Practical Implementation of Diabetes Technology: Real‐World Use

Abstract

IntroductionT he purpose of the practical implementation article of the ATTD Yearbook is to characterize the current diabetes technology landscape around the globe, focusing on emerging trends in device uptake, clinical utility and guidance, access to devices, educational strategies, and perceived benefit and burden of device use (1). Articles selected for this review were published between July 2018 and June 2019 and contained original research related to diabetes technology use in the real world rather than a structured research setting. Keyword searches included ''education, access, economics, cost effectiveness, real world, behavior, barriers, registry, outcomes, implementation, decision support, and technology.'' A total of 42 articles were retrieved, and 10 were selected for review here.This year's article starts with highlighting new data from the Type 1 Diabetes (T1D) Exchange Registry from 2016 to 2018, which provides relevant insight into diabetes technology trends in the United States (2). As highlighted below, technology uptake has rapidly expanded in the past decade. This is most notable in use of continuous glucose monitoring (CGM), with a five-fold increase in reported use compared with 8 years prior, and a 10-fold increase in use for children <12 years old. Insulin pump use has slightly increased as well. Technophiles can celebrate this trend.The second major point is more sobering: despite this increase in diabetes technology utilization, glycemic control has not improved overall. Glycemic data mirror the data from 8 years prior, with an actual worsening of glycemic control in adolescents. This paradox suggests a more nuanced picture of technology effectiveness, a picture that must include individual factors, clinical factors, and system factors all contributing to the ''real-world'' glycemic benefits of technology.This year's article therefore focuses on extra-technological factors that support or hinder efforts of individuals using diabetes technology to manage diabetes. First, access, insurance coverage, and cost-effectiveness data on sensor augmented pump (SAP) and hybrid closed loop (HCL) are reviewed. Next, new data from educational randomized control trials (RCT) are presented to emphasize the essential place for education in all diabetes self-management. Finally, two studies of automated decision support are reviewed in order to illustrate some of the potential benefits and challenges of bringing this technology to the clinical environment.

Practical Diabetes Technology: Overcoming Barriers in the Real World

“…These results provide useful benchmarking data for a variety of combinations of diabetes technologies. Time in range in children with type 1 diabetes using treatment strategies based on nonautomated insulin delivery systems in the real world Cherubini V 1 , Bonfanti R 2 , Casertano A 3 , De Nitto E 4 , Iannilli A 1 , Lombardo F 5 , Maltoni G 6 , Marigliano M 7 , Bassi M 8 , Minuto N 8 , Mozzillo E 3 , Rabbone I 9 , Rapini N 10 , Rigamonti A 2 , Salzano G 5 , Scaramuzza A 11 , Schiaffini R 10 , Tinti D 9 , Toni S 4 , Zagaroli L 1 , Zucchini S 6 , Maffeis C 7 , Gesuita R 12 1 Department of Women's and Children's Health, Azienda Ospedaliero Universitaria Ospedali Riuniti di Ancona Umberto I G M Lancisi G Salesi, Ancona, Italy; 2…”

Availability of psychological care in pediatric diabetes centers – a real need?

“…Data from the SWEET registry show an improvement in glycemic control and a lower number of diabetes ketoacidosis (DKA) episodes in those using an insulin pump or CGM system or both [3]. A systematic review by Messer et al indicated that the technologization of T1D treatment leads to an improvement of glycemic outcomes (hemoglobin A1C, time in range -TIR) in youth with T1D, when the needs associated with financial and, more important, educational support, are met [4]. This indicates that the high advancement and availability of new technologies are not the only solution for improving diabetes care and support, and probably might also not be the most important determinant of better treatment outcomes.…”

Diabetes technologies for children and adolescents with type 1 diabetes are highly dependent on coverage and reimbursement: results from a worldwide survey

“…[10][11][12] In addition, people wearing these devices have reported increased flexibility and feeling of well-being. 13 Despite these benefits, there are considerable differences between countries in healthcare system coverage of diabetes technologies, [14][15][16][17] clinicians' role in counseling,…”

“…Despite these benefits, there are considerable differences between countries in healthcare system coverage of diabetes technologies,14–17 clinicians’ role in counseling, and individuals’ and families’ preferences that prevent diabetes technologies from being used 14 18 19. In addition, the hassle of wearing devices, dislike of alarms and inadequate counseling may also decrease their use 18 20 21…”