Evaluation of real-life clinical outcomes in Australian youth with type 1 diabetes on hybrid closed-loop therapy: A retrospective study

Management of Type I Diabetes Mellitus at a Rural Paediatric Diabetes Clinic

OBJECTIVE

Australia currently lacks a standardised paediatric diabetes care model. This study explores the model of care and outcomes of paediatric Type 1 diabetes mellitus (T1D) at a rural multidisciplinary paediatric diabetes clinic.

METHODS

A retrospective cross-sectional study.

DESIGN

A single centre quantitative study.

SETTING

A rural multidisciplinary paediatric diabetes clinic.

PARTICIPANTS

Patients under 19 years old with a T1D diagnosis who attended the paediatric diabetes clinic for at least 12 months.

MAIN OUTCOME MEASURES

Baseline demographics, glycosylated haemoglobin (HbA1c) levels, time in range, clinic appointment adherence, and diabetes-related hospitalisations over a 12-month period from October 2021 to September 2022.

RESULTS

Fifty-two patients, with a median age of 13.5 (IQR 7) years and 58% females, were included. Of the patients, 40% lived more than 50 km away from the diabetes clinic, 73% were on continuous subcutaneous insulin infusion, and 92% used continuous glucose monitoring. The median HbA1c was 8.3% (67 mmol/mol), with four patients (8%) achieving the international target HbA1c level of less than 7.0% (53 mmol/mol). The CGM users' average time in range was 54%. A total of 29 patients (56%) attended all annual clinic reviews. Six patients (12%) were hospitalised for diabetes-related complications.

CONCLUSION

Paediatric T1D managed in a rural multidisciplinary paediatric diabetes clinic, with experienced local clinicians and support from a tertiary centre, can attain outcomes in glycaemic control, clinic attendance, and diabetes-related hospitalisation comparable to those of large Australian metropolitan clinics. However, glycaemic outcomes remain suboptimal when compared to international standards.

Real-world glycaemic outcomes in children and young people on advanced hybrid closed-loop therapy: A population-based study in Western Australia

AIMS

To evaluate real-world glycaemic outcomes in children with type 1 diabetes (T1D) commencing advanced hybrid closed loop therapy (AHCL) and to explore these outcomes based on the cohort's clinical and socioeconomic characteristics.

METHODS

A single-centre, population-based retrospective study in children commencing AHCL (Smart Guard, Control IQ, CamAPS) with minimum 70% data from two-weeks CGM pre-AHCL was conducted between December 2021 and June 2023 in Western Australia. CGM metrics (time in range (TIR) 3.9-10 mmol/L, time below range (TBR) < 3.9 mmol/L, glucose management indicator (GMI)) were analysed at baseline, monthly and 6 months. HbA1c at baseline and 6 months were also collected. The proportion meeting glycaemic targets of TIR > 70%, TBR < 4% and GMI < 7.0% were determined. Change in TIR from baseline to 6 months was examined by the following characteristics: %TIR, age group and Index of Relative Socioeconomic Disadvantage (IRSD) of residential postcode.

RESULTS

CGM data of 309 children, mean (SD) age 12.4 (3.2) years were analysed. Glycaemia improved from baseline to 6 months with (mean) TIR +8% (95% CI 7, 9; P ≤ 0.001), GMI -0.3% (95% CI -0.3, -0.2; P < 0.001) and (median) TBR -0.3% (95% CI -0.4, -0.1; P < 0.001). Proportion meeting glycaemic targets increased from 13.3% at baseline to 30.6% at 6 months. Improvement in TIR did not differ based on age group or IRSD Quintile. Greater increase in TIR was seen in those with lowest TIR at baseline (+20.9%, -0.2%; P < 0.001 for baseline TIR < 40%, >70%). There was a 0.27% reduction in HbA1c in 6 months (n = 116) (P < 0.001).

CONCLUSIONS

AHCL improves glycaemia, irrespective of age and socioeconomic characteristics, with greatest changes seen in those with lowest baseline TIR.

Ten Years of Improving Glycemic Control in Pediatric Diabetes Care: Data From the Norwegian Childhood Diabetes Registry

OBJECTIVE

To evaluate, from 2013 to 2022, how HbA1c, the incidence of acute complications, and use of diabetes technology changed at the national level in Norway and how glycemic control was associated with use of diabetes technology, carbohydrate counting, or participation in a quality improvement project.

RESEARCH DESIGN AND METHODS

This longitudinal observational study was based on 27,214 annual registrations of 6,775 children from the Norwegian Childhood Diabetes Registry from 2013 to 2022. Individuals aged >18 years, those with diabetes other than type 1, and those without HbA1c measurements were excluded. The outcome measure was HbA1c. The predictor variables in the adjusted linear mixed-effects model were 1) the use of diabetes technology, 2) the use of carbohydrate counting for meal bolusing, and 3) whether the patient's diabetes team participated in a quality improvement project.

RESULTS

Mean HbA1c decreased from 8.2% (2013) to 7.2% (2021), and the proportion of youth reaching an HbA1c <7.0% increased from 13% (2013) to 43% (2022). Insulin pump use increased from 65% (2013) to 91% (2022). Continuous glucose monitoring (CGM) use increased from 34% (first recorded in 2016) to 97% (2022). Insulin pump, CGM, and carbohydrate counting were associated with lower HbA1c and higher achievement of glycemic targets. Girls had a higher mean HbA1c than boys. Mean HbA1c levels were lower in clinics that participated in a quality improvement project for the following 4 years after the project.

CONCLUSIONS

Diabetes technology, carbohydrate counting, and systematic quality improvement in pediatric departments led to improved glycemic control.

Real-World Evidence of Automated Insulin Delivery System Use

Objective: Pivotal trials of automated insulin delivery (AID) closed-loop systems have demonstrated a consistent picture of glycemic benefit, supporting approval of multiple systems by the Food and Drug Administration or Conformité Européenne mark receipt. To assess how pivotal trial findings translate to commercial AID use, a systematic review of retrospective real-world studies was conducted. Methods: PubMed and EMBASE were searched for articles published after 2018 with more than five nonpregnant individuals with type 1 diabetes (T1D). Data were screened/extracted in duplicate for sample size, AID system, glycemic outcomes, and time in automation. Results: Of 80 studies identified, 20 met inclusion criteria representing 171,209 individuals. Time in target range 70-180 mg/dL (3.9-10.0 mmol/L) was the primary outcome in 65% of studies, with the majority of reports (71%) demonstrating a >10% change with AID use. Change in hemoglobin A1c (HbA1c) was reported in nine studies (range 0.1%-0.9%), whereas four reported changes in glucose management indicator (GMI) with a 0.1%-0.4% reduction noted. A decrease in HbA1c or GMI of >0.2% was achieved in two-thirds of the studies describing change in HbA1c and 80% of articles where GMI was described. Time below range <70 mg/dL (<3.9 mmol/L) was reported in 16 studies, with all but 1 study showing stable or reduced levels. Most systems had >90% time in automation. Conclusion: With larger and more diverse populations, and follow-up periods of longer duration (∼9 months vs. 3-6 months for pivotal trials), real-world retrospective analyses confirm pivotal trial findings. Given the glycemic benefits demonstrated, AID is rapidly becoming the standard of care for all people living with T1D. Individuals should be informed of these systems and differences between them, have access to and coverage for these technologies, and receive support as they integrate this mode of insulin delivery into their lives.