Continuous Glucose Monitoring in Older Adults With Type 1 and Type 2 Diabetes Using Multiple Daily Injections of Insulin: Results From the DIAMOND Trial

Use of systems thinking and adapted group model building methods to understand patterns of technology use among older adults with type 1 diabetes: a preliminary process evaluation

BACKGROUND

A growing number of older adults (ages 65+) live with Type 1 diabetes. Simultaneously, technologies such as continuous glucose monitoring (CGM) have become standard of care. There is thus a need to understand better the complex dynamics that promote use of CGM (and other care innovations) over time in this age group. Our aim was to adapt methods from systems thinking, specifically a participatory approach to system dynamics modeling called group model building (GMB), to model the complex experiences that may underlie different trajectories of CGM use among this population. Herein, we report on the feasibility, strengths, and limitations of this methodology.

METHODS

We conducted a series of GMB workshops and validation interviews to collect data in the form of questionnaires, diagrams, and recordings of group discussion. Data were integrated into a conceptual diagram of the "system" of factors associated with uptake and use of CGM over time. We evaluate the feasibility of each aspect of the study, including the teaching of systems thinking to older adult participants. We collected participant feedback on positive aspects of their experiences and areas for improvement.

RESULTS

We completed nine GMB workshops with older adults and their caregivers (N = 33). Each three-hour in-person workshop comprised: (1) questionnaires; (2) the GMB session, including both didactic components and structured activities; and (3) a brief focus group discussion. Within the GMB session, individual drawing activities proved to be the most challenging for participants, while group activities and discussion of relevant dynamics over time for illustrative (i.e., realistic but not real) patients yielded rich engagement and sufficient information for system diagramming. Study participants liked the opportunity to share experiences with peers, learning and enhancing their knowledge, peer support, age-specific discussions, the workshop pace and structure, and the systems thinking framework. Participants gave mixed feedback on the workshop duration.

CONCLUSIONS

The study demonstrates preliminary feasibility, acceptability, and the value of GMB for engaging older adults about key determinants of complex health behaviors over time. To our knowledge, few studies have extended participatory systems science methods to older adult stakeholders. Future studies may utilize this methodology to inform novel approaches for supporting health across the lifespan.

Initiating GLP-1 Therapy in Combination with FreeStyle Libre Provides Greater Benefit Compared with GLP-1 Therapy Alone

Background and Aim: Glucagon-like peptide-1 receptor agonists (GLP-1 RA) therapy provides glycemic benefits to individuals with type 2 diabetes (T2D). However, the effects of GLP-1 RA therapy in combination with FreeStyle Libre systems (FSL) are unknown. This study aimed to compare changes in hemoglobin A1c (HbA1c) between people acquiring GLP-1 with FSL (GLP-1+FSL) versus GLP-1 without FSL (GLP-1). Methods: This real-world study used Optum's de-identified Market Clarity Data, a linked electronic health records (EHR)-claims database, and included adults with T2D and HbA1c ≥8% who acquired their first GLP-1 RA medication between 2018 and 2022. GLP-1+FSL subjects acquired their first FSL within ±30 days of their first GLP-1 acquisition. Cohorts were matched 1:5 on baseline insulin therapy, age, sex, baseline HbA1c, and GLP-1 type. Paired changes in HbA1c were compared between unmatched and matched groups at 6 months. Results: The study included 24,724 adults in the unmatched cohort (GLP-1+FSL, n = 478; GLP-1, n = 24,246). The matched cohort included 478 GLP-1+FSL users and 2,390 GLP-1 users: mean age 53.5 ± 11.8 and 53.5 ± 11.3 years, HbA1c 10.25 ± 1.68% and 10.22 ± 1.69%, respectively. HbA1c reduction was greater in the GLP-1+FSL group compared with the GLP-1 group in the unmatched cohort (-2.43% vs. -1.73%, difference 0.70%, P < 0.001, respectively) and in the matched cohort (-2.43% vs. -2.06%, difference 0.37%, P < 0.001). GLP-1+FSL vs. GLP-1 treatment was associated with greater HbA1c reduction in the intensive insulin (-2.32% vs. -1.50%), nonintensive insulin (-2.50% vs. -1.74%), and noninsulin group (-2.46% vs. -1.78%), as well as in patients using semaglutide (-2.73% vs. -1.92%) and dulaglutide (-2.45% vs. -1.71%) GLP-1 RA, all P < 0.001. Conclusions: Adults with suboptimally controlled T2D, initiating GLP-1 RA with FreeStyle Libre, had greater improvement in HbA1c compared with those treated with GLP-1 RA only. These results suggest an additional glycemic benefit of FSL when used with a GLP-1 RA in T2D treatment.

Continuous Glucose Monitoring in Older Adults: What We Know and What We Have Yet to Learn

OBJECTIVE

To assess the growing use of continuous glucose monitoring (CGM) systems by older adults and explore additional areas integration that could benefit adults with frailty.

BACKGROUND

The use of CGM devices has expanded rapidly in the last decade. This has been supported by substantial data showing significant benefit in glycemic metrics: hemoglobin A1c improvements, less hypoglycemia, and improved quality of life. However, sub-populations, such as older persons, exist where available data are limited. Furthermore, frail older adults represent a heterogeneous population with their own unique challenges to the management of diabetes. This group has some of the poorest outcomes related to the sequela of diabetes. For example, hypoglycemia resulting in significant morbidity and mortality is more frequent in older person with diabetes than in younger persons with diabetes.

METHOD

We present a concise literature review on CGM use in the older adult as well as expand upon glycemic and nonglycemic benefits of CGM for patients, caregivers, and providers. Retrospective analysis of inpatient glycemic data of 16,935 older adults with Type 2 diabetes mellitus at Atrium Health Wake Forest Baptist indicated those with fraility managed with insulin or sulfonylurea had the highest rates of delirium (4.8%), hypoglycemia (3.5%), cardiovascular complications (20.2%) and ED visits/hospitalizatoins (49%). In addition, we address special consideration of specific situations including inpatient, palliative and long term care settings.

CONCLUSION

This review article summarizes the available data for CGM use in older adults, discusses the benefits and obstacles with CGM use in this population, and identifies areas of future research needed for improved delivery of care to older persons with diabetes.

Characteristics Associated With Elevated Time Below Range in Elderly Patients With Type 1 Diabetes Using an Automated Insulin Delivery System

BACKGROUND

This study investigated the characteristics associated with an increased risk of hypoglycemia, in elderly patients with type 1 diabetes mellitus (T1D) using automated insulin delivery (AID) systems.

METHODS

Cross-sectional observational study including patients >60 years, using sensor-augmented insulin pump therapy with predictive low-glucose management (SAPT-PLGM), hybrid closed-loop (HCL), and advanced hybrid closed-loop (AHCL), for more than three months. A geriatric assessment was performed, and body composition was determined to investigate its association with achieving time below range (TBR) <70 mg/dL goals.

RESULTS

The study included 59 patients (47.5% of men, mean age of 67.6 years, glycated hemoglobin [HbA1c] of 7.5 ± 0.6%, time in range (TIR) 77.8 ± 9.9%). Time below range <70 and <54 mg/dL were 2.2 ± 2.3% and 0.4 ± 0.81%, respectively. Patients with elevated TBR <70 mg/dL (>1%) had higher HbA1c levels, lower TIR, elevated time above range (TAR), and high glycemic variability. Regarding body composition, greater muscle mass, grip strength, and visceral fat were associated with a lower TBR <70 mg/dL. These factors were independent of the type of technology used, but TIR was higher when using AHCL systems compared with SAPT-PLGM and HCL systems.

CONCLUSIONS

In elderly patients treated with AID systems with good functional status, lower lean mass, lower grip strength, and lower visceral fat percentage were associated with TBR greater than 1%, regardless of the device used. A similar finding along was found with CGM indicators such as higher HbA1c levels, lower TIR, higher TAR, and higher CV. Geriatric assessment is crucial for personalizing patient management.

Stakeholder Engagement in Type 1 Diabetes Research, Quality Improvement, and Clinical Care

The integration of stakeholder engagement (SE) in research, quality improvement (QI), and clinical care has gained significant traction. Type 1 diabetes is a chronic disease that requires complex daily management and care from a multidisciplinary team across the lifespan. Inclusion of key stakeholder voices, including patients, caregivers, health care providers and community advocates, in the research process and implementation of clinical care is critical to ensure representation of perspectives that match the values and goals of the patient population. This review describes the current framework for SE and its application to research, QI, and clinical care across the lifespan.

The role of real-time continuous glucose monitoring in diabetes management and how it should link to integrated personalized diabetes management

Diabetes is a complex metabolic condition that demands tailored, individualized approaches for effective management. Real-time continuous glucose monitoring (rtCGM) systems have improved in terms of design, usability and accuracy over the years and play a pivotal role in the delivery of integrated personalized diabetes management (iPDM). iPDM is a comprehensive multidisciplinary approach that combines individualized care strategies utilizing technologies and interventions and encourages the active involvement of the person with diabetes in the care provided. The use of stand-alone rtCGM and its integration with other diabetes technologies, such as hybrid automated insulin delivery, have enabled improved glycaemic and quality of life outcomes for people with diabetes. As the uptake of rtCGM and associated technologies is increasing and becoming the standard of care for people with diabetes, it is important that efforts are focused on associated goals such as reducing health inequalities in terms of access, aligning structured education with rtCGM usage, choosing the right technology based on needs and preferences, and minimizing burden while aiming for optimal glucose outcomes. Utilizing rtCGM in other settings than outpatients and in diabetes cohorts beyond type 1 and type 2 diabetes needs further exploration. This review aims to provide an overview of the role of rtCGM and how best to link rtCGM to iPDM, highlighting its role in enhancing personalized treatment strategies.

Continuous glucose monitoring in older adults with diabetes: Data from the diabetes prospective follow-up (DPV) registry

AIMS

To analyse predictors for continuous glucose monitoring (CGM) use in people with diabetes aged ≥60 years using insulin therapy and to assess the rates of CGM use during recent years (2019-2021).

RESEARCH DESIGN AND METHODS

Prospective study including 6849 individuals with diabetes and insulin therapy (type 2 diabetes: n = 5320; type 1 diabetes: n = 1529) aged ≥60 years. Data from 129 treatment centres were retrieved from the Diabetes Prospective Follow-up Registry (DPV) in March 2023.

RESULTS

Sensor use in individuals aged ≥60 years has increased in type 1 (2019: 28%, 2020: 39%, 2021: 45%) and type 2 diabetes (2019: 10%, 2020: 16%, 2021: 18%). Predictors for sensor use in older individuals with type 1 diabetes are younger age and CSII use (p < 0.001). Predictors in older individuals with type 2 diabetes are younger age, longer diabetes duration, higher BMI and CSII use (p < 0.001).

CONCLUSIONS

CGM has become more common in older adults with diabetes and will presumably increase further. Age is a predictor for sensor use in older adults with diabetes. Age-related physical barriers and insufficient usability of devices, lack of interest in technologies, but possibly also effects of prejudice on the grounds of age may contribute to this finding.

Guideline for the Management of Diabetes Mellitus in the Elderly in China (2024 Edition)

With the deepening of aging in China, the prevalence of diabetes in older people has increased noticeably, and standardized diabetes management is critical for improving clinical outcomes of diabetes in older people. In 2021, the National Center of Gerontology, Chinese Society of Geriatrics, and Diabetes Professional Committee of Chinese Aging Well Association organized experts to write the first guideline for diabetes diagnosis and treatment in older people in China, the Guideline for the Management of Diabetes Mellitus in the Elderly in China (2021 Edition). The guideline emphasizes that older patients with diabetes are a highly heterogeneous group requiring comprehensive assessment and stratified and individualized management strategies. The guideline proposes simple treatments and de-intensified treatment strategies for older patients with diabetes. This edition of the guideline provides clinicians with practical and operable clinical guidance, thus greatly contributing to the comprehensive and full-cycle standardized management of older patients with diabetes in China and promoting the extensive development of clinical and basic research on diabetes in older people and related fields. In the past 3 years, evidence-based medicine for older patients with diabetes and related fields has further advanced, and new treatment concepts, drugs, and technologies have been developed. The guideline editorial committee promptly updated the first edition of the guideline and compiled the Guideline for the Management of Diabetes Mellitus in the Elderly in China (2024 Edition). More precise management paths for older patients with diabetes are proposed, for achieving continued standardization of the management of older Chinese patients with diabetes and improving their clinical outcomes.

Supporting the 'lived expertise' of older adults with type 1 diabetes: An applied focus group analysis to characterize barriers, facilitators, and strategies for self-management in a growing and understudied population

INTRODUCTION

There is a growing number of older adults (≥65 years) who live with type 1 diabetes. We qualitatively explored experiences and perspectives regarding type 1 diabetes self-management and treatment decisions among older adults, focusing on adopting care advances such as continuous glucose monitoring (CGM).

METHODS

Among a clinic-based sample of older adults ≥65 years with type 1 diabetes, we conducted a series of literature and expert informed focus groups with structured discussion activities. Groups were transcribed followed by inductive coding, theme identification, and inference verification. Medical records and surveys added clinical information.

RESULTS

Twenty nine older adults (age 73.4 ± 4.5 years; 86% CGM users) and four caregivers (age 73.3 ± 2.9 years) participated. Participants were 58% female and 82% non-Hispanic White. Analysis revealed themes related to attitudes, behaviours, and experiences, as well as interpersonal and contextual factors that shape self-management and outcomes. These factors and their interactions drive variability in diabetes outcomes and optimal treatment strategies between individuals as well as within individuals over time (i.e. with ageing). Participants proposed strategies to address these factors: regular, holistic needs assessments to match people with effective self-care approaches and adapt them over the lifespan; longitudinal support (e.g., education, tactical help, sharing and validating experiences); tailored education and skills training; and leveraging of caregivers, family, and peers as resources.

CONCLUSIONS

Our study of what influences self-management decisions and technology adoption among older adults with type 1 diabetes underscores the importance of ongoing assessments to address dynamic age-specific needs, as well as individualized multi-faceted support that integrates peers and caregivers.

13. Older Adults: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

A conceptual model of the continuous glucose monitoring integration process for older adults with diabetes developed using participatory systems science methods

AIMS

Continuous glucose monitoring (CGM) use remains low in older adults. We aimed to develop a conceptual model of CGM integration among older adults with type 1 and type 2 diabetes.

METHODS

We previously engaged older adults with type 1 diabetes using participatory system science methods to develop a model of the system of factors that shape CGM integration. To validate and expand the model, we conducted semi-structured interviews with 17 older adults with type 1 and type 2 diabetes and 3 caregivers. Vignettes representing each integration phase were used to elicit outcomes and strategies to support CGM use. Data were analyzed using team-based causal loop diagraming.

RESULTS

The model includes six phases spanning (1) CGM uptake; (2) device set-up; acquisition of (3) belief in oneself to use CGM effectively; (4) belief that CGM is preferable to blood glucose monitoring; (5) belief in future CGM benefits CGM; and (6) development of a sense of reliance on CGM. Causal loop diagrams visualize factors and feedback loops shaping outcomes at each phase. Participants proposed support strategies spanning clinical, educational, and behavioral interventions.

CONCLUSIONS

The model underscores the complex transition of learning new technology and provides opportunities for tailored support for older adults.

An updated algorithm for an effective choice of continuous glucose monitoring for people with insulin-treated diabetes

PURPOSE

Continuous Glucose Monitoring (CGM) is a key tool for insulin-treated people with diabetes (PwD). CGM devices include both real-time CGM (rtCGM) and intermittently scanned CGM (isCGM), which are associated with an improvement of glucose control and less hypoglycemia in clinical trials of people with type 1 and type 2 diabetes.

METHODS

This is an expert position to update a previous algorithm on the most suitable choice of CGM for insulin-treated PwD in light of the recent evidence and clinical practice.

RESULTS

We identified six different clinical scenarios, including type 1 diabetes, type 2 diabetes, pregnancy on intensive insulin therapy, regular physical exercise, new onset of diabetes, and frailty. The use of rtCGM or isCGM is suggested, on the basis of the predominant clinical issue, as suboptimal glucose control or disabling hypoglycemia, regardless of baseline HbA1c or individualized HbA1c target.

CONCLUSION

The present algorithm may help to select the best CGM device based on patients' clinical characteristics, needs and clinical context, offering a further opportunity of a "tailored" therapy for people with insulin-treated diabetes.

Health Care Professionals' Perspectives on Use of Diabetes Technologies for Managing Visually Impaired Patients With Diabetes

BACKGROUND

Despite well-established safety and efficacy of diabetes technologies in management of diabetes, their utility in visually impaired patients is currently unknown. We aimed to identify providers' preferences and challenges to prescribing diabetes technologies for visually impaired patients.

METHODS

A survey-based study among health care providers in the United States seeing visually impaired patients with diabetes and using diabetes technologies was conducted. The quantitative and qualitative responses were analyzed using Student t test and χ2 tests.

RESULTS

Of 79 providers, 66 completed the survey and were included in the analysis. Insulin pens and hybrid closed-loop systems were preferred insulin delivery systems for managing visually impaired patients with diabetes. Despite 96% of the providers recommending continuous glucose monitoring (CGM) for their visually impaired patients with diabetes, only 55% were aware of the voice-activation feature of Dexcom G6. Voice activation to announce glucose values and audible glucose alerts were two major incentives for selecting CGM. System initialization was seen as a prevalent challenge of using CGM in visually impaired patients with diabetes. Providers who are using CGM for visually impaired patients reported benefits for patients using the voice-activation feature for six months included HbA1c reductions of >0.5% (by 87% of providers) and less hypoglycemia (by 45% of providers).

CONCLUSIONS

The CGM is the preferred glucose monitoring method for managing visually impaired patients with diabetes. Providers face many challenges of initiating CGM in these high-risk patients. Voice-activation feature of G6 CGM is underutilized and providers who used the system reported positive outcomes in visually impaired patients.

Coverage for Continuous Glucose Monitoring for Individuals with Type 2 Diabetes Treated with Nonintensive Therapies: An Evidence-Based Approach to Policymaking

Numerous studies have demonstrated the clinical benefits of continuous glucose monitoring (CGM) in individuals with type 1 diabetes (T1D) and type 2 diabetes (T2D) who are treated with intensive insulin regimens. Based on this evidence, CGM is now a standard of care for individuals within these diabetes populations and widely covered by commercial and public insurers. Moreover, recent clinical guidelines from the American Diabetes Association and American Association of Clinical Endocrinology now endorse CGM use in individuals treated with nonintensive insulin regimens. However, despite increasing evidence supporting CGM use for individuals treated with less-intensive insulin therapy or noninsulin medications, insurance coverage is limited or nonexistent. This narrative review reports key findings from recent randomized, observational, and retrospective studies investigating use of CGM in T2D individuals treated with basal insulin only and/or noninsulin therapies and presents an evidence-based rationale for expanding access to CGM within this population.

Use of Telemedicine in Adults with Type 1 Diabetes: Do Age and Use of Diabetes-Related Technology Matter?

Objective: Older adults are generally less proficient in technology use compared with younger adults. Data on telemedicine use during the COVID-19 pandemic in older persons with type 1 diabetes (T1D) and the association of telemedicine with the use of diabetes-related technology are limited. We evaluated care delivery to older adults compared with younger adults with T1D in a prepandemic and pandemic period. Methods: Data from electronic health records were evaluated for visit types (in-person, phone, and video) from two sequential 12-month intervals: prepandemic (April 2019-March 2020) and pandemic (April 2020-March 2021). Results: Data from 2,832 unique adults with T1D were evaluated in two age cohorts: younger (40-64 years) and older (≥65 years). Half of each group used continuous glucose monitoring (CGM), whereas 54% of the younger and 37% of the older cohort used pump therapy (p < 0.001). During the pandemic compared with the prepandemic period, visit frequency increased in both the younger (0.65 vs. 0.76 visits/patient/quarter; p < 0.01) and older (0.72 vs. 0.80 visits/patient/quarter; p < 0.01) cohorts. During the pandemic, older adults used more phone visits compared with younger adults (48% vs. 32%; p = 0.001). Patients using either pump therapy or CGM were more likely to use video visits compared with phone visits in both younger (41% vs. 24%; p < 0.001) and older cohorts (53% vs. 42%; p < 0.001). Conclusions: Adults using diabetes-related technologies, independent of age, accessed more video visits than those not using devices. Telemedicine visits appeared to maintain continuity of care for younger and older adults with T1D, supporting the future of a hybrid-care model.

The Growing Role of Technology in the Care of Older Adults With Diabetes

The integration of technologies such as continuous glucose monitors, insulin pumps, and smart pens into diabetes management has the potential to support the transformation of health care services that provide a higher quality of diabetes care, lower costs and administrative burdens, and greater empowerment for people with diabetes and their caregivers. Among people with diabetes, older adults are a distinct subpopulation in terms of their clinical heterogeneity, care priorities, and technology integration. The scientific evidence and clinical experience with these technologies among older adults are growing but are still modest. In this review, we describe the current knowledge regarding the impact of technology in older adults with diabetes, identify major barriers to the use of existing and emerging technologies, describe areas of care that could be optimized by technology, and identify areas for future research to fulfill the potential promise of evidence-based technology integrated into care for this important population.

Improving glucose control in patients with type 2 diabetes using retrospective continuous glucose monitoring

BACKGROUND

The prevalence and cost of type 2 diabetes mellitus (T2DM) is rising. Diabetes care should be individualized based on patient risk factors and goals. Professional continuous glucose monitoring (CGM) is a tool for primary care providers to assist patients with diabetes management.

LOCAL PROBLEM

Nurse practitioners at an outpatient primary care practice began using CGM in patients with T2DM in 2019 to guide treatment due to the high number of patients not reaching glucose targets. There was no policy in place to guide patient selection for CGM.

METHODS

This quality improvement (QI) project, conducted in an outpatient primary care clinic, evaluated the effect of retrospective CGM use in patients with T2DM through a retrospective chart review to create a policy for use.

INTERVENTIONS

Hemoglobin A1c (HbA1c) measurements pre-CGM and post-CGM use were compared. CGM reports were evaluated for the presence of hypoglycemia. Additionally, number of times a patient used CGM between HbA1c laboratory examinations as well as insulin status were determined by reviewing the electronic health record.

RESULTS

Patients using CGM for HbA1c higher than goal (n = 60) noted a 1.01% decrease in HbA1c ( p < .01). The decrease was similar regardless of exogenous insulin status. Hypoglycemia was detected in 54.3% of patients (n = 44), including 45% (n = 27) of those with elevated HbA1c levels.

CONCLUSIONS

Retrospective CGM is a cost-effective tool to individualize management of patients with T2DM in primary care. A policy was created to guide CGM use in patients not reaching glucose goals and those with concern for hypoglycemia.

Short-term multifactorial intervention (STEMI): An approach using structured blood glucose monitoring (BGM) and conventional therapies in persons with diabetes

Background

Achieving glucose and glycosylated hemoglobin (HbA1c) targets have been shown to reduce long-term microvascular complications of diabetes; however, suboptimal glucose control is common. We tested whether glucose control could be improved within 8 weeks by employing structured blood glucose monitoring (BGM) qid in addition to seven times per day prior to visits for diabetes education and medication management that occurred every 2-4 weeks.

Methods

This single-center, prospective study was conducted on 78 adults with either type 1 diabetes (T1D) or type 2 diabetes (T2D), HbA1c >8%, and serum creatinine (sCr) <2.0 mg/dl. HbA1c was checked at baseline, Week 2, Week 4, and at Week 8. Patients were evaluated by a physician and a certified diabetes educator (CDE) at baseline, Week 2, and Week 4 for treatment adjustments and lifestyle advice based on a review of BGM done qid plus 7-point profiles conducted before Weeks 2, 4, and 8. Study outcomes were change in HbA1c from baseline to Week 8 and change in mean glucose on the 7-point profile from Week 2 to Week 8. These were compared using one-way repeated measures ANOVA.

Results

Of the 78 patients, 64.1% had T2D, 50% were women, and 72% were Caucasian. Mean age (±SD) was 51.3.5 ± 11.1 years, and median diabetes duration was 9 (5-17) years. The percentage of patients using insulin increased from 58.9% at baseline to 67.9% at Week 8. The mean (±SD) HbA1c was 9.53% (±1.71) at baseline, declined -1.38% from baseline to week 8 (CI -1.62 to -0.14, P < 0.001). The mean (±SD) glucose on the 7-point profile was 187 (±52) mg/dl at Week 2, and 157 (±5) mg/dl at Week 8. (P < 0.01).

Conclusions

An intensive glucose optimization program using structured BGM qid plus 7-point profiles, diabetes education, and conventional anti-diabetic therapies was successful in reducing HbA1c by 1.38% over 8 weeks in patients with poor glucose control.

Beyond A1C: exploring continuous glucose monitoring metrics in managing diabetes

Hemoglobin A1c (HbA1c) has long been considered a cornerstone of diabetes mellitus (DM) management, as both an indicator of average glycemia and a predictor of long-term complications among people with DM. However, HbA1c is subject to non-glycemic influences which confound interpretation and as a measure of average glycemia does not provide information regarding glucose trends or about the occurrence of hypoglycemia and/or hyperglycemia episodes. As such, solitary use of HbA1c, without accompanying glucose data, does not confer actionable information that can be harnessed to guide targeted therapy in many patients with DM. While conventional capillary blood glucose monitoring (BGM) sheds light on momentary glucose levels, in practical use the inherent infrequency of measurement precludes elucidation of glycemic trends or reliable detection of hypoglycemia or hyperglycemia episodes. In contrast, continuous glucose monitoring (CGM) data reveal glucose trends and potentially undetected hypo- and hyperglycemia patterns that can occur between discrete BGM measurements. The use of CGM has grown significantly over the past decades as an ever-expanding body of literature demonstrates a multitude of clinical benefits for people with DM. Continually improving CGM accuracy and ease of use have further fueled the widespread adoption of CGM. Furthermore, percent time in range correlates well with HbA1c, is accepted as a validated indicator of glycemia, and is associated with the risk of several DM complications. We explore the benefits and limitations of CGM use, the use of CGM in clinical practice, and the application of CGM to advanced diabetes technologies.

Expanding the Role of Continuous Glucose Monitoring in Modern Diabetes Care Beyond Type 1 Disease

Application of continuous glucose monitoring (CGM) has moved diabetes care from a reactive to a proactive process, in which a person with diabetes can prevent episodes of hypoglycemia or hyperglycemia, rather than taking action only once low and high glucose are detected. Consequently, CGM devices are now seen as the standard of care for people with type 1 diabetes mellitus (T1DM). Evidence now supports the use of CGM in people with type 2 diabetes mellitus (T2DM) on any treatment regimen, not just for those on insulin therapy. Expanding the application of CGM to include all people with T1DM or T2DM can support effective intensification of therapies to reduce glucose exposure and lower the risk of complications and hospital admissions, which are associated with high healthcare costs. All of this can be achieved while minimizing the risk of hypoglycemia and improving quality of life for people with diabetes. Wider application of CGM can also bring considerable benefits for women with diabetes during pregnancy and their children, as well as providing support for acute care of hospital inpatients who experience the adverse effects of hyperglycemia following admission and surgical procedures, as a consequence of treatment-related insulin resistance or reduced insulin secretion. By tailoring the application of CGM for daily or intermittent use, depending on the patient profile and their needs, one can ensure the cost-effectiveness of CGM in each setting. In this article we discuss the evidence-based benefits of expanding the use of CGM technology to include all people with diabetes, along with a diverse population of people with non-diabetic glycemic dysregulation.

An Observational Crossover Study of People Using Real-Time Continuous Glucose Monitors Versus Self-Monitoring of Blood Glucose: Real-World Evidence Using EMR Data From More Than 12,000 People With Type 1 Diabetes

BACKGROUND

We used real-world electronic health record (EHR) data to examine HbA1c levels among children and adults with type 1 diabetes (T1D) who are classified as continuous glucose monitor (CGM) users after T1D diagnosis and switch to self-monitoring of blood glucose (SMBG) during follow-up, versus people who opt for SMBG after T1D diagnosis and switch to CGM during follow-up visits.

METHODS

We conducted an observational, case-crossover study using electronic medical record (EMR) data from the T1D Exchange Quality Improvement Collaborative. The primary outcome in this study was HbA1c. Baseline HbA1c levels were taken at the index date, corresponding to initial device classification, and compared with HbA1c value recorded at the clinic visit following device switch.

RESULTS

Of all patients classified in the SMBG group, 7,706 switched to CGM use within the 5-year study time frame, and 5,123 of all initial CGM users switched to SMBG within the study time frame and were included in this analysis. At baseline, median (interquartile range [IQR]) HbA1c for SMBG use was 8.1 (2.4), whereas postcrossover to CGM use, there was a decline in median (IQR) levels to 7.7 (1.9) (P < .001). For baseline CGM users, median (IQR) HbA1c levels were 7.9 (2.0), and postcrossover to SMBG, median (IQR) HbA1c levels increased to 8.0 (2.9) (P < .001).

CONCLUSION

We found that people who switched to CGM use had significantly improved HbA1c levels compared to those who switched to glucose monitoring with SMBG.

Type 1 Diabetes and Aging

The number of older adults with type 1 diabetes (T1D) is increasing due to an overall increase in life expectancy and improvement in diabetes management and treatment of complications. They are a heterogeneous cohort due to the dynamic process of aging and the presence of comorbidities and diabetes-related complications. A high risk for hypoglycemia unawareness and severe hypoglycemia has been described. Periodic assessment of health status and adjustment of glycemic goals to mitigate hypoglycemia is imperative. Continuous glucose monitoring, insulin pump, and hybrid closed-loop systems are promising tools to improve glycemic control and mitigate hypoglycemia in this age group.

Prevalence, characteristics, and health-related quality of life of continuous glucose monitoring use according to the Behavioral Risk Factor Surveillance System 2014-2020

BACKGROUND: Continuous glucose monitoring (CGM) can improve behavioral and clinical outcomes. The use of CGM in real-world practice appears to be increasing. However, actual prevalence and characteristics of using CGM in real-world practice are unknown. OBJECTIVE: To investigate the prevalence of CGM use by American adults with diabetes mellitus and differences in demographics and health-related quality of life (HRQOL) between users of CGM and self-monitoring of blood glucose (SMBG). METHODS: This serial cross-sectional study using 2014-2020 Behavioral Risk Factor Surveillance System data included nonpregnant adults with self-reported diabetes using CGM or 4-15 times daily SMBG. Outcomes were prevalence of CGM use, demographics, and the 4-item Centers for Disease Control and Prevention HRQOL (CDC HRQOL-4). Unadjusted analysis was performed using univariable regression, and adjusted analysis was performed using nearest neighbor matching to compare CDC HRQOL-4 between SMBG and CGM groups in SAS Studio version 5.2. RESULTS: Among 12,053 included respondents, 231 (1.9%) reported using CGM, and prevalence increased from 0.4% in 2014 to 4.1% in 2020. Compared with SMBG users, CGM users were more likely to be younger (50.3 years vs 56.1 years; P < 0.001), employed (59.6% vs 30.6%; P = 0.001), earn at least $75,000/year (48.5% vs 22.0%, P < 0.001), have insurance coverage (99.7% vs 95.4%; P = 0.005), and report fewer comorbidities (history of myocardial infarction, stroke, arthritis, depressive disorder, and kidney disease; all P < 0.05). After nearest neighbor matching, diabetes management-related characteristics were shown to have statistically significant differences between CGM and SMBG users including: age at diabetes diagnosis (30.6 vs 35.6 years; P = 0.005), not seeing a doctor because of cost concern (2.6% vs 7.8%; P = 0.011), checking hemoglobin A1c biannually (91.3% vs 86.6%; P = 0.047), performing daily foot self-examination (58.9% vs 69.6%; P = 0.028), receiving foot examination by a health care professional annually (87.9% vs 93.5%; P = 0.048), and receiving a shingles vaccine in the past (16.5% vs 10.1%; P = 0.024). CDC HRQOL-4 were shown to be similar between the 2 groups across the 4 domains (general health, physical, mental, and combined physical and mental health). CONCLUSIONS: An increased trend in CGM use was observed from 2014 to 2020. Economic factors were associated with CGM use over SMBG, and CGM use did not show a difference in HRQOL measured across the 4 domains.

Human hypoimmune primary pancreatic islets avoid rejection and autoimmunity and alleviate diabetes in allogeneic humanized mice

Transplantation of allogeneic pancreatic donor islets has successfully been performed in selected patients with difficult-to-control insulin-dependent diabetes and impaired awareness of hypoglycemia (IAH). However, the required systemic immunosuppression associated with this procedure prevents this cell replacement therapy from more widespread adoption in larger patient populations. We report the editing of primary human islet cells to the hypoimmune HLA class I- and class II-negative and CD47-overexpressing phenotype and their reaggregation into human HIP pseudoislets (p-islets). Human HIP p-islets were shown to survive, engraft, and ameliorate diabetes in immunocompetent, allogeneic, diabetic humanized mice. HIP p-islet cells were further shown to avoid autoimmune killing in autologous, diabetic humanized autoimmune mice. The survival and endocrine function of HIP p-islet cells were not impaired by contamination of unedited or partially edited cells within the p-islets. HIP p-islet cells were eliminated quickly and reliably in this model using a CD47-targeting antibody, thus providing a safety strategy in case HIP cells exert toxicity in a future clinical setting. Transplantation of human HIP p-islets for which no immunosuppression is required has the potential to lead to wider adoption of this therapy and help more diabetes patients with IAH and history of severe hypoglycemic events to achieve insulin independence.

All Children Deserve to Be Safe, Mothers Too: Evidence and Rationale Supporting CGM Use in Gestational Diabetes Within the Medicaid Population

Gestational diabetes mellitus (GDM) is a common metabolic disease of pregnancy that threatens the health of several million women and their offspring. The highest prevalence of GDM is seen in women of low socioeconomic status. Women with GDM are at increased risk of adverse maternal outcomes, including increased rates of Cesarean section delivery, preeclampsia, perineal tears, and postpartum hemorrhage. However, of even greater concern is the increased risk to the fetus and long-term health of the child due to elevated glycemia during pregnancy. Although the use of continuous glucose monitoring (CGM) has been shown to reduce the incidence of maternal and fetal complications in pregnant women with type 1 diabetes and type 2 diabetes, most state Medicaid programs do not cover CGM for women with GDM. This article reviews current statistics relevant to the incidence and costs of GDM among Medicaid beneficiaries, summarizes key findings from pregnancy studies using CGM, and presents a rationale for expanding and standardizing CGM coverage for GDM within state Medicaid populations.

Assessing non-adjunctive CGM safety at home and in new markets (ANSHIN)

INTRODUCTION

Continuous glucose monitoring (CGM) can guide treatment for people with type 1 (T1D) and type 2 diabetes (T2D). The ANSHIN study assessed the impact of non-adjunctive CGM use in adults with diabetes using intensive insulin therapy (IIT).

MATERIALS AND METHODS

This single-arm, prospective, interventional study enrolled adults with T1D or T2D who had not used CGM in the prior 6 months. Participants wore blinded CGMs (Dexcom G6) during a 20-day run-in phase, with treatment based on fingerstick glucose values, followed by a 16-week intervention phase and then a randomized 12-week extension phase with treatment based on CGM values. The primary outcome was change in HbA1c. Secondary outcomes were CGM metrics. Safety endpoints were the number of severe hypoglycaemic (SH) and diabetic ketoacidosis (DKA) events.

RESULTS

Of the 77 adults enrolled, 63 completed the study. Those enrolled had mean (SD) baseline HbA1c of 9.8% (1.9%), 36% had T1D, and 44% were ≥65 years old. Mean HbA1c decreased by 1.3, 1.0 and 1.0 percentage points for participants with T1D, T2D or age ≥65, respectively (p < .001 for each). CGM-based metrics including time in range also improved significantly. SH events decreased from the run-in period (67.3 per 100 person-years) to the intervention period (17.0 per 100 person-years). Three DKA events unrelated to CGM use occurred during the total intervention period.

CONCLUSIONS

Non-adjunctive use of the Dexcom G6 CGM system improved glycaemic control and was safe for adults using IIT.

Statistical techniques used in analysing simultaneous continuous glucose monitoring and ambulatory electrocardiography in patients with diabetes: A systematic review

OBJECTIVES

There has been a steady increase in the number of studies of the complex relationship between glucose and electrical cardiac activity which use simultaneous continuous glucose monitors (CGM) and continuous electrocardiogram (ECG). However, data collected on the same individual tend to be similar (yielding correlated or dependent data) and require analyses that take into account that correlation. Many opt for simplified techniques such as calculating one measure from the data collected and analyse one observation per subject. These simplified methods may yield inconsistent and biased results in some instances. In this systematic review, we aim to examine the adequacy of the statistical analyses performed in such studies and make recommendations for future studies.

RESEARCH QUESTIONS

What are the objectives of studies collecting simultaneous CGM and ECG data? Do methods used in analysing CGM and continuous ECG data fully optimise the data collected?

DESIGN

Systematic review.

DATA SOURCES

PubMed and Web of Science.

METHODS

A comprehensive search of the PubMed and Web of Science databases to June 2022 was performed. Studies utilising CGM and continuous ECG simultaneously in people with diabetes were included. We extracted information about study objectives, technologies used to collect data and statistical analysis methods used for analysis. Reporting was done following PRISMA guidelines.

RESULTS

Out of 118 publications screened, a total of 31 studies met the inclusion criteria. There was a diverse array of study objectives, with only two studies exploring the same exposure-outcome relationship, allowing only qualitative analysis. Only seven studies (23%) incorporated methods which fully utilised the study data using methods that yield the correct power and minimize type I error rate. The rest (77%) used analyses that summarise the data first before analysis and/or totally ignored data dependency. Of those who applied more advanced methods, one study performed both simple and correct analyses and found that ignoring data structure resulted in no association whilst controlling for repeated measures yielded a significant relationship.

CONCLUSION

Most studies underutilised statistical methods suitable for analysis of dynamic continuous data, potentially attenuating their statistical power and overall conclusions. We recommend that aggregated data be used only as exploratory analysis, while primary analysis should use methods applied to the raw data such as mixed models or functional data analyses. These methods are widely available in many free, open source software applications.

Past, Present, and Future of Continuous Glucose Monitors (CGMs)

n/a.

"Nothing is linear": Characterizing the determinants and dynamics of CGM use in older adults with type 1 diabetes

AIMS

Continuous glucose monitoring (CGM) can reduce hypoglycemia in older adults with type 1 diabetes (T1D). We aimed to characterize factors that influence effective use in this age group.

METHODS

Older adults with type T1D (age ≥ 65) and their caregivers participated in one of a series of parallel group model building workshops, a participatory approach to system dynamics involving drawing and scripted group activities. Data were synthesized in a qualitative model of the hypothesized system of factors producing distinct patterns of CGM use in older adults. The model was validated through virtual follow-up interviews.

RESULTS

Data were collected from 33 participants (four patient-caregiver dyads, mean age 73.8 ± 4.4 years [range 66-85 years]; 16 % non-CGM users, 79 % pump users). The system model delineates drivers of CGM uptake, drivers of ongoing CGM use, and feedback loops that either reinforce or counteract future CGM use. Participants emphasized the importance of different sets of feedback loops at different points in the duration of CGM use.

CONCLUSIONS

The holistic system model underscores that factors and feedback loops driving effective CGM use in older adults are both individualized and dynamic (e.g., changing over time), suggesting opportunities for staged and tailored age-specific education and support.

Estimation of a Machine Learning-Based Decision Rule to Reduce Hypoglycemia Among Older Adults With Type 1 Diabetes: A Post Hoc Analysis of Continuous Glucose Monitoring in the WISDM Study

BACKGROUND

The Wireless Innovation for Seniors with Diabetes Mellitus (WISDM) study demonstrated continuous glucose monitoring (CGM) reduced hypoglycemia over 6 months among older adults with type 1 diabetes (T1D) compared with blood glucose monitoring (BGM). We explored heterogeneous treatment effects of CGM on hypoglycemia by formulating a data-driven decision rule that selects an intervention (ie, CGM vs BGM) to minimize percentage of time <70 mg/dL for each individual WISDM participant.

METHOD

The precision medicine analyses used data from participants with complete data (n = 194 older adults, including those who received CGM [n = 100] and BGM [n = 94] in the trial). Policy tree and decision list algorithms were fit with 14 baseline demographic, clinical, and laboratory measures. The primary outcome was CGM-measured percentage of time spent in hypoglycemic range (<70 mg/dL), and the decision rule assigned participants to a subgroup reflecting the treatment estimated to minimize this outcome across all follow-up visits.

RESULTS

The optimal decision rule was found to be a decision list with 3 steps. The first step moved WISDM participants with baseline time-below range >1.35% and no detectable C-peptide levels to the CGM subgroup (n = 139), and the second step moved WISDM participants with a baseline time-below range of >6.45% to the CGM subgroup (n = 18). The remaining participants (n = 37) were left in the BGM subgroup. Compared with the BGM subgroup (n = 37; 19%), the group for whom CGM minimized hypoglycemia (n = 157; 81%) had more baseline hypoglycemia, a lower proportion of detectable C-peptide, higher glycemic variability, longer disease duration, and higher proportion of insulin pump use.

CONCLUSIONS

The decision rule underscores the benefits of CGM for older adults to reduce hypoglycemia. Diagnostic CGM and laboratory markers may inform decision-making surrounding therapeutic CGM and identify older adults for whom CGM may be a critical intervention to reduce hypoglycemia.

Real-world study of flash glucose monitoring among adults with type 2 diabetes within the Swedish National Diabetes Register

BACKGROUND

The Swedish National Diabetes Register (NDR) initiated registration of the FreeStyle Libre® system and other continuous glucose monitoring (CGM) systems in June 2016. We investigated change in HbA1c for people with type 2 diabetes (T2DM) using FreeStyle Libre in Sweden.

METHODS

We included adults with T2DM, registered in the NDR after January 1, 2014, and an index date for first use of FreeStyle Libre of June 2016 or later. Methodology was a before/after comparison of HbA1c within 6 months before the index date versus HbA1c around 6 and 12 months after the index date.

RESULTS

711 adults with T2DM using FreeStyle Libre had HbA1c measurements within the study period. Mean HbA1c was significantly reduced at 6 months (-0.50%-unit) and at 12 months (-0.52%-unit) in this group. Degree of change was negatively correlated to baseline HbA1c. Reductions in HbA1c were observed in incident users of FreeStyle Libre with T2DM who were truly naïve to CGM or had unknown prior experience of CGM, and aged 25-74 years.

CONCLUSIONS

This real-world study on the Swedish NDR shows that people with T2DM using FreeStyle Libre system for 6 and 12 months significantly reduced their HbA1c.

13. Older Adults: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Making sense of glucose sensors in end-stage kidney disease: A review

Diabetes mellitus remains the leading cause of end-stage kidney disease worldwide. Inadequate glucose monitoring has been identified as one of the gaps in care for hemodialysis patients with diabetes, and lack of reliable methods to assess glycemia has contributed to uncertainty regarding the benefit of glycemic control in these individuals. Hemoglobin A1c, the standard metric to evaluate glycemic control, is inaccurate in patients with kidney failure, and does not capture the full range of glucose values for patients with diabetes. Recent advances in continuous glucose monitoring have established this technology as the new gold standard for glucose management in diabetes. Glucose fluctuations are uniquely challenging in patients dependent on intermittent hemodialysis, and lead to clinically significant glycemic variability. This review evaluates continuous glucose monitoring technology, its validity in the setting of kidney failure, and interpretation of glucose monitoring results for the nephrologist. Continuous glucose monitoring targets for patients on dialysis have yet to be established. While continuous glucose monitoring provides a more complete picture of the glycemic profile than hemoglobin A1c and can mitigate high-risk hypoglycemia and hyperglycemia in the context of the hemodialysis procedure itself, whether the technology can improve clinical outcomes merits further investigation.

Increase Access, Reduce Disparities: Recommendations for Modifying Medicaid CGM Coverage Eligibility Criteria

Numerous studies have demonstrated the clinical value of continuous glucose monitoring (CGM) in type 1 diabetes (T1D) and type 2 diabetes (T2D) populations. However, the eligibility criteria for CGM coverage required by the Centers for Medicare & Medicaid Services (CMS) ignore the conclusive evidence that supports CGM use in various diabetes populations that are currently deemed ineligible. In an earlier article, we discussed the limitations and inconsistencies of the agency's CGM eligibility criteria relative to current scientific evidence and proposed practice solutions to address this issue and improve the safety and care of Medicare beneficiaries with diabetes. Although Medicaid is administered through CMS, there is no consistent Medicaid policy for CGM coverage in the United States. This article presents a rationale for modifying and standardizing Medicaid CGM coverage eligibility across the United States.

Usability and Teachability of Continuous Glucose Monitoring Devices in Older Adults and Diabetes Educators: Task Analysis and Ease-of-Use Survey

BACKGROUND

Continuous glucose monitoring (CGM) devices continuously sense and relay glucose concentration data from the interstitial fluid to a mobile phone or receiver. Older adults benefit from this continuous monitoring of glucose levels. Proper deployment of the sensing wire is facilitated by a specialized applicator.

OBJECTIVE

Our aim was to assess a new seventh-generation (G7) CGM device (Dexcom, Inc) for use by adults 65 years of age or older and certified diabetes care and education specialists (CDCESs). Ease of use related to intradermal insertion and mobile app setup will be assessed and compared to the fifth- and sixth-generation systems.

METHODS

Formal task analysis was conducted to enumerate the number and complexity of tasks associated with CGM deployment. We recruited 10 older adults with no prior CGM experience and 10 CDCESs to assess ease of use through hands-on insertion and initiation of a G7 system followed by a survey and, for older adults, a system usability scale survey.

RESULTS

About half as many tasks are needed to deploy G7 compared to G6. Older adults and CDCESs reported overall high usability of the G7 CGM device. CDCESs noted G7's easier setup compared to previous generations. The system usability scale score for the CGM system was 92.8, which reflects excellent usability.

CONCLUSIONS

For CDCESs and for older adults using the G7 CGM system, cognitive burden is relatively low and reduced compared to previous CGM systems. Easing of this burden and simplification of the glucose monitoring aspect of proper diabetes management will likely contribute to improved outcomes in this population.

Time above range for predicting the development of type 2 diabetes

Aim

To investigate the prognostic value of time range metrics, as measured by continuous glucose monitoring, with respect to the development of type 2 diabetes (T2D).

Research design and methods

A total of 499 persons without diabetes from the general population were followed-up for 5 years. Time range metrics were measured at the start and medical records were checked over the period study.

Results

Twenty-two subjects (8.3 per 1,000 person-years) developed T2D. After adjusting for age, gender, family history of diabetes, body mass index and glycated hemoglobin concentration, multivariate analysis revealed 'time above range' (TAR, i.e., with a plasma glucose concentration of >140 mg/dL) to be significantly associated with a greater risk (OR = 1.06, CI 1.01-1.11) of developing diabetes (AUC = 0.94, Brier = 0.035).

Conclusions

Time above range provides additional information to that offered by glycated hemoglobin to identify patients at a higher risk of developing type 2 diabetes in a population-based study.

Use of Telecommunication and Diabetes-Related Technologies in Older Adults With Type 1 Diabetes During a Time of Sudden Isolation: Mixed Methods Study

BACKGROUND

The COVID-19 lockdown imposed a sudden change in lifestyle with self-isolation and a rapid shift to the use of technology to maintain clinical care and social connections.

OBJECTIVE

In this mixed methods study, we explored the impact of isolation during the lockdown on the use of technology in older adults with type 1 diabetes (T1D).

METHODS

Older adults (aged ≥65 years) with T1D using continuous glucose monitoring (CGM) participated in semistructured interviews during the COVID-19 lockdown. A multidisciplinary team coded the interviews. In addition, CGM metrics from a subgroup of participants were collected before and during the lockdown.

RESULTS

We evaluated 34 participants (mean age 71, SD 5 years). Three themes related to technology use emerged from the thematic analysis regarding the impact of isolation on (1) insulin pump and CGM use to manage diabetes, including timely access to supplies, and changing Medicare eligibility regulations; (2) technology use for social interaction; and (3) telehealth use to maintain medical care. The CGM data from a subgroup (19/34, 56%; mean age 74, SD 5 years) showed an increase in time in range (mean 57%, SD 17% vs mean 63%, SD 15%; P=.001), a decrease in hyperglycemia (>180 mg/dL; mean 41%, SD 19% vs mean 35%, SD 17%; P<.001), and no change in hypoglycemia (<70 mg/dL; median 0.7%, IQR 0%-2% vs median 1.1%, IQR 0%-4%; P=.40) during the lockdown compared to before the lockdown.

CONCLUSIONS

These findings show that our cohort of older adults successfully used technology during isolation. Participants provided the positive and negative perceptions of technology use. Clinicians can benefit from our findings by identifying barriers to technology use during times of isolation and developing strategies to overcome these barriers.

Pilot study in human healthy volunteers on the use of magnetohydrodynamics in needle-free continuous glucose monitoring

The benefits of continuous glucose monitoring (CGM) in diabetes management are extensively documented. Yet, the broader adoption of CGM systems is limited by their cost and invasiveness. Current CGM devices, requiring implantation or the use of hypodermic needles, fail to offer a convenient solution. We have demonstrated that magnetohydrodynamics (MHD) is effective at extracting dermal interstitial fluid (ISF) containing glucose, without the use of needles. Here we present the first study of ISF sampling with MHD for glucose monitoring in humans. We conducted 10 glucose tolerance tests on 5 healthy volunteers and obtained a significant correlation between the concentration of glucose in ISF samples extracted with MHD and capillary blood glucose samples. Upon calibration and time lag removal, the data indicate a Mean Absolute Relative Difference (MARD) of 12.9% and Precision Absolute Relative Difference of 13.1%. In view of these results, we discuss the potential value and limitations of MHD in needle-free glucose monitoring.

Healthcare Utilization, Costs, and Adverse Events of Real-Time Continuous Glucose Monitoring versus Traditional Blood Glucose Monitoring Among US Adults with Type 1 Diabetes

OBJECTIVE

To compare healthcare utilization, costs, and incidence of diabetes-specific adverse events (ie, hyperglycemia, diabetic ketoacidosis, and hypoglycemia) in type 1 diabetes adult patients using real-time continuous glucose monitoring (rtCGM) versus traditional blood glucose monitoring (BG).

METHODS

Adult patients (≥18 years old) with type 1 diabetes in a large national administrative claims database between 2013 and 2015 were identified. rtCGM patients with 6-month continuous health plan enrollment and ≥1 pharmacy claim for insulin during pre-index and post-index periods were propensity-score matched with BG patients. Healthcare utilization associated with diabetic adverse events were examined. A difference-in-difference (DID) method was used to compare the change in costs between rtCGM and BG cohorts.

RESULTS

Six-month medical costs for rtCGM patients (N = 153) increased from pre- to post-index period, while they decreased for matched BG patients (N = 153). DID analysis indicated a $2,807 (P = .062) higher post-index difference in total medical costs for rtCGM patients. Pharmacy costs for both cohorts increased. DID analysis indicated a $1,775 (P < .001) higher post-index difference in pharmacy costs for rtCGM patients. The incidence of hyperglycemia for both cohorts increased minimally from pre- to post-index period. The incidence of hypoglycemia for rtCGM patients decreased, while it increased marginally for BG patients. Inpatient hospitalizations for rtCGM and BG patients increased and decreased marginally, respectively.

CONCLUSIONS

rtCGM users had non-significantly higher pre-post differences in medical costs but significantly higher pre-post differences in pharmacy costs (mostly due to the rtCGM costs themselves) compared to BG users. Changes in adverse events were minimal.

Continuous Glucose Monitoring in Primary Care: Understanding and Supporting Clinicians' Use to Enhance Diabetes Care

PURPOSE

Diabetes affects approximately 34 million Americans and many do not achieve glycemic targets. Continuous glucose monitoring (CGM) is associated with improved health outcomes for patients with diabetes. Most adults with diabetes receive care for their diabetes in primary care practices, where uptake of CGM is unclear.

METHODS

We used a cross-sectional web-based survey to assess CGM prescribing behaviors and resource needs among primary care clinicians across the United States. We used descriptive statistics and multivariable regression to identify characteristics associated with prescribing behaviors, openness to prescribing CGM, and to understand resources needed to support use of CGM in primary care.

RESULTS

Clinicians located more than 40 miles from the nearest endocrinologist's office were more likely to have prescribed CGM and reported greater likelihood to prescribe CGM in the future than those located within 10 miles of an endocrinologist. Clinicians who served more Medicare patients reported favorable attitudes toward future prescribing and higher confidence using CGM to manage diabetes than clinicians with lower Medicare patient volume. The most-needed resources to support CGM use in primary care were consultation on insurance issues and CGM training.

CONCLUSIONS

Primary care clinicians are interested in using CGM for patients with diabetes, but many lack the resources to implement use of this diabetes technology. Use of CGM can be supported with education in the form of workshops and consultation on insurance issues targeted toward residents, recent graduates, and practices without a nearby endocrinologist. Continued expansion of Medicare and Medicaid coverage for CGM can also support CGM use in primary care.

Use of Continuous Glucose Monitoring in Older Adults: A Review of Benefits, Challenges and Future Directions

Many new technologies have been developed over the past decade, and these have substantially changed the way diabetes is managed. Continuous glucose monitoring is now the standard of care for many people living with diabetes, and among its numerous benefits, it has been shown to improve glycaemic outcomes and enhance quality of life. Older adults carry a high burden of diabetes and have a high risk of hypo-glycaemia and hypo-glycaemic unawareness, and continuous glucose monitoring can help to improve glycaemic management in this vulnerable population. Unfortunately, only a few trials have evaluated the effectiveness of continuous glucose monitoring in older adults. Certainly, the implementation of continuous glucose monitoring in older adults can come with many challenges, including logistical, educational and reimbursement barriers. This article will discuss the benefits of continuous glucose monitoring in older adults with diabetes, the clinical studies that support its use and the barriers to its optimal implementation in this population.

American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update

OBJECTIVE

The objective of this clinical practice guideline is to provide updated and new evidence-based recommendations for the comprehensive care of persons with diabetes mellitus to clinicians, diabetes-care teams, other health care professionals and stakeholders, and individuals with diabetes and their caregivers.

METHODS

The American Association of Clinical Endocrinology selected a task force of medical experts and staff who updated and assessed clinical questions and recommendations from the prior 2015 version of this guideline and conducted literature searches for relevant scientific papers published from January 1, 2015, through May 15, 2022. Selected studies from results of literature searches composed the evidence base to update 2015 recommendations as well as to develop new recommendations based on review of clinical evidence, current practice, expertise, and consensus, according to established American Association of Clinical Endocrinology protocol for guideline development.

RESULTS

This guideline includes 170 updated and new evidence-based clinical practice recommendations for the comprehensive care of persons with diabetes. Recommendations are divided into four sections: (1) screening, diagnosis, glycemic targets, and glycemic monitoring; (2) comorbidities and complications, including obesity and management with lifestyle, nutrition, and bariatric surgery, hypertension, dyslipidemia, retinopathy, neuropathy, diabetic kidney disease, and cardiovascular disease; (3) management of prediabetes, type 2 diabetes with antihyperglycemic pharmacotherapy and glycemic targets, type 1 diabetes with insulin therapy, hypoglycemia, hospitalized persons, and women with diabetes in pregnancy; (4) education and new topics regarding diabetes and infertility, nutritional supplements, secondary diabetes, social determinants of health, and virtual care, as well as updated recommendations on cancer risk, nonpharmacologic components of pediatric care plans, depression, education and team approach, occupational risk, role of sleep medicine, and vaccinations in persons with diabetes.

CONCLUSIONS

This updated clinical practice guideline provides evidence-based recommendations to assist with person-centered, team-based clinical decision-making to improve the care of persons with diabetes mellitus.

Targeting Technology in Underserved Adults With Type 1 Diabetes: Effect of Diabetes Practice Transformations on Improving Equity in CGM Prescribing Behaviors

OBJECTIVE

Continuous glucose monitoring (CGM) is associated with improved outcomes in type 1 diabetes, but racial-ethnic disparities exist in use. We were interested in examining whether addressing structural health care barriers would change provider prescribing behaviors to make CGM access more equitable.

RESEARCH DESIGN AND METHODS

From January 2019 to December 2021, we used multilevel stakeholder input to develop and implement several non-grant-funded practice transformations targeted toward equity, which included 1) developing a type 1 diabetes clinic, 2) conducting social needs assessments and management, 3) training support staff to place trial CGMs at the point of care, 4) optimizing prescription workflows, and 5) educating providers on CGM. Transformations were prioritized based on feasibility, acceptability, and sustainability. To examine effect on prescribing behaviors, we collected monthly aggregate data from the electronic medical record and performed multiple linear regression to examine and compare change in CGM prescriptions over the 3 years of transformation.

RESULTS

In total, we included 1,357 adults with type 1 diabetes in the analysis (mean ± SD age 38 ± 18 years; 30% Black [n = 406], 45% Hispanic [n = 612], 12% White [n = 164]; and 74% publicly insured [n = 1,004]). During the period of transformation, CGM prescription rates increased overall from 15% to 69% (P < 0.001). Improvements were seen equally among Black (12% to 72%), Hispanic (15% to 74%), and White adults (20% to 48%) (between-group P = 0.053).

CONCLUSIONS

Diabetes practice transformations that target equity, offload provider burdens, and focus on feasible sustainable stakeholder-driven solutions can have powerful effects on provider prescribing behaviors to reduce root causes of inequity in CGM among underserved adults with type 1 diabetes. Continued focus is needed on upstream determinants of downstream CGM use.

Hospital-care utilization and medical cost patterns among patients with insulin-dependent diabetes

OBJECTIVE

Using claims data from an integrated payer-provider, we compared the costs incurred by insulin-dependent diabetes mellitus (IDDM) patients who received Hospital Inpatient/Observation/Emergency Department care (HIghER care) for diabetes-related events with those who did not receive such care to identify a target population for interventions in future studies.

METHODS

A retrospective study pooled real-world claims data for IDDM with type 1 or type 2 DM between July 1, 2018 and June 30, 2019. Medical claims were used to calculate the total and diabetes-related allowed medical costs to the Enterprise and per-member per month (pmpm) costs.

RESULTS

A total of 19,378 members' medical and prescription drug coverage were analyzed. Only 8.4% of the IDDM population received HIghER care but incurred 20% of medical expenses, and nearly 40% of diabetes-related medical costs. For HIghER care patients, medical spending was higher in every inpatient and outpatient category (Wilcoxon two sample tests, all p < 0.0001). Non-diabetes related prescription drug costs were greater in this group (Wilcoxon, Z = 2.2879, p = 0.0221), but diabetes-related prescription drug costs were higher for non-HIghER care (Wilcoxon, Z = -9.5918, p < 0.0001). In a longitudinal study of 29,602 patients over 24 months, prior-year receipt of HIghER care was a significant predictor of HIghER care the subsequent year (odds ratio 3.28) CONCLUSIONS: Medical spending for HIghER care patients was disproportionately high and greater in every inpatient and outpatient category. Receipt of HIghER care in the previous year was highly predictive of HIghER care episodes the following year.

In Vitro Evaluation of Miniaturized Amperometric Enzyme Sensor Based on the Direct Electron Transfer Principle for Continuous Glucose Monitoring

BACKGROUND

The bacterial derived flavin adenine dinucleotide (FAD)-dependent glucose dehydrogenase (FADGDH) is the most promising enzyme for the third-generation principle-based enzyme sensor for continuous glucose monitoring (CGM). Due to the ability of the enzyme to transfer electrons directly to the electrode, recognized as direct electron transfer (DET)-type FADGDH, although no investigation has been reported about DET-type FADGDH employed on a miniaturized integrated electrode.

METHODS

The miniaturized integrated electrode was formed by sputtering gold (Au) onto a flexible film with 0.1 mm in thickness and divided into 3 parts. After an insulation layer was laminated, 3 openings for a working electrode, a counter electrode and a reference electrode were formed by dry etching. A reagent mix containing 1.2 × 10^-4 Unit of DET-type FADGDH and carbon particles was deposited. The long-term stability of sensor was evaluated by continuous operation, and its performance was also evaluated in the presence of acetaminophen and the change in oxygen partial pressure (pO₂) level.

RESULTS

The amperometric response of the sensor showed a linear response to glucose concentration up to 500 mg/dL without significant change of the response over an 11-day continuous measurement. Moreover, the effect of acetaminophen and pO₂ on the response were negligible.

CONCLUSIONS

These results indicate the superb potential of the DET-type FADGDH-based sensor with the combination of a miniaturized integrated electrode. Thus, the described miniaturized DET-type glucose sensor for CGM will be a promising tool for effective glycemic control. This will be further investigated using an in vivo study.

Ageing well with diabetes: A workshop to co-design research recommendations for improving the diabetes care of older people

AIMS

To identify key research questions where answers could improve care for older people living with diabetes (PLWD), and provide detailed recommendations for researchers and research funders on how best to address them.

METHODS

A series of online research workshops were conducted, bringing together a range of PLWD and an acknowledged group of academic and clinical experts in their diabetes care to identify areas for future research. Throughout the pre-workshop phase, during each workshop, and in manuscript preparation and editing, PLWD played an active and dynamic role in discussions as part of both an iterative and narrative process.

RESULTS

The following key questions in this field were identified, and research recommendations for each were developed: How can we improve our understanding of the characteristics of older people living with diabetes (PLWD) and their outcomes, and can this deliver better person-centred care? How are services to care for older PLWD currently delivered, both for their diabetes and other conditions? How can we optimise and streamline the process and ensure everyone gets the best care, tailored to their individual needs? What tools might be used to evaluate the level of understanding of diabetes in the older population amongst non-specialist Healthcare Professionals (HCPs)? How can virtual experts or centres most effectively provide access to specialist multi-disciplinary team (MDT) expertise for older PLWD and the HCPs caring for them? Is a combination of exercise and a nutrition-dense, high protein diet effective in the prevention of the adverse effects of type 2 diabetes and deterioration in frailty, and how might this be delivered in a way which is acceptable to people with type 2 diabetes? How might we best use continuous glucose monitoring (CGM) in older people and, for those who require support, how should the data be shared? How can older PLWD be better empowered to manage their diabetes in their own home, particularly when living with additional long-term conditions? What are the benefits of models of peer support for older PLWD, both when living independently and when in care?

CONCLUSIONS

This paper outlines recommendations supported by PLWD through which new research could improve their diabetes care and calls on the research community and funders to address them in future research programmes and strategies.

Association Between Real-Time Continuous Glucose Monitor Use and Diabetes-Related Medical Costs for Patients with Type 2 Diabetes

Little is known about the impact of real-time continuous glucose monitoring (rtCGM) on diabetes-related medical costs within the type 2 diabetes (T2D) population. A retrospective analysis of administrative claims data from the Optum Research Database was conducted. Changes in diabetes-related health care resource utilization costs were expressed as per-patient-per-month (PPPM) costs. A total of 571 T2D patients (90% insulin treated) met study inclusion criteria. Average PPPM for diabetes-related medical costs decreased by -$424 (95% confidence interval [CI] -$816 to -$31, P = 0.035) after initiating rtCGM. These reductions were driven, in part, by reductions in diabetes-related inpatient medical costs: -$358 (95% CI -$706 to -$10, P = 0.044). Inpatient hospital admissions were reduced on average -0.006 PPPM (P = 0.057) and total hospital days were reduced an average of -0.042 PPPM (P = 0.139). These findings provide real-world evidence that rtCGM use was associated with diabetes-related health care resource utilization cost reductions in patients with T2D.

Analysis of "Accuracy of a Seventh-Generation Continuous Glucose Monitoring System in Children and Adolescents With Type 1 Diabetes"

In an article in the Journal of Diabetes Science and Technology, Laffell et al examined the accuracy and performance of a seventh-generation "G7" continuous glucose monitor (CGM) system in participants with type 1 diabetes aged 2 to 17 years. The study had notable points which increase the generalizability of the authors' findings to usual clinical practice, such as accuracy assessment across a wide range of glycemia in the arm and abdominal area, at variable rates of change and time periods (beginning and end of sensor wear). However, accuracy measurements in the younger cohort (2-6 years old) were relatively few. Overall and per-sensor accuracy assessments using standard accuracy metrics were consistently high. The authors also highlighted the enhanced features of the G7 system compared to earlier generation systems, which support better usability.

Relationships Among Perception of Cognitive Function, Diabetes Self-Management, and Glucose Variability in Older Adults: A Mixed Methods Study

The aim of the current study was to explore relationships among perceived cognitive function, glucose variability, and self-management in older adults with type 2 diabetes mellitus (T2DM). A mixed methods design was used with data from: (a) questionnaires on perceived cognitive function and diabetes self-management; (b) continuous glucose monitoring (CGM) reports; and (c) semi-structured interviews. Thirty adults with T2DM (47% female; mean age = 68.5 [SD = 5.2] years) participated. Those who exercised more days per week had more stable glucose. Those who reported fewer days of diet adherence had more hypoglycemia. Participants who reported higher levels of memory dissatisfaction exhibited higher levels of glucose variability. Findings point to the potential of glucose variability as a target to reduce the effect of diabetes on cognitive function. Instruction in recognition of glucose patterns found via CGM can be integrated into self-management education to improve self-management and subsequent glucose control and cognitive function. [Research in Gerontological Nursing, xx(x), xx-xx.].