Thought for the Day

Wednesday, November 10, 2010

Medtronic and "upgrading"

My insulin pump, a Medtronic Paradigm 522, is out of warranty, so my insurance will cover a new one. Medtronic would like me to upgrade to a Revel, but I don't think I will.
Everyone has their own wants and needs, and Medtronic may be the best brand for a lot of people. I just don't think it's right for me at this time. I've heard their sales pitches and looked at the features online. Even as Medtronic explains it, I don't feel great about choosing Medtronic.

Here are the features Medtronic mentions in a comparison with other pump brands, with my thoughts on them highlighted.

          o Insulin Pump With Built-In CGM
I don't care. I've used the CGM, and I'm unimpressed. I wrote about it here before, saying how I both loved and hated it. From what I've heard, the other CGM option available is much more user-friendly, even though it is not integrated with a pump. The bottom line is that a CGM that is seldom used is not much better than no CGM at all.

          o Always Tracks Active Insulin
This feature matters, but Medtronic is only marginally better than Animas, which loses track of active insulin during a battery change, once every few weeks. Omnipod is stupid in its handling of active insulin, so it's not much to beat them.

          o Simple Bolus Calculation
I don't know why Medtronic considers this a feature of their pump. Medtronic is just like everyone else, except for not having a food database. They are critical of the difficulties in using the food databases in the other pumps, but that ignores the fact that with Medtronic you still need to get the carb count, maybe reading a label or something, and punch it in.

          o Pediatric Friendly Features
Not being a child, I don't care, obviously. And it's annoying to have to say that I don't care, but I do every time I talk to a Medtronic rep.

          o Specialized Type II Features
As a type 1 diabetic, I don't care, obviously. And it's annoying to have to say that I don't care, but I do every time I talk to a Medtronic rep.

          o Easy Task Completion
The interface is not that good that Medtronic should think it's worth bragging about. Where do they find designers and user interface experts?

          o Active Lifestyle
Swimming, sweating, bike riding in the rain. All of these things are facilitated by waterproofing. Medtronic actually calls out "The pump can be detached" as a way you can adapt your pump therapy to your active lifestyle. That's so stupid it's insulting.

          o Convenient Software with Clinical Evidence
CareLink sucks. Really, where do they get human interface experts? It's convenient in the same sense that the forms for filing your income tax return with the IRS are convenient. Thanks tons, Medtronic.

          o Diabetes Support Team
Medtronic does seem to lead on this, but I only use their support a couple of times a year. So I don't rate this as a high priority for me.

          o Partner for Life
All pump companies would like to be my partner for life. It is profitable.
Some companies have dropped out of the pump business. So right now, Medtronic is the oldest company in the insulin pump business. Is PanAm the best airline, or do you prefer to fly TWA?
This is not a selling point for me.

Here are some of the technical features of Medtronic's next generation pump, with my comments highlighted:

New Basal Features in the Paradigm Revel™:
· The smallest basal increment (0.025 U/hr)
· Basal Delivery Pulse based on basal rate volume:
   - Delivers in pulses of 0.025 for basal rates from 0.025 to 1 unit per hour
   - Delivers in pulses of 0.05 for basal rates from 1 unit per hour to 9.95 units per hour
   - Delivers in pulses of 0.10 for basal rates of 10 units per hour or more

I don't care about any of these.

New Bolus Features in the Paradigm Revel™:
· Missed Bolus Reminders
   - Set up to 4 per day by time period (i.e.: 11:00 AM – 12:45 PM for lunch missed bolus reminder)

I don't care. Forget to bolus? Happens about once every five years for me. This feature would just be reminding me to bolus when I didn't bolus because I didn't need to.

· The smallest bolus increment (0.025 units) of any pump
· Widest Carbohydrate Ratios available from 1:1gram to 1:200grams
· Adjustable Bolus Scroll Rate feature allows for the most precise bolus dosing:   - Default setting is 0.1 units
   - When the scroll rate is set to 0.025 units, boluses smaller than 1 unit are calculated to the nearest 0.025 unit
   - When the scroll rate is set to 0.025 or 0.05 units, boluses between 1 to 10 units are calculated to the nearest 0.05 unit
   - All boluses greater than 10 units are calculated to the nearest 0.1 units
· Variable Bolus Delivery Speed (regardless of scroll rate selected)
   - Boluses in the range of 0.025 to 0.975 units are delivered in 0.025 pulses delivered at a very gentle rate of 1 unit in 1 minute 16 seconds.
   - Boluses from 0.975 to 9.975 are delivered in 0.05 unit pulses and delivered at a rate of 1.5 units per minute.
   - Boluses of 10 units and larger are delivered in pulses of 0.10 and are delivered in 5 minutes. Even a 25 unit bolus is delivered in 5 minutes.

I don't care about any of these.

· Active Insulin is displayed on the "Estimate Detail," "Status" and the "Bolus + Delivery" screens
   - Active insulin will be displayed even if the Bolus Wizard is not used

Neat. However, it's not a big deal to have it finally work the way it always should have. And like a lot of these improvements, this seems like a software/firmware upgrade which must have been fairly easy to do.

· High and Low glucose alerts will sound on the Revel™ from a RF meter reading

I don't care. If I check my blood sugar with the meter, I know if I'm high or low from the meter.

· Capture Option
   - Allows users to electronically save certain types of information, including BG measurements, amount of insulin used, carbohydrates eaten, exercise and other information that is useful in diabetes management with the CareLink

Nice. However, this saves only a little bit of information. You can fill in more later in CareLink. This is getting better, but still feels like 20th century, rather 21st century technology.

New CGM Features in the Paradigm Revel™:

So far, I have found the CGM almost unusable. All of my comments should be seen in this light. A feature might sound good on its own, but the drawbacks of the whole system probably render it irrelevant to me.

· Predictive Alerts
   - Can alert user of a hypo or hyper event 5-30 minutes prior to threshold being hit
   - An internal study published this year showed that when Predictive Alerts are used, the hypo detection rate increased by 36% compared to using a low glucose alert alone


· Rate of Change Alerts
   - Alerts patients to rapid changes in glucose regardless of where the Sensor Glucose is. Rate of change alerts can be set for fall or rise rates from 1.1 mg/dl/min to 5.0 mg/dl/min

Imagine, my blood sugar is 40 but rising quickly, so I get a rate of change alarm. My blood sugar is 350 but falling rapidly, so I get a rate of change alarm. I should not get these alarms.
The only reason I can imagine to provide these alerts in addition to predictive alerts is if the sensor may be totally inaccurate.

· Customizable alert thresholds
   - Up to 8 different time buckets can be programmed with individualized high and low thresholds


· Historical Sensor Glucose Graphs are displayed for the previous 3, 6, 12 and 24 hours
· Glucose Sensor graph timeouts can be set to 2, 4, 6 minutes or none. If NONE is selected the graph will not time out unless and alert/alarm occurs· Area-Under-the-Curve ( AUC ) metric   - New measure of glucose exposure under and over preset glucose threshold

These features are nice, but not a big deal.

· CGM demo option for training purposes

This is totally irrelevant to anyone but a Medtronic sales rep.

· All alerts can be silenced for a set period of time up to 24 hours

I hope they didn't spend any time working on this feature that they could have used doing something useful.

Other important information:

· USB included with all pump purchases not just CGM orders

Neat. However, it's not a big deal to have it finally work the way it always should have.

· Alert Directed Navigation
   - When an alert goes off the Revel™ goes directly to the screen to resolve alert, dramatically minimizing button pushing

Neat. However, it's not a big deal to have it finally work the way it always should have.

· Simplified menus and language used (Manual Prime changed to Fill Tubing)

Wow! I mean, wow they really think this is worth mentioning? It only calls attention to the fact that they didn't do it right the first time.

· Auto Calibration has been improved
   - Sensor patients can use RF feature to beam readings directly to the Revel™, but they will be asked if they want to use BG reading for calibration

Neat. However, it's not a big deal to have it finally work the way it always should have. Seems like a software/firmware upgrade that should have been done a long time ago.

· CareLink Professional and Personal have been updated and will be available later in March
   - Guardian REAL-Time will be on the new version of CL Pro

First, it's been my experience that CareLink sucks. Second, I am personally insulted that there's a version of CareLink that provides additional features for health care professionals, but it's not for lowly diabetic patients.

Once again, I remind everyone that these are just my opinions. I haven't used a Revel or the latest Medtronic CGM sensors.
You may need features I don't care about. You may like things I dislike.
I'm just sharing my thoughts on the decision I'm making.

My current pump.

What an insulin pump looked like a dozen years ago.

A 21st century pump.



Scully said...

this has been insanely educational. and you are SO RIGHT with everything you wrote! I always felt medtronic was years behind and you just proved that.
I can't thank you enough for this post. This really has been an eye opener!! WOW

Wendy said...

Great feedback!

I really appreciate a 1st person review based on extensive experience with the product.

I've ruled Omnipod out primarily because of the IOB feature. That's a feature I rely HEAVILY on when managing my daughter -- *I* can't feel what she's feeling when she's feeling it, so accurate IOB feels essential to ME when making decisions regarding her insulin administration. I always wondered if it was as big a deal to someone who knows what it feels like to actually HAVE diabetes...I imagine IOB is equally has useful, regardless.

At any rate, we used Cozmo for almost 3 years and loved it. After Smith's announced they were leaving the industry, we switched to the Animas Ping, but our warranty period remained the same. I have to say that I'm INCREDIBLY pleased with our Ping experience.

Her warranty expires in January, and we'll definitely be renewing for another 4 years with Animas!

Marcus Grimm said...

Hilarious post. :)

That said, I did recently upgrade the Revel. As you know, I tested the Medtronic CGM and found it comparable to the Dexcom, and having both integrated into a single device was a plus for me.

In doing so, I also wagered that the Animas/Dex combo wouldn't be on the market for a while. IF it comes out soon, I'll be ticked. In short, I waited for nearly a year and grew tired of it.

In addition, I've been considering moving to a Lantus routine during my next marathon build, to see if a different cocktail can help build the results I want.

Anne said...

I actually find the falling/rising CGM alerts to be really useful. I have been able to prevent a lot of lows and reduce a lot of highs because of it.

I don't know why Medtronic refuses to make their pump waterproof. When I had a Minimed (precursor company) I felt like the Wicked Witch of the West because if I got stuck in a rainstorm I might melt.

jpnairn said...

Hi, Anne,
Are you using a Revel or a DexCom? My point was that "predictive alerts" when I'm in range but falling or rising sound great.
I don't need additional alerts to "warn" me if my blood sugar is doing exactly what I want it to be doing, as when it is high, but coming down or low, but coming up.
Predictive alerts should serve the purpose you describe, preventing lows and reducing highs.

Mike Fraser said...

Jerry, all good points. I went to Minimed exactly one year before the FDA approved their CGM. As we know they were the first to market the CG (as I recall), and I saw the impact of that device in my workouts. My first insulin pump was the Animas R1000...and it was waterproof. I use to do a ton of whitewater sport kayaking, so that was a big deal.

When I contemplated switching to Minimed for the option of the CGM, I thought long and hard about loosing my waterproof pump capabilities. I waited over a year for Animas to show any sign of having a CGM in the works, but didn't see any. So, the switch to Minimed was made.

Readers of my blog have read about some of my regards (CGM needle gauge, alarms don't phase me when sleeping), but you raise some very good points about features on the Minimed pump which a large company hopes many customers overlook when shopping. Features and options Common sense options no less) that most in the common market place have had implemented for a while now.

Minimed has been calling frequently to remind me that my pump is out of warranty, and the only "safe/smart" thing to do is of course $$$UPGRADE$$$. Yet, I hold back, because change is always in the air. There are some things I would like to see changed on their pumps, which if are not addressed or developed within the next year or two, will cause me to reasses my pump needs.

Good write-up.

jpnairn said...

Hi, Mike,
When Medtronic calls, do they keep going over their list of features, including things you've already told them you don't care about?
I swear my annoyance could play a part in this medical decision.

T1FloatHammerSprint said...


Until Medtronic gives me a water proof warranty I will be finding a new company when my warranty comes up...

Or how about this... My cell phone has had a color screen for close to ten years, when is the pump getting a screen that doesn't look like it came from when they launched the Apollo 13!

Jen said...

Jerry, I'm late with this response...your post was hilarious (on purpose or not). I'm on the Animas Ping. I love it. My simplest reasons for choosing between the two were: 1. how it looked 2. that it was waterproof. Those were my two priorities and that was BEFORE triathlon.

In the past 5 years since having my first pump and an upgrade pump I've been very happy and have had none of the issues Medtronic users have. There have been no regrets with my purchase. I also have Dexcom and while I want the device to be one unit i can hold off and be patient until it is. Why rock the boat when I've got smooth sailing, ya know?

Rachelle said...

I'm really late with this too, but I wanted to comment and tell you how much I appreciate these reviews.

My Paradigm pump (Medtronic) has absolutely no issues as far as I'm concerned, but the CGM is annoyingly inaccurate most times and the transmitters have very short lifespans. I agree with you about having it integrated - it's really not THAT big of a deal... so I think it's time for me to make the switch to Dexcom :)

ps - I also agree on your thoughts about CareLink, I don't even use it to tell you the truth.

Anonymous said...

I love the CGM feature. I didn't need or want a pump until that came out. Yes its innacurate but the trends are important. I use it running and biking all the time and its accurate enough and the trend tells me more than stopping for a finger prick would tell.

I hate that Minimed wont waterproof the pump or replace it. Its not even water resistant. I just now put the pump down on what turned out to be a wet counter and water seeped into the case. It will cost thousands for my copay to replace. They are incompetent.

Of course I haven't done a TRI since I switched from lantus to the pump.