Optimal Use of Diabetes Devices: Clinician Perspectives on Barriers and Adherence to Device Use

Abstract

Insulin pumps and continuous glucose monitors (CGM) are increasingly important components of managing type 1 diabetes (T1D) and have been shown to improve glycemic control, health-related quality of life, and treatment satisfaction. [1][2][3][4][5] Device users report benefits such as increased flexibility and freedom and decreased stress.6,7 However, consistent adherence to wearing these devices requires a complex set of user behaviors. Device wearers must change insulin pump and CGM sites frequently; order and maintain the proper supplies and prescriptions; calibrate the CGM through regular blood glucose checks; count carbohydrates; and administer boluses.8,9 Table 1 outlines the numerous adherence tasks required for using insulin pumps and CGM, divided by frequency of engagement in each task.Greater CGM adherence-and engagement in the tasks outlined in Table 1-has been linked to optimal diabetes outcomes. [10][11][12][13][14][15] Specifically, wearing a CGM 6 or more days a week, 15 or at least 60% of the time, 14 has been linked to greater improvements in HbA1c compared to wearing a CGM fewer than 6 days a week. More frequent blood glucose monitoring has been linked to greater CGM adherence and greater benefit from CGM.12 Furthermore, greater adherence to CGM has been linked to better treatment satisfaction; frequent users may focus more on benefits outweighing the hassles while infrequent users focus more on hassles Abstract Background: Insulin pumps and continuous glucose monitors (CGM) can improve glycemic control for individuals with type 1 diabetes (T1D). Device uptake rates continue to show room for improvement, and consistent adherence is needed to achieve better outcomes. Diabetes health care providers have important roles to play in promoting device use and adherence. Methods:We surveyed 209 clinicians who treat people with type 1 diabetes to examine perceptions of barriers to device uptake, attitudes toward diabetes technology, and resources needed for clinicians to improve device uptake. We compared findings with our survey of adults with T1D.Results: Younger clinicians treated more patients using insulin pumps (r = -.26, P < .001) and CGM (r = -.14, P = .02), and had more positive attitudes about diabetes technology (r = -.23, P = .001). The most frequently endorsed modifiable barriers were perceptions that patients dislike having the device on their body (73% pump; 63% CGM), dislike the alarms (61% CGM), and do not understand what to do with device information or features (40% pump; 46% CGM). Clinicians wanted lower cost and better insurance coverage for their patients, and they recommended counseling and education to help address barriers and improve adherence to devices. Conclusion:Clinicians perceive many barriers to their patients initiating and adhering to diabetes devices. Findings highlight opportunities for intervention to improve clinician-patient communication around device barriers to help address them.

Biopsychosocial Factors Associated With Satisfaction and Sustained Use of Artificial Pancreas Technology and Its Components: a Call to the Technology Field

“…Adherence to CGM and insulin pump use has typically been examined in the context of number of days of wear in the former [46, 47] and missed boluses in the latter [48, 49]. A comprehensive list of individual self-management tasks for CGMs (e.g., respond to alerts) and insulin pumps (e.g., carrying supplies, counting carbohydrates, administering boluses, checking blood glucose) has been described by Tanenbaum and colleagues [50]. Examination of the relationships between specific T1D self-management behaviors (e.g., blood glucose checking, carbohydrate inputs, and insulin bolusing) using objectively downloaded data from blood glucose monitors and insulin pumps has also been conducted [51, 52].…”

Who Should Access Closed-Loop Technology? A Qualitative Study of Clinician Attitudes in England

“…While previous researchers have explored clinician attitudes to other aspects of technology in type 1 diabetes care, little is known on clinician views about access to closed-loop technology. [13][14][15][16][17] To address this gap, we undertook a qualitative study of clinician attitudes in England, guided by the following research question: what are clinicians' attitudes toward user eligibility for future closed-loop systems in mainstream care in England?…”

Monitoring of Pediatric Type 1 Diabetes

“…While alerts and alarms can help to improve glycemic control, their impact on day-to day-life must be carefully considered. Alarm fatigue is one of the factors most frequently cited by patients who discontinue CGM use (38)(39)(40). Alarm settings must be appropriately individualized for each patient to optimize glycemic control while minimizing the impact on quality of life, taking into consideration age, current glucose control, impact on daily life, and hypoglycemia awareness.…”

“…Qualitative analysis of online blogs suggests that data sharing enhances feelings of safety, but also emphasizes the importance of setting boundaries and avoiding judgments about glycemic excursions (43). The importance of setting communication boundaries with parents and caretakers, particularly during adolescence, should focus on enhancing patient safety and must avoid "policing" teen behavior in order to minimize conflict, which has been cited as a factor discouraging CGM use among adolescents (40,44).…”