Where Do We Stand on Time In Range? A Conversation with Dr. Partha Kar
By Frida Velcani and Emily Fitts
We interviewed Dr. Partha Kar to learn about how people are using time in range in his clinic and what obstacles our society will need to overcome to promote wider use of time in range
Time in range is a powerful tool for people with diabetes to measure their blood glucose levels in real-time, observe patterns and trends, and make daily treatment decisions to avoid health complications. The diaTribe team is working on bringing together the diabetes community – people with diabetes, researchers, industry representatives, policymakers, and other nonprofits – to make time in range a norm in diabetes care. The focus of the Time in Range Coalition is to remove barriers to diabetes care and to spur the adoption of new technologies, therapies, and behaviors that are necessary to advance time in range in the diabetes community.
To learn more about how the coalition can expand the use of time in range to more communities, we interviewed Dr. Partha Kar – a National Specialty Advisor for Diabetes at NHS England and a highly respected Consultant in Diabetes and Endocrinology at Portsmouth Hospitals NHS Trust. Dr. Kar has led a number of initiatives, including improving technology use guidelines, developing innovative programs to bolster hospital safety, and increasing mental health access for people with diabetes.
Frida Velcani: People generally have different outlooks on time in range. Do you think it should be used in diabetes care and management across the board? Based on your experience helping people with diabetes in your clinic, what impact has time in range had on diabetes self-management?
Dr. Partha Kar: Time in range is the next big leap in diabetes care. Right now, time in range is heavily linked to access to technologies like continuous glucose monitoring (CGM). I believe that as access expands, time in range will also improve. If you want to find time in range using the fingerstick method, you will have to prick your fingers a significant number of times. That’s the drawback to it. Though you will have a group of motivated people who will do ten fingersticks a day to get an accurate picture of time in range, the reality is that the average person will go down to three to four fingersticks after an initial period of time.
There is plenty of exciting data on time in range and also anecdotal evidence from my interactions with people. We’ve moved away from a culture of telling people to get to an A1C of 7%. People with diabetes are unsure of what that even means. On the other hand, if I tell them: “let’s see if we can get you between 70-180 mg/dl, 60% of the time …meaning, 40% of the time you can be outside that,” I’m changing the dialogue by saying I don’t want them to be 100% perfect. This has certainly made a difference to people because they come back to me and say, “I had 54% time in range.” My response is, “Wow, excellent! Let’s make those other changes and get to 60% time in range.” And then let’s continue to make small changes to improve it even more!
Frida: In your opinion, what is the most compelling evidence for using time in range, and what additional data do you think is needed to further validate its use?
Dr. Kar: I think the most compelling evidence comes from the position papers and consensus statements from expert reference groups. I think the data that shows us how time in range correlates to a certain A1C has also been really powerful.
The majority of people with diabetes have type 2, so more research needs to be done to improve care for this population. For example, I think more research is needed to figure out how multiple daily injections of insulin (MDI) impact people with type 2 diabetes. Time in range could also come in handy for evaluating the effects of SGLT-2 inhibitors and GLP-1 agonists on people with type 2. For example, some recent papers have shown an impressive increase in time in range for people with type 2 on insulin who use an SGLT-2 inhibitor.
Emily Fitts: What are the immediate and long-term obstacles we need to overcome to promote widespread adoption of time in range by people with diabetes and healthcare professionals?
Dr. Kar: In terms of immediate obstacles:
Changing the mindset of healthcare professionals is an immediate obstacle. Whenever something new comes along, it takes a fair bit of time to change clinical practice.
The associated technology is too pricey right now for most of the population to access it. When you have an insurance-based system, only the people who can afford the technology will get it. However, if you have a publicly funded healthcare system, there will still be certain criteria in place that limit who gets access to the technology.
In terms of long-term obstacles:
The tendency for healthcare professionals to accept new paradigms of care depends on people with diabetes. For example, in the United Kingdom, we guaranteed Freestyle Libre to 20% of the population with diabetes. For the first time, primary care providers were seeing people with diabetes come into the clinic with their devices and seeing their blood glucose numbers in real-time. This resulted in a lot of people with diabetes trying to educate their primary care providers about CGM, and subsequently, primary care providers going to endocrinologists to ask them to prescribe it for people with diabetes. If we only depended on endocrinologists, we wouldn’t have gotten such rapid uptake of CGM. I’m very hopeful that the more data we show primary care providers, the more people we can get on board.
As a society, there should also be universal pressure on payers to pursue outcome-based contracts. For example, payers should require that companies or providers get 80% of the people they treat to a certain time in range.
Emily: COVID-19 has brought to light many disparities associated with health outcomes. What do you think are the emerging needs in diabetes care and what can healthcare professionals do to support people with diabetes?
Dr. Kar: I think COVID-19 has brought into sharper focus what we already knew. As a society, we spend a lot of time talking about new technologies and therapies. What we slightly lose focus of is that these conversations don’t really change the game for those in really deprived positions.
One thing that local clinicians, including myself, are doing to help is identifying people who have slipped out of service due to whatever reason and bringing them back into play. We are looking at lists and picking people who haven’t come to the clinic for two years or never showed up for a visit. If their A1C is more than 10%, I would consider giving them a CGM to help with their diabetes self-management.
A big question on people’s minds is, what impact does COVID-19 have on my insurance? We’ve had reports of one or two companies that have said they are not giving people with type 1 diabetes mortgage insurance because they believe them to be at higher risk for severe illness from COVID-19. I think having this assumption for every single person with type 1 diabetes is fundamentally wrong.