Diabetes Technology in the “Real World”: Expanding Access and Addressing Disparities
2024; Mary Ann Liebert, Inc.; Volume: 26; Issue: S1 Linguagem: Inglês
10.1089/dia.2024.2512
ISSN1557-8593
AutoresAnanta Addala, Stuart A. Weinzimer,
Tópico(s)Diabetes and associated disorders
ResumoDiabetes Technology & TherapeuticsVol. 26, No. S1 Original ArticlesFree AccessDiabetes Technology in the "Real World": Expanding Access and Addressing DisparitiesAnanta Addala and Stuart A. WeinzimerAnanta AddalaDivision of Pediatric Endocrinology & Diabetes, Department of Pediatrics, Stanford University, Palo Alto, CA.Search for more papers by this author and Stuart A. WeinzimerDepartment of Pediatrics, School of Medicine, Yale University, New Haven, CT.Search for more papers by this authorPublished Online:1 Mar 2024https://doi.org/10.1089/dia.2024.2512AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookXLinked InRedditEmail IntroductionThis year continues to demonstrate the success of diabetes technology on a grand scale. Real-world data continue to demonstrate the efficacy of diabetes technology and the unwavering persistence of disparities in glycemic outcomes and diabetes technology use. As in prior years, we have again this year showcased several articles that illustrate, primarily in type 1 diabetes (T1D), the continuing improvements in glycemic benchmarks achievable with the application of diabetes technologies available to us today. We then highlight several notable studies related to type 2 diabetes (T2D) and the inpatient care setting, two populations in whom the use of diabetes technologies are vastly underutilized and potentially stand to have the greatest impact to overcome the therapeutic inertia inherent to these clinical care systems. Finally, we highlight the favorable health economics of subsidized diabetes technology and detail interventions at the level of the clinician, clinic, and government to address disparities. These studies on the economic feasibility and evidence-based solutions of expanding access to diabetes technology serve as a call to action for the diabetes community.This article includes original research articles retrieved from PubMed that were published between July 2022 and June 2023 and contain search terms related to diabetes technologies, including insulin pump, hybrid closed loop, HCL, continuous glucose monitor, CGM, intermittently scanned CGM, isCGM, real-time continuous glucose monitoring, and rtCGM. Important context terms for the search included "insulin pump," "hybrid closed loop," "continuous glucose," "automated insulin," "disparity," "disparities," "realworld," "real world," "barriers," "discontinuation," "practical," "clinical care," "underrepresented," and "equity." Over 250 article titles were reviewed for pertinence and possible inclusion in this article. Of these, 55 abstracts were reviewed in detail, and 14 were selected for inclusion in this article.Key Articles ReviewedAssociation of Achieving Time in Range Clinical Targets with Treatment Modality among Youths with Type 1 DiabetesDovc K, Lanzinger S, Cardona-Hernandez R, Tauschmann M, Marigliano M, Cherubini V, Preikša R, Schierloh U, Clapin H, AlJaser F, Pelicand J, Shukla R, Biester TJAMA Netw Open2023; 6:e230077Hybrid Closed-Loop Systems and Glycemic Outcomes in Children and Adults with Type 1 Diabetes: Real-World Evidence from a U.S.-based Multicenter CollaborativeNoor N, Kamboj MK, Triolo T, Polsky S, McDonough RJ, Demeterco-Berggren C, Jacobsen L, Sonabend R, Ebekozien O, DeSalvo DJDiabetes Care2022; 45:e118–e119Predictors of Insulin Pump Initiation among People with Type 2 Diabetes from a US Claims Database Using Machine LearningHankosky ER, Katz ML, Fan L, Liu D, Chinthammit C, Brnabic AJM, Eby ELCurr Med Res Opin2023; 39:843–853Rates and Correlates of Uptake of Continuous Glucose Monitors among Adults with Type 2 Diabetes in Primary Care and Endocrinology SettingsMayberry LS, Guy C, Hendrickson CD, McCoy AB, Elasy TJ Gen Intern Med2023; 38:2546–2552Use of the FreeStyle Libre System and Diabetes Treatment Progression in T2DM: Results from a Retrospective Cohort Study Using a Canadian Private Payer Claims DatabaseHarris SB, Levrat-Guillen FDiabetes Obes Metab2023; 25:1704–1713Real-Time Continuous Glucose Monitoring in the Hospital: A Real-World ExperienceSpierling Bagsic SR, Fortmann AL, Belasco R, Bastian A, Lohnes S, Ritko A, Sandoval H, Chichmarenko M, Soriano EC, Talavera L, Philis-Tsimikas AJ Diabetes Sci Technol2023; 17:656–666Attitudes and Behaviors with Diabetes Technology Use in the Hospital: Multicenter Survey Study in the United StatesMadhun NZ, Galindo RJ, Donato J, Hwang PR, Shabir HF, Fowler MJ, Molitch-Hou E, Bena JF, Umpierrez GE, Lansang MCDiabetes Technol Ther2023; 25:39–49Availability and Access to Pediatric Diabetes Care: A Global Descriptive StudyPulungan AB, de Beaufort C, Ratnasari AF, Puteri HA, Lewis-Watts L, Bhutta ZAClin Pediatr Endocrinol2023; 32:137–146Nationally Subsidized Continuous Glucose Monitoring: A Cost-Effectiveness AnalysisPease AJ, Zoungas S, Callander E, Jones TJ, Johnson SR, Holmes-Walker DJ, Bloom DE, Davis EA, Zomer EDiabetes Care2022; 45:2611–2619Outcomes and Experiences of Families with Children with Type 1 Diabetes on Insulin Pumps through Subsidised Pump Access Programs in Western AustraliaFu VR, Irwine K, Browne-Cooper K, Taplin CE, Jones TW, Davis EA, Abraham MBFront Endocrinol (Lausanne)2023; 14:1173559A Longitudinal View of Disparities in Insulin Pump Use among Youth with Type 1 Diabetes: The SEARCH for Diabetes in Youth StudyEverett EM , Wright D, Williams A, Divers J, Pihoker C, Liese AD, Bellatorre A, Kahkoska AR, Bell R, Mendoza J, Mayer-Davis E, Wisk LEDiabetes Technol Ther2023; 25:131–139Targeting Technology in Underserved Adults with Type 1 Diabetes: Effect of Diabetes Practice Transformations on Improving Equity in CGM Prescribing BehaviorsMathias P, Mahali LP, Agarwa SDiabetes Care2022; 45:2231–2237Disparities in Hemoglobin A1c Levels in the First Year after Diagnosis among Youths with Type 1 Diabetes Offered Continuous Glucose MonitoringAddala A, Ding V, Zaharieva DP, Bishop FK, Adams AS, King AC, Johari R, Scheinker D, Hood KK, Desai M, Maahs DM, Prahalad P for the Teamwork, Targets, Technology, and Tight Control (4T) Study GroupJAMA Netw Open2023; 6:e238881Inequity in Access to Continuous Glucose Monitoring and Health Outcomes in Paediatric Diabetes, a Case for National Continuous Glucose Monitoring Funding: A Cross-Sectional Population Study of Children with Type 1 Diabetes in New ZealandBurnside MJ, Williman JA, Davies HM, Jefferies CA, Paul RG, Wheeler BJ, Wiltshire EJ, Anderson YC, de Bock MILancet Reg Health West Pac202217; 31:100644"Big Data" Real-World Experience Supports Technology UseAssociation of Achieving Time in Range Clinical Targets with Treatment Modality among Youths with Type 1 DiabetesDovc K1,2, Lanzinger S3,4, Cardona-Hernandez R5, Tauschmann M6, Marigliano M7,8, Cherubini V9, Preikša R10, Schierloh U11, Clapin H12, AlJaser F13, Pelicand J14,15, Shukla R16, Biester T171Department of Pediatric Endocrinology, Diabetes and Metabolic Diseases, University Children's Hospital, Ljubljana, Slovenia; 2Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia; 3Institute of Epidemiology and Medical Biometry, ZIBMT, Ulm University, Ulm, Germany; 4German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany; 5Division of Pediatric Endocrinology, Hospital Sant Joan de Déu, Barcelona, Spain; 6Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria; 7Pediatric Diabetes and Metabolic Disorders Unit, Regional Center for Pediatric Diabetes, University City Hospital of Verona, Verona, Italy; 8Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Verona, Italy; 9Division of Pediatric Diabetology, Department of Women's and Children's Health, Salesi Hospital, Ancona, Italy; 10Institute and Clinic of Endocrinology, Lithuanian University of Health Sciences, Kaunas, Lithuania; 11Department of Pediatric Diabetes and Endocrinology, Centre Hospitalier Luxembourg, Luxembourg; 12Department of Diabetes and Endocrinology, Perth Children's Hospital, Perth, Australia; 13Department of Pediatrics, Amiri Hospital, Ministry of Health, Dasman, Kuwait; 14Pediatric and Adolescent Diabetes Program, Department of Pediatrics, San Camilo Hospital, San Felipe, Chile; 15Medicine School, Universidad de Valparaiso, San Felipe, Chile; 16Department of Diabetes and Endocrinology, Center for Diabetes & Endocrine Diseases, Kanpur, India; 17Children's Hospital, Auf der Bult, Hannover, GermanyJAMA Netw Open 2023;6:e230077This study is also discussed in DIA-2024-2502, page S-14, and DIA-2024-2508, page S-117.Continuous glucose monitoring (CGM) devices have demonstrated efficacy in people with type 1 diabetes (T1D). In adults with T1D, the use of real-time CGM (rtCGM) has been associated with improved glycemic control compared with intermittently scanned CGM (isCGM), but there are limited data available for youths. This study assessed real-world data on achievement of time in range clinical targets associated with different treatment modalities in youths with T1D.MethodsThis multinational cohort study included individuals younger than 21 years (youths) with T1D for a duration of at least 6 months who provided CGM data between January 1, 2016, and December 31, 2021. The participants were enrolled from the international Better Control in Pediatric and Adolescent Diabetes: Working to Create Centers of Reference (SWEET) registry. Data from 21 countries were included. Participants were divided into four treatment modalities: isCGM with or without insulin pump use and rtCGM with or without insulin pump use. The primary outcome was the proportion of individuals in each treatment modality group achieving recommended CGM clinical targets.ResultsAmong the 5219 participants (2714 [52.0%] male; median age, 14.4 [IQR, 11.2–17.1] years), the median duration of diabetes was 5.2 (IQR, 2.7–8.7) years and median hemoglobin A1c level was 7.4% (IQR, 6.8%–8.0%). The treatment modality was associated with the proportion of individuals achieving the recommended clinical targets. Adjusted for sex, age, diabetes duration, and body mass index standard deviation score, the proportion achieving the recommended greater than 70% time in range target (70–180 mg/dL) was highest with rtCGM plus insulin pump use (36.2% [95% CI, 33.9%–38.4%]), followed by rtCGM plus injection use (20.9% [95% CI, 18.0%–24.1%]), isCGM plus injection use (12.5% [95% CI, 10.7%–14.4%]), and isCGM plus insulin pump use (11.3% [95% CI, 9.2%–13.8%]) (P < 0.001). Similar trends were observed for less than 25% time above (rtCGM plus insulin pump, 32.5% [95% CI, 30.4%–34.7%]; vs isCGM plus insulin pump, 12.8% [95% CI, 10.6%–15.4%]; P < 0.001) and less than 4% time below range target (rtCGM plus insulin pump, 73.1% [95% CI, 71.1%–75.0%]; vs isCGM plus insulin pump, 47.6% [95% CI, 44.1%–51.1%]; P < 0.001). The adjusted time in range was highest among rtCGM plus insulin pump users (64.7% [95% CI, 62.6%–66.7%]). Treatment modality was associated with the proportion of participants experiencing severe hypoglycemia and diabetic ketoacidosis events.ConclusionsUse of rtCGM and insulin pump was associated with increased time in range and a decrease in time below range.Hybrid Closed-Loop Systems and Glycemic Outcomes in Children and Adults with Type 1 Diabetes: Real-World Evidence from a U.S.-based Multicenter CollaborativeNoor N1,2, Kamboj MK3, Triolo T4, Polsky S4, McDonough RJ5, Demeterco-Berggren C6, Jacobsen L7, Sonabend R8, Ebekozien O1,9, DeSalvo DJ81T1D Exchange, Boston, MA; 2Aga Khan University, Karachi, Pakistan; 3Nationwide Children's Hospital, Columbus, OH; 4Barbara Davis Center for Diabetes, Aurora, CO; 5Children's Mercy Kansas City, Kansas City, MO; 6Rady Children's Hospital, San Diego, CA; 7University of Florida, Florida, Gainesville, FL; 8Texas Children's Hospital, Houston, TX; 9University of Mississippi, Oxford, MSDiabetes Care 2022;45:e118–e119New diabetes technologies, including insulin pumps, continuous glucose monitors (CGM), and most recently their combination in hybrid closed-loop (HCL) systems, have been demonstrated in multiple clinical trials to improve glycemic outcomes in people with type 1 diabetes (T1D). This study compared glycemic outcomes in users of HCL systems with those of users of insulin pumps and CGM without automation and those using CGM with multiple daily injection (MDI) regimens in a large multicenter database.MethodsElectronic medical record data from the T1D Exchange Quality Improvement Collaborative were analyzed for 28,019 people aged > 6 years with T1D of at least 1 year's duration, classified by age, racial and ethnic identity, and treatment modality. The outcomes of interest included most recent hemoglobin A1c (HbA1c) level, time in range (TIR), time above range (TAR), and time below range (TBR).ResultsAmong 28,019 individuals, the HCL users (2047) had the lowest HbA1c, followed by the pump + CGM users (12,306), and then MDI + CGM users (13,613). TIR was higher, and TAR and TBR lower, in the HCL users compared with pump + CGM and MDI + CGM users. Notably, despite the same outcome patterns by treatment modality among all racial and ethnic groups, HbA1c levels were higher in all categories in non-Hispanic Black and Hispanic individuals than in non-Hispanic White peers.ConclusionsThis report demonstrates the value of HCL in a large real-world database to achieve lower HbA1c levels and improved TIR but, as in many other clinical reports, highlights the disparities in reaching optimal targets in all populations. Social disparities continue to exist despite access to the best available technologies to treat diabetes.CommentsThis year has seen the publication of a number of outstanding clinical reports of very large industry-based and academic-based registries comprising glycemic outcomes in people with T1D. These databases demonstrate that diabetes technologies, including automated insulin delivery (AID) systems, have become the standard of care and have had a massive impact in routine clinical use.In the first study, Dovc and colleagues report on the achievement of time in range (TIR) as a function of treatment modality in the large multinational SWEET registry of youth with T1D (1). Unsurprisingly, youths using insulin pumps and real-time continuous glucose monitors (rtCGM) achieved the highest TIR, particularly those using AID systems, followed by the rtCGM + injection users. Perhaps more surprisingly, the intermittently scanned CGM (isCGM) + injection users had higher TIR than the isCGM pump users, although differences were small. Further support for the use of rtCGM over isCGM is illustrated by the lower rates of severe hypoglycemia and diabetic ketoacidosis in the rtCGM group, findings that may at least in part be explained by the absence of alarm functions in earlier iterations of isCGM.Most notably, although only 264 of the 5219 participants were using AID systems, this group was nearly able to achieve the challenging 70% TIR goal proposed by the ATTD 2019 Consensus panel for most adults with diabetes (2). Similar findings were reported by Alonso et al. (3) in a large, single-center report of technology use in the pediatric population: improvements in hemoglobin A1c (HbA1c) levels between 2016 and 2017 and 2020–2021 were attributed to the increasing migration of patients to technologically advanced diabetes devices (e.g., from glucose meters to CGM or from open-loop + CGM to AID) (3).In addition to the real-world successes of AID technologies in the general (4) and publicly insured (5) populations, the brief report from the Type 1 Diabetes Exchange Quality Improvement Collaborative by Noor and colleagues succinctly capsulizes both the major successes of AID systems and the lingering failures of these systems to benefit all demographics equally (6). While the 2047 AID users in the QI Collaborative achieved lower HbA1c levels and greater TIR than other forms of therapy, persistent differences were seen in outcomes in non-White populations; the continuing disparity in outcomes despite the most advanced therapies is a theme that this article will continue to explore in a later section.Using Technology to "Move the Needle" in Type 2 DiabetesPredictors of Insulin Pump Initiation among People with Type 2 Diabetes from a US Claims Database Using Machine LearningHankosky ER, Katz ML, Fan L, Liu D, Chinthammit C, Brnabic AJM, Eby ELEli Lilly and Company, Lilly Corporate Center, Indianapolis, INCurr Med Res Opin 2023;39:843–853Individuals with type 2 diabetes (T2D) are increasingly using insulin pumps, albeit at a slower rate compared with people with type 1 diabetes (T1D), but factors associated with insulin pump initiation in the T2D population in the real world have been not been well studied.MethodsThis retrospective, nested case-control study identified the predictors of insulin pump initiation among people with T2D. Adults with T2D in the United States who were new to bolus insulin use were identified from the IBM MarketScan Commercial database (2015–2020). The candidate variables of pump initiation were entered into conditional logistic regression (CLR) and penalized CLR models.ResultsUsing incidence density sampling, from the sample of 32,104 eligible adults with T2D, 726 insulin pump initiators were identified and matched with 2904 who did not initiate pump use. The consistent predictors of insulin pump initiation across the base case, sensitivity, and post hoc analyses included continuous glucose monitor (CGM) use, visiting an endocrinologist, acute metabolic complications, higher count of hemoglobin A1c (HbA1c) tests, lower age, and fewer diabetes-related medication classes.ConclusionsThe predictors for pump initiation are useful in designing targeted efforts to improve access and acceptance of insulin pumps among persons with T2D. Many of the predictors identified in this analysis also could be used clinically to identify the patients in need of treatment intensification, greater engagement in their diabetes management, or more proactive management by health-care providers.Rates and Correlates of Uptake of Continuous Glucose Monitors among Adults with Type 2 Diabetes in Primary Care and Endocrinology SettingsMayberry LS1,2,3, Guy C4, Hendrickson CD5, McCoy AB2, Elasy T1,31Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; 2Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN; 3Center for Health Behavior and Health Education, Vanderbilt University Medical Center, Nashville, TN; 4School of Medicine, University of Mississippi, Jackson, MS, 5Division of Diabetes, Endocrinology, and Metabolism, Department of Medicine, Vanderbilt University Medical Center, Nashville, TNJ Gen Intern Med 2023;38:2546–2552This study is also discussed in DIA-2024-2510, page S-153.Although clinical trials have indicated that continuous glucose monitoring (CGM) benefits adults with type 2 diabetes (T2D), the rate of CGM use and correlates in real-world care settings are unknown. This study examined the prevalence and correlates of CGM use as well as the rates of new CGM prescriptions across clinic types and medication regimens.MethodsThe retrospective cohort design used electronic health records in a large academic medical center in the southeastern United States to identify adults with T2D who had a primary care or endocrinology visit during 2021. The main measures were age, gender, race, ethnicity, insurance, clinic type, insulin regimen, hemoglobin A1c (HbA1c) values, CGM prescriptions, and prescribing clinic type.ResultsAmong 30,585 adults with T2D, 13% had used a CGM. The CGM users were younger and more had private health insurance (P < 0.05) compared with the nonusers; 72% of CGM users had an intensive insulin regimen, and 12% were not taking insulin. The CGM users had higher HbA1c values (both most recent and most proximal to the first CGM prescription) than the nonusers. The CGM users also were more likely to receive endocrinology care than nonusers, but 23% had only primary care visits in 2021. For each month in 2021, a mean of 90.5 (± 12.5 SD) people started using CGM. From 2020 to 2021, the overall monthly rates of CGM prescriptions to new users grew 36%, but grew by 125% in primary care. With endocrinology practices, most users starting CGM had an intensive insulin regimen (82% vs 49% starting in primary care); in primary care, 28% starting CGM in primary care were not using insulin (vs 5% in endocrinology).ConclusionsCGM uptake for T2D has been increasing rapidly, and most of that growth is seen via primary care. Health-care systems have an opportunity to support the growth in CGM use and related workflows in primary care.Use of the FreeStyle Libre System and Diabetes Treatment Progression in T2DM: Results from a Retrospective Cohort Study Using a Canadian Private Payer Claims DatabaseHarris SB1, Levrat-Guillen F21Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; 2Abbott Laboratories Ltd, Berkshire, UKDiabetes Obes Metab 2023;25:1704–1713An estimated one-third of Canadians are living with prediabetes or diabetes. Data from Canadian private drug claims were used to investigate whether flash glucose monitoring with the FreeStyle Libre system (FSL) among Canadians with type 2 diabetes (T2D) was associated with changes in treatment intensification compared with blood glucose monitoring (BGM) alone.MethodsThis retrospective study used a Canadian national private drug claims database comprising approximately 50% coverage of insured individuals in Canada to identify people with T2D who were using FSL or BGM. The algorithm identified T2D patients based on their treatment history and followed them over a 24-month study period, tracking their therapy progression. The Andersen-Gill model for recurrent time-to-event data was used to evaluate whether the rate of treatment progression differed between the FSL and BGM treatment cohorts. The survival function was used to calculate comparative treatment progression probabilities between the two cohorts.ResultsIn total, 373,871 people with T2D met the inclusion criteria: 137,110 (37%) were new to diabetes therapy before the index date, and 236,761 (63%) already had been receiving therapy. Of the therapy-naive cohort, 130,791 (95.4%) were started on noninsulin therapies at the index date, and 6319 (4.6%) were started on insulin therapy. Of the experienced cohort, 208,152 (87.9%) were using noninsulin therapies, and 28,609 (12.1%) were on insulin therapy. Across the treatment (FSL) and control (BGM) groups, FSL users had a higher probability of treatment progression compared with BGM alone (relative risk 1.86 and 2.81, respectively; P < 0.001). A higher probability of treatment progression was independent of type of therapy or prior experience with therapy. The FSL cohort had a much greater portion of patients who started with noninsulin treatment but ended with insulin treatment compared with the BGM group.ConclusionsPeople with T2D using FSL had a greater probability for treatment progression compared with BGM alone, irrespective of the starting therapy. This may suggest that FSL can be used to support escalation of diabetes therapy to improve therapeutic inertia in T2D.CommentsRandomized trials have now demonstrated the benefit of CGM in adult patients with T2D, and in our ATTD Yearbook section last year we noted real-world improvements in diabetes outcomes in this population. Notably, improvements were achieved not only for those on intensive regimens but also nonintensive and even noninsulin regimens, and CGM use was also associated with reductions in acute adverse events (7–9). However, pumps and sensors continue to be used to a much lower extent in people with T2D compared with those with T1D.The studies highlighted this year show the important role that diabetes technology can play not only in directly guiding daily management but also serving to overcome therapeutic inertia. However, in order to capitalize on these opportunities, educating patients with T2D about the benefits of diabetes technologies and actively promoting access to them must become a standard component of their care.Hankosky and colleagues probed a large U.S. claims database to identify predictors of insulin pump use in adult patients with T2D (10). CGM users were five times more likely and those receiving care from an endocrinologist were almost three times more likely to be on pump therapy than those with only primary care visits. Younger age, higher HbA1c, and previous adverse metabolic events were also strong predictors.Mayberry and colleagues described similar findings related to CGM use after investigating electronic medical records at a large outpatient diabetes center: twice as many patients were initiated on CGM by the endocrinology practice compared with the primary care office (11). Granted, there are many potentially confounding variables: for example, people may be referred from primary care to an endocrinologist specifically for assistance with more complicated insulin regimens or more labile glucose patterns or after acute metabolic events. On a positive note, the authors reported that despite an early lag in CGM prescriptions, primary care prescribing rates for new CGM had nearly doubled by the last year in the analysis.Ultimately, increased use of technology, whether under the direction of primary care providers or endocrinologists, bodes well for patient care, at both the micro and macro levels, to improve individual outcomes and contain overall health-care costs. Harris and colleagues presented a similar analysis of 350,000 individuals with T2D identified via a private claims database that insures up to half of Canadians (12). Irrespective of the diabetes treatment modality at enrollment date, use of isCGM was strongly associated with escalating clinically indicated pharmacotherapy (e.g., transitioning from no drug therapy to oral antihyperglycemic or from noninsulin injectable to a more complex insulin regimen).Although the authors did not conduct an economic analysis, the implications of overcoming therapeutic inertia extend beyond optimizing individual outcomes to limiting the staggering health-care costs attributable to diabetes complications today. It is clear that the introduction of diabetes technology at earlier stages of diabetes management in a primary care environment can have profound individual and societal benefits, and that greater efforts are needed to support primary care practitioners to feel empowered and confident to prescribe these technologies to their patients.A New Frontier—Diabetes Technology in the HospitalReal-Time Continuous Glucose Monitoring in the Hospital: A Real-World ExperienceSpierling Bagsic SR1, Fortmann AL1, Belasco R1, Bastian A1, Lohnes S1, Ritko A2, Sandoval H1, Chichmarenko M1, Soriano EC1, Talavera L1, Philis-Tsimikas A11Scripps Whittier Diabetes Institute, Scripps Health, San Diego, CA; 2Scripps Health, San Diego, CAJ Diabetes Sci Technol 2023;17:656–666To improve outcomes for patients with diabetes, glycemic control in the hospital setting is imperative. Bedside point-of-care (POC) glucose monitoring has remained the gold standard for decades even though it provides only momentary glimpses into a patient's glycemic control. Continuous glucose monitoring (CGM) has been shown to improve glycemic control in the ambulatory setting, but the lack of inpatient experience and data remain barriers to its approval by U.S. Food and Drug Administration (FDA) and its expanded use in the hospital setting.MethodsThe FDA exercised its enforcement discretion to not object to the use of CGM systems for the treatment of patients in hospital settings to support health-care-related efforts to reduce the COVID-19 exposure of health-care workers. Subsequently Scripps Health, a large not-for-profit health care system in San Diego, California, implemented CGM as the new standard of care (SOC) for glucose monitoring and management in the hospital.ResultsDetailed implementation procedures for employing this new SOC; a description the patients receiving CGM as SOC, their glycemic control, and hospital outcomes; and lessons learned over two years and nearly 900 hospital encounters involving CGM are featured in this report.ConclusionsIn hospital settings, CGM is feasible with a dedicated diabetes care team and remote monitoring.Attitudes and Behaviors with Diabetes Technology Use in the Hospital: Multicenter Survey Study in the United StatesMadhun NZ1, Galindo RJ2, Donato J3, Hwang PR4, Shabir HF4, Fowler MJ5, Molitch-Hou E6, Bena JF7, Umpierrez GE2, Lansang MC11Endocrinology and Metabolism Institute, Cleveland Clinic Foundation, Cleveland, OH; 2Division of Endocrinology, Emory University School of Medicine, Atlanta, GA; 3Department of Hospital Medicine, Cleveland Clinic Foundation, Cleveland, OH; 4Division of Hospital Medicine, Emory University School of Medicine, Atlanta, GA; 5Division of Diabetes, Endocrinology, and Metabolism, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; 6Section of Hospital Medicine, Department of Medicine, University of Chicago, Chicago, IL; 7Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, OHDiabetes Technol Ther 2023;25:39–49This study assessed the attitudes, behaviors, and barriers with diabetes technology use in the general medicine hospital wards.MethodsA nonincentivized, web-based, anonymous survey captured demographic and practice data regarding continuous subcutaneous insulin infusion (CSII) and continuous glucose monitor (CGM) use in the hospital at four large hospital systems in the United States.ResultsAmong 128 survey respondents, 76%, 10%, and 6% were hospitalists, advanced practice providers, and primary care physicians, resp
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