Abstract
Introduction
As we cement ourselves firmly in 2022, we bring with us familiar and not‐so‐familiar issues that impact on the human factors aspects of diabetes. Novel technologies such as Siri that integrated continuous glucose monitors to support sight‐impaired individuals highlight the innovative ways technologies are being used to serve a broader patient population, while preclinic assessments and exploration of the impact of data sharing on quality of life provide useful insights into the priorities and concerns of users and caregivers.
User experiences, both personal and from a parent perspective, provide new insights into the needs and challenges people face when initiating novel technologies. These insights are important both in themselves, but also in terms of how they can inform onboarding strategies so that expectations are both realistic and matched with user experience. Attitudes and barriers related to device use must be explored openly and constructively to ensure the right technology solution for each individual person living with it as well as those providing diabetes support. As diabetes devices become the standard of care for many, it is crucial to ensure understanding about the benefits and limitations of such devices in the context of wearing it/using them every day for however many years the contract lasts.
Similarly, challenges faced when going about one's daily lives are highlighted in research reporting tensions between school nurses and parents regarding nurses' skills in operating diabetes technologies and refusal of nurses to use sensors due to potential liability burden involved. These structural and personal challenges continue to pose difficulties for optimal diabetes management and again highlight the need for guiding policies, enhanced training, and collaboration between stakeholders to ensure children with diabetes are safe and well at school.
Never more than now has it been so important to consider the lived experiences of disease and disease management, in terms of behaviors, technologies, and, perhaps most importantly, access to therapies and devices. Much has been written about social determinants of health and inequalities in healthcare, which featured heavily at the recent American Diabetes Association conference. Growing evidence clearly demonstrates the widening inequalities in terms of access to diabetes technologies. Data from the Type 1 Diabetes Exchange in the United States and from the UK National Paediatric Diabetes Audit data show worrying trends in worsening access for those from poorer socioeconomic and ethnic minority groups. Such data perhaps replicates longstanding inequalities in access to insulin and amplifies the variation in terms of access to healthcare around the world. We include a number of articles this year on disparities in diabetes technology use and glycemic control across gender, racial, and socioeconomic parameters.
Key Articles Reviewed for the Article
Akturk HK, Snell‐Bergeon JK, Shah VN
Messer LH, Tanenbaum ML, Cook PF, Wong JJ, Hanes SJ, Driscoll KA, Hood KK
Barnard‐Kelly K, Kelly RC, Chernavvsky D, Lal R, Cohen L, Ali A
Polonsky WH, Fortmann AL
Elbalshy M, Boucher S, Crocket H, Galland B, MacKenzie C, de Bock MI, Jefferies C, Wiltshire E, Wheeler BJ
March CA, Nanni M, Kazmerski TM, Siminerio LM, Miller E, Libman IM
Wong JJ, Barley RC, Hanes S, Tanenbaum ML, Lanning M, Naranjo D, Hood KK
Faulds ER, Hoffman RP, Grey M, Tan A, Tubbs‐Cooley H, Militello LK, Happ MB
Commissariat PV, Whitehouse AL, Hilliard ME, Miller KM, Harrington KR, Levy W, DeSalvo DJ, Van Name MA, Anderson B, Tamborlane WV, DiMeglio L, Laffel LM
Addala A, Auzanneau M, Miller K, Maier W, Foster N, Kapellen T, Walker A, Rosefacefanbauer J, Maahs DM, Holl RW
Meunier L, Aguadé AS, Videau Y, Verboux D, Fagot‐Campagna A, Gastaldi‐Menager C, Amadou C
Agarwal S, Schechter C, Gonzalez J, Long JA
Continuous Glucose Monitor with Siri Integration Improves Glycemic Control in Legally Blind Patients with Diabetes
Akturk HK, Snell‐Bergeon JK, Shah VN
Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO
Background
Continuous glucose monitoring (CGM) is safe and effective in optimizing glycemic control in insulin‐treated patients with diabetes. However, the safety of CGM use in legally blind patients with diabetes is unknown.
Methods
This is a retrospective study of seven legally blind patients with diabetes on intensive insulin therapy who were using Dexcom G6 with voice‐enabled Apple's Siri feature. CGM metrics, HbA1c, and frequency of severe hypoglycemia were measured for 12 months.
Results
There was a significant reduction in HbA1c after 3, 6, and 12 months of Dexcom G6 with Apple Siri use (P<0.0001). Time in range increased at 12 months (50.9% – 5.5% at 3 months vs 56.8% – 5.5% at 12 months, P=0.029) without increase in time spent in hypoglycemia. There was a significant reduction in severe hypoglycemia requiring medical assistance for 12 months.
Conclusions
The use of voice‐enabled CGM improves blood sugar control and reduces severe hypoglycemia in legally blind patients with diabetes on intensive insulin therapy.
Comment
Despite the considerable technological advances in the treatment of diabetes, there are still some shortcomings in the adaptation of the instrumentation in diabetes for people with special needs (1). Diabetes care can be challenging in visually impaired patients with diabetes who require intensive insulin treatment. Insulin administration products such as pens, pumps, and CGM are not widely tailored for visually impaired patients with diabetes. Dexcom G6 with Siri feature represents significant progress in assisting visually impaired people with diabetes. Along with the impressive innovation, there are still technological challenges. Because the system is passive, the patient must use an alarm installed in the sensor to receive an alert about high or low sugar values and only then use the app. This situation can be challenging for patients with technological illiteracy—those who have difficulty coping with technology for various reasons, such as older people or people coming from low socioeconomic backgrounds.
Cost, Hassle, and On‐Body Experience: Barriers to Diabetes Device Use in Adolescents and Potential Intervention Targets
Messer LH1, Tanenbaum ML2, Cook PF3, Wong JJ2, Hanes SJ2, Driscoll KA4, Hood KK2
1Barbara Davis Center, University of Colorado School of Medicine, Aurora, CO; 2Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA; 3College of Nursing, University of Colorado, Aurora, CO; 4Department of Clinical and Health Psychology, University of Florida, Gainesville, FL
This manuscript is also discussed in article on Diabetes Technology and Therapy in the Pediatric Age Group, page XX
Background
Diabetes in adolescents has the highest HbA1c of any age group. Diabetes devices (insulin pumps and continuous glucose monitors [CGM]) can help with glycemic control, and while their use has increased, they are still underused in this population. The goal of this study was to evaluate adolescent‐reported barriers to diabetes device use so that physician assistance can be targeted.
Methods
The authors surveyed 411 adolescents with type 1 diabetes (mean age 16.30±2.25 years) on barriers to diabetes device use, technology use attitudes (general and diabetes specific), benefits and burdens of CGM, self‐efficacy for diabetes care, diabetes distress, family conflict, and depression. We characterized barriers to device uptake; assessed demographic and psychosocial differences in device users, discontinuers, and nonusers; and determined differences in device use by gender and age.
Results
The majority of adolescents used an insulin pump (n=307, 75%) and more than half used CGM (n=225, 55%). Cost/insurance‐related concerns were the most commonly endorsed barrier category (61%) followed by wear‐related issues (58.6%), which include the hassle of wearing the device (38%) and dislike of device on the body (33%). Adolescents who endorsed more barriers also reported more diabetes distress (P=0.003), family conflict (P=0.003), and depressive symptoms (P=0.014). Pump and CGM discontinuers both endorsed more barriers and more negative perceptions of technology than current users but reported no difference from device users in diabetes distress, family conflict, or depression. Gender was not related to the perceptions of devices.
Conclusions
Clinicians can proactively assess attitudes toward diabetes technology and the perceived benefits/burdens to encourage device use and potentially prevent device discontinuation in youth.
Comment
Visibility of disease state has long been recognized as a barrier to uptake of diabetes devices, despite potential improvements in glycemic control and quality of life. Messer and colleagues surveyed 411 adolescents with type 1 diabetes (mean age 16.30 – 2.25 years) about a range of diabetes‐related beliefs. These included barriers to diabetes device use, technology use attitudes, benefits and burdens of continuous glucose monitoring systems, self‐efficacy for diabetes care, diabetes distress, family conflict, and depression. Interestingly, 75% of respondents use an insulin pump and 55% use CGM, yet wear‐related issues were reported as barriers by 58.6% of respondents. This came second only to cost/insurance‐related issues, which were cited by 61% of respondents. Wear‐related issues included the hassle of wearing the device (38%) and dislike of the device on the body (33%). The authors argue that clinicians can proactively assess attitudes toward diabetes technology and perceptions of benefits/burdens when encouraging device uptake, which would potentially prevent discontinuation. There are several useful measures to assess expectations of devices, as well as technology acceptance. Matching expectations to experience is key to ensuring users are able to realize most benefits of diabetes devices, while minimizing burden in the context of everyday lived experience. While hassles of diabetes devices have been associated with older systems, there has been a growing misconception among healthcare professionals that newer systems are more acceptable. The data in the survey clearly shows this is not the case.
Feasibility of Spotlight Consultations Tool in Routine Care: Real‐World Evidence
Barnard‐Kelly K1,2, Kelly RC2, Chernavvsky D3, Lal R4, Cohen L2, Ali A5
1Faculty of Health & Social Science, Bournemouth University, Bournemouth, UK; 2BHR Limited, Portsmouth, UK; 3Dexcom Ltd, San Diego, CA; 4Stanford University School of Medicine, Palo Alto, CA; 5Blackburn and Darwen CCG, Blackburn, UK
J Diabetes Sci Technol Mar 12;1932296821994088. doi: 10.1177/1932296821994088. Online ahead of print
Background
Burnout is at an all‐time high among diabetics and healthcare professionals (HCPs). Spotlight AQ, a new “smart” adaptable patient questionnaire, is intended to improve consultations by quickly identifying patient priorities and presenting them in the context of best‐practice care pathways. We wanted to see if Spotlight AQ could be used in everyday treatment.
Materials and methods
The Spotlight prototype tool was trialed at three centers: two UK primary care centers and one U.S. specialist center (June–September 2020). Participants with type 1 (T1D) or type 2 diabetes (T2D) completed the questionnaire prior to their routine consultations. Results were immediately available and formed the basis of the clinical discussion and decision‐making within the clinic visit.
Results
A convenience sample of 49 adults took part, n=31 T1D (n=18 female); and n=18 T2D (n=10 male, n=4 female, n=4 gender unreported). Each identified two priority concerns. “Psychological burden of diabetes” was the most common priority concern (T1D n=27, 87.1%) followed by “gaining more skills about particular aspects of diabetes” (T1D n=19, 61.3%), “improving support around me” (n=8, 25.8%) and “diabetes‐related treatment issues” (n=8, 25.8%). Burden of diabetes was widespread as was lack of confidence around self‐management. Similarly, psychological burden of diabetes was the primary concern for participants with T2D (n=18,100%) followed by “gaining more skills about aspects of diabetes” (n=7, 38.9%), “improving support around me” (n=7, 38.9%), and “diabetes‐related treatment issues” (n=4; 22.2%).
Conclusions
The use of Spotlight AQ in everyday treatment is appropriate and practicable. Gaining new abilities and managing the psychological impact of diabetes are two high‐priority areas that must be addressed if high levels of suffering are to be reduced.
Comment
In an American Diabetes Association position statement published in 2012, it was emphasized that collaborative, multidisciplinary teams are best suited to provide optimal care of patients with diabetes, and to facilitate patients' performance of appropriate self‐management. Unfortunately, in many diabetes centers, this is not the case. As noted in this study, currently, healthcare visits are designed to focus on biomedical results of diabetes within a healthcare framework, despite the increased awareness concerning the important role of psychosocial aspects of diabetes in improving patients' quality of life and glycemic control. The use of patient‐centered e‐tools within routine care is a novel and important aspect of diabetes technology. This study demonstrated that it could improve the healthcare experience for both healthcare practitioners and their patients. In the COVID‐19 era, traditional face‐to‐face consultations are no longer the only option. The implementation of personalized healthcare e‐tools may significantly help improve the treatment of people with diabetes.
Impact of Real‐Time CGM Data Sharing on Quality of Life in the Caregivers of Adults and Children with Type 1 Diabetes
Polonsky WH1,2, Fortmann AL3
1Behavioral Diabetes Institute, San Diego, CA; 2Department of Medicine, University of California, San Diego, CA; 3Scripps Whittier Diabetes Institute, La Jolla, CA
Background
To evaluate caregivers' experiences with real‐time continuous glucose monitoring (RT‐CGM) data sharing and its effect on quality of life (QoL) and health measures.
Methods
Parents of children with type 1 diabetes (T1D) (N=303) and spouses/partners of T1D adults (N=212) using the Dexcom G5 Mobile or G6 RT‐CGM system and who were actively following their T1Ds' RT‐CGM data completed a survey examining their perceived value of data sharing, the impact of sharing on their own QoL and their child/partner's health, and how they used RT‐CGM data to support their T1Ds' diabetes management. Regression analyses examined whether their actions were linked to reported changes in QoL and health outcomes.
Results
Most respondents were non‐Hispanic white (91.1% parents; 88.7% partners), female (78.2% parents; 54.7% partners), and college‐educated (65.3% parents; 61.8% partners). The majority reported that data sharing had enhanced hypoglycemic confidence (97.7% parents; 98.1% partners), overall well-being (60.4% parents; 63.2% partners), and sleep quality (78.0% parents; 61.3% partners). The authors noted three positive caregiver actions that were broadly consistent and significant predictors of QoL and health benefits for both parents and partners: celebrating success related to glycemic control, providing encouragement when glycemic control is challenging, and teamwork discussions about how the caregiver should respond to out‐of‐range values.
Conclusions
RT‐CGM data sharing was correlated with a range of QoL and health benefits for caregivers. The level of benefits was influenced by the collaborative actions performed by caregivers to support their child's or partner's diabetes management. Longitudinal studies are needed to decide the most effective strategies for collaborative data sharing.
Comment
Another survey study examined perceived value of data sharing of real‐time CGM with one or more family/friend followers. Of 302 adult participants, most had lived with T1D for more than a decade (76.5%) and had used real‐time CGM for more than a year (58%). Most participants reported improved hypoglycemic confidence (89.4%), improved overall well-being (54.3%) and reduced diabetes distress (36.1%). Specific benefits included fewer episodes of severe hypo, better sleep, and improved HbA1c. In relation to health and quality of life benefits, independent predictors included celebrating success relating to glycemic control, providing encouragement, and teamwork discussions on how the follower could best respond to out‐of‐range values. Such collaborative management clearly influenced benefits. Diabetes has often been referred to as a “family condition” due to the nature of impact on family members/friends as well as the individual with diabetes. The share facility offered by real‐time CGM can clearly be used in positive and constructive ways, improving relationships and greater understanding about how challenging diabetes can be. Setting boundaries and ensuring that actions do not become negative behaviors is important to ensure supportive actions for enhanced outcomes rather than becoming a cause of conflict or distress. Such negative behaviors include bugging the user about their glucose readings or not knowing how best to respond to glucose values. Further research into the ways friends and families can best support the person with diabetes, using technologies such as the share facility, would identify which specific actions taken (or not taken) are most critical for optimal health and quality of life of both parties.
Exploring Parental Experiences of Using a Do‐It‐Yourself Solution for Continuous Glucose Monitoring Among Children and Adolescents with Type 1 Diabetes: A Qualitative Study
Elbalshy M1, Boucher S1, Crocket H2, Galland B1, MacKenzie C3, de Bock MI4,5, Jefferies C6,7, Wiltshire E8,9, Wheeler BJ1,10
1Department of Women's and Children's Health, Dunedin School of Medicine, University of Otago, New Zealand; 2Te Huataki Waiora School of Health, Sport & Human Performance, University of Waikato, Dunedin, New Zealand; 3Pharmacy Department, Southern District Health Board, Dunedin, New Zealand; 4Department of Paediatrics, University of Otago, Christchurch, New Zealand; 5Department of Paediatrics, Canterbury District Health Board, Christchurch, New Zealand; 6Paediatric Endocrinology, Starship Children's Health, Auckland, New Zealand; 7Liggins Institute, University of Auckland, New Zealand; 8Department of Paediatrics and Child Health, University of Otago, Wellington, New Zealand; 9Paediatrics and Child Health, Capital and Coast District Health Board, Wellington, New Zealand; 10Paediatric Endocrinology, Southern District Health Board, Dunedin, New Zealand
Background
MiaoMiao (MM) is a Bluetooth transmitter, which when combined with a Smartphone/device, transforms the Abbott FreeStyle Libre flash glucose monitoring system into a Do‐It‐Yourself (DIY) continuous glucose monitor (CGM). Families are increasingly adopting DIY CGM solutions; however, not much is known about parent and child experiences with these add‐on technologies. The authors aimed to investigate experiences of families using MM‐CGM including challenges faced and their advice to others who may choose to use the technology.
Methods
Between May and July 2019, the authors conducted 12 semistructured interviews (in person or via video conference) with parents of children (aged ≤ 16 years) with type 1 diabetes using MM‐CGM. Interviews were audio-recorded. The interviews were then professionally transcribed, and key themes were identified through thematic analysis.
Results
Overall, parents used MM‐CGM to proactively manage their child's blood glucose. In all participants, this led to a perceived decrease in frequency of hypoglycemia. Participants reported that the visibility and easy access to blood glucose readings, glucose trends, and customized alarms on parents' phones decreased their disease burden and improved their sleep quality. Common barriers to using MM‐CGM included difficulty in the process of setting it up, connectivity issues, and lack of support from medical teams.
Conclusion
This study underscores the potential feasibility of using a DIY CGM system like MM‐CGM, which could empower users and provide a cost‐effective tool for enabling remote monitoring of blood glucose in real time.
Comment
Do‐It‐Yourself diabetes technologies are increasingly used by adults with type 1 diabetes as well as by children and young people under the supervision of their parents. Such systems include automated insulin dosing systems and continuous glucose monitoring systems. The current study explored parental attitudes of 12 users of the MiaoMiao Bluetooth transmitter paired with a Smartphone/device that converts FreeStyle Libre flash glucose monitoring data into a DIY CGM. Semistructured interviews explored reasons for choosing the DIY system, initiation, setting up process, and other negative issues. Most participants (n=10) found the initial set‐up challenging, particularly relating to difficulties setting up Nightscout and sharing CGM data between iOS and Android devices. In line with other DIY studies, users expressed a desire for a “plug and play” alternative. Lagging between devices was reported by seven participants and most (n=9) experienced temporary signal loss. Despite these reported negatives, all participants reported a perceived decrease in self‐reported frequency of hypoglycemia, improved sleep, and better quality of life as a result of reduced parental stress and anxiety. The study demonstrates that families are seeking out alternative methods to support their child's diabetes management, and DIY systems are part of such alternatives. What remains unclear is the extent to which such findings are replicable in a broader cohort of families living with type 1 diabetes who are perhaps less technologically confident or capable.
Modern Diabetes Devices in the School Setting: Perspectives from School Nurses
March CA1, Nanni M2, Kazmerski TM3, Siminerio LM4, Miller E3, Libman IM1
1Division of Pediatric Endocrinology and Diabetes, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA; 2University of Pittsburgh School of Medicine, Pittsburgh, PA; 3Division of Adolescent and Young Adult Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA; 4Department of Medicine, University of Pittsburgh, Pittsburgh, PA
Objective
To investigate the experiences, practices, and attitudes of school nurses concerning modern diabetes devices (insulin pumps, continuous glucose monitors, and hybrid‐closed loop systems).
Research design and methods
Semistructured interviews were conducted with 40 public school nurses caring for children in elementary and middle schools. Developed with stakeholder input, the interview questions explored experiences working with devices and communicating with the healthcare system. Deidentified transcripts were analyzed through an iterative process of coding to identify major themes.
Results
Of the school nurses included in the interviews, there was a range of educational backgrounds (58% undergraduate, 42% graduate), geographic settings (20% urban, 55% suburban, 25% rural), and years of experience (20% < 5 years, 38%, 5–15 years, 42% > 15 years). Four major themes emerged: (a) As devices become more common, school nurses must quickly develop new knowledge and skills, yet are challenged by inconsistent training opportunities; (b) Enthusiasm for devices is tempered by concerns about implementation due to poor planning prior to the school year and potential disruptions by remote monitors; (c) Barriers exist to integrating devices into schools, including school/classroom policies, liability/privacy concerns, and variable staff engagement; and (d) Collaboration between school nurses and providers is limited; better communication may benefit children with diabetes.
Conclusions
School‐age children are using devices more and more. School nurses appreciate the potential of the equipment, but they also face structural and personal challenges. As technology gradually becomes the standard of care, guiding policies must be formulated. Enhanced training and collaboration with diabetes providers may help to optimize school‐based management of these devices for children.
Comment
The treatment of children and adolescents with type 1 diabetes is based on broad support circles. Children spend most of their time in educational settings, and therefore, in addition to parents and primary caregivers, kindergarten and school nurses are responsible for treating diabetes in this context. Therefore, it is very important to know school and kindergarten nurses' points of view regarding the treatment of children with diabetes and their attitudes toward the use of diabetes technologies. Although the current study describes significant progress in nurses' attitudes toward assimilating the use of diabetes technologies in schools over the past 15 years, there are still a number of challenges (2). Nurses reported tension between themselves and parents regarding the nurses' skill in operating the technology. Particularly noteworthy is the refusal of some nurses to use sensors due to the potential liability burden involved. This study highlights the importance of improving collaboration between school nurses and parents, especially when it comes to implementing diabetes technologies in the care of children with diabetes.
Parental Perspectives: Identifying Profiles of Parental Attitudes and Barriers Related to Diabetes Device Use
Wong JJ, Barley RC, Hanes S, Tanenbaum ML, Lanning M, Naranjo D, Hood KK
Division of Endocrinology and Diabetes, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
Background
Despite the proven benefits of using diabetes devices, the use of insulin pumps and continuous glucose monitors (CGM) remains low. Current research aims to determine the profile of adolescent parents with type 1 diabetes based on their attitudes toward specific diabetes technologies and barriers to the adoption of diabetes technologies.
Methods
Online survey data were collected from 471 parents in the T1D Exchange Clinic Network (child's age=12.0±3.2 years; diabetes duration=7.0±2.9 years; HbA1c=8.4% ± 1.3; 75% using insulin pump; 27% using CGM).
Results
K‐means cluster analyses revealed five parent profiles: Embracers (50.7%), Burdened (15.7%), Hopeful but Hassled (14.2%), Distrusting (12.7%), and Data Minimalists (6.6%). ANOVAs and chi‐square tests identified differences between groups based on diabetes distress, worry over hypoglycemia, device use, and demographic characteristics.
Conclusions
Providers encouraging device uptake may benefit from tailoring their approaches based on these different groups and their corresponding interests and needs.
Comment
Because parents play a key role in treating their children's diabetes, it is important to understand in which cases the use of diabetes technologies helps them and in which cases it adds to the burden.
Some parents may be careful not to rely on a device due to anxiety of mechanical failure, and some parents experience distress, fear of hypoglycemia, and feeling overwhelmed by the enormous amount of glycemic data provided by CGMs.
This study characterizes parents' difficulties and divides them into distinct categories.
It was encouraging to find that more than 50% of the parents fell into the Embracers group, with highly positive attitudes toward technology and minimal barriers. However, it is important to note that about one‐third of the parents reported varying levels of burden and close to 20% expressed negative attitudes toward the use of technology (e.g., distrust of technology or avoidance of using information from the CGM).
This classification may help the multidisciplinary team treating diabetes to better understand the challenges parents face using diabetes technologies and assist parents through treatment that is tailored to address their specific problems.
Self‐Management Among Pre‐Teen and Adolescent Diabetes Device Users
Faulds ER1, Hoffman RP2, Grey M3, Tan A4, Tubbs‐Cooley H4, Militello LK4, Happ MB4
1The Ohio State University College of Nursing, The Ohio State University Medical Center, Columbus, OH; 2Division of Pediatric Endocrinology Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH; 3Yale University School of Nursing, New Haven, CT; 4The Ohio State University College of Nursing, Columbus, OH
Objective
Despite increasing use of diabetic devices, few adolescents with type 1 diabetes (T1D) reach their blood glucose goals. The authors studied the correlation between the use of insulin pumps and continuous glucose monitoring (CGM) and blood glucose control.
Research design and methods
This prospective cohort study included 80 youths (10–18 years of age) with T1D. Multiple linear regression and linear mixed models (LMM) were used to estimate the effects of device self‐management on HbA1c and daily time in range (TIR) (70–180 mg/dL), respectively.
Results
Every blood glucose (BG) input/day was associated with a 0.2% decrease in HbA1c (95% CI: −0.297, −0.013), each bolus/day was associated with a 0.2% decrease (−0.327, −0.057), and use of CGM was associated with a 0.5% decrease (−1.00, −0.075). Among CGM users (n=45) every 10% increase in CGM use was associated with a 0.3% decrease in HbA1c (−0.390, −0.180). In LMM accounting for within subject and between subject variability, there was a negative association between BG input/day frequency (coefficient=−1.880, [−2.640, −1.117]) and time in range. Residual random effects for CGM users were large, showing time in range varied between youth with an SD of 15.0% (3 h and 36 min) (SE 2.029, [11.484, 19.530]). Time in range varied significantly from day to day with SD of 18.6% (4 h and 40 m) (SE0.455 [17.690, 19.473]).
Conclusions
Adolescents' device self‐management behavior is significantly related to HbA1c and time in range. The authors report that there is a correlation between reduced time in range and increased self‐management behavior, which is novel and worthy of further studies.
Comment
Management of type 1 diabetes in adolescents continues to be a significant challenge in diabetes care. Recent studies have shown that despite the increase in the use of diabetes technologies, there has been no significant improvement in glycemic outcomes (only 17% of adolescents with type 1 diabetes meet glycemic targets as measured by glycosylated hemoglobin HbA1c) (3).
One of the most interesting findings in this study was the correlation between self‐management behaviors and TIR for youth using CGM. Although numerous studies have shown improved glycemic control measured by HbA1c when more frequent self‐management behaviors were performed, a closer statistical examination showed that lower TIR (poorer control) correlated with more frequent SMBG monitoring, more frequent BG input into the pump, and more frequent bolus administration, whereas higher TIR correlated with a decrease in these behaviors. These unexpected findings suggest that adolescents are heterogenous in their self‐management behaviors in response to their glycemic trends.
Sources and Valence of Information Impacting Parents' Decisions to Use Diabetes Technologies in Young Children < 8 Years Old with Type 1 Diabetes
Commissariat PV1, Whitehouse AL1, Hilliard ME,1 Miller KM3, Harrington KR1, Levy W2, DeSalvo DJ2, Van Name MA4, Anderson B2, Tamborlane WV4, DiMeglio L5, Laffel LM1
1Joslin Diabetes Center, Harvard Medical School, Boston, MA; 2Texas Children's Hospital, Baylor College of Medicine, Houston, TX; 3Jaeb Center for Health Research, Tampa, FL; 4Yale School of Medicine, Department of Pediatric Endocrinology and Diabetes, New Haven, CT; 5Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
Background
There is a variety of resources available to help families understand the quick evolving diabetes technologies that are offered as treatment alternatives for their children. This study looked into where and how families of young children with type 1 diabetes obtain information about diabetes technology, as well as the valence (good vs bad) of such information.
Semistructured
Semistructured interviews were conducted with parents (86% mothers) of 79 youth < 8 years old with type 1 diabetes for ≥ 6 months ([mean ± standard deviation] age 5.2±1.5 years, diabetes duration 2.4±1.3 years, 77% white, A1c 63±10 mmol/mol [7.9±0.9%], 66% pump‐treated, 58% using continuous glucose monitors [CGMs]). Interviews were transcribed and underwent content analysis to derive central themes.
Results
Most parents reported learning about new technologies from three direct sources: diabetes care providers, people with diabetes, and caregivers of children with diabetes. Parents also cited three indirect sources of information: online forums, publications, and diabetes‐specific conferences. Parents reported hearing primarily positive things about technologies. Families not using pump and/or CGM noted reluctance to use technology due to family‐specific concerns (e.g., cost, child's unwillingness to wear device) rather than information from outside sources. Many of these parents stated willingness to start using after family‐specific concerns were addressed.
Conclusion
Parents of young children were given mostly good information regarding diabetes technologies, primarily from healthcare providers and those who had personal experience with or for their children with devices. It is incumbent upon us to optimize the use of diabetes technologies in young children.
Comment
The role of parents in their children's type 1 diabetes management is crucial. Effective treatment often requires intensive care, and optimal glucose levels are difficult to achieve. In an attempt to cope with the burden, parents seek additional information from various external resources other than their diabetes team. Previous studies have shown that most of the caregivers reported that they were assisted by the Internet for information regarding their children's diabetes, with social media as both the source used most commonly and for the most amount of time on average. Therefore, it was interesting to find that in this study, parents' knowledge about diabetes technologies comes primarily from person‐to‐person sources, specifically providers and others using technologies. It is also important to note that parents reported their decision to avoid diabetes technology was based on family‐specific factors such as waiting until their child was ready and willing to wear the device or concern about cost rather than negative outside information.
A Decade of Disparities in Diabetes Technology Use and HbA1c in Pediatric Type 1 Diabetes: A Transatlantic Comparison
Addala A1, Auzanneau M2,3, Miller K4, Maier W3,5, Foster N4, Kapellen T6, Walker A7, Rosefacefanbauer J3,8, Maahs DM1,9, Holl RW2,3
1Division of Pediatric Endocrinology, Stanford University, Stanford, CA; 2University of Ulm, Institute of Epidemiology and Medical Biometry, ZIBMT, Ulm, Germany; 3German Center for Diabetes Research (DZD), Neuherberg, Germany; 4Jaeb Center for Health Research, Tampa, FL; 5Helmholtz Zentrum München ‐ German Research Center for Environmental Health, Institute of Health Economics and Health Care Management, Neuherberg, Germany; 6University of Leipzig, Department of Women and Child Health, Hospital for Children and Adolescents, Leipzig, Germany; 7Health Equity Initiatives, UF Diabetes Institute, University of Florida, Gainesville, FL; 8Leibniz Center for Diabetes Research at Heinrich Heine University, Institute for Biometrics and Epidemiology, German Diabetes Center, Düsseldorf, Germany; 9Stanford Diabetes Research Center, Stanford, CA
This manuscript is also discussed in article on Diabetes Technology and Therapy in the Pediatric Age Group, page XX, and in article on Real-World Diabetes Technology: What Do We Have? Who Are We Missing?, page XX
Objective
Inequalities in access to diabetes technology may worsen differences in HbA1c as children use it more widely worldwide. The authors hypothesized that growing differences in diabetes technology use by socioeconomic status (SES) would be linked to higher HbA1c levels.
Research design and methods
Participants aged <18 years with diabetes duration ≥1 year in the Type 1 Diabetes Exchange (T1DX, United States, n=16,457) and Diabetes Prospective Follow‐up (DPV, Germany, n=39,836) registries were categorized into lowest (Q1) to highest (Q5) SES quintiles. Multiple regression analyses compared the relationship of SES quintiles with diabetes technology use and HbA1c from 2010 to 2012, through 2016 to 2018.
Results
HbA1c was higher in participants with lower SES (in 2010–2012 and 2016–2018, respectively: 8.0% and 7.8% in Q1 and 7.6% and 7.5% in Q5 for DPV; 9.0% and 9.3% in Q1 and 7.8% and 8.0% in Q5 for T1DX). For DPV, the association between SES and HbA1c did not change between the two time periods, whereas for T1DX, disparities in HbA1c by SES increased significantly (P < 0.001). After adjusting for technology use, results for DPV did not change, whereas the increase in T1DX was no longer significant.
Conclusions
Although no causal implications can be inferred, diabetes technology use is lowest and HbA1c is greatest in those in the lowest SES quintile in the T1DX, and this gap has widened in the last decade. In the DPV registry, the links between SES and technology use and HbA1c were weaker.
Comment
Diabetes technologies have long been associated with improved quality of life for many as well as an increased burden for some. Debates center on tradeoffs between improved sleep, improved time in target glycemic range, and greater control, for example, versus increased visibility of disease state. While important, a broader question of access to diabetes technologies is arguably an equally pressing concern. Addala and colleagues report diabetes technology use over the past decade to be lowest in those of the lowest SES quintile, while at the same time these same individuals have the highest HbA1c. While the associations are noncausal, data from the United States and Germany show broadening access over the past 10 years. This comes at a time when use of diabetes technologies such as insulin pumps, continuous glucose monitors, and increasingly automated insulin delivery systems has increased worldwide and they are becoming the cornerstone of diabetes management for many. Such inequities in device use by SES are unexplained by any clinical factors. A strong association between SES and HbA1c is not new; however, the inability of children and young people to access devices that are potentially life‐transforming requires urgent attention. Wider factors such as access to physicians, healthcare expenditure, and payer structures, as Addala and colleagues acknowledge, may also contribute to a greater or lesser degree, as do other social determinants of health. In this complicated picture, considerable work must be done to ensure that no child or young person who could benefit from diabetes technologies is prevented from access.
Age, Male Gender, and Social Deprivation Are Associated with a Lower Rate of Insulin Pump Therapy Initiation in Adults with Type 1 Diabetes: A Population‐Based Study
Meunier L1, Aguadé AS1, Videau Y2, Verboux D1, Fagot‐Campagna A1, Gastaldi‐Menager C1, Amadou C3
1CNAM (Caisse Nationale d'Assurance Maladie), French National Health Insurance, Paris, France; 2ERUDITE (Research Team on the Use of Individual Data related to Economic Theory), University of Paris‐Est Créteil, Créteil, France; 3Department of Diabetes and Endocrinology, University of Paris‐Saclay and Sud‐Francilien Hospital, Corbeil‐Essonnes, France
Objectives
The goal of this population‐based study in France in 2015 was to determine characteristics associated with the commencement of insulin pump therapy in individuals with insulin‐dependent diabetes.
Method
People with insulin‐requiring diabetes and their characteristics were identified from the national health data system. Factors associated with insulin pump therapy initiation were identified by logistic regression analysis.
Results
The study focused on 614,913 adults with diabetes treated by multiple daily injections before 2015: 4,083 of them initiated insulin pump therapy during the year (71% of them had type 1 diabetes, T1D). Factors associated with insulin pump therapy initiation were the number of consultations with an endocrinologist within the past 2 years (2 vs 0, odds ratio [OR]=1.5, P<0.01), the presence of a chronic cardiovascular or neurovascular disease (OR=1.6 for T1D, OR=1.3 for type 2 diabetes [T2D], P<0.01), and treatment with antidepressants/anxiolytics (OR=1.2 for T1D, OR=1.4 for T2D, P<0.01). The other determinants were female gender (OR=1.5, P<0.01) and history of hospitalization for acute metabolic complications (OR=1.14, P<0.01) in T1D. Factors associated with less insulin pump therapy initiation were age, duration of diabetes, end‐stage renal disease, and social deprivation (OR=0.662, P<0.01, T1D only).
Conclusion
In 2015, in France, the predictors of insulin pump therapy initiation in adults with insulin‐dependent diabetes were entirely compatible with clinical practice standards. In adults with T1D, age, male gender, and social deprivation are still linked to a reduced rate of insulin pump therapy initiation.
Comment
Sticking with the inequalities theme, this deep dive into insulin pump initiation by Meunier and colleagues reveals relevant associated factors in people identified from the national health data system. Focusing on a large-scale cohort of 614,913 adults who were all treated with multiple daily injections (MDI) before 2015, only 4,083 initiated pump therapy during that year. Of these, unsurprisingly, the majority (71%) had type 1 diabetes. The authors found that age, male gender, and social deprivation are still associated with a lower rate of insulin pump start. The likelihood of initiating pump therapy decreased with the patient's age, with people with T1D aged 15–24 having a 9.5‐fold higher probability of initiating pump therapy than people who were aged 65 years or over. Similarly, women were 1.5 times more likely to start pump therapy than men. Large geographic variability was also identified with lowest incidence rates at 0.10% and the highest at 7%; the average incidence of initiation was 2.05%. The study is useful because it provides novel objective data on the profile of people with diabetes treated with pumps in France. The highlighted inequalities are similar to those reported in national audit data in the UK and T1DX data in the United States, thus demonstrating that factors beyond healthcare system are clearly at play.
Racial‐Ethnic Disparities in Diabetes Technology Use Among Young Adults with Type 1 Diabetes
Agarwal S1, Schechter C2, Gonzalez J1,3, Long JA4,5
1Fleischer Institute of Diabetes and Metabolism, New York‐Regional Center for Diabetes Translation Research, Division of Endocrinology, Albert Einstein College of Medicine, Bronx, NY; 2Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, NY; 3Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY; 4University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; 5Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
This manuscript is also discussed in article on Real-World Diabetes Technology: What Do We Have? Who Are We Missing?, page XX
Background
Recent studies emphasize racial‐ethnic differences in insulin pump and continuous glucose monitor (CGM) use of people with type 1 diabetes (T1D), but drivers of disparities are still poorly understood beyond socioeconomic status (SES).
Methods
We recruited a diverse sample of young adults (YA) with T1D from six diabetes centers across the United States, enrolling equal numbers of non‐Hispanic (NH) white, NH Black, and Hispanic YA. We used multivariate logistic regression to examine to what extent SES, demographics, healthcare factors (care setting, clinic attendance), and diabetes self‐management (diabetes numeracy, self‐monitoring of blood glucose, and Self‐Care Inventory score) explained insulin pump and CGM use in each racial‐ethnic group.
Results
The authors recruited 300 YA with T1D, aged 18–28 years. Fifty‐two percent were publicly insured, and the mean HbA1c was 9.5%. Large racial‐ethnic disparities in insulin pump and CGM use existed: 72% and 71% for NH white, 40% and 37% for Hispanic, and 18% and 28% for NH Black, respectively. After multiple adjustments, insulin pump and CGM use remained disparate: 61% and 53% for NH white, 49% and 58% for Hispanic, and 20% and 31% for NH Black, respectively.
Conclusions
Continuous subcutaneous insulin infusion (CSII) and continuous glucose monitoring (CGM) use was the lowest in NH Black, intermediate in Hispanic, and highest in NH white YA with T1D. SES was not the only driver of differences, nor did additional demographic, healthcare, or diabetes‐specific factors explain the whole picture, especially between NH Black and white YA. Future work should research how minority YA preferences, provider implicit bias, systemic racism, and mistrust of medical systems contribute to understanding of the differences in diabetes technology use.
Comment
In line with adult and child studies on inequalities reported in this article, this study on young adults remains consistent in terms of disparities in insulin pump and CGM use among different ethnic groups. Three hundred young adults with T1D (aged 18–28 years), of whom 52% were publicly insured and mean HbA1c was 9.5%, were recruited from six diabetes centers across the United States. Unsurprisingly, large racial‐ethnic disparities in insulin pump and CGM user were identified as the majority of non‐Hispanic white participants used the technology (72% and 71%, respectively) compared to 40% and 37% for Hispanic and 18% and 28%, respectively, for non‐Hispanic black participants. Drivers of disparities included provider implicit bias, systemic racism, and mistrust of medical systems. When socioeconomic status, demographics, healthcare factors, and diabetes self‐management were accounted for, significant disparities remained. The authors report findings are consistent with an emerging body of literature showing minority patient preferences for diabetes therapies and interventions are not routinely addressed by healthcare providers. As patient‐provider therapeutic relationships have been shown to affect disparities in care, particularly with regard to shared decision‐making, opportunities clearly exist for culturally tailored and standardized approaches to address this imbalance.
Footnotes
Author Disclosure Statement
No competing financial interests exist.