The Digital/Virtual Diabetes Clinic: The Future Is Now-Recommendations from an International Panel on Diabetes Digital Technologies Introduction

Using continuous glucose monitoring to measure and improve quality metrics: Updates on the Healthcare Effectiveness Data and Information Set 2024 Glucose Management Indicator measure

Value-based diabetes care is a proactive approach to providing quality care to individuals with diabetes. This approach focuses on improving clinical outcomes rather than the volume of services provided. Implementation of value-based diabetes care requires an established set of standardized quality measures against which all stakeholders can assess and benchmark their performance. The National Committee for Quality Assurance recently added the Glucose Management Indicator to its Healthcare Effectiveness Data and Information Set. The Glucose Management Indicator can be used as a measure of glucose control. This article discusses the benefits of value-based care, the importance of diabetes quality measures, and how the rapidly increasing adoption of continuous glucose monitoring is impacting these measures while improving the lives of individuals with diabetes.

The critical elements of digital health in diabetes and cardiometabolic care

Digital innovations provide novel opportunities to individualize a person's care to best match their lifestyle needs and circumstances and to support them as they live their daily lives with diabetes. These innovations also serve to provide actionable data and insights for the care team giving them a "Webb telescope-like" view into their individual self-management journey, allowing them to see what cannot be seen during infrequent and limited office visits, thereby facilitating collaboration and communication to optimize the care plan on a timely basis. Technology advances are enabling diabetes care to transition from episodic, synchronous, primarily in-person care to include synchronous virtual care options and to continuous, on-demand, data-informed, asynchronous digital care better matching the demands of living with a relentless 24/7 chronic condition. In this paper we will discuss the critical elements and considerations in designing and implementing successful diabetes digital health tools in clinical practice.

From iPSCs to Pancreatic β Cells: Unveiling Molecular Pathways and Enhancements with Vitamin C and Retinoic Acid in Diabetes Research

Diabetes mellitus, a chronic and non-transmissible disease, triggers a wide range of micro- and macrovascular complications. The differentiation of pancreatic β-like cells (PβLCs) from induced pluripotent stem cells (iPSCs) offers a promising avenue for regenerative medicine aimed at treating diabetes. Current differentiation protocols strive to emulate pancreatic embryonic development by utilizing cytokines and small molecules at specific doses to activate and inhibit distinct molecular signaling pathways, directing the differentiation of iPSCs into pancreatic β cells. Despite significant progress and improved protocols, the full spectrum of molecular signaling pathways governing pancreatic development and the physiological characteristics of the differentiated cells are not yet fully understood. Here, we report a specific combination of cofactors and small molecules that successfully differentiate iPSCs into PβLCs. Our protocol has shown to be effective, with the resulting cells exhibiting key functional properties of pancreatic β cells, including the expression of crucial molecular markers (pdx1, nkx6.1, ngn3) and the capability to secrete insulin in response to glucose. Furthermore, the addition of vitamin C and retinoic acid in the final stages of differentiation led to the overexpression of specific β cell genes.

The impact of telehealth education on self-management in patients with coexisting type 2 diabetes mellitus and hypertension: a 26-week randomized controlled trial

BACKGROUND

The prevalence of coexisting type 2 diabetes mellitus and hypertension is increasing globally and posing significant health challenges. Effective self-management is crucial for controlling the disease and preventing complications. Telehealth education has emerged as a promising approach to enhancing self-management.

OBJECTIVE

This study aimed to investigate the effects of telehealth education on glycolipid metabolism, blood pressure, and self-management in patients with coexisting type 2 diabetes mellitus and hypertension.

METHODS

This study included 174 patients diagnosed with type 2 diabetes and hypertension from October 2022 to March 2023 at the 900th Hospital of the Joint Logistic Support Force of the Chinese People's Liberation Army. The patients were randomly assigned to the control group or the telehealth education group. The control group received conventional diabetes education including diet and exercise guidance, while the telehealth education group received additional online education through the WeChatapplication. Both groups were followed up for 26 weeks and the changes in glycolipid metabolism, blood pressure, and self-management were compared between the groups.

RESULTS

After 26 weeks of intervention, the telehealth education group showed statistically significant reductions in weight, body mass index, fasting blood glucose, 2 h postprandial blood glucose, and hemoglobin A1c compared to the control group (P < 0.05). The telehealth education group also exhibited a significant decrease in systolic blood pressure and low-density lipoprotein-C level (P < 0.05). The Summary of Diabetes Self-Care Activities score, which reflects the level of diabetes self-management, demonstrated that the telehealth education group had a significantly better total score as well as superior scores in all five sub-categories (diet, blood glucose testing, medication use, and foot care) compared to the control group (P < 0.05).

CONCLUSION

Our findings confirmed that telehealth education effectively enhanced the self-management capabilities of patients with coexisting type 2 diabetes and hypertension, leading to better glycolipid and blood pressure control. The use of telehealth education may potentially improve the interaction between medical staff and patients in the management of chronic diseases.

How to Use Continuous Glucose Monitoring Efficiently in Diabetes Management: Opinions and Recommendations by German Experts on the Status and Open Questions

Today, continuous glucose monitoring (CGM) is a standard diagnostic option for patients with diabetes, at least for those with type 1 diabetes and those with type 2 diabetes on insulin therapy, according to international guidelines. The switch from spot capillary blood glucose measurement to CGM was driven by the extensive and immediate support and facilitation of diabetes management CGM offers. In patients not using insulin, the benefits of CGM are not so well studied/obvious. In such patients, factors like well-being and biofeedback are driving CGM uptake and outcome. Apps can combine CGM data with data about physical activity and meal consumption for therapy adjustments. Personalized data management and coaching is also more feasible with CGM data. The same holds true for digitalization and telemedicine intervention ("virtual diabetes clinic"). Combining CGM data with Smart Pens ("patient decision support") helps to avoid missing insulin boluses or insulin miscalculation. Continuous glucose monitoring is a major pillar of all automated insulin delivery systems, which helps substantially to avoid acute complications and achieve more time in the glycemic target range. These options were discussed by a group of German experts to identify concrete gaps in the care structure, with a view to the necessary structural adjustments of the health care system.

Continuous glucose monitoring for the routine care of type 2 diabetes mellitus

Although continuous glucose monitoring (CGM) devices are now considered the standard of care for people with type 1 diabetes mellitus, the uptake among people with type 2 diabetes mellitus (T2DM) has been slower and is focused on those receiving intensive insulin therapy. However, increasing evidence now supports the inclusion of CGM in the routine care of people with T2DM who are on basal insulin-only regimens or are managed with other medications. Expanding CGM to these groups could minimize hypoglycaemia while allowing efficient adaptation and escalation of therapies. Increasing evidence from randomized controlled trials and observational studies indicates that CGM is of clinical value in people with T2DM on non-intensive treatment regimens. If further studies confirm this finding, CGM could soon become a part of routine care for T2DM. In this Perspective we explore the potential benefits of widening the application of CGM in T2DM, along with the challenges that must be overcome for the evidence-based benefits of this technology to be delivered for all people with T2DM.

Importance of FDA-Integrated Continuous Glucose Monitors to Ensure Accuracy of Continuous Glucose Monitoring

Continuous glucose monitoring (CGM) has been shown to improve glycemic control and self-monitoring, as well as to reduce the risk of hypoglycemia. Integrated CGM (iCGM) FDA-cleared systems with published performance data are established nonadjunctive and accurate CGM tools that can directly inform decision-making in the treatment of diabetes (i.e., insulin dosing). Studies have assessed accuracy and safety data of CGMs that were eventually cleared for iCGM by the FDA and that informed the recommendation for their nonadjunctive use. Subsequent robust clinical trials and real-world studies demonstrated clinical effectiveness with improvements in a range of patient outcomes. In recent years, a number of non-iCGM-approved CGM devices have entered the market outside the United States worldwide. Some of these non-iCGM-approved CGM devices require additional user verification of blood glucose levels to be performed for making treatment decisions, termed adjunctive. Moreover, in many non-iCGM-approved CGM devices, accuracy studies published in peer-reviewed journals are scarce or have many limitations. Consequently, non-iCGM-approved CGM devices cannot be automatically perceived as having the same performance or quality standards than those approved for iCGM by the FDA. As a result, although these devices tend to cost less than iCGMs that carry FDA clearance and could therefore be attractive from the point of view of a health care payer, it must be emphasized that evaluation of costs should not be limited to the device (such as the usability preference that patients have for nonadjunctive sensors compared to adjunctive sensors) but to the wider value of the total benefit that the product provides to the patient.

The German Fast Track Toward Reimbursement of Digital Health Applications: Opportunities and Challenges for Manufacturers, Healthcare Providers, and People With Diabetes

BACKGROUND

Digital health applications (DiGA) supporting the management of diabetes are among the most commonly available digital health technologies. However, transparent quality assurance of DiGA and clinical proof of a positive healthcare effect is often missing, which creates skepticism of some stakeholders regarding the usage and reimbursement of these applications.

METHODS

This article reviews the recently established fast-track integration of DiGA in the German reimbursement market, with emphasis on the current impact for manufacturers, healthcare providers, and people with diabetes. The German DiGA fast track is contextualised with corresponding initiatives in Europe.

RESULTS

The option of a provisional prescription and reimbursement of DiGA while proving a positive healthcare effect in parallel may expedite the adoption of DiGA in Germany and beyond. However, hurdles for a permanent prescription and reimbursement of DiGA are high and only one of 12 that have achieved this status specifically addresses people with diabetes.

CONCLUSION

The DiGA fast track needs to be further enhanced to cope with remaining skepticism and contribute even more to a value-based diabetes care.

The role of real-time continuous glucose monitoring in diabetes management and how it should link to integrated personalized diabetes management

Diabetes is a complex metabolic condition that demands tailored, individualized approaches for effective management. Real-time continuous glucose monitoring (rtCGM) systems have improved in terms of design, usability and accuracy over the years and play a pivotal role in the delivery of integrated personalized diabetes management (iPDM). iPDM is a comprehensive multidisciplinary approach that combines individualized care strategies utilizing technologies and interventions and encourages the active involvement of the person with diabetes in the care provided. The use of stand-alone rtCGM and its integration with other diabetes technologies, such as hybrid automated insulin delivery, have enabled improved glycaemic and quality of life outcomes for people with diabetes. As the uptake of rtCGM and associated technologies is increasing and becoming the standard of care for people with diabetes, it is important that efforts are focused on associated goals such as reducing health inequalities in terms of access, aligning structured education with rtCGM usage, choosing the right technology based on needs and preferences, and minimizing burden while aiming for optimal glucose outcomes. Utilizing rtCGM in other settings than outpatients and in diabetes cohorts beyond type 1 and type 2 diabetes needs further exploration. This review aims to provide an overview of the role of rtCGM and how best to link rtCGM to iPDM, highlighting its role in enhancing personalized treatment strategies.

Telemedicine maintains good glucose control in children with type 1 diabetes but is not time saving for healthcare professionals: KITES randomized study

AIMS

To evaluate glucose control non-inferiority and time benefits of telemedicine follow-up in children with type 1 diabetes (CwD).

METHODS

In a single-center 9-month-long randomized controlled study (clinicaltrials.gov NCT05484427), 50 children were randomized to either telemedicine group (TG) followed-up distantly by e-mail, or to face-to-face group (FFG) attending standard personal visits. The primary endpoint was non-inferiority of HbA1c at final visit (level of non-inferiority was set at 5 mmol/mol). The secondary endpoints were subcutaneous glucose monitoring parameters and time consumption from both study subjects' and the physicians' point of view.

RESULTS

Non-inferiority of HbA1c in the TG was proven (mean HbA1C 45.8 ± 7.3 [TG] vs. 50.0 ± 12.6 [FFG] mmol/mol, 6.3 vs. 6.7 % DCCT, p = 0.17; between groups HbA1C difference 95 % CI -10.2 to 1.9 mmol/mol). Telemedicine saved time for participants (mean visit duration [MVD] 50 [TG] vs. 247 min [FFG], p < 0.001). There were no other differences between groups neither in CGM parameters nor physician's time consumption (MVD 19 [TG] vs. 20 min [FFG], p = 0.58).

CONCLUSIONS

Nine-month telemedicine follow-up of the children with well-controlled T1D is not inferior to standard face-to-face visits. Telemedicine visits saved time for the participants but not for their diabetologists.

Type 1 and Covid-19: Diagnosis, Clinical Care, and Health Outcomes during the Pandemic

The coronavirus disease 2019 (COVID-19) pandemic disrupted health care, creating challenges for people with diabetes and health care systems. Diabetes was recognized as a risk factor for severe disease early in the pandemic. Subsequently, risk factors specific for people with type 1 diabetes were identified, including age, hemoglobin A1c level, and lack of continuous glucose monitoring . Telemedicine, especially when accompanied by diabetes data, allowed effective remote care delivery. However, pre-existing racial disparities in access to diabetes technology persisted and were associated with worse outcomes. Events of the COVID-19 pandemic underscore the importance of continuing to develop flexible and more equitable health care delivery systems.

Testing 3 Digital Health Platforms to Improve Mental Health Outcomes in Adults With Type 1 Diabetes: A Pilot Trial

OBJECTIVE

Our aim in this study was to examine the potential impact of a 3-pronged digital health pilot intervention (TRIFECTA) on diabetes distress and depressive symptoms among adults with type 1 diabetes (T1D) in British Columbia.

METHODS

We recruited 60 adults with T1D (mean age 38.9±15.1 years, 75% female, 77% Caucasian) who participated in the 6-month pilot intervention involving 3 digital health platforms: monthly, provider-led, group-based sessions over Zoom (virtual huddles); a WhatsApp peer texting group; and a web-based "Ask-the-expert" portal. Assessments were conducted at baseline and 6 months and measured diabetes distress (T1D Diabetes Distress Scale), depressive symptoms (9-item Personal Health Questionnaire), and TRIFECTA engagement metrics.

RESULTS

Participation in TRIFECTA was associated with significant reductions in Overall Distress (p=0.011) and 4 distress subscales: Powerlessness (p=0.006), Management Distress (p=0.001), Hypoglycemia Distress (p=0.029), and Eating Distress (p<0.001). A higher number of virtual huddles attended predicted lower Overall Distress (p=0.019) and Family/Friends Distress (p=0.023). A higher number of "Ask-the-expert" posts viewed predicted lower Overall Distress (p=0.046), whereas a higher number of WhatsApp messages posted predicted lower Management Distress (p=0.006). Furthermore, engagement in all 3 metrics was a predictor for lower Negative Social Perceptions Distress (p<0.05). No associations were seen in other distress subscales or for depressive symptoms.

CONCLUSIONS

Participation in TRIFECTA was linked to reduced diabetes distress levels, but not depressive symptoms, in a platform-dependent manner. This study provides promising pilot data for a subsequent large-scale and fully powered randomized controlled trial.

Long-Term Results of a Digital Diabetes Self-Management and Education Support Program Among Adults With Type 2 Diabetes: A Retrospective Cohort Study

PURPOSE

The purpose of this study is to examine the long-term impact of a digital diabetes self-management education and support (DSMES) program on A1C among adults with type 2 diabetes (T2DM).

METHODS

Data analyzed were from a retrospective cohort of commercially insured members with T2DM enrolled in the Omada for Diabetes program between January 1, 2019, and January 31, 2022 (n = 1,322). Linear mixed models measured changes in A1C and weight across 12 months (collected at baseline and every 3 months over 1 year) overall and stratified by A1C at baseline (≥8% vs <8%).

RESULTS

On average, members were 53.5 years old, 56.9% female, and 71.5% White, with a mean baseline body mass index (BMI) of 36.9 and A1C of 7.6%. Members with baseline A1C ≥8% demonstrated clinically and statistically significant adjusted mean reductions in A1C during follow-up, from 9.48% at baseline to 7.33%, 7.57%, 7.59%, and 7.47% at 3, 6, 9, and 12 months, respectively. Those with A1C <8% maintained glycemic stability (6.73%, 6.50%, 6.54%, 6.62%, and 6.51%, respectively). Collectively, members experienced a -1.17 kg/m2 mean reduction in BMI over 12 months.

CONCLUSIONS

This study provides real-world evidence that members with elevated baseline A1C (≥8%) enrolled in a digital DSMES program experienced clinically meaningful and statistically significant reductions in A1C. Those with baseline A1C within goal treatment range (<8%) maintained glycemic stability over 1 year. The findings support existing evidence that scalable digital DSMES solutions can help individuals with T2DM manage their condition.

Artificial Intelligence and Machine Learning for Improving Glycemic Control in Diabetes: Best Practices, Pitfalls, and Opportunities

OBJECTIVE

Artificial intelligence and machine learning are transforming many fields including medicine. In diabetes, robust biosensing technologies and automated insulin delivery therapies have created a substantial opportunity to improve health. While the number of manuscripts addressing the topic of applying machine learning to diabetes has grown in recent years, there has been a lack of consistency in the methods, metrics, and data used to train and evaluate these algorithms. This manuscript provides consensus guidelines for machine learning practitioners in the field of diabetes, including best practice recommended approaches and warnings about pitfalls to avoid.

METHODS

Algorithmic approaches are reviewed and benefits of different algorithms are discussed including importance of clinical accuracy, explainability, interpretability, and personalization. We review the most common features used in machine learning applications in diabetes glucose control and provide an open-source library of functions for calculating features, as well as a framework for specifying data sets using data sheets. A review of current data sets available for training algorithms is provided as well as an online repository of data sources.

SIGNIFICANCE

These consensus guidelines are designed to improve performance and translatability of new machine learning algorithms developed in the field of diabetes for engineers and data scientists.

Sustaining telehealth in pediatric diabetology beyond COVID-19: How to set the tone

In the post-COVID-19 era, telehealth experience and knowledge must be structured to deliver high-quality care. Type 1 diabetes is a chronic disease that lends itself to being a model for telehealth diffusion, especially in the pediatric setting where the use of cloud-connected technologies is widespread. Here, we present "how to set the tone" and manage a telemedicine session according to our experiences and those reported in the literature, according to the health professional perspective. A practical workflow on how healthcare professionals can structure a virtual diabetes clinic is reported, as well as critical issues related to limits in physical examination, communication registers, relationships, and visit settings. A proactive virtual visit model could be feasible, stratifying patients according to continuous glucose monitoring metrics, and personalized interventions can be provided to each patient. Analysis of benefits and hassles due to telehealth for each patient has to be considered, as well as their personal perspective, expectations, and reported barriers, mainly related to connection issues and digital literacy.

7. Diabetes Technology: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Patient perspectives of diabetes care in primary care networks in Singapore: a mixed-methods study

BACKGROUND

Type 2 diabetes (T2D) remains an important chronic condition worldwide requiring integrated patient-centred care as advocated by the Chronic Care Model (CCM). The Primary Care Networks (PCNs) in Singapore organise general practitioners (GPs) with nurses and care coordinators to deliver team-based care for patients with chronic conditions. This study examined the quality of care in the PCNs as defined by the CCM from the patients' perspective.

METHODS

This study followed a cross-sectional convergent mixed-method design with T2D patients across three PCN types (GP-led, Group, and Cluster). The Patient Assessment of Chronic Illness Care (PACIC, range 1-5) was completed by a convenience sample of 343 patients. Multivariate linear regression was performed to estimate the associations between patient and service characteristics and PACIC summary score. Twenty-four participants were purposively recruited for interviews on the experienced care until thematic saturation was reached. Quantitative and qualitative data were collected concurrently and independently. Integration occurred during study design and data analysis using the CCM as guidance. Quantitative and qualitative results were compared side-by-side in a joint comparison table to develop key concepts supported by themes, subthemes, and patients' quotes.

RESULTS

The PACIC mean summary score of 3.21 for 343 patients evidenced that some have received CCM consistent care in the PCNs. Being younger and spending more time with the GP were associated with higher PACIC summary scores. PACIC summary scores did not differ across PCN types. The 24 patients interviewed in the qualitative study reported receiving team-based care, nurse services, good continuity of care, as well as patient-centred care, convenient access, and affordable care. Key concepts showed that integrated care consistent with the CCM was sometimes received by patients in the PCNs. Patient activation, delivery system design/decision support, goal setting/tailoring, and problem-solving/contextual counselling were sometimes received by patients, while follow-up/coordination was generally not received.

CONCLUSIONS

Patients with T2D from the Singapore Primary Care Networks received integrated care consistent with the Chronic Care Model, particularly in patient activation, delivery system design/decision support, goal setting/tailoring, and problem-solving/contextual counselling. Follow-up/coordination needed improvement to ensure higher quality of diabetes care.

Roadmap to the Effective Use of Continuous Glucose Monitoring: Innovation, Investigation, and Implementation

For 25 years, continuous glucose monitoring (CGM) has been evolving into what it is now: a key tool to both measure individuals' glycemic status and to help guide their day-to-day management of diabetes. Through a series of engineering innovations, clinical investigations, and efforts to optimize workflow implementation, the use of CGM is helping to transform diabetes care. This article presents a roadmap to the effective use of CGM that outlines past, present, and possible future advances in harnessing the potential of CGM to improve the lives of many people with diabetes, with an emphasis on ensuring that CGM technology is available to all who could benefit from its use.

Roadmap to the Effective Use of Continuous Glucose Monitoring in Primary Care

Diabetes technology has undergone a remarkable evolution in the past decade, with dramatic improvements in accuracy and ease of use. Continuous glucose monitor (CGM) technology, in particular, has evolved, and coevolved with widely available consumer smartphone technology, to provide a unique opportunity to both improve management and decrease the burden of management for populations across nearly the entire spectrum of people living with diabetes. Capitalizing on that opportunity, however, will require both adoption of and adaptations to the use of CGM technology in the broader world of primary care. This article focuses on mechanisms to expand pathways to optimized glycemic management, thereby creating a robust roadway capable of improving care across broad populations managed in primary care settings. Recent expansions in access to devices combined with improved mechanisms for data access at the time of primary care visits and improved training and evolving systems of support within primary care, hold potential to improve glycemic management in diabetes across the health care spectrum.

Results From a Virtual Clinic for the Follow-up of Patients Using the Advanced Hybrid Closed-Loop System

BACKGROUND

Evidence regarding the implementation of medium-term strategies in advanced hybrid closed-loop (AHCL) system users is limited. Therefore, this study aimed to describe the efficacy and safety of the AHCL system in patients with type 1 diabetes (T1D) on a six-month follow-up in a virtual diabetes clinic (VDC).

METHOD

A prospective cohort of adult patients with T1D treated using the AHCL system (Mini Med 780G; Medtronic, Northridge, California) in a VDC follow-up. Standardized training and follow-up were conducted virtually. Clinical data and metabolic control outcomes were reported at baseline, and at three and six months.

RESULTS

Sixty-four patients (mean age = 42 ± 14.6 years, 65% men, 54% with graduate education) were included. Percentage time in range (%TIR) increased significantly regardless of prior therapy with intermittently scanned continuous glucose monitoring + multiple daily injections and sensor-augmented pump therapy with predictive low-glucose management after starting AHCL and persisted during the follow-up period with no hypoglycemic events. The %TIR 70 to 180 mg/dL according to socioeconomic strata was 73.4% ± 5.3%, 78.1% ± 8.1%, and 84.2% ± 7.5% for the lower, middle, and upper strata, respectively. The sensor was used more frequently in the population with a higher education level. Adherence to sensor use and SmartGuard retention were higher in patients who underwent the VDC follow-up.

CONCLUSIONS

Medium-term follow-up of users of AHCL systems in a VDC contributes to safely achieving %TIR goals. Virtual diabetes clinic follow-up favored adherence to sensor use and continuous SmartGuard use. Socioeconomic strata were associated with a better glycemic profile and education level was associated with better adherence to sensor use.

Guideline Development for Medical Device Technology: Issues for Consideration

Advances in the development of innovative medical devices and telehealth technologies create the potential to improve the quality and efficiency of diabetes care through collecting, aggregating, and interpreting relevant health data in ways that facilitate more informed decisions among all stakeholder groups. Although many medical societies publish guidelines for utilizing these technologies in clinical practice, we believe that the methodologies used for the selection and grading of the evidence should be revised. In this article, we discuss the strengths and limitations of the various types of research commonly used for evidence selection and grading and present recommendations for modifying the process to more effectively address the rapid pace of device and technology innovation and new product development.

Healthcare professional and manager perceptions on drivers, benefits, and challenges of telemedicine: results from a cross-sectional survey in the Italian NHS

BACKGROUND

The Covid-19 pandemic provided new challenges and opportunities for patients and healthcare providers while accelerating the trend of digital healthcare transformation. This study explores the perspectives of healthcare professionals and managers on (i) drivers to the implementation of telemedicine services and (ii) perceived benefits and challenges related to the use of telemedicine across the Italian National Health Service.

METHODS

An online cross-sectional survey was distributed to professionals working within 308 healthcare organisations in different Italian regions. Quantitative and qualitative data were collected through a self-administered questionnaire (June-September 2021). Responses were analysed using summary statistics and thematic analysis.

RESULTS

Key factors driving the adoption of telemedicine have been grouped into (i) organisational drivers (reduce the virus spread-80%; enhance care quality and efficiency-61%), (ii) technological drivers (ease of use-82%; efficacy and reliability-64%; compliance with data governance regulations-64%) and (iii) regulatory drivers (regulations' semplification-84%). Nearly all respondents perceive telemedicine as useful in improving patient care (96%). The main benefits reported by respondents are shorter waiting lists, reduced Emergency Department attendance, decreased patient and clinician travel, and more frequent patient-doctor interactions. However, only 7% of respondents believe that telemedicine services are more effective than traditional care and 66% of the healthcare professionals believe that telemedicine can't completely substitute in-person visits due to challenges with physical examination and patient-doctor relationships. Other reported challenges include poor quality and interoperability of telemedicine platforms and scarce integration of telemedicine with traditional care services. Moreover, healthcare professionals believe that some groups of patients experience difficulties in accessing and using the technologies due to socio-cultural factors, technological and linguistic challenges and the absence of caregivers.

CONCLUSIONS

Respondents believe that telemedicine can be useful to complement and augment traditional care. However, many challenges still need to be overcome to fully consider telemedicine a standard of care. Strategies that could help address these challenges include additional regulations on data governance and reimbursements, evidence-based guidelines for the use of telemedicine, greater integration of tools and processes, patient-centred training for clinicians, patient-facing material to assist patients in navigating virtual sessions, different language options, and greater involvement of caregivers in the care process.

Innovations in Diabetes Device Training: A Scoping Review

OBJECTIVE

The coronavirus disease 2019 pandemic highlighted a pre-existing need for alternatives to traditional in-person diabetes device trainings. Barriers to care, which include the heavy burden of training, pose a threat to optimal adoption and utilization of these devices. We searched the literature for alternative methods of training, evaluated user satisfaction, and compared short-term clinical outcomes with guideline-based glucometric targets and historical training results.

METHODS

A scoping review of Embase articles from 2019 to 2021 was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines using key words relevant to diabetes technologies. Original full-text articles investigating training of new users on devices were included. Titles and abstracts were screened for eligibility by 2 independent reviewers, and results were summarized.

RESULTS

Of 25 articles retrieved from the database, 11 met the criteria. Alternative training strategies included video conferencing, phone calls, mobile applications, and hybrids with traditional trainings. Overall, there was a high degree of user satisfaction with virtual visits, with a preference for hybrid approaches (6 articles). Although glucometrics varied between articles, short-term glucometrics were satisfactory overall (8 articles), including improved glycated hemoglobin measurements and time in range. Two articles compared time in range over various time points after traditional and remote training. One found equivalency, and the other identified a 5% improvement with remote training.

CONCLUSION

Alternative training approaches are a viable option to reduce the barriers to care and to alleviate training burden. Intentional implementation of alternatives should be considered a solution to address current barriers.

Diabetes Research and Resource Sharing During the COVID-19 Pandemic: A Systematic Review and Experience from an Academic/Non-Profit Resource Website

BACKGROUND

The magnitude of the response of the diabetes professional community to the COVID-19 pandemic is not known. We aimed to examine diabetes technology research trends and resources offered by professional organizations during this period.

METHODS

We explored patterns of the response from the professional diabetes community to the pandemic by (1) systematically searching for articles related to diabetes, COVID-19, and diabetes technologies; (2) examining publication trends of research protocols (clinicaltrials.gov) and preprints (medRxiv); and (3) reviewing online resources from professional organizations including our website (COVIDinDiabetes.org; an Emory University-Diabetes Technology Society collaboration).

RESULTS

We identified 492 articles published between December 2019 and December 2022 meeting our inclusion criteria. Telemedicine and continuous glucose monitoring were the most common reported technologies from most parts of the world. The largest number of preprint articles was published in 2020, with a decline in 2021 and 2022. The number of research protocols related to COVID-19 was the highest in 2020 and declined in 2021 and 2022. Resources from organizations included protocols adapted to treat patients with diabetes and COVID-19, training programs, emergency preparedness, and literature on diabetes and COVID-19. On our website (COVIDinDiabetes.org), there were 12 236 visits and 18 149 pageviews, with 1.6 actions per visits, with most visits coming from North America (N = 7233, 54.2%), South America (N = 2663, 21.8%), and Europe (N = 1219).

CONCLUSIONS

We conclude that the COVID-19 pandemic promoted unprecedented global research productivity related to diabetes and COVID-19 and that the transition to the use of technology resources has been evident during this period.

Diabetes care practices and outcomes in 40.000 children and adolescents with type 1 diabetes from the SWEET registry during the COVID-19 pandemic

AIMS

This study aimed to provide a global insight into initiatives in type 1 diabetes care driven by the COVID-19 pandemic and associations with glycemic outcomes.

METHODS

An online questionnaire regarding diabetes care before and during the pandemic was sent to all centers (n=97, 66,985 youth with type 1 diabetes) active in the SWEET registry. Eighty-two responded, and 70 (42,798 youth with type 1 diabetes) had available data (from individuals with type 1 diabetes duration >3 months, aged ≤21 years) for all 4 years from 2018 to 2021. Statistical models were adjusted, among others, for technology use.

RESULTS

Sixty-five centers provided telemedicine during COVID-19. Among those centers naive to telemedicine before the pandemic (n=22), four continued only face-to-face visits. Centers that transitioned partially to telemedicine (n=32) showed a steady increase in HbA1c between 2018 and 2021 (p<0.001). Those that transitioned mainly to telemedicine (n=33%) improved HbA1c in 2021 compared to 2018 (p<0.001).

CONCLUSIONS

Changes to models of care delivery driven by the pandemic showed significant associations with HbA1c shortly after the pandemic outbreak and 2 years of follow-up. The association appeared independent of the concomitant increase in technology use among youth with type 1 diabetes.

First Real-World Experience With Bigfoot Unity: A 6-Month Retrospective Analysis

The Bigfoot Unity Diabetes Management System, a smart pen cap system cleared by the U.S. Food and Drug Administration in May 2021, incorporates continuous glucose monitoring data, real-time glycemic alerts, and clinician-directed dose recommendations. This study analyzed real-world clinical outcomes data for an initial cohort (n = 58, from 13 clinics) managing multiple daily injection insulin therapy using the pen cap system for 6 months. We examined glycemic control, including hypoglycemia events and interaction with and use of the pen cap system. In a cohort mainly consisting of adults with type 2 diabetes and an average age of 62 years, the results demonstrate close adherence to established glycemic targets, including a relatively short amount of time spent in the hypoglycemic range.

U, Shivaram JM, Belehalli P, M. A. S, H. C. C, Sikkandar MY, Brioschi ML. Diabetic Foot Assessment and Care: Barriers and Facilitators in a Cross-Sectional Study in Bangalore, India

(1) Background: This cross-sectional study aims to highlight the assessment and foot care practices in an advanced clinical setting, the clinical characteristics of the patients, and to understand the barriers and facilitators for effective foot care from the perspectives of healthcare practices, resources, and patients' socioeconomic and cultural practices, and other aspects in terms of new technologies for effective foot care such as infrared thermography. (2) Methods: Clinical test data from 158 diabetic patients and a questionnaire to assess the foot care education retention rate were collected at the Karnataka Institute of Endocrinology and Research (KIER) facility. (3) Results: Diabetic foot ulcers (DFUs) were found in 6% of the examined individuals. Male patients were more likely to have diabetes complications, with an odds ratio (OR) of 1.18 (CI = 0.49-2.84). Other diabetes problems raised the likelihood of DFUs by OR 5 (CI = 1.40-17.77). The constraints include socioeconomic position, employment conditions, religious customs, time and cost, and medication non-adherence. The attitude of podiatrists and nurses, diabetic foot education, and awareness protocols and amenities at the facility were all facilitators. (4) Conclusions: Most diabetic foot complications might be avoided with foot care education, regular foot assessments as the standard of treatment, and self-care as a preventive/therapeutic strategy.

Digital Health and Shared Decision-Making in Diabetes Care - A Survey Initiative in Patients and Clinicians

OBJECTIVE

To assess the landscape of digital health resources in the United States, better understand the impact of the digital health on shared decision-making and identify potential barriers and opportunities for progress in the care of persons with diabetes.

METHODS

The study consisted of two phases: (1) A qualitative phase in which one-on-one interviews were conducted virtually with 34 physicians (Endocrinologists, Endos: n=15; primary care physicians, PCPs: n=19) between February 11-18, 2021, and (2) A quantitative phase in which two online, email-based surveys in the English language were conducted between April 16 and May 17, 2021: one with healthcare professionals (HCP) (n=403: n=200 Endos and n=203 PCPs), and one with persons with diabetes (n=517: patients with type 1 diabetes, n=257; patients with type 2 diabetes, n=260).

RESULTS

Diabetes digital health tools were found to be helpful in shared decision-making, but leading barriers include cost, coverage, and lack of time by healthcare professionals. Among diabetes digital health tools, continuous glucose monitoring (CGM) systems were used most commonly and viewed as most effective in improving quality of life and facilitating shared decision-making. Strategies for increasing use of diabetes digital health resources included lower cost, integration into electronic health records, and increased simplicity of tools.

CONCLUSION

This study revealed that both Endos and PCPs feel that diabetes digital health tools have an overall positive impact. Integration with telemedicine and simpler, lower cost tools with increased patient access can further facilitate shared decision-making and improved diabetes care and quality of life.

Clinical, Economic, and Patient-Reported Benefits of Connected Insulin Pen Systems: A Systematic Literature Review

INTRODUCTION

The objective of this systematic literature review was to evaluate the available literature concerning the clinical, economic, and patient-reported benefits of insulin pen platforms, including connected insulin pens/caps/sleeves and insulin platforms, as well as mobile apps capable of receiving near real-time insulin dosing information.

METHODS

Medline and Embase databases and the Cochrane Library were searched for published literature between January 2015 and May 2021, and manual searches for conference abstracts from 2018 to May 2021 were performed. These searches were supplemented by internet searches for relevant literature and clinical trials. Study selection involved the population, intervention, comparator, outcomes, time frame, and study design outline. Included studies investigated connected insulin systems or connected caps/sleeves enabling pens to be connected, or apps able to connect to these systems, in individuals of all ages with type 1 or type 2 diabetes mellitus.

RESULTS

Searches identified a total of 26 publications (mostly observational studies and conference abstracts) for inclusion, representing ten unique, predominantly small studies. Evidence in this field is still in its early stages, and only two randomized controlled trials met our inclusion criteria. Available results showed that connected insulin pens and their systems potentially helped reduce suboptimal insulin use and may therefore improve glycemic control. Satisfaction of people with diabetes with the technologies used was high, and economic benefits were noted. Features of effective connected insulin pen devices include simplicity of use and data upload/sharing, useful "point-of-care" alerts, and simple and understandable data presentation to facilitate more effective consultations.

CONCLUSIONS

Connected insulin pen systems could be increasingly considered as part of routine clinical care for insulin-treated persons with diabetes who must manage the complexity of their daily insulin routine. Future research focusing on the way data obtained from these devices can be most effectively used alongside other information is urgently needed.

Reducing the Cost of Diabetes Care with Telemedicine, Smartphone, and Home Monitoring

The effect of an increasing diabetes population has resulted in escalated costs and overburdened physicians. The increase in cost is not due to the disease per se, but because of its largely preventable complications. Patient-friendly technologies are proven to significantly reduce complications and thereby cost, but seldom practised. Telemedicine is increasingly being utilized in diabetology to improve access to health care, quality of care, and clinical/psychosocial outcomes in patients with diabetes (PWD). In PWD, patient-physician interactions are essential for improving health outcomes and preventing long-term complications. Smartphones are one of the basic modalities for telemedicine application. Mobile phone messaging applications, including text messaging and multimedia message service, could offer a convenient and cost-effective way to support desirable health behaviors. There are diabetes-related mobile apps mainly focusing on self-management of diabetes, lifestyle modification, and medication adherence motivation. With the widespread availability of high-speed Internet, remote monitoring has also become popular. Home monitoring of blood glucose and blood pressure, wearable devices, and continuous glucose monitoring also play a vital role in bringing down the long‑term vascular complications of diabetes and thereby reduce the overall cost and improve the quality of life of patients. There are hundreds of tech platforms for diabetes management, of which only a few with proven efficacy and safety are recommended by physicians.

Precision Medicine in Type 1 Diabetes

Type 1 diabetes is a complex, chronic disease in which the insulin-producing beta cells in the pancreas are sufficiently altered or impaired to result in requirement of exogenous insulin for survival. The development of type 1 diabetes is thought to be an autoimmune process, in which an environmental (unknown) trigger initiates a T cell-mediated immune response in genetically susceptible individuals. The presence of islet autoantibodies in the blood are signs of type 1 diabetes development, and risk of progressing to clinical type 1 diabetes is correlated with the presence of multiple islet autoantibodies. Currently, a "staging" model of type 1 diabetes proposes discrete components consisting of normal blood glucose but at least two islet autoantibodies (Stage 1), abnormal blood glucose with at least two islet autoantibodies (Stage 2), and clinical diagnosis (Stage 3). While these stages may, in fact, not be discrete and vary by individual, the format suggests important applications of precision medicine to diagnosis, prevention, prognosis, treatment and monitoring. In this paper, applications of precision medicine in type 1 diabetes are discussed, with both opportunities and barriers to global implementation highlighted. Several groups have implemented components of precision medicine, yet the integration of the necessary steps to achieve both short- and long-term solutions will need to involve researchers, patients, families, and healthcare providers to fully impact and reduce the burden of type 1 diabetes.

Clinical Practice Experiences Using a Professional Diabetes Management Ecosystem During COVID

BACKGROUND

Challenges of patient care in diabetes were exacerbated by COVID, undermining the ability of patients to engage in-person with health care professionals (HCPs). To combat this, there has been accelerated adoption of telemedicine to support patient and provider connectivity.

METHODS

We collated survey information regarding telemedicine from 21 European clinical institutions. Health care professionals joined virtual meetings focusing on the OneTouch Reveal (OTR) ecosystem and its utility for conducting telemedicine. Selected HCPs provided clinical case studies to explain how the OTR ecosystem supported patient care.

RESULTS

Remote consultations increased by nearly 50% in 21 European clinics during the pandemic (Belgium [24%], Iberia [65%], Germany [34%], Italy [54%]). In all, 52% of people with diabetes using OTR app to connect remotely with HCPs had type 1 diabetes and 48% had type 2 diabetes. Remote connection methods included telephone (60%), email (19%), video chat (10%), text only (3%), or a mix of these methods (8%). Health care professionals usually reviewed patient data during consultations (45%) rather than before consultations (25%). Fifty-five percent of HCPs indicated digital ecosystems like OTR ecosystem would become their standard of care for diabetes management. In-depth conversations with HCPs provided a deeper understanding of how a digital ecosystem integrated into clinical practice and population management. In addition, five patient case studies using OTR ecosystem were provided by a selection of our HCPs.

CONCLUSION

Diabetes management solutions, such as OTR ecosystem, supported telemedicine during the pandemic and will continue to play a valuable role in patient care beyond the pandemic.

Association of Achieving Time in Range Clinical Targets With Treatment Modality Among Youths With Type 1 Diabetes

IMPORTANCE

Continuous glucose monitoring (CGM) devices have demonstrated efficacy in adults and more recently in youths and older adults with type 1 diabetes. In adults with type 1 diabetes, the use of real-time CGM compared with intermittently scanned CGM was associated with improved glycemic control, but there are limited data available for youths.

OBJECTIVE

To assess real-world data on achievement of time in range clinical targets associated with different treatment modalities in youths with type 1 diabetes.

DESIGN, SETTING, AND PARTICIPANTS

This multinational cohort study included children, adolescents, and young adults younger than 21 years (hereinafter referred to collectively as youths) with type 1 diabetes for a duration of at least 6 months who provided CGM data between January 1, 2016, and December 31, 2021. 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 4 treatment modalities: intermittently scanned CGM with or without insulin pump use and real-time CGM with or without insulin pump use.

EXPOSURES

Type 1 diabetes and the use of CGM with or without an insulin pump.

MAIN OUTCOMES AND MEASURES

Proportion of individuals in each treatment modality group achieving recommended CGM clinical targets.

RESULTS

Among the 5219 participants (2714 [52.0%] male; median age, 14.4 [IQR, 11.2-17.1] years), 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%). Treatment modality was associated with the proportion of individuals achieving 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 was highest with real-time CGM plus insulin pump use (36.2% [95% CI, 33.9%-38.4%]), followed by real-time CGM plus injection use (20.9% [95% CI, 18.0%-24.1%]), intermittently scanned CGM plus injection use (12.5% [95% CI, 10.7%-14.4%]), and intermittently scanned CGM plus insulin pump use (11.3% [95% CI, 9.2%-13.8%]) (P < .001). Similar trends were observed for less than 25% time above (real-time CGM plus insulin pump, 32.5% [95% CI, 30.4%-34.7%]; intermittently scanned CGM plus insulin pump, 12.8% [95% CI, 10.6%-15.4%]; P < .001) and less than 4% time below range target (real-time CGM plus insulin pump, 73.1% [95% CI, 71.1%-75.0%]; intermittently scanned CGM plus insulin pump, 47.6% [95% CI, 44.1%-51.1%]; P < .001). Adjusted time in range was highest among real-time CGM 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.

CONCLUSIONS AND RELEVANCE

In this multinational cohort study of youths with type 1 diabetes, concurrent use of real-time CGM and an insulin pump was associated with increased probability of achieving recommended clinical targets and time in range target as well as lower probability of severe adverse events compared with other treatment modalities.

4. Comprehensive Medical Evaluation and Assessment of Comorbidities: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

The metabolic control and laboratory evaluation in patients with type 2 diabetes during the COVID-19 pandemic and the impact of telemedicine: a single-center experience

Objective: The study aimed to evaluate the metabolic control during the COVID-19 pandemic in subjects with type 2 diabetes mellitus (T2DM) and whether care through telemedicine significantly impacted it.

Material and methods: This was a retrospective study for which three time-periods were prespecified: the COVID-19 pandemic period, pre-COVID-19 period, and before pre-COVID-19. The following information were collected: anthropometric and laboratory parameters (glycated hemoglobin (HbA1c), blood glucose, lipid profile, creatinine, eGFR, etc.), self-measured blood glucose (SMBG), blood pressure (BP), diabetes therapy, number of on-site and of telemedicine consultations. The mean values of all available measurements for HbA1c, SMBG, BP, weight, and body mass index (BMI) were calculated.

Results: During the COVID-19 pandemic, the HbA1c values increased (6.78±0.77% to 6.96±0.87%, p<0.0001; + 0.18±0.67%), despite treatment intensification (p<0.01), while BMI and total cholesterol values slightly decreased (32.01±5.5 kg/m2 to 31.7±5.4 kg/m2, p<0.0001, and 178.1±40.8 mg/dl to 170.5±38.4 mg/dl, p<0.05). The deterioration of glycemic control (to HbA1c >7%) were rather seen in males (to 7.01±0.92%, p<0.0001), patients from rural areas (to 7.08±0.96%, p<0.001) and younger than 65 y.o. (to 7.05±0.82%, p<0.001). More male patients had a mean HbA1c increase of >0.5% during the COVID-19 pandemic (32.3% vs 21.5%, p<0.05). Patients who received more diabetes care visits through telemedicine had a more attenuated increase in HbA1c (6.79±0.80% to 6.90±0.83%, p<0.05 vs 6.76±0.72% to 7.08±0.92%, p<0.0001).

Conclusions: The glycemic control slightly deteriorated during the COVID-19 pandemic (but with overall HbA1c within target), with certain patient categories being more affected. Diabetes care though telemedicine allowed the maintenance of the metabolic control.

7. Diabetes Technology: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Improvement in glycaemic control in patients with type 2 diabetes with treatment using an interactive mobile application - A pilot study from India

AIMS

We studied the outcome of glycaemic management using Diahome, a smart-phone application compared to conventional treatment. Overall acceptability of the application among users was also assessed.

METHODS

This is a retrospective, case-control study of patients on virtual diabetes care using the Diahome app (n = 441) and those visited the hospital out-patient services (n = 446) between April and June 2021. Men and women aged 45-60 years with type 2 diabetes (T2DM) were selected.

RESULTS

A total of 173 records with initial and follow-up visits were analyzed (app users n = 91, non-app users n = 82). Participants were aged 59 ± 12 years and were obese. The two groups were similar by age, gender distribution and duration of T2DM. Fasting blood glucose significantly reduced only among the app-users from a baseline level of 156 ± 70 mg/dl to 129 ± 40 mg/dl at follow-up (p < 0.02). Reduction in HbA1c levels was observed in both groups (p < 0.0001); percentage improvement was better among app (15.8%) than in non-app users (10.4%), p = 0.004. Triglycerides level were higher at both time points among app-users (p < 0.05) as compared to the other group. More than 56% of the users rated the performance of Diahome app as excellent; virtual consultation was rated the highest (71.5%) among the Diahome services.

DISCUSSION

Glycaemic management of diabetes using a dedicated mobile application was superior to in-person hospital visits. Its long-term effectiveness and cost savings need to be ascertained.

The impact of the COVID-19 pandemic on diabetes services: planning for a global recovery

The COVID-19 pandemic has disproportionately affected certain groups, such as older people (ie, >65 years), minority ethnic populations, and people with specific chronic conditions including diabetes, cardiovascular disease, kidney disease, and some respiratory diseases. There is now evidence of not only direct but also indirect adverse effects of COVID-19 in people with diabetes. Recurrent lockdowns and public health measures throughout the pandemic have restricted access to routine diabetes care, limiting new diagnoses, and affecting self-management, routine follow-ups, and access to medications, as well as affecting lifestyle behaviours and emotional wellbeing globally. Pre-pandemic studies have shown that short-term delays in delivery of routine care, even by 12 months, are associated with adverse effects on risk factor control and worse microvascular, macrovascular, and mortality outcomes in people with diabetes. Disruptions within the short-to-medium term due to natural disasters also result in worse diabetes outcomes. However, the true magnitude of the indirect effects of the COVID-19 pandemic on long-term outcomes and mortality in people with diabetes is still unclear. Disasters tend to exacerbate existing health disparities; as we recover ambulatory diabetes services in the aftermath of the pandemic, there is an opportunity to prioritise those with the greatest need, and to target resources and interventions aimed at improving outcomes and reducing inequality.

Monitoring of paediatric type 1 diabetes

PURPOSE OF REVIEW

This article reviews recent developments in methods used to monitor paediatric type 1 diabetes (T1D), including an examination of the role of glycated haemoglobin (haemoglobin A1c) and its limitations for long-term assessment of glycaemia in individual patients, self-monitoring of blood glucose, continuous glucose monitoring (CGM) systems and ketone monitoring.

RECENT FINDINGS

Monitoring of glycemia and ketones, when indicated, is a cornerstone of paediatric T1D management and is essential to optimize glycaemic control. Ongoing technological advancements have led to rapid changes and considerable improvement in the methods used to monitor glucose concentrations in people with T1D. As a result of recent innovations that have enhanced accuracy and usability, CGM is now considered the optimal method for monitoring glucose concentrations and should be introduced soon after diagnosis of T1D.

SUMMARY

Patients/families and healthcare providers must receive comprehensive education and proper training in the use of CGM and interpretation of the vast amounts of data. Future challenges include ensuring equal access to and optimizing clinical use of CGM to further improve T1D care and outcomes.

The future of telehealth in type 1 diabetes

PURPOSE OF REVIEW

Although telemedicine and telehealth services have been a part of type 1 diabetes (T1D) clinical care for several decades, the expansion of in-home telemedicine during the COVID-19 pandemic significantly increased interest in long-term use as part of routine care. This review highlights the current literature regarding telemedicine in T1D care as well as the benefits and barriers to use in a postpandemic world.

RECENT FINDINGS

Telemedicine has increased patient contact with healthcare providers, allowing for more frequent insulin dose adjustments and improvements in glycemic outcomes. In addition to routine clinical care, T1D device training and mental healthcare have been successful through telemedicine. Significant barriers to continued telemedicine care exist, including patient access and technology knowledge, language, and loss of face-to-face interaction. Healthcare providers additionally face unpredictable reimbursement and loss of continuity across state lines, and lack of resources and training for device downloads and telemedicine software.

SUMMARY

Telemedicine can be successfully used in T1D care and has the potential to significantly impact glycemic and long-term outcomes. Due to continued interest for in-person visits by people with T1D and providers, it is likely that long-term telemedicine use will include a hybrid format.

[Validation of a questionnaire for the analysis of digital competence in patients with type 1 diabetes mellitus]

OBJECTIVE

Validation of a questionnaire designed to stratify the level of digital competence in chronic patients.

METHOD

Cross-sectional study, carried out in the Endocrinology and Nutrition Section of the Complejo Asistencial Universitario de León (CAULE). We selected the digital competencies section of the Cambados questionnaire, designed for the identification of digital chronic patient, with a maximum score of 20 points. The questionnaire was completed for validation by patients for whom were prescribed a digital tool for glycemic control. Reliability was assessed by assessing the correct use of the prescribed tool and internal consistency.

RESULTS

The questionnaire was completely filled in by 171 patients, with a mean age of 44.36 (SD 17.36). The mean score obtained in the questionnaire was 11.04 (SD 4.74) and a score over 12 was the most appropriate cut-off point to discriminate between patients according to their level of digital competence. 48.54% of the patients made adequate use of the tool. The scale showed good internal consistency with a Cronbach's alpha of 0.77.

CONCLUSIONS

The results reached in the present study allow us to affirm that the responses obtained from the patients in the digital competency definition questionnaire are a good indicator of the use of digital tools.

Adaptations des pratiques d’ETP destinées aux personnes diabétiques en France durant la crise de la COVID-19 : enquête descriptive sur 153 programmes d’ETP durant le confinement de mars 2020

Introduction

Pour protéger la population de la maladie à coronavirus 2019 (COVID-19), le gouvernement français a choisi le confinement général de la France métropolitaine et des départements d’outre-mer durant la phase la plus aiguë de la pandémie (mars 2020). L’organisation des soins a été bouleversée. Les patients atteints de diabète sont parmi les plus à risque de formes graves de la COVID-19. Dès lors, leur prise en charge, y compris hospitalière, leur suivi ambulatoire et les offres éducatives en ont été bouleversés.

Objectifs

Cette étude vise à décrire les modifications, adoptées par les professionnels de santé, dans les programmes d’éducation thérapeutique du patient (ETP)-Diabète, qui ont été maintenues durant le premier confinement.

Méthodes

Enquête par questionnaire menée auprès des coordonnateurs de programmes ETP-Diabète, durant la période de confinement du 13 mars au 11 mai 2020.

Résultats

Au total, 153 coordonnateurs de programmes ETP-Diabète ont répondu à l’enquête. Au total, 72 % (n = 110) des programmes ont été interrompus, contre 27 % (n = 42) qui ont poursuivi leurs activités en les adaptant, dont 7 % (n = 10) qui ont mis en place des activités spécifiques liées à la COVID-19 et la maladie chronique.

Conclusion

1) L’arrêt de l’ETP relève de plusieurs causes : fermeture exigée des structures, par les tutelles, redéploiement des professionnels vers d’autres activités, patients absents des services. L’ETP est plus intégrée dans les consultations de soins et, à de rares exceptions, quelques patients ont été éduqués par ceux qui restaient en poste. Pour les programmes ETP maintenus, les adaptations ont porté sur le développement des pratiques à distance renforçant l’adaptation des contenus de l’ETP. 2) Cette crise a révélé la fragilité de l’ETP qui a souvent dû être reléguée au second plan, mais elle a aussi développé des opportunités de e-ETP, sans remise en question par les répondants de la notion de programme autorisé par les Agences régionales de santé (ARS). Ces programmes pourraient être envisagés, dorénavant, de façon hybride, considérant le risque que cela comporte d’accentuer la fracture numérique et de s’adresser à des personnes de niveau socioculturel élevé.

Telemedicine for the Clinical Management of Diabetes; Implications and Considerations After COVID-19 Experience

Telemedicine is a clinical approach that was seldom used in the day-to-day practice, if not only in certain settings, before the COVID-19 pandemic. As stated by the WHO, telemedicine is: the delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies (ICT) for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, …. Telemedicine has actually represented the most useful and employed tool to maintain contacts between patients and physicians during the period of physical distance imposed by the pandemic, especially during the lockdown. Diabetes in particular, a chronic disease that often needs frequent confronting between patient and health professionals has taken advantage of the telehealth approach. Nowadays, technological tools are more and more widely used for the management of diabetes. In this review results obtained by telemendicine application in type 1 and type 2 diabetic individuals during COVID-19 are revised, and future perspectives for telemedicine use to manage diabetes are discussed.

Use and Perception of Telemedicine in People with Type 1 Diabetes During the COVID-19 Pandemic: A 1-Year Follow-Up

Background: In the spring of 2020, our research group circulated a worldwide survey with the aim of gathering information on the use and perception of telemedicine in people living with type 1 diabetes at the start of the COVID-19 pandemic. The data suggested that a large number of respondents had rapidly adopted to telemedicine, as in-person visits were not possible, and that this was perceived positively by many. In this study, we conducted a 1-year follow-up to investigate changes in opinions and experiences to telemedicine over the past year of the pandemic. Methods: An anonymous questionnaire was distributed through social media (Twitter, Facebook, and Instagram) between May 9 and May 15, 2021, using an open-access web-based platform (SurveyMonkey.com). The survey was identical to that used in the original study, covering questions relating to the use and perception of telemedicine, diabetes treatment and control, and medical supplies during the COVID-19 pandemic. The questionnaire was available in English, Spanish, German, French, and Italian. We compared the results from the two surveys descriptively and statistically, results were stratified according to age, gender, and HbA_1c. Results: There were 531 survey responses from 40 countries (Europe 54%, North America 36%, South America 2%, and Africa and Asia 2%). A large percentage of respondents (67%) reported meeting with their health care provider remotely since the beginning of the pandemic, a significant increase compared with the 28% in the 2020 survey (P < 0.001). Eighty-three percent of respondents found remote appointments to be somewhat-to-extremely useful, similar to the 86% satisfaction rate in the previous survey (P = 0.061). Remote appointments were most frequently undertaken through telephone (50%) and video call (45%), which are significant changes compared with those in 2020 (72% and 28%, respectively, P < 0.001). Forty-five percent of respondents in 2021 were likely to consider remote appointments instead of in-person appointments in the future-being significantly lower than the 75% in the initial survey (P < 0.001)-whereas 37% indicated they would not. The majority of respondents (84%) reported no issues in their access to diabetes supplies and medication over the past year. Conclusions: This study showed that the use of telemedicine in the form of remote appointments increased during the COVID-19 pandemic in people living with type 1 diabetes, with high levels of satisfaction. However, a remarkable decline took place in the past year in the proportion of patients stating a willingness to continue with remote appointments beyond the pandemic. It seems that a personalized approach is needed since a substantial proportion of respondents in this follow-up still indicated a preference for in-person diabetes care, hence the use of telemedicine should be considered on an individual basis.