Episode 40 - Accu-Chek SmartGuide: CGM Generation 2.0 for MDI | Amy Jolley | GNL Podcast

People on MDI have had one generation of CGM technology: a sensor that tells you what your glucose is doing now, with a 15-minute trend arrow. While pump users have moved through five iterations, injection users have been waiting. The Accu-Chek SmartGuide is the first attempt at a second generation - and this episode asks whether it delivers.

Amy Jolley is a Highly Specialised Dietitian, Lead Educator at the Diabetes Technology Network UK, and Lead for the Young Adult and Transition Service at Salford NHS Foundation Trust. This episode is not endorsed by Roche Diagnostics, but the experience of a healthcare professional's experience of putting 17 people onto the SmartGuide in one week, running group onboarding sessions, and asking them to come back and tell her what actually happened. Her host, John Pemberton, is founder of The Glucose Never Lies® and a person living with T1D. 

This episode covers:
- Why MDI has been stuck at Generation 1 while pump technology moved through five iterations
- Night Low Predict: RAG ratings, first-half versus second-half of the night, and how to teach it
- Glucose Predict: the 45-minute action window versus the two-hour awareness window
- What 17 early adopters actually reported back
- How the 45-minute look ahead reduces the rage bolus
- Why calibration is an educational opportunity, not a drawback
- CGM market saturation and the DTN quality standard
- The DTN Competency Assessment Framework: four tiers, self-assessment, a training passport for clinicians
- GNL Grace in clinical practice: Amy's feedback from a specialist service supporting 700 AID users

Show notes: https://theglucoseneverlies.com/accu-chek-smartguide-mdi-cgm-series/

Have more questions? Ask GNL Grace, a diabetes educational advisor built by a team with skin in the game. Grace gets you 80% of the way there with 20% of the effort; the final 20% takes self-discovery, guided by human expertise and trial-and-error learning. https://theglucoseneverlies.com/gnl-grace/

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Disclaimer
This podcast is for education and informational purposes only. It does not constitute medical advice and is not a substitute for individualised care.

The Glucose Never Lies® is independent by design
We do not accept sponsorships and advertising. We operate via education grants and donations from listeners who value independence. So, consider:
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Enquiries
Collaboration: John Pemberton, john@theglucoseneverlies.com
Creatives: Anjanee Kohli, anj@theglucoseneverlies.com

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Instagram Anjanee Kohli: https://www.instagram.com/anjanee.dietitian
X: https://twitter.com/GlucoseNLies

Disclaimer

This podcast is for education and informational purposes only. It does not constitute medical advice and is not a substitute for individualised care.

The Glucose Never Lies® is independent by design

We do not accept sponsorships and advertising. We operate via education grants and donations from listeners who value independence. So, consider:
Buying the GNL a Coffee:
https://www.buymeacoffee.com/jspfree2

Enquiries

Collaboration: John Pemberton — john@theglucoseneverlies.com

Creatives: Anjanee Kohli — anj@theglucoseneverlies.com

Follow The Glucose Never Lies®

Website: https://theglucoseneverlies.com/

Instagram: https://www.instagram.com/theglucoseneverlies

LinkedIn: https://www.linkedin.com/company/theglucoseneverlies

LinkedIn: John Pemberton: https://www.linkedin.com/in/john-pemberton-587104361/

X: https://twitter.com/GlucoseNLies

Disclaimer
This content is for informational purposes only and does not constitute medical advice.

© The Glucose Never Lies Ltd. All rights reserved.

Transcript

SPEAKER_00 0:11

Welcome to the Glucose Never Lies Podcast, and this is the third device that we're going to talk about on the CGM series. And today you will see that I am not joined by a representative at Friend the Manufacturer, someone much better than that. My good friend Amy Jolly, who works at Salford but also is of DTN fame, lead educator. How are you doing?

SPEAKER_01 0:31

Yeah, I'm great, thank you. Thanks for asking me on.

SPEAKER_00 0:33

Well, you know, episode 40, you're coming on at the right stage. The audience is building, so I didn't want to get you on too early because otherwise there won't be enough people to listen to what you've got to say. So we've got you on at the right time. Um so yeah, just for people joining this um this sort of series now, we've already been through a couple of things. We've been through what the accuracy standards are, we've been through the questions that you need to assess that, and then we've also had the DEXCOM team on and the Abbott team on. So we've kind of covered quite a bit of ground. So what we're not going to do is go back over the accuracy piece because the only systems that are going to get talked about within this series are the ones who get a five out of five on the CGM study design score. Have at least 90% of readings in 2020, which is extremely accurate results and will certainly lead to um no risk decisions. And no more than 1% outside 4040, which is where you would make an insulin dosine error. So that is just taken for granted. We're only going to talk about the systems that achieve that. Uh, and the smart guide certainly hits that, and arguably their most accurate piece is within the hypoglycemia range, that is where their most accurate um levels are, which will be interesting because that's part of their um difference when we talk about the portfolio. So we're gonna be talking about the AkiCheck Smart Guide, um, which is made by Roche or Roche, um, whichever way, wherever you're coming from. And uh Amy, you've had uh quite a bit of experience with the Smart Guide, both in terms of a little bit of the coming to market with the team at Roche, but also with the experience you were one of the first centers to get access to it, is that right?

SPEAKER_01 2:02

Yeah, that's right. I was really lucky that Roche um approached me. They offered me an opportunity to do a product evaluation. So, one basically that I could get used to the system, um, how I might use it in my clinic, but also then I could get the feedback from people with type 1 diabetes on what was useful, what was like, you know, what was this system worth kind of what it's been marketed as? And that's exactly what I did. Uh put 17 people on within a week, um, just to kind of go away and use it and give me as much feedback as possible on what they thought was good and not so good.

SPEAKER_00 2:37

17 in a week, that sounds like a busy week.

SPEAKER_01 2:40

Yeah. I like a challenge.

SPEAKER_00 2:44

So we'll do a little bit of introduction. I'll I'll tell you what I understand about it, and then maybe you can tell me when you first got sort of your hands on it and you were experiencing it with the patients and teaching it, um, what sort of things you're discussing, what might might be different to some of the other systems. And obviously, just like the DEXCOM and the Abbott um podcast, we're not going to talk about the boring things that CGM do because people already know that. We want to know about what's different, you know, what's different with these things and how we're going to teach them. So, just as a little bit of a um a warm-up, it's a 14-day sensor, it's a disc that goes on the arm typically, an hour warm-up, readings every five minutes, waterproof as you would expect. It's adults only at the moment, so there's no pediatric indication, hence why no one came speaking to me about whether we would use it with the the people who we support. But they only come to the people who would work for the DTN or a part of the DTN anyway, so that's fine. And it's obviously got CE marking, um, no compatibility with AID systems, but it does have its own, and in the future it's gonna be sort of connected with my Shubber. So that's kind of like a bit of an overview. And from my understanding, there's a little calibration routine you've got to do when you put it on. So after 12 hours, you've got to do two finger pricks to make sure that the system is running accurately, and then the the features that we're gonna talk about become active. So that's kind of pretty standard. It runs from an app on a phone. You have to have two apps, but you can toggle between them quickly. What what was your experience of onboarding people about the physical bits?

SPEAKER_01 4:08

So everybody who went onto it, I was already using a CGM. So I wasn't teaching people kind of the what a CGM was. Um, I was just explaining what the difference was with this system. So I guess the key parts were um around the calibration because people weren't used to that being mandatory. Um, I think that that was something that a couple of people were a bit like, oh, I don't really like doing finger pricks, but I feel that that was an educational moment for me to explain that it's really great to carry on doing finger prick testing, particularly in times of um very high glucose, very low glucose if you're making big decisions. So actually, really, when we'd had the conversation about the benefit of finger pricking at that point, that became not an issue. And it is only at the start of each sensor, so it's not continuously needed throughout the sensor life. And then in terms of the app.

SPEAKER_00 4:55

Sorry, yeah. No, no, I was gonna say I think that's a really important point because um, you know, some people think that finger pricks are a thing of the past, and certainly if people to listen to the first two parts of the episode, uh CGM is amazing, it's absolutely brilliant, 99% of the time, absolutely all golden. But there is 1% of the time where it's gonna be outside 40-40. And if you trust it implicitly, all day every day, 365 days a year, you are gonna make some insulin dosing errors, especially when you know you look at the CGM, and as a person with diabetes, you just know it ain't right because it can't be based on the previous events. If you're not finger pricking in those points in time, then it's on you because you know you're gonna be making a mistake, potentially too much insulin or not enough. So I don't think that's a bad thing to have to get an opportunity to teach the value of finger pricking, good hand washing, and also good technique with a decent meter. So I'd agree with that. But sorry, I interrupted you. Carry on.

SPEAKER_01 5:43

No, it's okay. And actually, I think that as healthcare professionals, we did ourselves a disservice because we kind of went along with the marketing of CGM when it launched, no more finger pricks was one of the taglines for one of the systems. And I think people kind of lent into that and was like, look at this, you can use, you don't need to prick your finger anymore. But actually, the message got lost and that uh, you know, for a part of the time the system's not going to be giving you accurate advice. So I do I feel that that it is always a good idea to to re-educate and re-remind people about the value of finger pricking and why that's that's essential in some circumstances. So actually, I've I thought that was a really good way that we did the onboarding in groups where possible for this system because there were 17 people. So it was a really great experience. People were chatting to each other and they were saying, I've not done a finger prick in years, and other people were saying I do them all the time. So it was like a really great kind of peer discussion about well, why would why would this be something that was necessary?

SPEAKER_00 6:39

And they were happy with because obviously it's got two applications. So two apps, you've got one which is kind of the standard app, and then there's the predict app. And what was that like toggling between it? Was there any difficulty with that? Was it pretty straightforward?

SPEAKER_01 6:51

No, so basically, once they downloaded the the smart guide app, um, you it it kind of led you on to downloading the other app and and linking them together. So it linked automatically, actually. So it wasn't a big deal. And and because it was within app and just a button you press, it wasn't like you were switching between two apps. It was it was just part of a seamless process. It would be good if it was all one app, obviously, just because of people's space. But yeah, that that wasn't an issue once we had explained, well, one is your CGM reader, it tells you your glucose, it tells you your 15-minute trend arrow. You can lock your insulin and your carbs in this what this app and look at your stats. And then the the predictors for when you want to know what's what's the future. So what's gonna go on in the next couple of hours or overnight?

SPEAKER_00 7:34

So it sounded like onboarding, uh it's pretty straightforward. I've actually used it myself and yeah, I thought it was pretty straightforward, just like anything now with the technologies and the apps, the people who create these things, it's just a pretty straightforward um onboarding journey. All good. So that then leads up to right something new. Roachers obviously has been a very prominent part of my diabetes career, certainly from the beginning with the expert meter. Everyone was on the expert meter, had a couple of false starts with um some recent products, but this sort of seems to be something where maybe they're sort of coming back with an innovative technology which may offer something different. I'm gonna give you my understanding of kind of where MDI versus pump therapy is in terms of its rollback and its journey, and maybe where Smart Guide comes in. And maybe you can tell me whether that sounds right or whether you think that's something different. Pump therapy, obviously, we started off with a standard pump, and then there came the low glucose suspend. I remember the days when I used to work at Medtronic, the old five, the or the G. And then it went to predictive low glucose suspend with a 60 G. And then it went to the beginning of a 60G, which was you know a bit of extra insulin when you're going high, and then the advanced hybrid closed loops where we're at now, which is being rolled out and fantastic, whether it's a 780G or a tandem control IQ, an omnipod 5 or a CAM APS in the UK, and we're pushing towards you know this fully closed loop situation. So we're now on the fifth iteration, kind of generation five on the pump scale. But then when you think of MDI in terms of what they what MDI people have had, they've had the standard CGN, which is like your trend arrows and some alerts for lows and highs, but we're at generation one. There's not like nothing's gone past there. Whereas this is potentially offering something different, which is building in a stronger predictive element, looking a bit further than 15 minutes into the future. So it's got three different predict levels. So I would say this is generation 2.0 for the MDI people, people who don't want to pump or maybe and can't get access to a pump. It's going on to generation two. So there is three different features. There's the night low predict, glucose predict, and low glucose predicts. We're going to leave low glucose to the end because that's kind of pretty boring and everyone will get that straight away. I think the two more interesting ones are this night low predict and this two-hour glucose predict. So, do you think that's fair from a framing perspective? Kind of like people with pumps have had all these generations of technologies and CGM's really pushed it forward, whereas people on injections are still like sat back, you know, kind of 15 minutes into the future sort of situation. Do you think that's fair?

SPEAKER_01 10:04

I do. And I am a real advocate for people who are remaining on MDI therapy about leveling up. Should the technology not catch up? Should we not expect more from the technology for people using this type of therapy? Because I remember telling you at an event a couple of years ago, three years ago, um, that we had 800 eligible people in Salford for um AID and just the phenomenal like workload that was going to create. And there were gonna be people who are gonna be waiting years and years to access this technology just because of waiting lists. So instead of leaving those people hanging and behind, why can't we provide them with something more advanced, more supportive to them? And I actually think when the expert meter was withdrawn, we kind of went a bit backwards because people didn't have, we didn't have the apps really then that people used on smartphones. And we went back to kind of people guessing they're insulin doses almost. Um and I know we have apps now, but in adult services, they're inconsistently used. Um, people might use them some days or some meals and not for others. So it's not as useful as when we had the expert meter when people had to do a fingerprick check to get the advice. So I'm really excited for any development for the people using MDI therapy.

SPEAKER_00 11:21

Yeah, I mean, and also for people on pump therapy who don't want an AID system, that would be me. So I don't use an AID system because quite frankly, I can but outperform one and I don't like things messing around with my insulin doses when I can outperform it, but that's just me. I'm a bit of a freak like that. But at the same time, I wouldn't mind a CGM that actually has more predictive value and maybe some kind of ability to learn from my glucose patterns or learn from previous hundreds and thousands of days worth of people's glucose patterns of what might come to the future. Um, and especially as we're getting on board with um apps that may be able to collect your insulin doses better with smart pens and things, we can start throwing that in to get better prediction. So it's kind of a long frame to say in the UK, these are what 400,000 people with type 1 diabetes, and there's what, 50,000, 60, 70,000 on an AID system? The vast, vast majority can be the people who want to need a technology that is going to advance and advance quickly. And as much as we would love everyone to have the opportunity to go on an AID system, the reality is it will be lucky forever to see 50% ever. So that at least half of the people, if not more, will need technologies which can get all the benefits that the you know the advances can do. So I think we've sort of teed this up nicely for kind of what is the future looking like. Well, what's here now? But then also what could the future look like for people who don't want an AID system. So I'm going to explain my understanding of Night Low Predict first, and then tell me does that mirror with your understanding, but also how did you go about teaching this? Because I've used it myself and I've got my own frame for understanding it. But I'd be interested when you spoke about it in these groups. How do people take it on board? What are they kind of thinking about? So, as I understand it, the night low predict is basically anywhere between, I think it's something about like 9.30, or you can set a time, a time frame in the evening for it to give you a ping with a prediction for the next seven hours as to whether your risk of going low. And what I do like about this technology is it doesn't give you a percentage, it doesn't give you a funky number, it just gives you a it gives you a nice rag rating. Red, amber, green. Everyone knows red, amber green. If it's in the red, it's telling you you need to do something. If it's in the green, you know, you kind of be pretty all good. So my understanding is if it gives you a green before bed, you're a 90% or 91 or 92% chance you're not gonna go low. So you can be pretty confident that night that you're not gonna go low. Whereas if it's in a red, you've got a obviously a good chance you're gonna go low and it suggests that you'll do something, for example, take supplementary carbohydrates. And in that case, is my understanding is half of the time it will be right. So you would actually stop half of the lows that you would have had, and the other half of the time it won't be right. And some people might go, well, do you know what? That's that's that's pretty crap. It's only like half. But you think about this. If you're gonna have eight lows in a month at night, and if you could stop four of them, i.e., you could have four extra full nights' sleep a month. Most people snap your hand off for that. So, you know, can people think half is not that great, actually? That's a big difference. And also, it's not like you're gonna go low because you're still gonna get the low alarm anyway. So you're not actually gonna get low, you're just gonna save yourself half of the time being woken up unnecessarily because you can take action before. So that's kind of my understanding. And as I understand it, it needs kind of 28 days to be fully functional to be at its most accurate for an individual. So the first 28 days, you might not get as high a level of accuracy as that. But once you get going with it, that's kind of like the frame, and you just get this nice little picture of this dial of red, amber, green. And that's my understanding. Is that kind of similar to what you how you understand it?

SPEAKER_01 14:48

Yes, it's it's um exactly how I understand it, and but it also it splits the evening up to the first half of the night and the second half of the night as well, because that can help inform people of what action they may or may not take, depending on that percentage accuracy that you've said. So for people who I think while it's saying I might have a low, but it's in the second half of the night, what I'll do is X instead of like why? So they might instead of having fast-acting carbs to just bring their glucose up, they might have something a bit slower acting or some protein, or they might even just put carbs next to the bed and just be happy to be woken, but have something to hand to grab it if the glucose does go low. Um, and they can re-request a prediction every 20 minutes between 9 p.m. and 2 a.m. So if they did take action following advice, they can recalculate their risk again to see if that action has supported the change in risk.

SPEAKER_00 15:44

Oh my gosh, that sounds like you saw the manual there. Well then.

SPEAKER_01 15:47

Do you know what that the other thing is?

SPEAKER_00 15:49

Very good, very, very informative.

SPEAKER_01 15:50

Very so what you want to know is to me with. I know the thing that people came back to me with was more like it was the reassurance that they weren't gonna have low glucose was was really, really positive. And the fact that that was so accurate, like they they didn't maybe have as big of an understanding of how accurate that was, but they were like, oh, it's been brilliant, like it's giving me reassurance to go to sleep without worrying. And then for the for the ones where it was saying high or very high risk, it didn't, there was the reaction wasn't panic. It was more like, great, I've got some more information here, I can do something with. I think my worry was that if something's gonna predict somebody might have a low glucose, people might carbload before bed just to to kind of offset that and then have very high glucose. But actually, from the people who went on it in this group of people, that wasn't the case. So I found that really reassuring. And maybe that was the way that we we taught it. We talked about the night low predict, or maybe it was just the group of people that were um eager to try new technology. People who generally come forward for these things are generally quite keen and and quite well read and understand the way that technology works and insulin works as well. So it was just, you know, it was a it was a small group of people, but the feedback was was that that night low predict was positive.

SPEAKER_00 17:06

Yeah, I mean, it certainly there's been some real world data from Germany that would kind of suggest that it's kind of directionally looking like it's going to reduce your hyperglycemia overnight directly by 30% or so. But it sounds like it's similar to it's more I'm more interested about the quality of what people are seeing. So what you're describing to me there is when you get a green, it's like all right, pink, I just like don't need to think about it, just go to bed. And if it's a red, you're actually having a decision to make. But then it sounds like the nuance is quite important from what you're describing there. Well, if it tells you you're going to go low in the first half, then you're thinking something more fast-acting, like maybe a couple glucose tablets just to boost you up. Whereas if you're kind of thinking the second half, as you mentioned, as something slower acting or some protein or whatever it might be, someone might do a bull. If they've got a lanthus, they might do a background insulin reduction, for example. Um if they didn't want to go for the extra carb route. So are those the kind of discussions that were hard if they're on a pump, they could obviously do a temporary basal rate if it's on a standard pump. Are those the kind of things that people were talking about or you were educated about? Is that what the discussion was? First half, do something a bit faster acting. Second half, actually, you use your different options?

SPEAKER_01 18:05

Yeah, we did, we did have those conversations. And again, actually it was really helpful. These um, these groups were supposed to last about like half an hour, 45 minutes, but they ended up being quite a lot longer because people were talking and sharing experiences. Um, but we were able to bring in things like um, you know, the system doesn't know you've drank alcohol or been physically active, so that'll change your decision. Um, you know, if you've had a really physically active evening or day, what what decisions do you make then to reduce your risk of hypoglycemia overnight? And they might be similar decisions that you make if you get a high risk for the second half of the night and that you want to prevent the glucose levels going lower later whilst you're asleep. So same with alcohol, same with prolonged exercise. It would know there was a bit of education coming in about that and types of carbohydrate introducing protein as as part of a preventative action as well.

SPEAKER_00 18:57

Yeah, I mean that that sounds that's actually really interesting because I'm sure there's quite a lot of people listening to this, maybe healthcare professionals or people with who are going to get the chance. Those are the kind of key tips that really will I guess you could learn yourself over time, but you could supercharge your learning by going, look, if it's gonna be first half of the night, you want to get something a bit faster acting, so you're looking like a faster acting carb. Second half of the night, maybe protein, maybe a sauractin. And the other thing I'm thinking, like, if you're on a green and you want to get on the nest, you've got no problems. You can get on the nest. You don't have to worry about that. Whereas if you're on a bit of a red, you might think, oh, do you know what? Well, I might not risk it tonight. That's why it's great to have you on, because you've obviously taught this, you've been there with groups, and I think it's important what you did actually mention is we're talking about it here, is like people are really engaged and they're they're suggesting these things. And you are, you're preaching to the converted, you've given this opportunity to a certain group of people, and of course, the people who come forward are the you know the people who are going to try everything. So I think it's also fair to say for healthcare professionals who are gonna put maybe a lot of people on this device, other people just be like, Do you know what? I'll just slap this thing on, and if it tells me I'm red, I'll just do a bit of this, and I'll be interested in your education. But being able to offer different options for the different scenarios, I think would be quite helpful. And what I'll try and do is knock up a little bit of a PDF. I'll get Claude, I'll get my Claude and my Grace on a PDF afterwards so we can um knock a bit of something up for people with regards to the night low predicts, what you might do in the first half of the night, second half of the night. Obviously, as you mentioned, it doesn't take into account people who've done exercise and alcohol that wasn't in the algorithm, but it's in no algorithm. And if you're gonna go out and you're gonna smash 20 units of alcohol, nobody's doing any evidence based on that. That is like off you go and you learn. You know, you've got separate bits of education for that.

SPEAKER_01 20:36

So you think though that kind of if you've done that and if you've done that, you've like gone out and had like four or five pints or whatever, like, and then you you risk came up as red anyway, that that would be like, right, I've got to take some serious action here because I'm definitely gonna have like a real low. Or if you've done that and you came back and your risk was green, you'd think, right, okay, I'll just do my normal action here that I would normally do if I've been drinking. And because the system is.

SPEAKER_00 21:03

You could sort of take it a level, couldn't you? Yeah, you could sort of move it along a level. You kind of like have, well, if it was green, then you need to take what you're gonna do in the red. And if it's of red, then you definitely need to be uh taken on board having your your chip muffin without without any insulin for sure. So that's nightlow predict. So then the other one, which was I to be honest, I enjoyed the night low predict in some ways, but the the one that was more interested in was the glucose predict. So I'll explain this again as I understand it, and you can tell me is this how you get it and how you taught it? So when you look at your screen, you basically have a view for two hours into the future, and it's kind of broken down. You can see like a 45-minute segment and a two hour segment. And what you have is kind of like a worm that goes from where your glucose is now to where it will be in two hours. And it has kind of these little bars above it, and the bars are basically what the the 50% likelihood of where your glucose ever will be. So it's not like a hundred percent, it's only like the half, half of the futures. So the way that I saw it was if it was a really thin worm, you could be quite confident that. It wasn't going to be high or low. Whereas if the worm was quite fat and that's only half of the potential futures, then it's likely to be very, very different. So you can't trust it as much. From my reading of the researchers, the accuracy up to 45 minutes of where it's going to be is pretty good and pretty trustworthy and pretty actionable. When you start to get out from 45 minutes to two hours, it kind of, there's so many things that can happen. It's like a little bit more guesswork. It's more of a kind of like an awareness window. So the way that I thought about myself was rather than just having a trend arrow seeing me 15 minutes in the future, this thing is going to give me a fairly decent look, 45 minutes, which is quite helpful for meetings and driving and different bits and pieces. But then if we kind of look in two hours out, I'm only going to consider that if it's a very, very thin worm. Because when you start looking at 50% of the futures at two hours out and it's quite fat already, I mean, it could be anyone's guess. But for me, to go from 15 minutes, really looking at your trend arrow to 45 minutes is quite a big jump in terms of the psychology of thinking about, you know, what's what's the future going to hold? Is that kind of how you understand it? And also when you were speaking to uh the groups, how did they interpret it? What were they thinking about? Was it going to be useful? Was it not useful? What were they saying?

SPEAKER_01 23:11

So when we got everyone together, we talked about how this was a CGM in its but most basic form and people can use it to read their glucose and look at their trend, look at their patterns. But they had this other feature now where they could look ahead potentially up to two hours in advance. So we had a like a conversation about where that might be useful, why why people might find that a new feature that would benefit them. And people straight away came in and was like, that'd be brilliant for meetings, lectures, exams for driving, those types of situations, things where they wanted to avoid alarms going off on their phones, or even just be able to manage their diabetes a little bit more tightly rather than making wild guesses about what their glucose may or may not do. So I kind of like explained that for the for the kind of first 45 minutes, we know the accuracy is pretty good. But as the confidence intervals lengthened, then we knew that the um the next kind of 45 minutes or so were less, less accurate, but more information than they'd had previously. So I just kind of sent people away to use it and then come back and tell me, like, you know, was this accurate? Was it helpful? What situations did you use it in? What did you do? And we got some like I got some really good written feedback around that people were able to prevent hypoglycemia at work, that they weren't pushing glucose levels up high to enter into situations to avoid low glucose levels. Um mainly kind of around around that that that was the written feedback. And when I've when I met with people and asked verbally, people just like actually it's just really nice to have a bit more information and that that they could see a little bit further in advance, and um, and it just it just gave them a bit more peace of mind. I think we'll see more. The more people that go on it, the more feedback we get, the more we'll understand how to teach it better and how to use it more efficiently. Um, because this is new to me as well, in that I I was kind of going in and thinking, well, this is how I think it would be helpful, but I don't have type 1 diabetes, so I'm not the one adjusting the insulin or adjusting carbs in those situations.

SPEAKER_00 25:12

Yeah, and I think um a lot of what you said earlier on actually is this is the future 45 minutes and two hours if you do nothing and just sit on your backside now. But if you go and run, if you go and do have a lot of carbs in between, of course that's not going to be your next 45 minutes to two hours. So I think that part is quite important for people to understand is like it's a lookout of what's been happening to the glucose level and trend arrow mainly. There's a little bit about Bola Sinsin and absorbed carbs in there, but from my understanding from the modelling, it's more based around a learning or a learning from lots of other people's previous days that it was modelled on and what the next 45 minutes and two hours will look like. I think what will be going to be really interesting for the future. So I think it's really useful as it is. 45-minute action window, two hours awareness, and it gives you a bit more than you've currently got now, peace of mind, and people will use it and they will find their own way. Just like, you know, I think what also was really nice what you said there is like we just sent them away. We sent them away and then they told us. They told us, and then we'll teach that on. And I think that's the beauty of having early adopters of any technology is like you get the companies and they'll be like, Well, this is how we're using it. Like you got no idea what people are gonna do until they get on it and they're gonna tell you. So don't come and tell me what they're gonna do. We'll tell you what they do, and then you can go and spread that out. So basically, that's what you're doing is you're saying, Well, look, this is kind of what the science says, this is what the potential is, but we want to know what you do with it, what you find useful, and then when people come who are like you, we can pass and pay that information on. So, yeah, I think you know it's such a learning experience with different technologies, different opportunities. There's nothing better than getting the the people who are going to use it telling you how they used it to their best effect. So yeah, that's pretty interesting.

SPEAKER_01 26:57

I think I got like I was gonna say, I got really like I got quite excited when I heard about it because I was thinking people come into clinic and they'll be really frustrated that day to day I do the same thing. So people tell me they do exactly the same thing, but they have different outcomes. And I'm like just thinking, you know, if if they had something that was telling them a little bit further in advance that actually before you set off on that run or before you went on that drive, the glucose was doing this in the next couple of hours, would that explain that frustration? No one's actually come back to me to say that that's something that they've like, they've really honed in on yet. But I think that that can sometimes really be like something that as a healthcare professional, I'm thinking this will be really, really useful. And then people come back and say, like, oh, I've not really picked up on that yet. Um one of the things that that people did find that so two people fed back to me was that it stopped them from post-meal bolusin to correct glucose levels because they they could see the trend of glucose was already coming down. So it avoided an injection, avoided possible hybrid. So I think what people in the first instance was telling me was it was more like kind of instant decisions that it was helping them with rather than thinking like about reflecting back over, well, this is why that happened.

SPEAKER_00 28:10

Yeah, I mean, less less reactivity. I think that's where people, most people with diabetes, where they the frustration comes in, the rage bolus in is because they can't get a further look than that trend arrow has got a double arrow up, and you're like, I need to do something right now, which is put loads of extra insulin in, or in my case, I'm gonna go for a walk. But actually, if you could see a little bit further, and as long as you've been putting your insulin doses in that actually it is gonna come down, then maybe you wouldn't be so keen to stick the rage bolus in. I mean, you might be because you don't like that double arrow up. But I think a lot of people on the short term front, which is completely understandable, I've been guilty of it loads of times. I see like a nine with a double arrow up, I'm doing something. I'm doing something right there and then it's either more insulin, I'm going for a walk. But if I knew in the next 45 minutes to two hours it was trending back down, I might not do, and it might just kind of chill me out a little bit. So yeah, I think it'll be interesting to see. And what I think is key, and this is why it's really great to have you on, is not the over-delivery. I mean, I've spoken to a few people at Rush, and it's like, oh, we've got a two hour prediction. I was like, do not overpromise that. Do not overpromise that that is gonna be really accurate for two hours because people will hate it because it won't be. However, the 45 minutes, on the other hand, if you know that that's a high level of accuracy, it's a lot more of an action window, and you teach it that way, they're gonna really like it. But if you oversell it, you're really gonna end up in a bad situation because no one can predict two hours into the future if you don't have solid insulin doses knowledge and also know what you're about to do for the next two hours. You know, like it's just not possible. But I think that 45 minutes is a real um like like a 2.0 step forward. So it'd be interesting to see what further further feedback comes from that, really. Yes. And I guess on that, I'm kind of gonna get on my hobby horse here now. But um one thing I'm really looking forward to, especially if Roche could team up with MySugar and do a really good job, or if Medtronic with the smart um smart MDI system, or if any one of the other CGM companies that have got connected pens, if they can actually model insulin on board properly, not the crap insulin on board that you know companies put on the devices two hours, three hours, four hours linear decay. I'm talking about the real units per kilo. If you have, if I'm 100 kilos and I'm having 30 units, not point three units per kilo, that's an eight-hour, that's an eight-hour insulin dose. If I have a five unit and not point not five, that's a four-hour insulin dose. If someone models that properly and actually then has glucose, carb entries, and proper insulin modelled properly, we're gonna start to see really good predictions at two hours. So as long as you're not doing anything in between. Maybe really good in it, maybe good predictions in three, four, five, six hours. So the company that gets that insulin modeling on physiological insulin, not the crap that people show you on the device, which just bears no resemblance to what's working in your body whatsoever, that will be the company from the MDI perspective for me that will really take it to 3.0 for the next generation. So that's the bit that I'm looking forward to.

SPEAKER_01 31:00

And links it to like your heart rate. And links it to your heart rate as well. Yeah, absolutely.

SPEAKER_00 31:05

You know, what you've done beforehand, your step count, you've you you link those three things in, you've you've put your activity in there. Everyone knows with diabetes, you've got food, you've got activity, and you've got insulin. If you can get a good marker on those three things, well, you've already got the glucose, if you get the insulin model properly, and then you get the activity with heart rate and step count, you'll be in business in terms of getting some really, really good predictions on things that people, you know, kind of use around them. I've seen some data sets of like people who've got this data of 10 years worth of people, heart rate monitors, EGMs, insulin doses, like the data's there, it's just ready to be kind of AI'd up and spec'd out for people. And, you know, that's what 3.0 and 4.0 is soon going to become. Hopefully, it'll come to a case where you'll be able to get as good predictions as hybrid closed loop therapy. But the only thing is you as a user will have to do the manual adjustments. But if you don't want a pump and if you don't want something making those decisions for you and you want to make those decisions, it won't be too long, hopefully, before people who are on injections with those metrics will actually be equally able to see into the future about where their glucose levels will be, and they'll actually be in control of them as well. So I think that is very interesting for the way to go forward, and especially when you consider worldwide the people who are going to go in an AID system, type 1 diabetes, 5%, 10% maximum. The big market, the big money, the big players is like 90% of the people. So, you know, if you're a company, that's where you should be um thinking about. I mean, if you come and speak to me, I'll consult for you, no problems. Give me give me some money, I'll tell you what to do. No problem. I know what to do.

SPEAKER_01 32:39

Um I don't think that that's the next step with this particular sensor, but I obviously I am aware that there are there is um there's upgrades already in in the pipeline, and part of the DTN is that we're going to be creating educational resources online for people who want to onboard onto the system and use it and we'll be we'll be using the newer system to do those videos. So I've not I've not seen it or used it properly yet in its newer form. Um so I can't say too much about it, but we will be recording the kind of that support in terms of using a bolus calculator and connected pen devices along with this sensor. So I know that they're moving things forward, but it's probably just not as quickly towards that full integration as what you've described. So it might be.

SPEAKER_00 33:21

I mean, if you can get insulin doses in there, yeah, and also good education. You've already described what good education looks like, which is this is what the thing does. You go and tell us how you use it and what works, and then we'll just repurpose that and tell the people what works for the people. That's you know, that's really that's the best education possible. So you're in a great place of obviously having the personal experience, you're with the DTN where you're going to be producing those materials. So I think um, you know, for people who are going to be starting to use this technology, I think that'll be a great resource for them to kind of supercharge their learning. And even if that's available for people with diabetes who maybe don't have a team who's as far forward thinking as whatever teams are around, they'll be able to access those resources online, which would be amazing to just go direct to the source.

SPEAKER_01 34:05

So uh and I think and the more that primary the more that primary care use it as well, so there's going to be people who are less specialist in particular, like just in diabetes, then the the resources you described earlier. So having something like Claude produce, like this is what you do if you green, amber, red as a basic form, like that they'll help people more access to more people because primary care will have more confidence to use the system and onboard people without them needing to come to specialist care.

SPEAKER_00 34:32

Yeah, absolutely. And that that's the way it should be is, you know, kind of for me, especially with resources now available online, you can't expect all of primary care and even secondary care to have knowledge of all the AID systems, all the MDI systems, smart MDI, you know, Rush Smart Guide, you know, all these different things. It's just too much. It's too much. And also, one central really good place to go for the information. And the other part is like, don't overcomplicate it. Major in the majors, don't like teach people about the percentages of this and the percentages of that. It's like it's a 45-minute action window. You can be pretty confident with that. Go and learn. Two hours, just be a little bit careful. Night low prep before you go to bed. If you say you're gonna go low in the first night, then you have some quick acting carbs. If it's gonna be the second half of the night, then you have some protein or some sort of acting carbs. I mean, that is as simple. That's all people need to know, and then crack on and go and find out for yourself.

SPEAKER_01 35:20

Yeah. And the market's becoming a bit kind of like saturated, isn't it? With with lots of information that isn't very always very useful. Or I mean, I've had emails from kind of foot three different companies in the last couple of weeks saying we want to get our CGM on local formulary, like can you help us? And you know, I've never heard of or I've heard of the companies, but I've not seen any of their data. And I think it can become really confusing for for people when there's so much choice. And that's why we need to be really careful about the quality of the product we're recommending or prescribing, um, and the quality of the education that goes alongside it so that people can use these products effectively as well. And they don't, they don't, it isn't just about the money or what's the cheapest, it's about what's actually the most accurate for that person.

SPEAKER_00 36:06

Yeah, and I've got to give the the DTN sort of um a real big piece of credit as well because they obviously came out with their statement in terms of which CGMs would um you know would be considered, and obviously there was with ICGM approval or kind of from the DSN forum chat that I've been involved with, get a five out of five from the scoring perspective there. And that leaves basically the only ones that are talked about on here. So the only ones that you discuss with your education materials on the DTN. So it's a really important point. But it's just a really important point because there's absolute I am all for, I am all for cheaper prices if the quality is good. But I'll I'll say this and I'll say it a million times. Insulin dosing CGM is not a commodities market. Because when the ultimate risk is death, you have to apply the precautionary principle and understand the risk and you need high-quality products. If you're wearing a CGM because you want to know what happens when you have a bun and you don't have you don't take insulin, crack on and use whatever crap you want because you're very low risk. You use what you want, you waste your money. But if you're gonna make an insulin dosing decision about it, it's a completely different risk portfolio. And at that point, it is not a commodities market anymore, it's a serious business. So um, I mean, we banged on on about that enough plenty of time anyway. So the third prediction, which is not really that sexy to be honest, is basically a pr a low predict, i.e., you're gonna go low in 30 minutes. The only real difference with this is you can actually change the level. So instead of it being, for example, an urgent low soon on the Dexcom at 3.1, you can change it up to kind of, I think it's from 3.1 to 0.6 or something like that. So if you've got people who want to know a little bit earlier than 3.1, you can set it there. I don't think we need to bang on about that, because to be honest, the main difference is the first two bits. It's the kind of red amber green before bed and the two-hour predicts. Let people find out what they're gonna use about it and you know, kind of come back and teach you. The DTN have got some some decent materials, but that's a perfect segue into a bit of work that I know you've been heavily involved in, which is you've just described there's loads of AID systems, if there's four decent ones, there's probably three or four decent CGMs, that's eight pieces of kit that do eight things slightly differently with different algorithms, with different bits and pieces. We've had a nice paper come out about uh Erica Richardson's paper, which is basically talking about look, we've got all these things, how are we going to teach them? And then you've now developed um a competency assessment sort of framework on how you do that. So tell us a little bit about what that is. I know I've been involved with you a little bit about kind of writing that up and how to thinking about positioning it so that people really can feel confident that they don't need to know everything, they just need to know enough to teach it confidently, but teach it in a way which people really can resonate with and they get the value out of the product. So tell me a little bit about what your framework is, how you developed it, and how it's going to help people.

SPEAKER_01 38:53

So we actually started out as two separate pieces of work in that the DTM wanted to support people in being able to assess their competencies, and that was a supportive tool so people could identify where they had training needs and or where they were they didn't want to work outside their scope of competence. So we were looking at supporting people rather than saying, oh, you don't meet the competency assessment you can't work in area. It was more of, okay, so this is where you need more support and more training. And then um Erica um and the Leicester team were working on this kind of national framework. And then so we came together and aligned the tools so that it it became really complementary of each other. So the the framework, the national framework is a consensus statement of and there's different levels of competency you might require in different roles in diabetes services, kind of going from basic up to up to kind of leadership. And then the assessment tool mirrors that so you can you can kind of um look at where you meet the the criteria of knowledge and skills against each of those little tiers. So there's four tiers, and it isn't um hierarchical. So we what we expect is that there'll be some consultant diabetologists who might be operating at tier two, and there might be some lead DSNs and dietitians who are operating at tier three or four. It's just about what your role dictates you need to do, rather than tier four being this is the best and tier one being the worst. That's not how it is at all. So, yeah, so we've we've written the assessment tool and it will be uploaded onto the DTN website in the very next kind of hopefully few weeks. And then John and like you said, you and I have have kind of wrote a position paper really on how you might implement that along with the other kind of co-um authors on the competency framework as well. Um and we'll we'll also be doing a webinar just to launch the tool and kind of make people aware of it. So teams can use it to map their skill mix, um, look at where their training needs are, look at whether they have any business plans they want to put in for kind of gaps in service. And also people can then use it to say, well, this is where I am. I'll like it in my job description. They can move it from, you know, they might move jobs, they might move areas, they can take it with them and and kind of say this is where I'd slot in to support this service. So it just makes it all a little bit more official for people.

SPEAKER_00 41:16

It's it's an implementation piece. I mean, that's when I read it when you sent it over. I thought it was, you know, a really, really nice tool. So my understanding is obviously you've got like the national framework, obviously Erica's paper from the lesser team, they've already developed kind of like what it looks like to get to these different tiers. But then there's one thing saying that, but then there's another thing about self-assessment as a person, as a team, maybe as a as a region or whatever, that you can then say, well, actually, this is where I fit because I can do these things. And therefore, my next step up the ladder is this, this, and this, and maybe I can access this. But what I also was nice to hear you say, which is people thinking for job progression, people thinking about going to business cases for new um professionals, or getting money to go and access training, or I even take it with them as sort of like a passport of training that's kind of you know um endorsed by the DTN and whoever else is going to endorse it. So I guess the way that I thought about it when I looked at it was like uh at Star Wars. So you can start off as a young Skywalker down at the bottom of the sort of tier one, and then you kind of like you develop a bit of training with your Yoda. So I'm guessing you're sort of what tier four, your master yoda at your place, and you kind of the young fledglings come in and then you're teaching them the sort of the lightsaber ticks and tools, and then they get to you know, young skywalker, that's it. And then eventually master, and then you get to the top here, which is Yoda, but I presume that's pratique, is it? Pratique's Yoda up at the top, is he?

SPEAKER_01 42:41

Absolutely, absolutely. Um that's right. I think like also, but you know, some people like you know, a young skywalker is where they want to be, that's where they need to be. They don't need to be anything other than that. And and it's just you know, that that validation as well. Like, you know, this is this is where I sit and I can recognize a pump and a CGM. I understand the nice guidance, I'm aware of it. There are then there are people who are really kind of involved and then maybe offering people sick day rules or managing high glucose, they might be supporting people on like, you know, choosing a CGM, those types of things, you know, that's a that's a different kind of set of competency. And so it's important to just, you know, really support people in that. These are where you look at what's your job role and what's in your job description. And if it isn't in your job description, should it be? And we think that technology should be in everyone's job descriptions and and to what kind of level of competency people should be achieving for that. Um and the self-assessment is it's a reflective thing. It's the idea is that you look at where you sit, but then you evidence it. So it isn't just about people saying, like, oh, I'm tier four. Well, you know, how, what are you doing? What's your evidence for that? And so we've we've kind of linked it into a pra, you know, well, appraisal documentation reflective work that we need to. Do just for revalidation as healthcare professionals. There shouldn't hopefully be any additional work that people need to do. It's just, you know, you complete the tool. But the idea is that you've got that support and that evidence. And what I'm really, really pleased about is the feedback from industry is that they like the idea that there's this kind of framework because they can match their study days and their offerings of webinars to those different levels as well. So they can pitch webinars at tier two, they can pitch webinars at tier three and tier four. I'm at a roadshow event um in a couple of days and it's pitched at tier four. Um and you can tell by the agenda. I am just kind of really pleased that industry are getting on board with like, you know, the whole idea that let's nationalise this, let's let's unify it so people know where to go and what would be suitable for them.

SPEAKER_00 44:55

Yeah, and uh there's a few things that I really liked about it, especially coming up as a dietitian in the technology world, is kind of it's always typically, oh, we can't you can't do that because you're uh whatever. It's like if you can do it, you can do it. If you can evidence it and you do it, then it's done. You know, it's either put up or shut up. And you either, and if you don't and you don't do those sessions and you're not a T4. Like if you don't teach it, if you don't know how to adjust these things, if you don't know what these things mean, I don't care what your job title is. If you don't know it, you're not this, you know, this thing. And if you can't evidence it, then you know it's there. And I think that's really nice. It means that if you're in it and you're working in it, it doesn't matter whatever your role is, if you can evidence it and you're delivering it, then you're tier whatever you are. So I actually really like that um from that perspective because it levels the playing field on what you do, not what your title is, which I think is nice. And you know, we all know that you and Geraldine are realistically the the tier five, tier tier six masters. You haven't you haven't you haven't you haven't noted it down there, but there's another tier that you guys are operating at. So um that's why you're teaching the tier four. The galaxy tier. That's why you're teaching the tier four. That's it. But yeah, no, I think it's a really nice piece of work, and I think it's an important piece of work because it's nice to have frameworks, but it's more important to know where you sit with them, where your progression potentially could be. And now the industry are coming on board, you can go and pitch yourself at the right study day because there's nothing worse than going to a study day, and you get there and you're like, I already know this, or even worse, you get there and you're like, This is way over my head, and I have no idea what's going on. You're not going to learn anything. You can pitch yourself to the right day. Um, that's ideal. And then, you know, if there's more need for tier two days, there's more need for tier two days. If there's more three, tier three, tier four. So um, yeah.

SPEAKER_01 46:31

What I would absolutely love is if is if this was like something people could upload, and then we can look at like areas where there's like, you know, if there's different areas that are saying, well, we need more, you know, if the northwest needed more tier two or tier three, and then like the southeast needed like a different level, it would be amazing if we could we could map that, but that's a different thing.

SPEAKER_00 46:55

Oh yeah, but also he's kind of getting a competition on the northwest, they're the tier four champions. You know, you could have your you could have your average tier, you're a tier two, you're a tier two part of the region. Pull your finger out. That's right. But yeah, no, I think it's a really good piece of work. Benchmarking for pediatrics has been massive. As soon as they brought natural benchmarking for H B O and C's, care processes, everything changed because people like a number. What gets measured gets managed. And if you're measuring the right thing, it gets managed properly. So I think you've done a nice piece of work there. So I'll give you some props for that. But I can't let you go and finish without um asking you about your experience with Grace. So obviously, I have been busy in the background making a type 1 diabetes educational advisor, which is the idea is 20% of the information to get you 80% of the way there. It can't get you 100% of the way there because for that you need a human being who knows technology, who knows the person in front of you. But if you want to get that 80% quickly with some pretty sound advice we've developed, which is basically a chat GPT for type 1 diabetes, but we called it Grace after my daughter. Uh, and then there's the supermax version, which I gave you access to to see how you go in clinic with it. What any any feedback from me? It can be good, bad, I don't care. Yeah, I'm just interested.

SPEAKER_01 48:05

Oh my god, I was so pleased. I think when you first sent me this, I was really busy because I was like preparing for like a symposium at ACTD and I was like, why are you like hammering me with all these emails? But I'm so pleased you persevere because I've absolutely loved trying it out. I think I already gave you a bit of feedback about like different things that like I'd like to export things and be able to edit and you you could fix that really quickly. Um but I've used it um to input so in the set it pump settings kind of area, like I've put in like this is my problem, explain the situation, and and Grace has come back with like this is where I would look at, this is where I would look at first. So, for example, there was someone who was on a control IQ system and they were having hypoglycemia despite using exercise mode, um, and they weren't actually exercising, it was just kind of daily activity. And we had them on the kind of like the settings that were recommended, put that in, put the weight in, put total daily dose in. And Grace came back with like, okay, this is how you might adjust how the person uses the system and this is why. So obviously it doesn't give like prescribing advice, which is great, just like suggestions. Um, so kind of went away and and tried those different um bits of advice for different systems, and and yeah, it's been really helpful to just think outside the box a little bit more, but also understand how the algorithms push in the insulin and where the where the drivers are and what you what you can adjust because a lot of like you said before, the AID systems, there's not a lot you can influence. And so it's knowing what you can influence and and why you would do that. So, why would you use sleep mode in control IQ for longer than when you're asleep? And why would you relax the carb ratio or why would you strengthen the carb ratio? I've used it for those. Um I've asked Grace for evidence for things. So I've had like someone came to me and said, Can I use a Medtronic um CTG in SmartGuard with TPN? So I was like, I'll just ask Grace. Look at the evidence for that, which there isn't any. And so yeah, just like little questions um that just really quickly bring back, and because the database is only with type one, type one diabetes, like kind of papers and evidence. So I know that it's closed off, it's not there's not any nuance there, and there's not anybody's kind of opinion in it, it's it's all evidence-based. And so I've got to be able to do that.

SPEAKER_00 50:20

Yeah, I mean, just basically tried to create something that was me on my best day and beyond my best day because basically I've collected 4,000 papers since I've started doing type 1 diabetes since 20 years ago, and we've basically put all them together and bounded it. So Grace is not allowed to go outside that, but we've layered in all sorts like the guidelines and we'll chuck in your competency assessments and all those sorts of things. Well, the whole idea is really there's so much stuff to know. You kind of know it at the time of being taught, but you can't just pull it off the tip of your tongue, and if you just need to know, you can bash it in, and it'll never give prescribing advice because it can't do because it will only give, for example, you put a weight or total daily dose, and it will say the evidence suggests for a person, the average person with this weight and this total daily dose, these are the settings that the evidence suggests would be pretty reasonable. But the person in front of you is your decision, or if you're the person with diabetes, you can't take that prescribing advice, it's just to get you 80% of the way there for you to have a conversation. So it'll be interesting to see how other healthcare professionals um think about that because I'm sure some will think, oh my god, it's like it's prescribing. It's absolutely not, it doesn't allow you to put personal details in about actual individuals, just generic information to get you a little bit of the way there. But yeah, I think for me, especially with seeing so much technology, seeing so many different systems come in, and there's so much you're taught or given information about, there's really only a few key things for each system that really drive it. And if you know what they are and you can find that out of the click of a button, you can make help you make so much better decisions with the limited time you've got with individuals. So you don't have to spend time thinking about all these settings. You can actually have a human-to-human conversation, which is always nice.

unknown 51:57

Yeah.

SPEAKER_01 51:57

And do you not think like, you know, things change as we learn about the systems? So I know that when I first started onboarding people onto Omnipod 5, which was which was as it launched, um, I don't I didn't know half as much about how the algorithm was going to work in the real world as I do now. And how Insulette have like cut all that information for real world together. But I've got my real world information as well from the the hundreds of people who I've onboarded onto the system. So as we learn, we can understand how we can make changes, but that can't always be the case for every single centre. There are some really small centres that aren't using systems as robustly or might not come into contact with them. So there's got to be something they can go and access where they, you know, we've seen this one person on CAM APS, we've seen this one person on Medtronic, you know, that they can go and to and get some reliable support from. And I think that's where I feel like Grace is evolving into is that is that reliable support.

SPEAKER_00 52:55

Yeah, I mean the dream is, well, the hope is we've got some good educational funding from some of the companies and also some of the community who've used it are pitching in a fiver for themselves and also paying it forward for a fiver for someone else so they can use it for free. But the idea is it should be free for any healthcare professional and any person with diabetes to use at a reasonable level. And then for those people who want to go super, super deep and write papers and get really into the weeds, there'll be an option to kind of people if they want to pay more and stuff like that. But the whole idea really is it's to be free for people to be accessed to a decent bit of information. So we'll see how it goes.

SPEAKER_01 53:30

Yeah.

SPEAKER_00 53:31

But I want to say thank you for it.

SPEAKER_01 53:32

Thank you for developing it. I just say thank you, because I think like you need, you know, you are you're forward thinking and you share everything and you put a lot of effort and work into it. And some of the like, so I feel like grace is something I'm gonna need to practice with and have a play around with to see like how to use it effectively. But I think that then that'd be something I can then pass down to my team and talk about at a team meeting and say, this is how I use it, this is how you can use it. So I just think that these these things are really supportive in a world where like we've gone from having a hundred people in Salford on AID systems to 700. And we're now like, okay, this is this is like a them basically every day we're talking to people all the time on these systems. So, you know, we've got to be in that thought process all the time as what's best, what's the evidence base, what can I do to support this person?

SPEAKER_00 54:20

Yeah, well we'll we'll see how it goes. Probably be bankrupt by next week, anyway, so we'll be fine. But no, I want to say thank you for your time. I think for me, my take homes from this particular conversation. Number one, the vast majority of people in the world are gonna be on multiple day injections, and it's about time we move from 1.0 to 2.0, and maybe SmartGuard, along with SmartMDI as well, from um from Medtronic, is the step in the right direction, along with connected pens for other systems which are gonna be coming forward as well. It's catching up a little bit. Where it's really gonna take off to 3.0 is gonna be when we start getting proper physiological insulin on board, not the pretend one that we see on the system, when we start seeing heart rate and step count going in, maybe when we see sleep trackers going in as well. All that information is pretty much there to be harvested to give a very good representation of what the future might hold. So I'm I'm really excited for that for the for the most people. I think you've given some fantastic tips about actually how to onboard people. Number one, teach them what the information does simply, give them potential options, and then say, you guys go and you tell us what works for you, and then we'll just push down. And then obviously that information is going to be coming available on the DTN through various different platforms, and we'll put something together on here as well, a little take home for people considering that. We've talked about obviously the two-hour look into the future, 45-minute action window, two-hour kind of awareness window, which is pretty nice to consider. And then finally, we talked about going from young Skywalker to Master Master Yoda on the diabetes technology front with your self-assessment, which can allow you to see where you're at, an honest reflection, access to right study days depending on what you need to know. Um, and then also potentially for business cases or your own little passport of training that you can take from one place to another and develop your skills as you go forward. So um yeah, pretty exciting stuff. And then a little bit about Grace. Is there anything that you want to leave the audience with before I'll let you get back to Caleb and Cole and the madness at your house?

SPEAKER_01 56:21

No, they're about to get back from football training, actually. So this is ending perfectly. I think like we've covered so much there and and um yeah, just that we've we've got a lot of things on the in the pipeline for the DTN. So we've got some expert views videos that we've we've done, Geraldine and I, but we've also now gotten people with diabetes recording those to to make it more personable and more like, well, what how do you use these in real life as well? So we've got quite a lot of things um coming. So we've yeah, we've got we've got some things on the pipeline. So take keep a keep an eye out on the DTN website.

SPEAKER_00 56:54

No, I will be for sure, and we're gonna get you and Geraldine on together anyway, is the the real professionals when we start talking about transition with technologies. It sounds like you're about to get us swamped by your kids. But yeah, no, um no, I just want to say thank you for your time. Hi guys, you okay? Yeah, have you have you got anything to say to the glucose never eyes audience? Anything about your mum, how amazing she is?

SPEAKER_01 57:13

I score two. It's got two and five goals. Well done. Yeah, mum's always working.

SPEAKER_00 57:20

Is she always a is she always away at conferences doing talks? All right, well, thank you for your time, and uh I'll catch you soon.

SPEAKER_01 57:27

Yeah.