Using Cluster Analysis to Understand Clinician Readiness to Promote Continuous Glucose Monitoring Adoption

Implementation and Evaluation of a Best Practice Advisory to Reduce Inequities in Technology Use for People With Type 1 Diabetes: Protocol for a Mixed Methods, Nonrandomized Controlled Trial

BACKGROUND

Continuous advancements in diabetes technologies have improved self-management for people with type 1 diabetes. Continuous glucose monitoring and automated insulin delivery systems have enhanced the quality of life and glycemic outcomes while reducing severe hypoglycemia and diabetes ketoacidosis hospitalizations. Despite these benefits, racial inequities in the use of advanced diabetes technology (ADT) persist.

OBJECTIVE

This study aims to develop and evaluate a best practice advisory (BPA) within the electronic medical record (EMR) to reduce racial and ethnic disparities in ADT use. We hypothesize that an EMR-based BPA designed to standardize the prescribing of ADTs will minimize racial and ethnic disparities in ADT adoption or progression in use among pediatric and adult people with type 1 diabetes.

METHODS

The Best Practice Advisories to Reduce Inequities in Technology Use (BPA-TECH) study will use a nonrandomized matched pair intervention design. Phase 1 will use qualitative methods to develop and refine the BPA, including focus groups and surveys of health care providers and people with type 1 diabetes or their caregivers. Phase 2 will evaluate the effectiveness of the BPA through a controlled before-after study of people with type 1 diabetes seen at 7 T1D Exchange Quality Improvement Collaborative (T1DX-QI) centers, with control people with type 1 diabetes matched from nonintervention T1DX-QI centers. The baseline and postintervention periods will be the 12 months before and 12 months after deployment of the BPA at the intervention centers, respectively. Eligibility criteria include people with type 1 diabetes aged ≥2 years with an EMR diagnosis of T1D during the baseline period. The primary outcome is the progression in ADT use from the baseline to postintervention periods.

RESULTS

This 3-year study began in July 2024, with data collection from key stakeholders for phase 1 qualitative research beginning in August 2024. For phase 2, we estimate approximately 3000 eligible non-Hispanic Black and Hispanic people with type 1 diabetes at the intervention centers and 15,000 matched controls. Data on ADT use, glycated hemoglobin (HbA1c), severe hypoglycemic events, and diabetes ketoacidosis events will be collected via the T1DX-QI coordinating center. The study is powered to detect a between-group difference of 15% in the proportion of patients in the intervention and control groups in meeting the primary endpoint. We anticipate the completion of this study by May 2027.

CONCLUSIONS

The BPA-TECH study aims to leverage health IT to address racial and ethnic disparities in ADT use among people with type 1 diabetes. By standardizing the approach to ADT prescribing for people with type 1 diabetes, the BPA-TECH has the potential to promote equity in diabetes management and improve clinical outcomes. The outcomes of this study will inform future efforts to reduce health care disparities.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06931275; https://clinicaltrials.gov/search?term=NCT06931275.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/71038.

Overcoming barriers in continuous glucose monitoring: Challenges and future directions in diabetes management

Recent updates on the efficacy of continuous glucose monitoring (CGM) and a critical examination of the current challenges in its implementation were summarized. The barriers to widespread adoption of this technology should be addressed, considering the impact of different cultural contexts. The strategies to overcome these obstacles and the benefits of CGM for future glucose management will be discussed.

Determinants of implementation of continuous glucose monitoring for patients with Insulin-Treated type 2 diabetes: a national survey of primary care providers

OBJECTIVES

To identify determinants of continuous glucose monitoring (CGM) implementation from primary care providers' (PCPs') perspectives and examine the associations of these determinants with both PCP intent to discuss CGM with eligible patients and facility-level uptake of CGM.

STUDY DESIGN

Cross-sectional survey.

METHODS

A survey about CGM implementation for patients with type 2 diabetes on insulin was distributed to all PCPs in the Department of Veterans Affairs (VA) health system from October 2023-April 2024. Multi-item scales measured perceived clinical benefits of CGM, workload capacity, knowledge about CGM, access to CGM resources, and support from leadership and other services. Responses were on a 5-point Likert scale from "Strongly Disagree" to "Strongly Agree". An item asked about likelihood of initiating discussions about starting CGM. Facility-level uptake was measured using VA administrative data. Multivariable regression models assessed the relationship between determinants of CGM implementation and both PCP intent to discuss CGM and facility-level uptake.

RESULTS

Of 1373 respondents, most perceived clinical benefits of CGM (79% "Agree" + "Strongly Agree"). Very few indicated sufficient access to resources (8%) and support from leadership & other services (5%). After adjustment for respondent characteristics, the scale most strongly associated with PCP intent to discuss CGM was PCP Knowledge About CGM (B = 0.54, P <.001). Facility uptake of CGM was associated with Clinical Benefits of CGM (B = 0.10, P =.026) and Support from Leadership & Other Services (B = 0.18, P <.001).

CONCLUSIONS

PCPs perceive benefits to CGM but lack sufficient knowledge, resources, and workload capacity to manage it alone. PCP education about CGM use and interprofessional support for uptake may increase the likelihood that eligible patients use CGM.

A Qualitative Study of Older Adult Perspectives on Continuous Glucose Monitoring for Type 2 Diabetes

BACKGROUND

Continuous glucose monitoring (CGM) may improve self-management and reduce hypoglycemia risk among individuals with diabetes. However, little is known about how older adults with insulin-treated type 2 diabetes (T2D) experience and incorporate this technology into their daily lives.

OBJECTIVE

To explore experiences, preferences, barriers, and questions related to using CGM among older adults with insulin-treated T2D with and without experience using CGM.

DESIGN

Qualitative focus group study.

PARTICIPANTS

English-speaking older adults with T2D in a large, integrated healthcare delivery system. Groups included either experienced CGM users or adults who had not previously used CGM. Recruitment efforts prioritized individuals ≥ 75 years of age.

APPROACH

Transcripts were analyzed using the Framework Method to identify perspectives on CGM. Specific thematic categories were hypoglycemia-related benefits, general benefits, usefulness and ease of use concerns, and CGM questions.

KEY RESULTS

The study included 26 participants: 17 (65%) were experienced CGM users, 58% were female; median age was 74 (range 62-88) years. Participants perceived and anticipated these CGM benefits: informing behavior changes, reducing in-the-moment hypoglycemia risk, improving awareness and decision-making, and strengthening clinician collaboration. Perceived CGM barriers included challenges with wearability and reliability, burdens to others, distrust of technology, sensory and learning challenges, insufficient clinician support or engagement, and access and payer hurdles. Despite these downsides, experienced users perceived CGM as a worthwhile alternative to daily fingerstick glucose checks. Non-users were able to formulate many usability questions, providing a snapshot of informational needs for this age group.

CONCLUSIONS

Older adults with insulin-treated T2D experienced or anticipated benefits from CGM for diabetes management. Findings indicate a need for tailored education and self-management support for older adults to learn and gain maximal benefit from this technology.

Student pharmacist counseling performance after hands-on continuous glucose monitoring education: A multi-institutional pragmatic randomized study

OBJECTIVE

To assess the impact of wearing a continuous glucose monitoring (CGM) device on student pharmacist counseling ability (primary), knowledge, confidence, and empathy (secondary).

METHODS

Students from two institutions were randomized to wear a CGM device (intervention) vs not (control). All received CGM education via lecture and live demonstration. Intervention group students were provided a CGM device. After two weeks, all students completed a standardized patient (SP) encounter regarding CGM prescription counseling. Pre-post CGM-related knowledge, confidence, and empathy were assessed. Analysis of variance was used to compare between-group counseling score difference, and analysis of covariance was used to compare changes in pre-post knowledge, confidence, and empathy scores. Analyses were performed using Stata/BE17.0.

RESULTS

Of 86 students enrolled, 63 consented and completed surveys (32 intervention, 31 control). The intervention group demonstrated higher average SP counseling score vs control (82.4 % vs 77.7 %, p = .046). The intervention group had greater change in confidence vs control from pre to post survey (+ 2.3 vs + 1.7, p = 0.03, range 1-5). No between-group differences were observed in knowledge or empathy.

CONCLUSION

The opportunity to wear a CGM device resulted in higher performance on CGM counseling and greater rise in CGM-related confidence. This study supports the use of resources to provide hands-on CGM training.

PRACTICE IMPLICATIONS

Hands-on education about new diabetes technology can help students prepare to care for and counsel patients.

Augmenting clinicians' analytical workflow through task-based integration of data visualizations and algorithmic insights: a user-centered design study

OBJECTIVES

To understand healthcare providers' experiences of using GlucoGuide, a mockup tool that integrates visual data analysis with algorithmic insights to support clinicians' use of patientgenerated data from Type 1 diabetes devices.

MATERIALS AND METHODS

This qualitative study was conducted in three phases. In Phase 1, 11 clinicians reviewed data using commercial diabetes platforms in a think-aloud data walkthrough activity followed by semistructured interviews. In Phase 2, GlucoGuide was developed. In Phase 3, the same clinicians reviewed data using GlucoGuide in a think-aloud activity followed by semistructured interviews. Inductive thematic analysis was used to analyze transcripts of Phase 1 and Phase 3 think-aloud activity and interview.

RESULTS

3 high level tasks, 8 sub-tasks, and 4 challenges were identified in Phase 1. In Phase 2, 3 requirements for GlucoGuide were identified. Phase 3 results suggested that clinicians found GlucoGuide easier to use and experienced a lower cognitive burden as compared to the commercial diabetes data reports that were used in Phase 1. Additionally, GlucoGuide addressed the challenges experienced in Phase 1.

DISCUSSION

The study suggests that the knowledge of analytical tasks and task-specific visualization strategies in implementing features of data interfaces can result in tools that lower the perceived burden of engaging with data. Additionally, supporting clinicians in contextualizing algorithmic insights by visual analysis of relevant data can positively influence clinicians' willingness to leverage algorithmic support.

CONCLUSION

Task-aligned tools that combine multiple data-driven approaches, such as visualization strategies and algorithmic insights, can improve clinicians' experience in reviewing device data.

Safety and Feasibility Evaluation of Automated User Profile Settings Initialization and Adaptation With Control-IQ Technology

BACKGROUND

Optimization of automated insulin delivery (AID) settings is required to achieve desirable glycemic outcomes. We evaluated safety and efficacy of a computerized system to initialize and adjust insulin delivery settings for the t:slim X2 insulin pump with Control-IQ technology in adults with type 1 diabetes (T1D).

METHODS

After a 2-week continuous glucose monitoring (CGM) run-in period, adults with T1D using multiple daily injections (MDI) (N = 33, mean age 36.1 years, 57.6% female, diabetes duration 19.7 years) were transitioned to 13 weeks of Control-IQ technology usage. A computerized algorithm generated recommendations for initial pump settings (basal rate, insulin-to-carbohydrate ratio, and correction factor) and weekly follow-up settings to optimize glycemic outcomes. Physicians could override the automated settings changes for safety concerns.

RESULTS

Time in range 70 to 180 mg/dL improved from 45.7% during run-in to 69.1% during the last 30 days of Control-IQ use, a median improvement of 18.8% (95% confidence interval [CI]: 13.6-23.9, P < .001). This improvement was evident early in the study and was sustained over 13 weeks. Time <70 mg/dL showed a gradual decreasing trend over time. Percentage of participants achieving HbA1c <7% went from zero at baseline to 55% at study end (P < .001). Only six of the 318 automated settings adaptations (1.9%) were overridden by study investigators.

CONCLUSIONS

Computerized initiation and adaptation of Control-IQ technology settings from baseline MDI therapy was safe in adults with T1D. The use of this simplified system for onboarding and optimizing Control-IQ technology may be useful to increase uptake of AID and reduce staff and patient burden in clinical care.

Unveiling the interplay between rational, psychological and functional factors in continuous glucose monitoring early adoption: Novel evidence from the Dexcom ONE case in Italy

BACKGROUND

The escalating prevalence of diabetes, with its multifaceted complications, poses a pressing challenge for healthcare systems globally. In response, the advent of continuous glucose monitoring (CGM) systems, offering technological solutions for daily diabetes management, presents significant opportunities. However, the widespread adoption faces several barriers, linked both to the technological configuration of the devices and to the psychological dimension of patients. Therefore, this study aims to apply and test a theoretical model that investigates the antecedents of the intention to use Continuous Glucose Monitoring systems.

METHODS

The research model was built to unveil the impacts of psychological factors, functional components and rational constructs derived from the Technology Acceptance Model (TAM) on CGM systems sustained adoption. To ensure the comparability of results, we have collected data from people who had used Dexcom ONE Dexcom (San Diego, CA) for the first time for at least one month. Employing Structural Equation Modelling (SEM) techniques, the hypothesized relationships among constructs were assessed.

RESULTS

The analyses confirmed the positive correlation of rational factors to the Intention to Use. Subjective Norm, intended as the physicians' influence, is positively correlated with the Perceived Usefulness. Trend Arrows, albeit being negatively correlated with Perceived Usefulness, have a positive correlation on Perceived Ease Of Use, reinforcing its mediating effect towards Perceived Usefulness. Among psychological factors, Trust in the CGM technology positively correlates with Intention to Use. Health Literacy is negatively correlated to the Intention to Use.

CONCLUSIONS

These findings contribute to theoretical and managerial understanding, providing recommendations to enhance the adoption of CGM systems like Dexcom ONE.

Social Determinants of Health Screening in Type 1 Diabetes Management

Type 1 diabetes management is intricately influenced by social determinants of health. Economic status impacts access to vital resources like insulin and diabetes technology. Racism, social injustice, and implicit biases affect equitable delivery of care. Education levels affect understanding of self-care, leading to disparities in glycemic outcomes. Geographic location can limit access to health care facilities. Stressors from discrimination or financial strain can disrupt disease management. Addressing these social factors is crucial for equitable diabetes care, emphasizing the need for comprehensive strategies that go beyond medical interventions to ensure optimal health outcomes for all individuals with type 1 diabetes.

Roadmap to the Effective Use of Continuous Glucose Monitoring by Diabetes Care and Education Specialists as Technology Champions

This article describes the implementation of a diabetes technology educational program targeting continuous glucose monitoring (CGM) adoption that significantly increased utilization of CGM in the Division of Pediatric Endocrinology at the University of Florida. The author proposes that diabetes care and education specialists (DCESs) are uniquely positioned in the health care ecosystem to serve as diabetes technology champions. The article provides a step-by-step roadmap that DCESs and clinicians can use as they lead efforts to expand CGM adoption and durable use.

Evaluation of a New Clinical Tool to Enhance Clinical Care of Control-IQ Users

BACKGROUND

The purpose of this study was to develop and test a new Clinic Tool to assist health care professionals with clinical care of persons with diabetes using the Control-IQ system.

METHODS

A Clinic Tool was iteratively developed with input from diabetes clinicians, which outlined a systematic process for assessing data, reviewing insulin settings, providing education, and documenting the encounter. Diabetes clinicians were recruited to trial the Clinical Tool in up to five clinical encounters (in-person, telehealth, or telephone). Quantitative surveys and free-text responses, including a knowledge quiz and the System Usability Scale (SUS), were administered to determine clinician satisfaction, confidence, knowledge, and implications for practice.

RESULTS

Twenty-nine clinicians (43% endocrinologists, mean 10.7 years in practice) enrolled in the study and completed 89 encounters using the Control-IQ Clinic Tool. Participants spent an average of 10 minutes using the Tool and reported excellent SUS scores within the 90%-95% percentile for usability. Knowledge quiz scores increased in 42% of participants. Both familiarity with Control-IQ and confidence providing clinical care to Control-IQ users significantly improved (P = .009 and P < .001 respectively). Ninety percent of participants agreed that the Tool will change their clinical care going forward.

CONCLUSION

The Control-IQ Clinical Tool is highly usable and impacted clinical care delivery to Control-IQ users. Tools that serve to improve clinician confidence in delivery of care to diabetes device users should be expanded, leveraged, and studied to assess the impact on adherence and glycemic control for persons with diabetes.

Association of Continuous Glucose Monitor Receipt and Diabetes Care Provider Type: A Cohort Study of West Virginia Medicaid Beneficiaries With Type 1 Diabetes

OBJECTIVE

To compare the prevalence of West Virginia Medicaid (WVM) beneficiaries with type 1 diabetes (T1D) with a WVM administrative claim for continuous glucose monitoring (CGM) supplies by whether they received medical care from a board-certified endocrinologist.

METHODS

A total of 1494 WVM beneficiaries aged 20-64 with T1D were retrospectively followed from May 2018 to April 2020. The sample consisted of 2 groups: those receiving medical care from board-certified endocrinologists and those receiving medical care from other providers. CGM prevalence is compared before and after WVM started providing insurance coverage for beneficiaries with T1D to use CGM systems in May 2019 using linear regression with and without adjustments for patient characteristics.

RESULTS

Thirty-five percent of beneficiaries received care from a board-certified endocrinologist at any point during the sample period. Post-May 2019, the prevalence of WVM administrative claims for CGM supplies was significantly higher among beneficiaries receiving care from an endocrinologist compared with other providers.

CONCLUSIONS

Receiving diabetes care from a board-certified endocrinologist is positively associated with having administrative claims for CGM supplies.

Increasing Continuous Glucose Monitoring Use for Non-Hispanic Black and Hispanic People With Type 1 Diabetes: Results From the T1D Exchange Quality Improvement Collaborative Equity Study

Despite the benefits of continuous glucose monitoring (CGM), there is lower use of this technology among non-Hispanic Black and Hispanic people with type 1 diabetes compared with their non-Hispanic White counterparts. The T1D Exchange Quality Improvement Collaborative recruited five endocrinology centers to pilot an equity-focused quality improvement (QI) study to reduce racial inequities in CGM use. The centers used rapid QI cycles to test and expand interventions such as provider bias training, translation of CGM materials, provision of CGM education in multiple languages, screening for social determinants of health, and shared decision-making. After implementation of these interventions, median CGM use increased by 7% in non-Hispanic White, 12% in non-Hispanic Black, and 15% in Hispanic people with type 1 diabetes. The gap between non-Hispanic White and non-Hispanic Black patients decreased by 5%, and the gap between non-Hispanic White and Hispanic patients decreased by 8%.

Disparities in Hemoglobin A1c Levels in the First Year After Diagnosis Among Youths With Type 1 Diabetes Offered Continuous Glucose Monitoring

IMPORTANCE

Continuous glucose monitoring (CGM) is associated with improvements in hemoglobin A1c (HbA1c) in youths with type 1 diabetes (T1D); however, youths from minoritized racial and ethnic groups and those with public insurance face greater barriers to CGM access. Early initiation of and access to CGM may reduce disparities in CGM uptake and improve diabetes outcomes.

OBJECTIVE

To determine whether HbA1c decreases differed by ethnicity and insurance status among a cohort of youths newly diagnosed with T1D and provided CGM.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used data from the Teamwork, Targets, Technology, and Tight Control (4T) study, a clinical research program that aims to initiate CGM within 1 month of T1D diagnosis. All youths with new-onset T1D diagnosed between July 25, 2018, and June 15, 2020, at Stanford Children's Hospital, a single-site, freestanding children's hospital in California, were approached to enroll in the Pilot-4T study and were followed for 12 months. Data analysis was performed and completed on June 3, 2022.

EXPOSURES

All eligible participants were offered CGM within 1 month of diabetes diagnosis.

MAIN OUTCOMES AND MEASURES

To assess HbA1c change over the study period, analyses were stratified by ethnicity (Hispanic vs non-Hispanic) or insurance status (public vs private) to compare the Pilot-4T cohort with a historical cohort of 272 youths diagnosed with T1D between June 1, 2014, and December 28, 2016.

RESULTS

The Pilot-4T cohort comprised 135 youths, with a median age of 9.7 years (IQR, 6.8-12.7 years) at diagnosis. There were 71 boys (52.6%) and 64 girls (47.4%). Based on self-report, participants' race was categorized as Asian or Pacific Islander (19 [14.1%]), White (62 [45.9%]), or other race (39 [28.9%]); race was missing or not reported for 15 participants (11.1%). Participants also self-reported their ethnicity as Hispanic (29 [21.5%]) or non-Hispanic (92 [68.1%]). A total of 104 participants (77.0%) had private insurance and 31 (23.0%) had public insurance. Compared with the historical cohort, similar reductions in HbA1c at 6, 9, and 12 months postdiagnosis were observed for Hispanic individuals (estimated difference, -0.26% [95% CI, -1.05% to 0.43%], -0.60% [-1.46% to 0.21%], and -0.15% [-1.48% to 0.80%]) and non-Hispanic individuals (estimated difference, -0.27% [95% CI, -0.62% to 0.10%], -0.50% [-0.81% to -0.11%], and -0.47% [-0.91% to 0.06%]) in the Pilot-4T cohort. Similar reductions in HbA1c at 6, 9, and 12 months postdiagnosis were also observed for publicly insured individuals (estimated difference, -0.52% [95% CI, -1.22% to 0.15%], -0.38% [-1.26% to 0.33%], and -0.57% [-2.08% to 0.74%]) and privately insured individuals (estimated difference, -0.34% [95% CI, -0.67% to 0.03%], -0.57% [-0.85% to -0.26%], and -0.43% [-0.85% to 0.01%]) in the Pilot-4T cohort. Hispanic youths in the Pilot-4T cohort had higher HbA1c at 6, 9, and 12 months postdiagnosis than non-Hispanic youths (estimated difference, 0.28% [95% CI, -0.46% to 0.86%], 0.63% [0.02% to 1.20%], and 1.39% [0.37% to 1.96%]), as did publicly insured youths compared with privately insured youths (estimated difference, 0.39% [95% CI, -0.23% to 0.99%], 0.95% [0.28% to 1.45%], and 1.16% [-0.09% to 2.13%]).

CONCLUSIONS AND RELEVANCE

The findings of this cohort study suggest that CGM initiation soon after diagnosis is associated with similar improvements in HbA1c for Hispanic and non-Hispanic youths as well as for publicly and privately insured youths. These results further suggest that equitable access to CGM soon after T1D diagnosis may be a first step to improve HbA1c for all youths but is unlikely to eliminate disparities entirely.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04336969.

Clarifying the unmet clinical need during medical device innovation in women's health - A narrative review

Medical technologies are pervasive across women's health, spanning across obstetric and gynecological care. FemTech, the sector responsible for developing these technologies, is growing at 15.6% per annum. However, there are concerns of disconnects between new product development (NPD) and the care afforded to women in consequence of implementing these innovations. The most crucial stage of NPD involves understanding the clinical need. Without a clear need and clinical use case, innovators risk developing solutions which do not address the issues women and caregivers experience. Thus, the product will miss the market and experience limited uptake. Tools for performing clinical needs assessments and defining the use case are being developed. This review provides an analysis of their strengths and weaknesses to inform FemTech innovators of the available resources. We further discuss concepts for creating a unified approach to assessing unmet needs such that technologies have a higher chance of improving women's healthcare.

Increasing Use of Diabetes Devices: What Do Health Care Professionals Need?

Despite evidence of improved diabetes outcomes with diabetes technology such as continuous glucose monitoring (CGM) systems, insulin pumps, and hybrid closed-loop (HCL) insulin delivery systems, these devices are underutilized in clinical practice for the management of insulin-requiring diabetes. This low uptake may be the result of health care providers' (HCPs') lack of confidence or time to prescribe and manage devices for people with diabetes. We administered a survey to HCPs in primary care, pediatric endocrinology, and adult endocrinology practices in the United States. Responding HCPs expressed a need for device-related insurance coverage tools and online data platforms with integration to electronic health record systems to improve diabetes technology uptake in these practice settings across the United States.

Tele-education model for primary care providers to advance diabetes equity: Findings from Project ECHO Diabetes

Introduction

In the US, many individuals with diabetes do not have consistent access to endocrinologists and therefore rely on primary care providers (PCPs) for their diabetes management. Project ECHO (Extension for Community Healthcare Outcomes) Diabetes, a tele-education model, was developed to empower PCPs to independently manage diabetes, including education on diabetes technology initiation and use, to bridge disparities in diabetes.

Methods

PCPs (n=116) who participated in Project ECHO Diabetes and completed pre- and post-intervention surveys were included in this analysis. The survey was administered in California and Florida to participating PCPs via REDCap and paper surveys. This survey aimed to evaluate practice demographics, protocols with adult and pediatric T1D management, challenges, resources, and provider knowledge and confidence in diabetes management. Differences and statistical significance in pre- and post-intervention responses were evaluated via McNemar's tests.

Results

PCPs reported improvement in all domains of diabetes education and management. From baseline, PCPs reported improvement in their confidence to serve as the T1D provider for their community (pre vs post: 43.8% vs 68.8%, p=0.005), manage insulin therapy (pre vs post: 62.8% vs 84.3%, p=0.002), and identify symptoms of diabetes distress (pre vs post: 62.8% vs 84.3%, p=0.002) post-intervention. Compared to pre-intervention, providers reported significant improvement in their confidence in all aspects of diabetes technology including prescribing technology (41.2% vs 68.6%, p=0.001), managing insulin pumps (41.2% vs 68.6%, p=0.001) and hybrid closed loop (10.2% vs 26.5%, p=0.033), and interpreting sensor data (41.2% vs 68.6%, p=0.001) post-intervention.

Discussion

PCPs who participated in Project ECHO Diabetes reported increased confidence in diabetes management, with notable improvement in their ability to prescribe, manage, and troubleshoot diabetes technology. These data support the use of tele-education of PCPs to increase confidence in diabetes technology management as a feasible strategy to advance equity in diabetes management and outcomes.

Implicit Racial-Ethnic and Insurance-Mediated Bias to Recommending Diabetes Technology: Insights from T1D Exchange Multicenter Pediatric and Adult Diabetes Provider Cohort

Background: Despite documented benefits of diabetes technology in managing type 1 diabetes, inequities persist in the use of these devices. Provider bias may be a driver of inequities, but the evidence is limited. Therefore, we aimed to examine the role of race/ethnicity and insurance-mediated provider implicit bias in recommending diabetes technology. Method: We recruited 109 adult and pediatric diabetes providers across 7 U.S. endocrinology centers to complete an implicit bias assessment composed of a clinical vignette and ranking exercise. Providers were randomized to receive clinical vignettes with differing insurance and patient names as proxy for Racial-Ethnic identity. Bias was identified if providers: (1) recommended more technology for patients with an English name (Racial-Ethnic bias) or private insurance (insurance bias), or (2) Race/Ethnicity or insurance was ranked high (Racial-Ethnic and insurance bias, respectively) in recommending diabetes technology. Provider characteristics were analyzed using descriptive statistics and multivariate logistic regression. Result: Insurance-mediated implicit bias was common in our cohort (n = 66, 61%). Providers who were identified to have insurance-mediated bias had greater years in practice (5.3 ± 5.3 years vs. 9.3 ± 9 years, P = 0.006). Racial-Ethnic-mediated implicit bias was also observed in our study (n = 37, 34%). Compared with those without Racial-Ethnic bias, providers with Racial-Ethnic bias were more likely to state that they could recognize their own implicit bias (89% vs. 61%, P = 0.001). Conclusion: Provider implicit bias to recommend diabetes technology was observed based on insurance and Race/Ethnicity in our pediatric and adult diabetes provider cohort. These data raise the need to address provider implicit bias in diabetes care.

Barriers and Facilitators to Diabetes Device Adoption for People with Type 1 Diabetes

PURPOSE OF REVIEW

Diabetes technology (insulin pumps, continuous glucose monitoring, automated insulin delivery systems) has advanced significantly and provides benefits to the user. This article reviews the current barriers to diabetes device adoption and sustained use, and outlines the known and potential facilitators for increasing and sustaining device adoption.

RECENT FINDINGS

Barriers to diabetes device adoption continue to exist at the system-, provider-, and individual-level. Known facilitators to promote sustained adoption include consistent insurance coverage, support for providers and clinics, structured education and support for technology users, and device user access to support as needed (e.g., through online resources). Systemic barriers to diabetes device adoption persist while growing evidence demonstrates the increasing benefits of newest devices and systems. There are ongoing efforts to develop evidence-based structured education programs to support device adoption and sustained use.

Help when you need it: Perspectives of adults with T1D on the support and training they would have wanted when starting CGM

AIMS

The purpose of this study was to explore preferences that adults with type 1 diabetes (T1D) have for training and support to initiate and sustain optimal use of continuous glucose monitoring (CGM) technology.

METHODS

Twenty-two adults with T1D (M age 30.95 ± 8.32; 59.1% female; 90.9% Non-Hispanic; 86.4% White; diabetes duration 13.5 ± 8.42 years; 72.7% insulin pump users) who had initiated CGM use in the past year participated in focus groups exploring two overarching questions: (1) What helped you learn to use your CGM? and (2) What additional support would you have wanted? Focus groups used a semi-structured interview guide and were recorded, transcribed and analyzed.

RESULTS

Overarching themes identified were: (1) "I got it going by myself": CGM training left to the individual; (2) Internet as diabetes educator, troubleshooter, and peer support system; and (3) domains of support they wanted, including content and format of this support.

CONCLUSION

This study identifies current gaps in training and potential avenues for enhancing device education and CGM onboarding support for adults with T1D. Providing CGM users with relevant, timely resources and attending to the emotional side of using CGM could alleviate the burden of starting a new device and promote sustained device use.

"I Didn't Really Have a Choice": Qualitative Analysis of Racial-Ethnic Disparities in Diabetes Technology Use Among Young Adults with Type 1 Diabetes

Background: Racial-ethnic disparities in diabetes technology use are well documented in young adults (YA) with type 1 diabetes (T1D), but modifiable targets for intervention still need to be identified. Our objective was to explore YA perspectives on technology access and support in routine clinical care. Materials and Methods: Participants were YA with T1D of Hispanic or non-Hispanic Black race-ethnicity from pediatric and adult endocrinology clinics in the Bronx, NY. We conducted semistructured individual interviews to explore how health care and personal experiences affected technology use. Interviews were audio-recorded and transcribed for analysis. We used a modified inductive coding approach with two independent coders and iterative coding processes to improve data reliability and validity. Results: We interviewed 40 YA with T1D: mean age 22 years; 62% female; 72% Medicaid insured; 72% Hispanic; 28% non-Hispanic Black; and mean hemoglobin A1C 10.3%. Themes were categorized into potentially exacerbating and alleviating factors of racial-ethnic disparities in technology use. Exacerbating factors included perceptions that providers were gatekeepers of information and prescription access to technology, providers did not employ shared decision making for use, and YA biases against technology were left unaddressed. Alleviating factors included provider optimism and tailoring of technology benefits to YA needs, and adequate Medicaid insurance coverage. Conclusions: Our results reveal potential intervention targets at the provider level to increase technology uptake among underrepresented YA with T1D. Diabetes health care providers need to be aware of inadvertent withholding of information and prescription access to technology. Provider approaches that address YA technology concerns and promote shared decision making help to mitigate racial/ethnic disparities in technology use.

Provider Implicit Bias Impacts Pediatric Type 1 Diabetes Technology Recommendations in the United States: Findings from The Gatekeeper Study

BACKGROUND

Diabetes technology use is associated with favorable type 1 diabetes (T1D) outcomes. American youth with public insurance, a proxy for low socioeconomic status, use less diabetes technology than those with private insurance. We aimed to evaluate the role of insurance-mediated provider implicit bias, defined as the systematic discrimination of youth with public insurance, on diabetes technology recommendations for youth with T1D in the United States.

METHODS

Multi-disciplinary pediatric diabetes providers completed a bias assessment comprised of a clinical vignette and ranking exercises (n = 39). Provider bias was defined as providers: (1) recommending more technology for those on private insurance versus public insurance or (2) ranking insurance in the top 2 of 7 reasons to offer technology. Bias and provider characteristics were analyzed with descriptive statistics, group comparisons, and multivariate logistic regression.

RESULTS

The majority of providers [44.1 ± 10.0 years old, 83% female, 79% non-Hispanic white, 49% physician, 12.2 ± 10.0 practice-years] demonstrated bias (n = 33/39, 84.6%). Compared to the group without bias, the group with bias had practiced longer (13.4±10.4 years vs 5.7 ± 3.6 years, P = .003) but otherwise had similar characteristics including age (44.4 ± 10.2 vs 42.6 ± 10.1, p = 0.701). In the logistic regression, practice-years remained significant (OR = 1.47, 95% CI [1.02,2.13]; P = .007) when age, sex, race/ethnicity, provider role, percent public insurance served, and workplace location were included.

CONCLUSIONS

Provider bias to recommend technology based on insurance was common in our cohort and increased with years in practice. There are likely many reasons for this finding, including healthcare system drivers, yet as gatekeepers to diabetes technology, providers may be contributing to inequities in pediatric T1D in the United States.

Evaluating the relationship between clinical and demographic characteristics of insulin-using people with diabetes and their health outcomes: a cluster analysis application

Background

The aim of this study was to determine how clusters or subgroups of insulin-treated people with diabetes, based upon healthcare resource utilization, select social demographic and clinical characteristics, and diabetes management parameters, are related to health outcomes including acute care visits and hospital admissions.

Methods

This was a non-experimental, retrospective cluster analysis. We utilized Aetna administrative claims data to identify insulin-using people with diabetes with service dates from 01 January 2015 to 30 June 2018. The study included adults over the age of 18 years who had a diagnosis of type 1 (T1DM) or type 2 diabetes mellitus (T2DM) on insulin therapy and had Aetna medical and pharmacy coverage for at least 18 months (6 months prior and 12 months after their index date, defined as either their first insulin prescription fill date or their earliest date allowing for 6 months’ prior coverage). We used K-means clustering methods to identify relevant subgroups of people with diabetes based on 13 primary outcome variables.

Results

A total of 100,650 insulin-using people with diabetes were identified in the Aetna administrative claims database and met study criteria, including 11,826 (11.7%) with T1DM and 88,824 (88.3%) with T2DM. Of these 79,053 (78.5%) people were existing insulin users. Seven distinct clusters were identified with different characteristics and potential risks of diabetes complications. Overall, clusters were significantly associated with differences in healthcare utilization (emergency room visits, inpatient admissions, and total inpatient days) after multivariable adjustment.

Conclusions

This analysis of healthcare claims data using clustering methodologies identified meaningful subgroups of patients with diabetes using insulin. The subgroups differed in comorbidity burden, healthcare utilization, and demographic factors which could be used to identify higher risk patients and/or guide the management and treatment of diabetes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06603-0.

Initiating hybrid closed loop: A program evaluation of an educator-led Control-IQ follow-up at a large pediatric clinic

BACKGROUND

Control-IQ (Tandem Diabetes) is a hybrid closed-loop (HCL) system that users self-initiate after completing online training. Best practices for clinical follow-up are not known. Our quality improvement objective was to evaluate the usefulness of an educator-led follow-up program for new HCL users in a type 1 diabetes pediatric clinic.

METHODS

We implemented an ''HCLCheck-in'' program, first determining when users started HCL, then having diabetes educators contact them for a follow-up call 2-weeks after start. Educators used a Clinical Tool to inform insulin dose and behavior recommendations, and used four benchmarks to determine need for further follow-up: ≥71% HCL use, ≥71% CGM use, ≥60% Time-in-Range (TIR, 70-180 mg/dL), <5% below 70 mg/dL. Family and educator satisfaction were surveyed.

RESULTS

One-hundred-twenty-three youth [mean age 13.6 ± 3.7 y, 53.7% female, mean HbA1c 7.6 ± 1.4% (60 mmol/mol)] completed an HCLCheck-in call a median (IQR) of 18(15, 21) days post-HCL start. 74 users (60%) surpassed benchmarks with 94% HCL use and 71% TIR. Of the 49 who did not, 16 completed a second call, and improved median TIR 12.5% (p = 0.03). HCL users reported high satisfaction with the program overall [median 10 (9, 10) out of 10]. Educators spent a median of 45 (32,70) minutes per user and rated satisfaction with the program as 8 (7,9.5) and the Tool as 9 (9, 10).

CONCLUSION

Our HCLCheck-in program received high satisfaction ratings and resulted in improved TIR for those initially not meeting benchmarks, suggesting users may benefit from early follow-up. Similar programs may be beneficial for other new technologies.

Technology readiness of medical students and the association of technology readiness with specialty interest

BACKGROUND

Technology readiness (TR) is a construct which characterizes an individual's propensity to utilize new technology. Despite increased technology use in healthcare, limited data exists on medical student TR and the relation of TR with specialty interest. This study assesses the TR of 2nd year medical students and its association with specialty interest.

METHODS

Respondents completed a survey assessing their most preferred specialty, specialty interests, and technology readiness using a 5-point Likert scale. Using Chi-square analysis, we examined the relation between demographics, TR, and specialty interest.

RESULTS

This study obtained a 45.7% (n = 53/116) response rate demonstrating that 79.2% (n = 42/53) of students were "technology ready." Male students were more likely to be technology ready (95.2%, n = 20/21, vs 68.8%, n = 22/32, p = 0.02) when compared to female students. Technology ready students were associated with being more interested in "Technology-Focused" specialties compared to students who were not technology ready (88.5%, n = 23/26 vs 70.4%, n = 19/27, p = 0.104).

CONCLUSIONS

As a cohort, most medical students were technology ready. It is inconclusive if technology ready students are more likely to be interested in technology-focused specialties due to the limited sample size of this study, although with an increased sample size, an improved understanding on technology readiness and its potential impact on student specialty interest may be obtained. Furthermore, knowledge of TR may aid in developing targeted technology-based education programs and in improving remedial approaches for students who are less comfortable with new technology.

Fostering Engagement With Health and Housing Innovation: Development of Participant Personas in a Social Housing Cohort

BACKGROUND

Personas, based on customer or population data, are widely used to inform design decisions in the commercial sector. The variety of methods available means that personas can be produced from projects of different types and scale.

OBJECTIVE

This study aims to experiment with the use of personas that bring together data from a survey, household air measurements and electricity usage sensors, and an interview within a research and innovation project, with the aim of supporting eHealth and eWell-being product, process, and service development through broadening the engagement with and understanding of the data about the local community.

METHODS

The project participants were social housing residents (adults only) living in central Cornwall, a rural unitary authority in the United Kingdom. A total of 329 households were recruited between September 2017 and November 2018, with 235 (71.4%) providing complete baseline survey data on demographics, socioeconomic position, household composition, home environment, technology ownership, pet ownership, smoking, social cohesion, volunteering, caring, mental well-being, physical and mental health-related quality of life, and activity. K-prototype cluster analysis was used to identify 8 clusters among the baseline survey responses. The sensor and interview data were subsequently analyzed by cluster and the insights from all 3 data sources were brought together to produce the personas, known as the Smartline Archetypes.

RESULTS

The Smartline Archetypes proved to be an engaging way of presenting data, accessible to a broader group of stakeholders than those who accessed the raw anonymized data, thereby providing a vehicle for greater research engagement, innovation, and impact.

CONCLUSIONS

Through the adoption of a tool widely used in practice, research projects could generate greater policy and practical impact, while also becoming more transparent and open to the public.

Barriers to Continuous Glucose Monitoring in People With Type 1 Diabetes: Clinician Perspectives

The purpose of this study was to determine clinician attitudes about the distinct barriers to uptake of continuous glucose monitoring (CGM) among people with diabetes. Survey data were collected measuring individual barriers, prerequisites to CGM, confidence in addressing barriers, and clinic staff resources. Results show that clinicians commonly report barriers to using CGM among people with diabetes in their clinic. Furthermore, clinicians who report a high number of barriers do not feel confident in overcoming the barriers to CGM. Interventions that attempt to empower clinicians to address concerns about CGM among people with diabetes may be warranted because low uptake does not appear to be directly related to available resources or prerequisites to starting CGM.

Technology Integration: The Role of the Diabetes Care and Education Specialist in Practice

Purpose

Technology is rapidly evolving and has become an integral component of diabetes care. People with diabetes and clinicians are harnessing a variety of technologies, including connected blood glucose meters, continuous glucose monitors, insulin pumps, automated insulin delivery systems, data-sharing platforms, telehealth, remote monitoring, and smartphone mobile applications to improve clinical outcomes and quality of life. Although diabetes technology use is associated with improved outcomes, this is enhanced when the person using it is knowledgeable and actively engaged; simply wearing the device or downloading an app may not automatically translate into health benefits. The diabetes care and education specialist (DCES) has a central role in defining and establishing a technology-enabled practice setting that is efficient and sustainable. The purpose of this article is to describe the role of the DCES in technology implementation and to demonstrate the value of diabetes technology in both the care of the individual and as a tool to support population-level health improvements.

Conclusion

By following the recommendations in this article, DCESs can serve as technology champions in their respective practices and work to reduce therapeutic inertia while improving health outcomes and providing patient-centered care for the populations they serve.

Integration of Diabetes Technology in Clinical Practice

This article attempts to aid clinicians in using diabetes devices in their clinical practice. It reviews device selection, initiation, and follow-up. It discusses work flow in an office and provides tips on billing. It stresses the need for patient choice, education, and on-going support through downloading and interpretation of data to optimize care.

Benefits and limitations of continuous glucose monitoring in type 1 diabetes

Introduction: Type 1 diabetes (T1D) is a chronic condition characterized by a complete deficiency in insulin production. Optimal management requires constant knowledge of glucose levels for safe and effective insulin administration. Self-monitoring of blood glucose (SMBG) using capillary blood glucose meters is cumbersome and provides limited information to guide management. Continuous glucose monitoring (CGM) technology addresses many of these gaps, but itself has limitations which have prevented people with diabetes and their clinicians from fully embracing this technology. This review covers the benefits and limitations of CGM use, and looks toward future application of this technology in the management of T1D.Areas covered: Impact of CGM on physical and psychosocial outcomes in people with T1D. Barriers to CGM uptake. Integration with insulin pumps and other technologies. Opportunities for future application.Expert opinion: CGM technology will be utilized by the majority of people with T1D and increasing numbers of people with type 2 diabetes due to improved insurance coverage and easier-to-use systems. Its use as part of artificial pancreas systems will add further utility, as it will help to protect from both hypoglycemia and hyperglycemia. People with diabetes will spend more time in range and experience fewer acute and chronic complications.

Realizing a Closed-Loop (Artificial Pancreas) System for the Treatment of Type 1 Diabetes

Recent, rapid changes in the treatment of type 1 diabetes have allowed for commercialization of an "artificial pancreas" that is better described as a closed-loop controller of insulin delivery. This review presents the current state of closed-loop control systems and expected future developments with a discussion of the human factor issues in allowing automation of glucose control. The goal of these systems is to minimize or prevent both short-term and long-term complications from diabetes and to decrease the daily burden of managing diabetes. The closed-loop systems are generally very effective and safe at night, have allowed for improved sleep, and have decreased the burden of diabetes management overnight. However, there are still significant barriers to achieving excellent daytime glucose control while simultaneously decreasing the burden of daytime diabetes management. These systems use a subcutaneous continuous glucose sensor, an algorithm that accounts for the current glucose and rate of change of the glucose, and the amount of insulin that has already been delivered to safely deliver insulin to control hyperglycemia, while minimizing the risk of hypoglycemia. The future challenge will be to allow for full closed-loop control with minimal burden on the patient during the day, alleviating meal announcements, carbohydrate counting, alerts, and maintenance. The human factors involved with interfacing with a closed-loop system and allowing the system to take control of diabetes management are significant. It is important to find a balance between enthusiasm and realistic expectations and experiences with the closed-loop system.

Predictive Glucose Trends From Continuous Glucose Monitoring: Friend or Foe in Clinical Decision Making?

In this commentary, we briefly review the currently recommended approaches to interpretation and management of continuous glucose monitor (CGM) rate of change (ROC) trend arrows and discuss the inherent difficulty in incorporating practical recommendations for their application into routine clinical care. We have limited our review and discussion to the currently available Dexcom G5 and G6 CGM systems and Abbott's Freestyle Libre flash glucose monitor (FGM) system, as they are the most widely used and currently approved for nonadjunctive use in the United States.

Continuous Glucose Monitoring Integration in Clinical Practice: A Stepped Guide to Data Review and Interpretation

BACKGROUND

The advent of continuous glucose monitoring (CGM) technology has transformed the approach to diabetes care. Multiple CGM systems are commercially available and increased accuracy has allowed development of hybrid and automated insulin delivery systems. Evidence of CGM clinical benefits has also increased exponentially in the last decade.

METHODS

Literature search, review of professional guidelines, and consensus statements were used to guide the preparation of this article. The clinical benefits of both professional and personal CGM in clinical practice as well as barriers to wider adotpion were explored. A stepped approach to review and interpretation of CGM data is suggested for use in the clinician's office regardless of the software used.

RESULTS

Although increasing, the use of CGM in patients with diabetes is still not widespread; multiple barriers are still in place, despite the approval of CGM systems for patients above the age of 2 years old, the extension of coverage for Medicare beneficiaries and the integration of CGM with multiple insulin pump systems. Integration of CGM technology in clinical practice presents various challenges, from concerns relative to time constraints during office visits to lack of systematic approach to interpretation of the data.

CONCLUSIONS

Understanding the usefulness of personal and professional CGM, appropriate patient selection as well as patient and provider training are crucial for the expansion of CGM therapy use in clinical practice. Utilizing the proposed stepped approach to CGM review and interpretation may allow wider adoption of CGM with more effective and efficient office visits.