Attitudes and Behaviors with Diabetes Technology Use in the Hospital: Multicenter Survey Study in the United States

Abstract

Objective:

To assess the attitudes, behaviors, and barriers with diabetes technology use in the general medicine hospital wards.

Research Design and Methods:

The authors developed a nonincentivized web-based anonymous survey that captured demographic and practice data regarding continuous subcutaneous insulin infusion (CSII) and continuous glucose monitor (CGM) use in the hospital.

Setting:

Four large hospital systems in the United States.

Results:

Among 128 survey respondents, 76%, 10%, and 6% were hospitalists, advanced practice providers, and primary care physicians, respectively. The majority of respondents rated the treatment of inpatient hyperglycemia (96%) and the continuation of CSII during the hospital stay (93%) “important.” While most respondents (64%) acknowledged knowing the existence of their institution's policies for CSII use, only 84% of those respondents felt somewhat to very familiar with the policy. The most common barrier to CSII use in the inpatient setting was lack of practitioner (70%) and nursing (67%) knowledge of using the device. With regard to CGM use in the hospital, a minority (28%) of respondents were aware of their institution's CGM policies. Less than half of the providers, 43.8%, stated that, when admitting a patient, they reviewed CGM data to guide insulin dosing.

Conclusions:

In this US multicenter survey, we found that most inpatient practitioners valued glycemic control, but many were not familiar with institutional policies, had lack of knowledge with CSII, and were not reviewing CGM data.

Introduction

The prevalence of diagnosed and undiagnosed diabetes mellitus (DM) in the United States has been steadily increasing. In 2018, almost 13.0% of adults aged 18 years or older in the United States carried a diagnosis of DM.¹ Patients with DM have a threefold greater chance of hospitalization compared with those without DM.² Diabetes has become one of the most common conditions managed in the hospital, and it is estimated that 26% of adults admitted to the hospital have diabetes.³

The role of technology in the management of ambulatory/outpatient diabetes (both type 1 and type 2) has become increasingly common in recent years. Continuous glucose monitors (CGM) and insulin pumps (continuous subcutaneous insulin infusion) [CSII]) are undergoing rapid technological advancement, and many patients with diabetes are now benefiting from CGM, CSII, and/or integrated hybrid closed-loop systems.⁴ In patients registered with the T1D Exchange Clinic Registry, insulin pump use increased from 57% in 2010–2012 to 63% in 2016–2018⁴ and to 70% in 2020.⁵ Use of CGM increased from 7% in 2010–2012 to 30% in 2016–2018, with an exponential increase in use beginning between the years 2013 and 2014.⁴

However, there is paucity of data regarding provider experience on CSII and CGM use in the inpatient setting. While there is no provider experience data, studies have shown that patient satisfaction is increased when allowed to continue their CSII in the inpatient setting.^6,7 Moreover, there is increasing data supporting that CGM provides better detection of hypoglycemia, particularly asymptomatic and nocturnal hypoglycemia, and that a “glucose telemetry system” with real-time CGM could prevent inpatient hypoglycemia.^8,9 In 2016, The Joint Commission collaborated with the American Diabetes Association (ADA) and mandated that institutions maintain insulin pump policies and protocols for accreditation.¹⁰ In 2021, The ADA published clinical practice recommendations and recommended that patients continue to use CSII when hospitalized as long as proper supervision is available and the patient is physically and mentally capable.¹¹ The American Association of Clinical Endocrinologists released a similar consensus statement advocating for continuation of CSII in the inpatient setting.¹²

Lastly, in June 2022, the Endocrine Society suggested that patients continue CSII therapy rather than changing to subcutaneous basal bolus insulin therapy in hospitals with access to personnel with expertise in CSII therapy.¹³ This guideline was also the first to remark on hybrid closed-loop technology recommending continuation of the same as long as it does not interfere with hospital care.¹³

Consensus statements regarding CGM use in the acute care setting were largely absent until recently. In April 2020, the Diabetes Technology Society formed a panel of experts in diabetes technologies from the United States, Europe, and Australia and published a consensus guideline statement with regard to CGM and CSII use in the acute care setting.¹⁴ The recently published Clinical Practice Guideline from the Endocrine Society recommended the use of CGM in patients with diabetes who were hospitalized with noncritical illness and deemed high risk for hypoglycemia.¹³ The guideline recommended against the use of CGM in patients with extensive skin infections, hypoperfusion, hypovolemia, those on vasoactive or pressor therapy, or those on medications that could interfere with CGM readings.¹³

With increasing interest and evidence on the use of DM technology in the hospital since COVID, we sought to determine the behaviors and attitudes of hospitalists, advanced practice providers (APPs), and primary care physicians (PCPs) with regard to CGM and CSII. Furthermore, we aimed to identify barriers that providers perceive as limiting their ability to care for patients utilizing CSII and CGM. We also aimed to determine the most common causes that lead to the discontinuation of the aforementioned technologies. We hope that the results of this survey will provide insight regarding the current state of diabetes technology use in the inpatient setting from the provider perspective.

Materials and Methods

Participants

The survey was conducted from September 2020 to December 2020. The survey was sent through an email through the respective institutions' investigators to hospitalists, PCPs, and APPs with inpatient (day and/or night) responsibilities at four large hospital systems (Cleveland Clinic, University of Chicago, Emory University, and Vanderbilt University). These hospital systems comprised academic teaching, Veterans Affairs, and community teaching and nonteaching hospitals. All respondents received a direct email from the principal investigator at each site. This email explained the purpose and objectives of the questionnaire as well as the voluntary, nonincentivized nature of the questionnaire. After the initial email request, one reminder email was sent ∼4 weeks later.

Questionnaire

The questionnaire (Appendix Fig. 1) was developed by our investigators comprising hospital medicine providers and endocrinologists, including one trained in questionnaire development and analysis (M.C.L.). To reach consensus, we subjected each questionnaire item to multiple cycles of review and revision. The questionnaire was designed to assess attitudes, behaviors, and barriers of inpatient providers to the use of CSII and CGM in the inpatient setting. Furthermore, the questionnaire inquired regarding the familiarity of the providers with their respective institutions' CSII and CGM policies. The questionnaire captured data on the respondent characteristics (practice setting, years of experience, volume of patients with CSII/CGM, and provider type) but did not record specific individual practitioner identifiable information. The questionnaire was only available in English. The 20-item questionnaire was anonymous, voluntary, and nonincentivized.

Questionnaires were distributed through email through the respective author/s in that institution using the secure Research Electronic Data Capture (REDCap) survey software (Vanderbilt University, TN, USA, 2004). Data were collected and stored in the Cleveland Clinic Foundation-secure database. The questionnaire and study design were approved by each collaborating institution's institutional review board (IRB).

Statistical methods

Responses to the survey were summarized overall, and then by role, institution type, and experience level using frequencies and percentages. Comparisons of binary and unordered categorical response questions were compared using Fisher exact tests or Pearson chi-square tests. Ordered response questions were compared using Wilcoxon rank-sum tests for two-group comparisons and Kruskal–Wallis tests for years of experience. When overall comparisons of the four experience levels were significant, pairwise comparisons using Bonferroni-corrected significance levels of 0.0083 were performed. Comparisons of role and institution type were made using 0.05 significance levels.

For statistical analysis based on provider roles, day hospitalists were compared versus all others. For analysis based on institution type, academic medical centers were compared versus all other. Finally, for analysis based on years of experience, providers were grouped by <2 years, 2–5 years, 6–10 years, and 10 or more years of experience. Analysis was performed using SAS software (version 9.4; Cary, NC).

Results

Respondent demographics

Survey invitations were sent to ∼500 inpatient providers and responses were obtained from 128 (25% response rate). Many of the respondents identified as day hospitalists (76%) and identified their primary clinical role of practice at academic medical centers (67.5%). Fifty-five percent of respondents reported greater than 5 years of clinical practice and 24% reported less than 2 years of practice (Table 1).

Table 1.

Baseline Characteristics

Factor	Total (N = 128)
Factor	N (Respondents)	Statistics, N (%)
How would you best describe your primary clinical role?	128
Day hospitalist		98 (76.6)
Nocturnist		9 (7.0)
PCP with inpatient care		8 (6.3)
Advanced practice provider (Nurse Practitioner and Physician Assistant)		13 (10.2)
Primary clinical role	128
Nonhospitalist		30 (23.4)
Hospitalist		98 (76.6)
Describe the institution in which you spend the majority of your inpatient time?	126
Academic Medical Center		85 (67.5)
Community Teaching Hospital		22 (17.5)
Community Non-Teaching Hospital		18 (14.3)
Veterans Affairs Hospital		1 (0.79)
Primary inpatient institution type	126
Other Medical Center		41 (32.5)
Academic Medical Center		85 (67.5)
How many years have you been practicing?	128
<1 Year		12 (9.4)
1–2 Years		19 (14.8)
3–5 Years		27 (21.1)
6–10 Years		29 (22.7)
10 or More years		41 (32.0)
How many years have you been practicing at your current institution?	128
<1 Year		16 (12.5)
1–2 Years		30 (23.4)
3–5 Years		32 (25.0)
6–10 Years		24 (18.8)
10 or More years		26 (20.3)

Views on the importance of glycemic control and inpatient CSII continuation

Almost all providers (96.1%) felt that treatment of hyperglycemia in noncritically ill patients was “important” or “very important” (Table 2).

Table 2.

Summary of Inpatient Providers' Attitudes Regarding Hyperglycemia and Diabetes Technologies

Category	Response category (%)
Category	Very familiar	Somewhat familiar	Not at all familiar	Unaware of policy
Familiarity with inpatient institutional policy for
CSII (n = 118)	11	47	11	30
CGM (n = 110)	7	21	4	67

	Very Important	Important	Slightly Important	Not Important
Importance of
Treating hyperglycemia in noncritically ill patients on regular nursing floor (n = 127)	50	46	4	0
Continuing CSII if no contraindication to continuation exists (n = 128)	59	34	7	0

	Strongly agree	Agree	Disagree	Strongly disagree	Do not review parameters
Confidence with
Managing DM after discontinuing CSII (n = 103)	14	47	25	14	—
Interpreting CSII parameters to guide therapy when discontinuing CSII (n = 133)	6	17	24	4	49

Values are percentages of total responses.

CGM, continuous glucose monitors; CSII, continuous subcutaneous insulin infusion; DM, diabetes mellitus.

Ninety-three percent of respondents reported a perceived importance of continuation of CSII in the inpatient setting if no contraindication to continuation of the device existed as “very important” or “important.” Nonhospitalists were significantly more likely to rate CSII continuation as important or very important compared with those who identified as hospitalists (P = 0.002).

Familiarity with existing policies and procedures

When asked whether their respective institution had policies for the use of CSII in the inpatient setting, 69% (N = 82) of respondents acknowledged that their institution has a policy for CSII use in the inpatient setting, but only 82% of these respondents (N = 69) reported being somewhat or very familiar with the policy (Table 2). Knowledge of CGM policies was lower with only 28% of respondents (N = 37) acknowledging that their institution has an inpatient CGM policy. Of those respondents who were aware of a CGM policy, most (62%) reported being only “somewhat familiar” with the details of the policy. Among the same group of respondents who stated familiarity (very or somewhat familiar) with their inpatient CGM policy, 67% stated that CGM was allowed for use on the wards and 54.8% stated that concomitant point-of-care glucose testing was needed for adjustment of diabetes medications.

Those who identified working at an academic center were more likely to indicate that they had an inpatient diabetes consult service, were less likely to know if there were institution policies for CGM usage and were less familiar with institution policies for CSII use.

All four institutions have a policy for CSII; one institution did not have a formal CGM policy at the time of the survey.

Confidence with management after discontinuation of CSII

The majority of our respondents (61%) indicated that they felt confident managing a patient's diabetes after discontinuing CSII. Half of the respondents (51%) report they do not review CSII settings (e.g., basal rates, carbohydrate ratios, insulin sensitivity factor) when admitting a patient with a CSII to guide therapy independent of whether continuing the pump or not. Of the 62 respondents who reported reviewing CSII settings, 50% felt confident reviewing the settings to guide further therapy after discontinuation of the CSII. It was noted that those who practiced at an academic center were less likely to be confident managing diabetes after insulin pump removal (P = 0.027) and were less likely to review pump settings to guide therapy (P = 0.018). Providers with more clinical experience (>10 years) were more confident managing diabetes and interpreting CSII setting after removal than those with less experience (2–5 years).

Perceived barriers to care

The most common reason cited for discontinuation of CSII was secondary to altered mental status and impaired level of consciousness (38%). Providers also cited Diabetic Ketoacidosis (27.3%) and the patient's inability to demonstrate appropriate pump usage (26.6%) as common reasons for discontinuation of CSII. When asked to cite any barriers to continuation of CSII in the inpatient setting, the most commonly cited barriers to continuation was the lack of practitioner's knowledge using CSII (70.3%) and perceived lack of nursing knowledge with regard to CSII use (67.2%). Risk of causing hypoglycemia was also cited as a common barrier to continuation (Tables 3 and 4).

Table 3.

Reasons for Discontinuation of Continuous Subcutaneous Insulin Infusion for Inpatient Diabetes Mellitus Management

Rank order	Discontinuation reason	Value
Rank order	Discontinuation reason	No.	%
1	Impaired level of consciousness or altered mental status	49	38.3
2	Diabetic ketoacidosis and hyperosmolar hyperglycemic state	35	27.3
3	Patient's inability to demonstrate appropriate pump usage	34	26.6
4	Pump malfunction	24	18.8
5	Lack of pump supplies	23	18
6	Lack of trained health care providers, diabetes educators, or diabetes specialist	22	17.2
7	Discontinuation reason: refusal or unwillingness to participate in self-care	12	9.4
8	Psychiatric illness that interferes with a patient's ability to self-manage the diabetes	11	8.6
9	Other	7	5.5
10	Patient at risk for suicide	1	0.78

n = 128. From most to least frequent.

Table 4.

Barriers to Continuing Continuous Subcutaneous Insulin Infusion in the Inpatient Setting

Rank order	Barrier	Value
Rank order	Barrier	No.	%
1	Lack of practitioner knowledge using pump	90	70.3
2	Perceived lack of nursing knowledge using pump	86	67.2
3	Risk of causing hypoglycemia	38	29.7
4	Fear of medicolegal implications	21	16.4
5	Endocrinology consult not readily available	14	10.9
6	Convenience	13	10.2
7	No barriers	12	9.4
8	Other	3	2.3

n = 128. From most to least frequent.

Those who practiced at academic centers were more likely to cite lack of practitioner knowledge as a continuation barrier (P = 0.004). With regard to provider experience, those with 10 or more years of experience were more likely to cite a perceived lack of nursing knowledge as a continuation barrier compared with those <2 years of experience.

Provider-reported behaviors surrounding CSII

More than half (69%) of the surveyed providers stated that they consulted their hospital's endocrinology service for patients admitted with CSII. Providers who identified practicing at an academic medical center were more likely to consult with endocrinology for patients admitted with an insulin pump. Almost all providers (96%) stated that they would continue the patients CSII if no contraindication to doing so. Providers preferred to discontinue CSII through the pump interface (58%) rather than physical removal of the pump if they were to discontinue the pump for any reason. After discontinuation of CSII, more than half (61.5%) of the providers stated that they used the patient's pump setting to determine how much basal insulin to start with or without mealtime insulin.

Almost a third (27.0%) preferred to use a weight-based calculation to start basal insulin with or without mealtime insulin, while 8.2% reported they would start a regular human insulin infusion, and 3% stated that they started correctional insulin monotherapy (i.e., no basal insulin).

Provider behaviors surrounding CGM

Respondents had variable exposure to continuous glucose monitors in the inpatient setting. Slightly more than half (52.8%) of the providers surveyed had cared for at least one patient with a CGM in the previous 6 months to the questionnaire. Of those providers who had exposure to CGM, 43.8% stated that, when admitting a patient, they reviewed the data from the monitor to guide therapy. Those providers who identified practicing in an academic center were less likely to review CGM data to guide therapy. With respect to clinical experience, those with 6–10 years of experience were less likely to review CGM data than those with 2–5 years of experience

Discussion

Our study is the first to investigate the attitudes and practices of inpatient licensed independent practitioners in the United States related to newer diabetes technologies. We have shown that most inpatient providers value glycemic control and use of insulin pumps; however, many reported limited knowledge of CSII and CGM devices for optimal use to guide clinical care in the inpatient setting. Our survey showed that providers largely continued CSII when no contraindication to continuation. Limited knowledge on the use of CSII was the largest barrier, with seventy percent of respondents citing lack of provider knowledge of pump use as a barrier to continuation. Interestingly, most of the respondents who reported lack of CSII knowledge were providers at academic settings.

Although these centers have dedicated inpatient endocrinology services, hospitalists and other inpatient providers are the first to encounter these patients. Their role is vital in their ability to either convey confidence by reassuring the patient that there is a team to provide care or can come across as unsure and unsympathetic if unable to respond to patients' requests to use the technology in a manner that is aligned with the hospital's policy.

Increasing evidence in the last decade has showed improved outcomes in patients with DM who use CSII and/or CGM. The integration of CGM and CSII together in sensor-augmented pump therapy and closed-loop hybrid systems has been even more promising in increasing glucose time in range. This has led to the increased use of these technologies in patients who have diabetes in the ambulatory setting. The integration of devices into the hospital milieu is less clear.

A qualitative survey was conducted in Germany comprising patients with type 1 diabetes (n = 136) and health care professionals (HCP, n = 96) regarding their attitudes and experience with CSII in the inpatient setting. The majority of responses were classified as poor experiences by both patients and providers (patients n = 127; HCP n = 115). Patients cited infringement of patient autonomy by fear of having their CSII removed by hospital staff. HCPs cited lack of familiarity with CSII and concerns regarding troubleshooting issues that may arise in case of pump failure.¹⁵ Another study that surveyed 18 patients and 16 registered nurses in the United States found similar attitudes of patient-perceived lack of familiarity of CSII by nursing staff. This perception was validated by nurses, who admitted a limited understanding of pump technology.¹⁶

Our study showed that most providers were comfortable with managing diabetes after discontinuation of CSII. Providers, though, did not leverage the use of pump settings to guide their medical decision-making after discontinuation of CSII. Most respondents stated that they did not interrogate CSII settings on the device itself. With regard to CGM, providers largely stated that they did not look at these data to make treatment changes.

Educational programs and collaboration between inpatient providers and endocrinologists are needed to safely optimize the use of CSII and CGM in the hospital setting. Furthermore, based on the work done by Grammes et al and Kaisen et al, there exists a lapse in familiarity at the nursing level. Inpatient diabetes management has many stakeholders including patients, nurses, and providers. Collaboration between all stakeholders involved will not only foster a safe environment for use of technologies, but also increase patient satisfaction and hopefully improve inpatient glycemic control.

Clear consensus guidelines have existed for quite a while regarding the appropriateness of use of CSII in the ambulatory setting. In contrast, recommendations from professional societies regarding the use of ambulatory or professional CGM in the inpatient setting were largely absent until the recent consensus guidelines from the Diabetes Technology Society and the Clinical Practice Guideline published from the Endocrine Society. We speculate that this is mostly secondary to lack of validation studies as well as FDA guidance. Not surprisingly, our cohort was less familiar with the use of CGM in the inpatient setting compared with CSII. Our authors agree with the Endocrine Society Clinical Practice Guideline; hospitals should have policies and procedures including informed consent, standardized order sets, and expertise from a health care professional who is knowledgeable in CSII and CGM interpretation. Elements needed for successful incorporation of CSII and CGM in the hospital are outlined in several publications.^17,18

Our study has its limitations. The respondent rate was only 25%, but this is fairly typical in the medical literature. In a study randomizing physicians to an incentive or reminder to fill out a survey, the average response rate was 11.4%.¹⁹ In a systematic review of survey responses from 25 different countries/subregions, response rates of health care professionals were consistently lower than those of patients,²⁰ with web-based ranking lower than in-person, mail, or email. Although we attempted to include hospital systems that included community hospitals, our respondents were largely from academic centers, and might reduce generalizability.

Although the survey was sent to varying providers at different types of medical centers (e.g., academic, nonteaching), most of our respondents were academic hospitalists. More representation from nonteaching community inpatient providers as well as nonmedicine (i.e., surgical services) would have given a clearer picture of current attitudes and behaviors across the spectrum of specialties and centers. Furthermore, more research inquiring into the patients' experience with the use of their diabetes technologies should be done. Lastly, patient safety outcomes should be researched to ascertain that no adverse outcomes occur by the implementation of these technologies in the inpatient setting.

Conclusion

With the increased use of CSII and CGM in patients with type 1 and type 2 DM, hospitalists and inpatient providers have been placed on the front line in deciding whether to continue or discontinue these technologies. We found that providers value glycemic control and use of diabetes technologies in the inpatient setting. Providers admittedly felt that they were not familiar with the use of these technologies to guide therapy. More collaboration between inpatient hospital medicine providers and endocrinologists is necessary to improve integration of diabetes technologies in the hospital milieu when indicated.

Footnotes

Acknowledgments

N.Z.M. wrote the article and is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. R.J.G., J.L.D., E.M.-H., M.J.F., H.F.S., P.R.H., G.E.U., and M.C.L. edited and revised the article. R.J.G., J.L.D., E.M.-H., M.J.F., H.F.S., P.R.H., and G.E.U. participated in the study design and collected data from practitioners at their respective institutions. J.F.B. was responsible for analysis of data.

Author Disclosure Statement

G.E.U. has received unrestricted research support for research studies (to Emory University) from Astra Zeneca and Dexcom, Inc. R.J.G. received research support to Emory University for investigator-initiated studies from Novo Nordisk, Dexcom, and Eli Lilly and consulting fees from Sanofi, Eli Lilly, Novo Nordisk, Pfizer, Merck, Boehringer, and Weight Watchers, outside of this work. G.E.U. has received research support (to Emory University) from Dexcom, Abbott, and Bayer. M.C.L. has received research support to Cleveland Clinic for an investigator-initiated study from Dexcom. N.Z.M., H.F.S., M.J.F., J.F.B., E.M.-H., P.R.H., and J.L.D. have no reported disclosures. In Memoriam—M.J.F.: The community of diabetes practitioners is greatly saddened by the death of Dr. Michael Fowler who was a beloved husband, father, and dedicated clinician to his community and beyond. With this work, we honored his legacy to patient care and dedication to improve diabetes in the hospital.

Funding Information

G.E.U. is partly supported by NIH/NATS UL1 TR002378 from the Clinical and Translational Science Award program, and 1P30DK111024-01 from the NIH/NIDDK; R.J.G. is partially supported by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) of the National Institutes of Health (NIH) under Award Number K23DK123384. G.E.U. is partly supported by NIH/NATS UL 3UL1TR002378-05S2 from the Clinical and Translational Science Award program, and NIH/NIDDK 2P30DK111024-06 from the NIH and the National Center for Research Resources.

Appendix

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