data is available as frequently as weekly (if not daily). And while tempting to consider weekly measurement of a campaign at the Point of Care, we know from experience that campaigns take time to gain momentum. While a large percentage of impact is observed within the first 30 days of campaign exposure, residual impact is seen for up to 90 days. Measuring a campaign in its infancy may set a false expectation of performance and set your campaign up for “failure.”

Establish expectations on timing upfront, allowing six months for measurement where possible, but no sooner than three months, to first assess your campaign’s impact. From there, more frequent tracking/follow-up reads may be established, assuming data from the initial read supports. Patience – in terms of data availability – pays off.

Republished with permission. Click here to read the original posting on MediaPost.

As patients experience greater financial risk and responsibility for their healthcare, patients are becoming more active decision makers. They are no longer passive and accepting of healthcare decisions made by providers. Patients are consumers of healthcare and we, as an industry, must change how we think about patient-centricity and focus the lens of our business around what the patient needs.

As we look at the healthcare consumerism trend, what can pharma companies do to better support patients?

We must change internally from a commercial perspective and invest to get patients the information and education they need at critical decision points.

Clinical landscape

Treaters are changing, and the way we treat patients is changing. Today, the number of PCPs has dropped, but the population, particularly the baby boomer generation, is increasing. A reduction in PCPs and increase in patient volume is resulting in less time spent with patients.

As a result, we’re seeing a stakeholder approach to treatment. When we start to look at how we plan HCP strategy – we cannot focus exclusively on physicians as the education of patients is increasingly happening with alternative stakeholders, such as pharmacists, case managers, and health coaches. An impactful HCP strategy should include these providers who are spending more time with your patients.

Financial landscape

High deductible health plans are on the rise, passing increased financial responsibility to patients. Employers are scrambling to adjust benefits to avoid substantial tax fines as patients struggle to adjust to the “new normal.” Patients are not only responsible for higher deductibles, but the type of deductibles are changing as well. Previously applied to medical benefits, now these deductibles are being integrated and include pharmacy benefits. For example, I was picking up an Rx that is normally $25 and was told it was now $170 – my thought: “how much do I really need this Rx?”

Patients are asking themselves the same questions. When you look at your patient savings programs, make sure that you’re working with someone, or building competencies internally, that can manage patient savings programs ensuring two important capabilities: the ability to impose flexible benefit structures and an intelligent application of that benefit. This ensures that you are delivering savings to the patients who need savings – not just a one size fits all approach – which can have a substantial impact on profitability.

As we look to the future, value-based reimbursement will increase in focus. Over the last few years, we have anticipated an increase in value-based reimbursement, but in early application, many physicians didn’t see the linkage between required outcomes and reimbursement.

This February, CMS and a number of private insurers met and came to consensus on the first eight areas of healthcare and 22 areas of quality measures. This helped to start streamlining and clarifying the expectations of both physicians and health systems to support reimbursement. Additionally, it helped providers that are participating in value-based reimbursement to understand the implications of performing and not performing. We anticipate this trend to continue, and accelerate.

In the movement toward value-based reimbursement, we should anticipate the rise of value-based contracting. Gone will be the days of deep discounting to secure preferred formulary status (with the possible exception of generics). When you look at innovative medications, we’re going to have to come to the table taking on some of the risk and responsibility – preferentially in a shared risk model. We will have to prove outcomes of our treatments, inclusive of the associated services and solutions we provide, to improve the overall financial profile to the plan.

Operational landscape

Patients are seeking information through non-traditional channels, which are critical for optimized engagement. Ninety-five percent of people have a mobile phone. By 2017, 65% of patients will be actively seeking health solutions via mobile device. Engaging patients via mobile is becoming a fundamental requirement. So how do patients want us to communicate?

When personalized resources and education are delivered in real-time, from a trusted healthcare source, adherence rates for medications have increased 3x over baseline.

Less fundamental, but growing in popularity, is engagement via social media. Forty-two percent of patients are engaged in social media and of that group, 40% act on something from social media. Historically, manufacturers have been more reluctant to participate in social media due to risk containment. With these engagement numbers growing, manufacturers will need to re-evaluate how to get involved, in a responsible and effective manner, to provide patients with the information and resources they need when and where they’re having the conversation about the company or the products.

Behavioral landscape

Beyond C.F.O., there is a critical 4^th dimension that can be overlooked – behavioral.

As they walk out of a physician’s office, 50% of patients do not remember what they discussed. Patients walk out with a prescription and often do not recall instructions around dosing or lifestyle changes. Assuming they take the prescription to the pharmacy, only about 50% are adherent and only 10% make the requested lifestyle changes.

Most non-adherence is not caused by drug costs. Express Scripts recently reported that 69% of the problem is behavioral – simple procrastination and forgetfulness, barriers which can be overcome with the right support resources. Improving these statistics can have a significant impact on outcomes – which are increasingly important to value-based care.

In summary, patients are becoming more engaged and empowered, leading to the importance of the trend of patient consumerism. How should Pharma respond? By addressing the 3E’s of healthcare consumerism:

• Empathy: mobilize our organizations to be able to serve patients differently – to be able to serve healthcare differently. Everyone must understand the patient and the value of the patient. It is important that all members of the organization – inclusive of support functions (legal, regulatory, finance, etc.) – understand what patients are going through as they make decisions.
• Engagement: expand how we think about patient engagement. We can no longer work on education and resources to HCPs exclusively. Our HCP strategy must include complementary providers who are spending more time with patients. Today’s patients want individualized information in the channels in which they normally engage. Brands must integrate tools and services within these channels to deliver the right information for the right need at the right time.
• Empowerment: prioritize patient resources. Patients are becoming active participants in decision making with their physicians and at the pharmacy. This is being driven by the increased proportion of cost that has shifted to the patient. Pharma can no longer deprioritize patient resources as budget reductions are made. These resources must take a minimum of a shared priority within strategic plans and spends.

Ultimately, as an industry we must invest in the education, tools, and resources to help patients become more informed and active participants of healthcare. As healthcare consumerism continues to rise, this investment must happen. If not, we will miss an opportunity that we have to impact overall brand and, most importantly, patient health.

Today’s best adherence programs emphasize the critical role of patient engagement in driving success. In my first article, I discussed the overall value of patient adherence programs and how implementing best practices for program design can make your programs more relevant to patients.

Taking this approach one step further, engagement programs can and should occur on many levels and within the various stages of adherence programs. Let’s explore how.

1. Understanding the product

Building patient engagement begins with a comprehensive understanding of the brand and the product. First and foremost, it is necessary to have a discussion about various factors that define a drug going to market, including indication (use of drug), therapy duration, side effect profile, distribution channel, and cost, before you can develop a patient adherence or support program. Consider, for example, how the level of engagement will vary greatly between specialty drugs, conventional products, and long-term or short-term therapies.

Remember: Adherence solutions are not “one size fits all.” For every brand, there can and should be a different approach. The level of services, types of services, and positioning of services will first be defined by the product.

2. Selecting the optimal channels

Once you have an understanding of the product, you can begin to evaluate the best channels for engaging with your patient. Adopting an omnichannel approach, whereby you provide many channel alternatives and let patients determine their channel of preference, is ideal. Just keep in mind that an omnichannel approach differs from multichannel — it involves not solely offering a variety of pathways, but serving patients with equally beneficial resources in each one.

Your investment and the product type influences the level of engagement, which in turn determines channel/communication type. For instance, 24/7 live nurse support — a necessary protocol for certain treatment protocols or serious health conditions — is vastly different than sending out basic text message reminders to take a medication, and the engagement within these programs should be recognized as such. Similarly, therapies that are dosed at varying intervals (once per month, every three weeks, etc.) require a different approach than a drug dosed at once daily. Conventional drugs treating asymptomatic diseases would likely focus on reminder-type messaging (perhaps with some disease management/wellness reinforcement), whereas an approach to an infused biologic product that may have a more serious side effect profile may try to optimize a full patient engagement strategy, pairing an experienced health care coach to interact, on an ongoing basis, with patients to assist them to remain on therapy and make it to their next infusion appointment.

3. Recognizing the ways patients define your program

Although the product and investment determines level of service and engagement, at every point, the patient profile should be assessed. Consideration should be given as to how individual patients want to be engaged (or not) and at what level. This holistic understanding of a patient’s history, current condition/medical situation, and mindset will determine how a patient engages in meaningful conversation. These factors will ultimately play a role in determining whether patients are likely to be compliant in adherence programs. In fact, putting yourself in the patient’s shoes to get a 360-view relates back to one of the most basic principles of designing effective adherence programs — to be aware of any and all potential barriers to adherence.

The typical patient profile (considering demographics, medical history, etc.) and the nuances of individuals themselves can influence engagement design and program services. These may entail more specialized services that go beyond more traditional medical care/support. Consider, for instance, a Hepatitis C drug prescribed orally: on paper, it may be “simple” to stay on the treatment, but because a subset of patients with this health condition could be more likely to have a history of drug addiction — a finding that could be uncovered in the patient-profile research and discovery stage — these patients may need the added support of a social worker to stay engaged in the program and adherent. In certain cases, the patient profile is as simple as recognizing the typical patient tendencies, such as in vaccinations that require a multi-dose regimen, where staggered timing can make it difficult for patients, like students going back to school or frequent travelers, to stick to the routine.

All in all, these various factors, considering both the product and the patient, will help you develop a well-rounded program that sets the stage for compliance. Along the way, remember to track and measure your successes and areas of improvement, and patient and product challenges. Doing so will allow you to continually innovate and successfully implement patient engagement tactics in the future.