Round Table Discussion on Inpatient Use of Continuous Glucose Monitoring at the International Hospital Diabetes Meeting

Abstract

In May 2015 the Diabetes Technology Society convened a panel of 27 experts in hospital medicine and endocrinology to discuss the current and potential future roles of continuous glucose monitoring (CGM) in delivering optimum health care to hospitalized patients in the United States. The panel focused on 3 potential settings for CGM in the hospital, including (1) the intensive care unit (ICU), (2) non-ICU, and (3) continuation of use of home CGM in the hospital. The group reviewed barriers to use and solutions to overcome the barriers. They concluded that CGM has the potential to improve the quality of patient care and can provide useful information to help health care providers learn more about glucose management. Widespread adoption of CGM by hospitals, however, has been limited by added costs and insufficient outcome data.

In May 2015, the Diabetes Technology Society (President David C. Klonoff, MD, FACP, FRCP, Burlingame, California) convened a panel of 27 experts in hospital medicine and endocrinology to discuss the current and potential future roles of continuous glucose monitoring (CGM) in delivering optimum health care to patients in the United States.

The main objective of the panel was to have a round table discussion on the current state of applicable uses of CGM in the hospital, potential future use, and current gaps in the use of this technology for inpatient glycemic control. Three cochairs, Dr Stanley Nasraway, Dr Guillermo Umpierrez, and Dr Amisha Wallia, each served as a moderator of a discussion on CGM use in (1) intensive care unit (ICU), (2) non-ICU, and (3) continuation of use of home CGM in the hospital. The focus of each discussion was to determine how and when CGM is used in the aforementioned patient populations and to enumerate the real-world pros and cons of CGM use in particular sections of the hospital, in specific patient subgroups, and/or in types of CGM. Experts were asked to identify any barriers to the widespread adoption of CGM as standard of care (ie, to increase patient safety) and provide recommendations for increasing current and future CGM use in hospitals.

Background

Continuous Glucose Monitors (CGM) can measure glucose in interstitial fluid (glucose oxidase enzymatic method) or intravenously (IV; fluorescent chemistry, midinfrared spec, hydrogel methods).¹ Today in the United States, CGM is available for use by patients (real-time) and professionals (retrospective), measure subcutaneous glucose in interstitial fluid via the glucose oxidase method with lag times up to 15 minutes.¹ This type of technology is currently FDA cleared for adjunctive use to compliment, not replace, information obtained from standard personal glucose monitoring systems in the outpatient setting. CGM aids in the detection of episodes of hyperglycemia and hypoglycemia, facilitating both acute and long-term therapy adjustments.

While various CGM devices have been studied in the inpatient setting, there are currently 5 CGMS for intravenous (IV) use approved in Europe: (1) GlucoClear by Edwards Life Sciences, (2) Glysure System by Glysure, (3) ERIUS by Maquet, and (4) Optiscanner 5000 by Optiscan and (5) Subcutaneous system Sentrino by Medtronic. In the United States there are no CGM devices specifically approved for use in the inpatient setting and no IV glucose monitoring systems approved by the Food and Drug Administration. Additional potential use in the hospital setting includes adjunctive therapy for inpatient glycemic control monitoring through the use of real-time or retrospective CGM by either intravenous or subcutaneous placement. Specific technological barriers to use in the inpatient setting include the buildup of tissue deposits (bio-film),² accuracy (poor circulation, anemia, edema), need for calibration, sensor drift, measurement lag, interference (acetaminophen, maltose, ascorbic acid, dopamine, mannitol), infection and anticoagulation risk.^3,4 In addition, the increased number of patients with diabetes mellitus (DM) using subcutaneous CGM in the home setting has resulted in a rise in patient’s requests for continuation of their use in the inpatient setting.

A summary of the discussions, the opinions expressed, and the consensus reached for each discussion follows.

ICU: Is There a Role for CGM in the Intensive Care of Patients?

Moderator: Stanley Nasraway, MD

Director of the Surgical Intensive Care Units and Professor of Surgery, Anesthesiology, and Medicine, Tufts University School of Medicine, Boston, Massachusetts

The majority of evidence on the use of CGM in the inpatient setting comes from the intensive care setting. Previous studies have shown acceptable sensor accuracy, lack of interference in prospective studies, and acceptable safety in high-risk patients (eg, acute coronary syndrome), however minimal change in overall glycemic control.^5-10 A large randomized clinical trial in 124 mechanically ventilated ICU patients on IV insulin infusion showed a similar percentage of time at a glucose level <110 mg/dl (59.0 ± 20 vs 55.0 ± 18% in the control group, P = .245) and mean glucose level (106 ± 18 vs 111 ± 10 mg/dl in the control group, P = .076); however the rate of severe hypoglycemia was lower in the real-time CGM group (1.6 vs 11.5% in the control group, P = .031) and absolute risk of hypoglycemia was reduced by 9.9% (95% CI 1.2-18.6).⁷ Other studies have also shown benefits such as reduction in the rate of hypoglycemia and shorter time to glycemic control.^7,10 A review table of clinic trials comparing glucose monitoring by point-of-care (POC) testing and CGM was also reviewed by the co-chairs.¹¹

The panel acknowledged that the there is no proven role for CGM in the ICU, even though many papers and editorials have concluded that CGM can perform accurately depending on sensor technology. Some CGM systems (Biostator) need large amounts of technical support and supervision, making their current use impractical. Although intravascular CGM has shown accurate performance, constraints such as biofilm, drift, and lag time need to be examined with the device in use.

Following the results of the NICE-SUGAR study,¹² there has been widespread debate in regards to how “intensive” glycemic control should be and achievable goals in the inpatient setting. Therefore, most hospitals target an ICU blood glucose (BG) range of 140-180 mg/dl as recommended,^13,14 which is achievable in the majority of patients. However, data from the surgical ICU with lower glycemic targets (<110 mg/dl) reported favorable outcomes.¹⁵ Generally, it was agreed that a reasonable hypothesis would be that glycemic control to a range of <140 mg/dl could demonstrate improved morbidity and mortality if the presence of hypoglycemia could be mitigated. The addition of an approved accurate inpatient CGM device to any glycemic control intervention is reasonable however more robust data (randomized controlled trials, prospective design) in high-risk groups are needed. More research in this area is definitely needed, with the goal of proving that tight glycemic control with less hypoglycemia produces better outcomes. Funding institutions, such as the National Institutes of Health (NIH) and the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), could consider the benefit of such studies, which could include best technologies (insulin algorithms/insulin dosing software) currently available, as well as the use of CGM systems for reduction of hypoglycemia at lower targets (110-140 mg/dl).

Currently, intensive insulin therapy can result in higher rate of hypoglycemic events, which can negate the benefit of intensive glucose control compared to moderate/less intensive control. If CGM can identify and prevent hypoglycemic events in the ICU setting in large populations, as previously reported in subgroups of populations,^6-9 and thereby lessen the adverse effects of hypoglycemia, then CGM could be considered as a safety tool reducing hyperglycemia while preventing hypoglycemia. Many of the experts believed that it is essential to gain additional knowledge, such as the data available through CGM, to improve glucose management techniques. They agreed that BG testing in the hospital by way of intermittent assisted BG monitoring¹⁶ by nursing staff may be insufficient. These experts felt that knowledge in regards to glucose concentrations in between testing intervals could be beneficial and believe that CGM could reveal new glycemic patterns that are not evident from assisted monitoring of blood glucose (AMBG). Several studies with the use of subcutaneous CGM devices in critically ill patients were given as examples.^17-19 Even with the performance of hourly glucose checks, some hypoglycemic levels—which were not expected—were discovered only through CGM. In the real world, intermittent BG monitoring is not always performed every hour due to time or staffing constraints, which increases the probability of adverse events.²⁰ Therefore, a potential role for CGM, could lessen the likelihood of human error and frequency of hypoglycemia, if proper utilization and training were available from an implementation perspective.

Several clinical and research studies suggested by the experts included (1) interstitial CGM versus rigorous hourly self-monitoring of BG; (2) investigate whether CGM can facilitate achievement of glycemic targets (eg, a blinded study with real-time [RT] CGM versus no CGM) for incidence of hypoglycemia; (3) assess whether use of CGM along with a computerized delivery algorithm for insulin will show better outcomes with safe lowering of BG levels; and (4) CGM in special populations with a high risk of hypoglycemia can be used as an early warning device in the ICU setting. In addition, different outcome studies were recommended: (1) quality of performance of new devices and (2) assessing the benefits of CGM overnight and in various settings and risk populations (eg, patients with type 1 diabetes, or who are pregnant).

From a hospital administrator’s perspective, investing in an expensive device has to benefit either (but preferably both) outcomes or cost. Sufficient investments could be justified based on favorable research in relation to (1) cost, (2) length of stay (ICU and hospital), (3) mortality, and (4) glycemic outcomes. If CGM use in the ICU is cost prohibitive overall, then there is the potential option of identifying specific patient populations where CGM use is requisite, such as with patients in cardiac surgery, trauma, neuro-ICU, tube feeding, on steroids, or who are pregnant. In addition, CGM is a vital component of the closed-loop system (artificial pancreas) and the use of CGM in the hospital, even if only in research units, will allow for more data to be collected and possibly accelerate the development of a successful artificial pancreas.

With regard to total error, experts shared that the FDA should be assured that frequent measurement versus intermittent measurement allows for an increase total error allowance. A modeling study by Krinsley et al showed that higher BG measurement frequency compensates for measurement inaccuracy for intervals as frequent as every 15 or more minutes and if a glucose monitor is more accurate than a typical CGM, then BG must still be tested as often as every 15 minutes for the best outcomes.²¹ Their model also demonstrated that the rate of hypoglycemia for a BGM with typical imprecision (CV of 5%) with hourly measurements was similar to the rate of hypoglycemia for glucose monitoring with imprecision of 10% CV when measurements were made every 5 min, which is typical for the performance and frequency of data reporting by a CGM.²² Accuracy requirements for glucose sensors can be lower in case of higher measurement frequencies; but the effect of the algorithm that deals with these glucose measurements is equally important as shown in simulation studies.²³ Therefore, the goals for CGM use in the hospital must be clarified (eg, dosing insulin, identifying trends, and/or preventing hypoglycemia, excursions, variability) as different levels of accuracy may be acceptable depending on intended use.

A contrast was made between evidence-based medicine and evidence-based practice, with some experts sharing that there is intrinsic logic to using CGM for clinical purposes because “we know it is best to prevent hypoglycemic events.Although we might not have all the evidence for it, it is worthwhile to keep using CGM and learning more with it from a research, quality, or clinical perspective.” Off-label use of technology is generally left to the discretion of the ordering provider in individual cases.

Consensus Reached by Experts

“We have a sense that CGM is physiologic and better than intermittent monitoring because it provides a more complete picture of the patient’s glycemic status around the clock, because of its automatic monitoring feature. Unlike intermittent monitoring, CGM can provide useful information about the direction of change, information about the magnitude of change and warnings to predict both low and high BG levels both before and after a threshold is reached. We believe that CGM has the potential to be an important tool in the hospital but we do not have strong enough evidence yet to support its immediate implementation in hospitals. We believe that it would be prudent to explore the use of CGM in the hospital because it has already made its way to the outpatient setting, and how can we have a modality in the outpatient setting and not be able to offer a good version of it in the inpatient setting? However, before coming out strongly in favor of CGM based on the available data, most participants here believe that we need to have solid outcome data that revalidate the original idea that glycemic control changes important patient outcomes, while using best available technologies, such as CGM, to mitigate hypoglycemia. Funding agencies should fund and replicate an outcome study, perhaps in a high-risk population such as cardiac or transplant patients, to reproduce and revalidate the idea that glycemic control, with reduction of hypoglycemia using best available technology, is important and necessary.”

What Is the Role of CGM in the Non-ICU Setting?

Moderator: Guillermo Umpierrez, MD

Professor of Medicine, Division of Endocrinology, Emory University, Atlanta, Georgia

To start off the discussion, Dr Umpierrez shared the results of a study that his group performed which compared inpatient glycemic control by CGM versus capillary point-of-care (POC) testing in general medicine patients with type 2 diabetes.²⁴ The results show that, in general, there was no differences in mean daily glucose, premeal, fasting, or 2-hour postprandial BG between the 2 groups. However, CGM was able to recognize a higher number of hypoglycemic events compared to POC testing in insulin-treated patients. CGM allowed increased recognition of hypoglycemic events compared with POC testing. They observed that more than 50% of hypoglycemic episodes occurred between dinner and breakfast, and many of these episodes were asymptomatic. This group also concluded that large inpatient randomized controlled studies are needed to assess the impact of RT CGM in reducing hypoglycemic events and improving clinical outcome in general medicine and surgery patients with diabetes. Given that 98.5% of hospitalized patients are admitted in non-ICU settings, the discussion focused on identifying what type of patient should be monitored by CGM. Experts agreed that CGM use would be indicated in high-risk patients, such as cardiovascular (CV) patients, in whom prolonged hypoglycemia, could affect outcome. The majority of experts conceded that other patient subgroups do not pose such a great risk to warrant RT-CGM and/or increased monitoring by staff.

Physicians in favor of increasing CGM use in non-ICU patients noted that CGM has taught health care professionals (HCPs) how to titrate insulin better, and has shown to reduce the number of hypoglycemia events in insulin treated patients. In addition, they observed that patients feel more secure with frequent BG monitoring. If patients were allowed to keep using their CGM while in hospital, then the hospital could capture these data and utilize it, which would benefit all parties. A good example of a device being adopted by a hospital before specific outcome data become available is when BGMs were used in the hospital after patients brought their ambulatory meters and nursing and medical staff began to appreciate their convenience, among other benefits in the inpatient setting. A similar scenario happened with pulse oximetry, which had humble beginnings but is now integrated into the central monitoring system.

Hospital medicine experts acknowledged the potential merits of CGM in improving glycemic control and in reducing/recognizing hypoglycemia, but at the current state of this technology, hospitals likely cannot justify allocating resources to implement CGM technology in the hospital floor without improved, more rigorous, outcome data.

Consensus Reached by Experts

“We recognize that CGM in non-ICU can be helpful in detecting hypoglycemic episodes and may facilitate insulin administration. Increasing data suggest that hypoglycemia is associated with increased rates of complications and mortality. If we can avoid hypoglycemia, we may intensify antidiabetic treatments and be more ambitious in lowering BG levels. However, there is a very small number of randomized controlled trials non-ICU settings, and data in reducing complications and mortality are inconclusive. More studies need to be performed, and with the appropriate sample sizes and potentially randomization schema. Even with the possible involvement by NIH, researchers need to focus on performing studies with practical implications. Practical uses of CGM might be for anyone at high risk for hypoglycemia, and/or specialized populations such as cardiac telemetry, dialysis, renal failure, and those peri- or postoperative. Monitoring all patients with diabetes in the hospital would be costly, so we need to be aware that there are significant limitations.

“In addition to reducing hypoglycemia, benefits of CGM in general medicine and surgery settings to be investigated in future studies are their impact on clinical outcomes (eg, length of stay and mortality), improvement of patient comfort and satisfaction; use of CGM during the transition of care from hospital to home in high-risk populations, and the role of education initiatives for patients and health care personnel on the use of this increasingly utilized technology in ambulatory setting.”

Is There a Role for Continuation of Home CGM Devices in the Inpatient Setting?

Moderator: Amisha Wallia, MD, MS

Assistant Professor, Division of Endocrinology, Metabolism & Molecular Medicine, Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, Illinois

Currently the FDA has approved subcutaneous CGM systems (CGMS) for the following indications: (1) as an adjunctive device to complement information obtained from standard home glucose monitoring devices and (2) to aid in detecting hyper- and hypoglycemic episodes, facilitating both acute and long-term therapy adjustments, which may minimize glycemic excursions. There are several clinical trials (example: US—REPLACE BG study NCT02258373) that are under way to establish its potential use as real time monitoring without the need for home glucose meter monitoring. The FDA has not approved outpatient CGM use in the hospital setting to date; its potential use is confounded by the several interferences that can affect CGMS performance (eg, lag time, vasoconstriction, edema, medications). However, increasingly there is a population of patients whom are admitted to acute care facilities (such as ERs or hospitals) using these devices. It is estimated that up to 11% of patients with type 1 DM are using subcutaneous home CGM, and in selected subgroups (age ≥ 26 years of age) up to 21%, and growing.^25,26

Use of CGM in the inpatient setting for making treatment decisions is off-label. In addition, there are also safety and liability issues, such as calibration concerns and institution-specific medication safety and nursing policies, which need to be considered. In terms of calibration, current FDA approved CGM devices need to be calibrated with a glucose device, and inpatient glucose control is largely managed by use of the inpatient glucose meter. Therefore, continued use of a CGM that is calibrated to an alternate device brings up both safety and accuracy concerns. There is also little to no research data available on outpatient CGM use in the inpatient setting.

However, many experts believe that outpatient CGM use in the hospital should be allowed for adjunctive and personal use, when able to be appropriately supported, given that outpatients are already using it and deriving benefits from it. It also presents a loophole in which there may be DM devices approved in the outpatient setting, which cannot be used in the inpatient setting. Therefore, the panel felt that more reports of potential safety systems in place for current use at individual hospitals or acute care centers are needed. It was suggested that use of patient safety waivers, clearly delineating the use and risks/benefits of continued patient use (as is often done with insulin pump devices) may play a role. Appropriate support, such as nursing/diabetes service/endocrinology services, along with appropriate safety protocols to help support such use, are imperative.

This discussion posed the following 3 questions regarding RT outpatient CGM devices.

(1) Are there circumstances that would allow a patient to continue to wear his/her device in hospital? When outpatients using a CGM are admitted to the hospital and request permission to continue using their CGM, they are frequently allowed to do so but patients and nursing staff are likely prohibited by the hospital from taking any action based on the CGMS data. Patients should be required to sign a waiver form, similar to an insulin pump form waiver form, which confirms that they will not initiate any treatment action and will simply alert their care providers of their concerns.

(2) Should these devices be allowed to influence decision making in hospital: adjunct use? A patient’s CGM data should not be used for making any glucose management decisions, based on the current level of accuracy available by these devices in the United States. Patients are still required to have their BG levels measured by hospital staff. However, personal CGM can increase patient satisfaction (making them feel safer or more comfortable), and can give the patient information that enables them to alert a nurse or care provider about a possible impending hypoglycemic or hyperglycemic episode. Modification of therapy must be done in conjunction with the hospital staff overseeing insulin/other diabetes medication use. Patients should alert their nurse regarding their BG levels, and hospital staff should oversee actual treatment (for hypo- or hyperglycemia) in the hospital. HCPs are responsible for institution and patient specific policies regarding the use of home CGM. These policies should take into account (1) continual accuracy assessment of the CGM in the hospital, (2) potential use of adjunctive data in plan of care, and (3) patient and nursing staff ability to interpret and record the data.

Potential medical and legal liabilities remain unaddressed and currently should be made at the institutional level. Each institution must weigh the potential risk and benefit of outpatient CGM use in the inpatient setting, based on their current infrastructure. In addition, hospitals are not reimbursed for CGM services.

(3) Are CGMS recommendations available to guide transitional care management upon discharge? Hospitals have yet to develop policies for CGM use in transitional care management. Potential uses may be in patients at high risk for readmission and those starting insulin or discharged on multidose insulin therapy.

Experts unanimously agree that using CGMSs on all patients in hospital is impractical and would unduly burden the system. Likely focusing clinical and research efforts on a subset of patients, (such as patients with high risk for recurring hypoglycemia, severe hypoglycemia, and hypoglycemia unawareness, and those with type 1 diabetes, renal failure, transplant, total parenteral nutrition [TPN], tube feeding, steroids, and hematologic issues), may be best to justify the expense and the extra work involved.

Consensus Reached by Experts

“Patients will be driving CGM forward in acute care facilities and these institutions will need to formulate policies to address these situations. There is consensus that CGM can be used as an alert system provided it is calibrated to the meter used by the hospital or meter by which clinical decisions are being made by the HCP team. CGM may be used in an outpatient surgery setting and possibly in transitional care, and in high-risk groups such as: type 1 DM, steroid, pregnancy, transplant, renal failure, TPN, tube-feeding, and hematology patients.”

Conclusion

There has been variability in the research supporting CGM use in the acute care setting. Use of different types of devices, differences in sample size, study design, and participant selection has made the evidence base for use of CGM in the inpatient setting limited. There is a general consensus that, although CGM has been shown to improve quality of patient care and can provide useful information to help HCPs learn more about glucose management, there are practical barriers, mainly cost and lack of outcome data, which have hindered widespread adoption of CGM by hospitals. While this report has focused on the United States, other consensus panels outside the United States have reached similar conclusions, calling for improved level of evidence and need for industry collaboration.²⁷ Although there are data on CGM use in outpatients, the benefits and costs have not been clearly demonstrated in inpatients. More research is clearly needed in high-risk populations.

CGM Panel Organizer

• David C. Klonoff, MD, FACP, FRCP (Edin), Fellow AIMBE

• Medical Director

• Diabetes Research Institute

• Mills-Peninsula Health Services

• San Mateo, California

• email: dklonoff@diabetestechnology.org

Cochairs

• Stanley A. Nasraway, MD

• Director of the Surgical Intensive Care Units and

• Professor of Surgery, Anesthesiology and Medicine

• Tufts University School of Medicine

• Boston, Massachusetts

• email: snasraway@tuftstuftsmedicalcenter.org

• Guillermo E. Umpierrez, MD

• Professor of Medicine in the Division of Endocrinology

• Emory University

• Atlanta, Georgia

• geumpie@emory.edu

• Amisha Wallia, MD, MS

• Assistant Professor

• Division of Endocrinology, Metabolism & Molecular Medicine

• Center for Healthcare Studies

• Northwestern University Feinberg School of Medicine

• Chicago, Illinois email: a-wallia@northwestern.edu

On Behalf of

Panel Members

• Sara Alexanian, MD

• Director, Inpatient Diabetes Program

• Quality Leader, Section of Endocrinology

• Department of Endocrinology, Diabetes and Nutrition

• Boston Medical Center

• Boston, Massachusetts

• email: sara.alexanian@bmc.org

• Enrico Cagliero, MD

• Associate Professor of Medicine

• Harvard Medical School

• Massachusetts General Hospital Diabetes Center

• Boston, Massachusetts

• email: ecagliero@partners.org

• Curtiss B. Cook, MD

• Professor of Medicine

• Mayo Clinic, Scottsdale, Arizona

• email: cook.curtiss@mayo.edu

• Boris Draznin, MD, PhD

• Director, Adult Diabetes Program

• Celeste and Jack Grynberg Professor of Medicine

• Division of Endocrinology, Metabolism and Diabetes

• University of Colorado

• Aurora, Colorado

• email: boris.draznin@ucdenver.edu

• Andjela Drincic, MD

• Associate Professor of Medicine

• Division of Diabetes, Endocrinology and Metabolism

• Medical Director

• The Nebraska Medical Center Diabetes Center

• email: andjela.drincic@unmc.edu

• Linda Gaudiani, MD, FACP, FACE

• Endocrinologist

• Marin General Hospital

• Greenbrae, California

• email: lmgmd@earthlink.net

• Roma Gianchandani, MD

• Associate Professor, Director, Inpatient Hyperglycemia Service

• Department of Internal Medicine

• Division of Endocrinology and Metabolism

• Ann Arbor, Michigan

• email: romag@umich.edu

• Janice L. Gilden, MD, FCP, FACE

• Chief of Endocrinology and Professor of Medicine

• Endocrine Fellowship Program Director

• Rosalind Franklin University of Medicine and Science

• Chicago, Illinois

• email: janice.gilden@rosalindfranklin.edu

• Mikhail Kosiborod, MD, FACC, FAHA

• Professor of Medicine

• Saint Luke’s Mid America Heart Institute

• University of Missouri-Kansas City

• Kansas City, Missouri

• email: mkosiborod@saint-lukes.org

• Kristen Kulasa, MD

• Assistant Clinical Professor of Medicine

• Director, Inpatient Glycemic Control

• Division of Endocrinology, Diabetes, and Metabolism

• University of California, San Diego

• San Diego, California

• email: kkulasa@ucsd.edu

• Lillian F. Lien, MD

• Division Chief of Endocrinology

• Professor of Medicine

• University of Mississippi Medical Center

• Jackson, Mississippi

• email: LLien@umc.edu

• Cecilia C. Low Wang, MD, FACP

• Associate Professor

• Department of Medicine

• University of Colorado Anschutz Medical Campus School of Medicine

• Director, Glucose Management Team, University of Colorado Hospital

• Aurora, Colorado

• email: cecilia.lowwang@ucdenver.edu

• Greg Maynard, MD, MSc, SFHM

• Chief Quality Officer

• UC Davis Medical Center

• Sacramento, California

• email: gmaynard@ucsd.edu

• Carlos E. Mendez, MD, FACP

• Director, Diabetes Management Program

• Samuel Stratton VA Medical Center

• Assistant Professor of Medicine

• Albany Medical College

• Albany, New York

• drcmendez@hotmail.com

• Thomas Pieber, MD

• Head of Division of Endocrinology and Metabolism

• Department of Internal Medicine

• Medical University of Graz

• Graz, Austria

• email: thomas.pieber@medunigraz.at

• Gerry Rayman, MB BS, FRCP, MD

• Head of Service

• The Diabetes Centre, Ipswich Hospital NHS Trust

• Ipswich, Suffolk, United Kingdom

• email: gerry.rayman@ipswichhospital.nhs.uk

• Chanhaeng Rhee, MD, MBA

• Assistant Professor and Quality Officer

• Director Diabetes Management Program

• Division of Endocrinology and Metabolism

• UT Southwestern Medical Center

• Dallas, Texas

• email: utsouthwestern.edu

• Daniel J. Rubin, MD, MSc, FACE

• Assistant Professor of Medicine, Division of Endocrinology

• Associate Program Director, Endocrinology Fellowship

• Temple University School of Medicine

• Chair, Glycemic Control Taskforce, Temple University Hospital

• Philadelphia, Pennsylvania

• email: djrubin@temple.edu

• Robert J. Rushakoff, MD

• Professor of Medicine

• Medical Director for Inpatient Diabetes

• UC San Francisco

• San Francisco, California

• email: robert.rushakoff@ucsf.edu

• Stanley Schwartz, MD

• Endocrinologist, Private Practice

• Ardmore, Pennsylvania

• email: stschwar8@verizon.net

• Mitchell G. Scott, PhD

• Professor of Pathology and Immunology

• Division of Laboratory and Genomic Medicine

• Co–Medical Director, Clinical Chemistry

• Washington University School of Medicine

• St. Louis, Missouri

• email: mscott@labmed.wustl.edu

• Jane Jeffrie Seley, DNP, MPH, BC-ADM, CDE, CDTC

• Diabetes Nurse Practitioner and Certified Diabetes Educator

• New York-Presbyterian/Weill Cornell

• New York, New York

• email: janeseley@nyp.org

• Garry Tobin, MD

• Associate Professor of Medicine

• Director, Diabetes Center

• Washington University in St. Louis

• Saint Louis, Missouri

• email: gtobin@dom.wustl.edu

• Robert A. Vigersky, MD

• Medical Director, Medical Affairs, Medtronic Diabetes

• Professor of Medicine

• Uniformed Services University of the Health Sciences

• Director Emeritus

• Diabetes Institute

• Walter Reed National Military Medical Center

• Bethesda, Maryland