Improving Diabetes Care Through Teamwork, Comprehensive Education, Tighter Goals, and Technology: Single-Center Data from Türkiye.

Real-World Diabetes Technology: Overcoming Barriers and Disparities.

The Official Journal of ATTD Advanced Technologies & Treatments for Diabetes Conference 22‐25 February 2023 I Berlin & Online

ATTD 2021 Invited Speaker Abstracts.

Use of CGM in T2D is rising rapidly, yet little is known regarding its effects on glucose management in the VHA. We thus identified new CGM users (new CGM sensor prescriptions for T2D on insulin) and non-users (T2D receiving glucose strips) during the years 2015-2020 and used national VHA healthcare data from visit encounters to compare change over 12 months in glucose control and new emergency room (ER) or hospital admissions. Changes in HbA1c and acute admissions were compared by linear mixed models and generalized linear models, respectively. Compared with 36,082 non-users, CGM users (n=16,013) differed in many ways but were well-balanced with overlap weighting from propensity score modeling. CGM users had a greater reduction in HbA1c over 12 months (-0.25%; 95% CI -0.21-0.29, p<0.0001) and a decline in hypoglycemia related ER visits/hospitalizations (OR = 0.78; CI 0.62-0.97) . Among CGM users, those < 65 years old or with initial HbA1c > 8. 4% (median) had greater reductions in HbA1c, while those at higher hypoglycemia risk had reduced hypoglycemia and hyperglycemia related ER visits/hospitalizations and all-cause hospitalizations (Table) . In this large national study in T2D, CGM initiation was linked with better glucose control and reduced ER and/or hospital admissions for hypoglycemia and showed even greater benefits in subsets of CGM users. Disclosure P.Reaven: Research Support; AstraZeneca, Dexcom, Inc. M.Newell: Research Support; Dexcom, Inc. S.Rivas: None. X.Zhou: None. G.J.Norman: Employee; Dexcom, Inc. J.Zhou: Research Support; Dexcom, Inc. Funding DexCom, Inc

There is increasing recognition that older onset type 1 diabetes (T1D) is not uncommon. Although CGM use is rising dramatically among those with T1D, little is known regarding its use and benefits within this older T1D population. To address these questions, we identified new CGM users (new CGM sensor prescriptions for T1D developing after military enrollment) and non-users (T1D receiving care and glucose strips from the VHA) during the years 2015-2020 and used national VHA healthcare data and ICD-9/ICD-diagnostic codes from visit encounters to compare baseline characteristics, change in glucose control and new emergency (ER) or hospital admissions. Linear mixed models and Cox proportional models (with propensity score overlap weighting) , were used to compare pre/post changes in HbA1c, and time to acute admissions, respectively. Compared with 4732 nonCGM users, CGM users (n=5,143) had similar HbA1c levels but differed in many ways at initiation of CGM, including: being significantly younger (59 vs. 65 years) , higher proportion White (83 vs. 75%) , and more frequently using glucagon (36 vs. 12 %) , short-acting insulin (99 vs. 86%) and insulin pumps (54 vs.7%) . After propensity overlap weighting, all characteristics were nearly identical between groups. Initiation of CGM was associated with reduced HbA1c levels (- 0.2 and -0.26% at 6 and 12 months (p’s< 0.001) compared with nonCGM users. Similarly, CGM users also had greater declines in risk for total hospitalizations (HR = .88; CI 0.79-0.98) and hypoglycemic (HR = .69; CI 0.53-0.90) and hyperglycemic (HR = .77; CI 0.64-0.94) related ER visits/hospitalizations (all p’s < 0.02) . In this large national study of CGM initiation in older T1D patients, CGM use was linked with improved glucose control as well as reduced ER and/or hospital admissions for hypoglycemia, hyperglycemia or any cause. Disclosure J.Zhou: Research Support; Dexcom, Inc. M.Newell: Research Support; Dexcom, Inc. S.Rivas: None. X.Zhou: None. G.J.Norman: Employee; Dexcom, Inc. P.Reaven: Research Support; AstraZeneca, Dexcom, Inc. Funding DexCom, Inc

Background: Although use of continuous glucose monitoring (CGM) has been linked with improved glucose control, including reductions in hemoglobin A1c and episodes of hypoglycemia, there has been little investigation of its possible role in reducing other serious clinical events. Objective: To estimate the effect of starting CGM in patients with type 2 diabetes (T2D) on mortality. Research Design: A cohort study comparing mortality between propensity score-matched CGM users and non-CGM users over 18 months. Setting: Veterans Affairs Health Care System. Participants: Adult patients with T2D receiving insulin who were identified as CGM users or non-CGM users between January 1, 2015, and December 31, 2020. Measurements: Primary outcome of all-cause mortality; secondary outcomes of serious all-cause hospitalization, cardiovascular events, and admissions related to hyperglycemia and hypoglycemia. Results: A total of 12,729 patients with T2D (94% male with mean age 66) who were new CGM users were 1:1 matched with non-CGM users. Total follow-up time was 17,676 and 17,034 person-years for CGM and non-CGM users. Risk for mortality was lower in CGM users (hazard ratio or HR 0.79: 95% confidence interval or CI 0.73-0.86), as were risks for all-cause hospitalization (0.91: 0.86, 0.96), cardiovascular events (0.84: 0.73, 0.96), and admissions for hyperglycemia (0.88: 0.81, 0.95). Lower risk for mortality persisted after accounting for early deaths, COVID-19, recent onset of diabetes, subsequent use of insulin pumps or newer diabetes medications, or when stratifying by frequency of CGM use, frailty index or mortality risk (all HRs: 0.83 or less, range of CI: 0.60-0.94). No differences between CGM and non-CGM users were seen with negative control outcomes. Limitations: Unmeasured health factors, behaviors, or other confounders may exist. Conclusion: In a large national cohort, initiation of CGM was associated with lower mortality in T2D patients using insulin and indicates use of CGM may have benefits that extend beyond glucose lowering.

How can we reach the target of glucose control in type 1 diabetes?

Background: The use of continuous glucose monitoring (CGM) has improved glycemic control. Disparity in CGM use has been reported; however, the utilization of CGM across a health system in real-world clinical settings remains unknown. We aimed to characterize patients who use CGM and compare them to patients with diabetes who do not use CGM in a large health system. Methods: We retrospectively reviewed the electronic health record (EHR) of patients who received care at NYU Langone Health from 2015. CGM users were those whose EHR records had at least one uploaded CGM report, while CGM non-users were those who had at least one outpatient encounter in which a diabetes diagnosis was documented and who did not have any CGM files uploaded into Epic. Results: We identified 10,515 CGM users and 108,395 CGM non-users. CGM use significantly increased in patients with type 2 diabetes (T2D) after 2019, with higher use of CGM in patients with T2D than those with type 1 diabetes (T1D) (63.6% vs. 36.4%; p<.001). The rate of CGM use was significantly different across racial/ethnic groups: 9.9% of Whites, 7.8% Hispanics/Latinos, 7.5% African Americans, 7.2% Asian, and 7.1% Native Americans. When comparing CGM user among racial groups, CGM user was higher (than non-use) among Whites (60.4% vs 53.1%) and Filipinos (0.68% vs 0.55%), but less frequent among African Americans (13.0% vs 15.6%), Chinese (0.71% vs 1.7%), and Koreans (0.19% vs 0.45%) (p<.001). Regarding the ethnicity, more CGM users were Salvadoran (0.83% vs 0.45%), while less were Puerto Rican (3.3% vs 3.6%), Dominican (1.2% vs 1.4%), and Mexican (0.55 vs 1.4) (p<.001). Conclusions: Using a large real-world clinical setting dataset, our study identified disparity in the CGM use in patients with T1D compared to T2D. Further we noted racial/ethnic disparities in the CGM use and heterogeneity within Hispanics and Asian Americans. Researchers and clinicians should consider interventions to reduce disparities in CGM prescription patterns. Disclosure Y.Zheng: None. E.Iturrate: None. B.Wu: None. J.Fletcher: None. G.D.Melkus: None. S.B.Johnson: None. Funding National Institutes of Health (P30DK111022)

Continuous glucose monitoring (CGM) use in older adults with type 1 diabetes (T1D) has shown benefits. However, the impact of CGM use, coupled with simplified treatment regimens and personalized glycemic goals that are better suited for older patients with multiple comorbidities and hypoglycemia, is not known. Older adults (≥65 years) with T1D with hypoglycemia (two or more episodes of hypoglycemia [blood glucose <70 mg/dL for ≥20 min over 2 weeks]) who were CGM naive or CGM users were randomized to intervention and control groups. The intervention consisted of the combined use of CGM with geriatric principles (i.e., adjusting goals based on overall health, and simplification of regimens based on CGM patterns and clinical characteristics) over 6 months. The control group received usual care by their endocrinologist. The primary end point was change in time when blood glucose was <70 mg/dL from baseline to 6 months. Cost-effectiveness was calculated using a health care sector perspective. We randomized 131 participants (aged 71 ± 5 years; 21% ≥75 years old) to the intervention (n = 68; CGM users = 33) or the control (n = 63; CGM users = 40) group. The median change in hypoglycemia from baseline to 6 months was -2.6% in the intervention group and -0.3% in the control group (median difference, -2.3% [95% CI -3.7%, -1.3%]; P < 0.001). This improvement was seen in both CGM naive (-2.8%; 95% CI -5.6%, -0.8%) and CGM users (-1.2%; 95% CI -2.7%, -0.1%). The HbA1c did not differ between the groups (7.5% vs. 7.3%). The intervention was cost-effective (incremental cost-effectiveness ratio $71,623 per quality adjusted life-year). In older adults with T1D and high risk of hypoglycemia, CGM use enhanced by geriatric principles can lower hypoglycemia without worsening glycemic control in a cost-effective fashion.

BackgroundThis study aims to identify the status of continuous glucose monitoring (CGM) use among individuals with type 1 diabetes mellitus (T1DM) in South Korea and to investigate whether age-related disparities exist.MethodsIndividuals with T1DM receiving intensive insulin therapy were identified from the Korean National Health Insurance Cohort (2019–2022). Characteristics of CGM users and non-users were compared, and the prescription rates of CGM and sensor-augmented pump (SAP) or automated insulin delivery (AID) systems according to age groups (<19, 19–39, 40–59, and ≥60 years) were analyzed using chi-square tests. Glycosylated hemoglobin (HbA1c) levels and coefficients of variation (CV) among CGM users were also examined.ResultsAmong the 56,908 individuals with T1DM, 10,822 (19.0%) used CGM at least once, and 6,073 (10.7%) used CGM continuously. Only 241 (0.4%) individuals utilized either SAP or AID systems. CGM users were younger than non-users. The continuous prescription rate of CGM was highest among individuals aged <19 years (37.0%), followed by those aged 19–39 years (15.8%), 40–59 years (10.7%), and ≥60 years (3.9%) (P<0.001 for between-group differences). Among CGM users, HbA1c levels decreased from 8.7%±2.4% at baseline to 7.2%±1.2% at 24 months, and CV decreased from 36.6%±11.9% at 3 months to 34.1%±12.7% at 24 months.ConclusionDespite national reimbursement for CGM devices, the prescription rates of CGM remain low, particularly among older adults. Given the improvements in HbA1c and CV following CGM initiation, more efforts are needed to increase CGM utilization and reduce age-related disparities.

Disclosure: E.E. Bell-Sambataro: None. J. Kilbarger: None. A. Lahoti: None. J.M. Ladd: None. Background: Diabetes technology (continuous glucose monitors (CGM) and insulin pumps), is associated with improved glycemic control and quality of life in children with type 1 diabetes (T1D), but technology use is not equitable. We explored whether rural/urban disparities exist in CGM and pump use among pediatric patients with T1D enrolled in an Accountable Care Organization (ACO) and thus on Medicaid. Methods: We conducted a retrospective cohort study using claims data from the central Ohio ACO database from January 1, 2018 to September 30, 2022. Individuals aged 1 to &amp;lt;21years were identified using T1D-specific billing codes. CGM or pump use was defined using established prescription codes. Rurality was based on zip codes of residence linked to RUCA codes. For descriptive analyses, we calculated proportions, means and standard deviations. T-tests were used to compare continuous variables; chi-square tests were used to compare categorical variables. Multivariable Poisson regression was used to model the association between rurality and CGM or pump use, adjusted for age, sex, race, and era (pre-/post-COVID pandemic). Results: We identified 1079 enrolled individuals with T1D during the study period; 878 (81.4%) were using CGM and 259 (24%) were using insulin pumps. In descriptive analysis, CGM users were younger than non-users (users 11.4±4.4years vs non-users 15.3±3.8years, p&amp;lt;0.01). The distribution of rurality between CGM users and non-users was similar (users 73.5% urban, 26.3% rural vs non-users 66.6% urban, 33.3% rural, p=0.05). There were no age or rurality differences between pump users and non-users (users 12.2±3.8years vs non-users 12.1±4.8years, p=0.86; users 72.6% urban vs non-users 72.1% urban, p=0.92). In regression modeling, rurality was not significantly associated with CGM use (adjusted risk ratio (aRR) 0.95, 95% confidence interval (CI) 0.89-1.02) whereas age, race, era, and pump use were significantly associated. Rurality was significantly associated with pump use (aRR 0.79, 95% CI 0.63-0.99) as were age, race and era. Conclusions: In this cohort limited to pediatric patients with T1D on Medicaid, rural residence did not have a significant effect on CGM use but did make pump use less likely. Those of older age or non-White race were significantly less likely to use CGM and pumps. Future efforts targeting these disparities should be undertaken to increase use of these standard of care technologies among all children. Presentation: 6/2/2024

Background Socioeconomic (SES) and ethnic inequalities in type 1 diabetes (T1D) outcomes are widespread. There is concern that unequal access to technologies, such as continuous glucose monitoring (CGM), may increase disparities. This systematic review summarises the evidence for inequalities in access to CGM for children and young people (CYP) and outcomes for CGM users. Methods MEDLINE, Embase, and Web of Science were searched for observational studies published between January 2020 and July 2023 which report CGM use stratified by any PROGRESS-plus criteria for T1D patients under 26. Reports based in low- or middle-income countries or ≤ 500 participants were excluded. Primary outcomes were the proportion of patients using CGM and HbA1c of CGM users. Quality assessment was performed using the Newcastle-Ottawa Scale. Unadjusted odds ratios were calculated from extracted data, though heterogeneity precluded meta-analysis. The protocol was pre-registered with PROSPERO (CRD42023438139). Results Of the 3,369 unique studies identified, 27 met inclusion criteria. We found decreased CGM use and higher discontinuation for low SES, low education, publicly insured, and minority ethnic, especially black, CYP. These associations were generally robust to adjustment for other sociodemographic variables, suggesting an independent effect. Lower SES inequalities were seen in countries where CGM is reimbursed. Although low SES and minority ethnicity were generally associated with poorer outcomes, there was no significant association between domains of disadvantage and higher HbA1c for CGM users, excepting parental education. Conclusions There are significant SES, ethnic, and education inequalities in CGM use for CYP with T1D, particularly when reimbursement is limited. This is contributing to outcome inequalities. However, evidence suggests CYP benefit equally from CGM use, irrespective of ethnicity and SES. Increasing CGM funding and use is likely to reduce outcome inequalities. Key messages • There are significant SES, ethnic, and education inequalities in continuous glucose monitoring use for young people with T1D. Inequalities are more marked when technology is not reimbursed. • Increasing access to CGM may reduce outcome inequalities, as evidence suggests that young people benefit equally from CGM use, regardless of ethnicity or SES.

Introduction: Young adults (YA) with type 1 diabetes (T1D) are at risk of poor glycemic control. Use of continuous glucose monitoring (CGM) has been shown to improve glucose control. However, real-world data on the impact of CGM use on glucose control in YA is limited. Methods: We analyzed data from electronic medical records collected across 2018 from a tertiary adult clinic of YA patients age 18- 30 yrs with T1D. A1C and insulin administration methods defined as sliding scale (SS), multiple daily injection while carbohydrate counting (MDI), or via pump therapy (Pump) were collected along with CGM use. Results: Data from 891 patients (mean age 26±3, T1D duration 12±7 years, 52% female, average A1C 7.9%±1.5) were analyzed. Twelve % (n= 110) were on SS; 37% (n=331) on MDI, and 51% (n= 450) on pump therapy; mean age of all 3 groups was 26 ± 3yrs. Use of CGM was recorded in 32% of patients on SS, while use of CGM was recorded in 46% and 66% of patients using MDI and pump, respectively. A1C differed between CGM users and non-users in each subgroup. Conclusion: With increasing complexity of insulin regimen, CGM use rises. However, independent of insulin administration method, CGM use was associated with lower A1C. These findings highlight the potential benefit of CGM use, in YA with T1D in adult clinic settings. Disclosure E. Toschi: None. R.A. Gabbay: Advisory Panel; Self; FormHealth, Health Reveal, Lark, Onduo, Vida Health. A. Clift: None. M. Bennetti: None. A. Atakov-Castillo: None.

Background: Socioeconomic status (SES) and ethnic inequalities in type 1 diabetes (T1D) outcomes are well-established. There is concern that unequal access to technologies, including continuous glucose monitoring (CGM), may increase disparities. This systematic review summarises the evidence for inequalities in the prevalence of CGM use for children and young people (CYP) and outcomes for CGM users.Methods: Medline, Embase and Web of Science were searched for observational studies published between January 2000 and July 2023 which report CGM use stratified by any PROGRESS-Plus criteria for T1D patients under 26. Reports based in low- or middle-income countries, ≤500 participants or only reporting hybrid closed-loop systems were excluded. Primary outcomes were the proportion of patients using CGM and HbA1c of CGM users. Quality assessment was performed using the Newcastle–Ottawa Scale. Unadjusted odds ratios were calculated from the extracted summary data, though heterogeneity precluded meta-analysis. The protocol was preregistered with PROSPERO (CRD42023438139).Results: Of the 3369 unique studies identified, 27 met the inclusion criteria. Thirty-three percent were of ‘good' or ‘very good' quality. We found decreased CGM use and higher discontinuation for low SES, low education, publicly insured and minority ethnic, especially Black, CYP. These associations were generally robust to adjustment for other sociodemographic variables, suggesting an independent effect. Lower SES inequalities were seen in countries where CGM is reimbursed. Although low SES and minority ethnicity were associated with poorer outcomes in general, for CGM users there was no significant association between domains of disadvantage and higher HbA1c, excepting parental education.Conclusions: There are significant SES, ethnic and education inequalities in CGM use for CYP with T1D, particularly when reimbursement is limited. This inequity is contributing to inequalities in T1D outcomes. However, evidence suggests CYP benefit equally from CGM use, irrespective of ethnicity and SES. Increasing CGM funding and use is likely to reduce outcome inequalities.

T he past year saw marked advances in research in pediatric diabetes with numerous studies investigating the use of closed-loop systems in the pediatric population. While such technologies are on the horizon for clinical use in pediatrics, other studies in the past year have highlighted the challenges with clinical implementation of insulin pump therapy, a technology that has been available for decades. The hope for an automatedor initially a semiautomated or hybrid closed-loop system requiring the user to give premeal boluses of insulinis well deserved. These systems aim to improve glucose control and lower the burden of care for children with type 1 diabetes (T1D) and their families. However, initial systems will continue to require significant user involvement as well as experienced and informed pediatric diabetes teams for successful adoption of these diabetes technologies. In addition, advances were seen in the use of a novel intranasal formulation of glucagon to treat hypoglycemia that simplifies the current injectable version of this potentially lifesaving medication. A randomized trial on the benefits of metformin in overweight adolescents with T1D found no benefit on HbA1c, but other potential metabolic improvements. Technology was also studied using telehealth to improve diabetes outcomes by delivering care to rural populations and in pediatric patients struggling to achieve treatment goals. Research in diabetes technology in pediatrics has accelerated in the past few years and with the advent of clinical availability of closed-loop technology promises to remain a rich field of investigation for years to come. Pediatric patients and their families should begin to reap the benefits of decades of work on these diabetes technologies to improve glucose control and lower the burden of care for diabetes. We conducted a Medline search for articles on the following topics: diabetes technology, insulin pump therapy (continuous subcutaneous insulin infusion [CSII]), continuous glucose monitoring (CGM), closed-loop systems, and new therapies in T1D relating to the pediatric age group (0-18 years). This article focuses on key articles that were published between July 1, 2015 and June 30, 2016. Use of insulin pump therapy in children and adolescents with type 1 diabetes and its impact on metabolic control: comparison of results from three large, transatlantic paediatric registries