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Patel PM, Thomas D, Liu Z, Aldrich-Renner S, Clemons M, Patel BV. Systematic review of disparities in continuous glucose monitoring and insulin pump utilization in the United States: Key themes and evidentiary gaps. Diabetes Obes Metab 2024. [PMID: 39010293 DOI: 10.1111/dom.15774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 06/14/2024] [Accepted: 06/23/2024] [Indexed: 07/17/2024]
Abstract
AIM This study aims to provide a comprehensive overview of real-world evidence pertaining to disparities in the utilization of continuous glucose monitors (CGMs)/insulin pumps to highlight potential evidentiary gaps and discern emerging themes from the literature. MATERIALS AND METHODS A systematic review of published manuscripts and abstracts was conducted from: MEDLINE, EMBASE, Nursing and Allied Health, Web of Science and CINHAL. Attributes related to patients, outcomes, interventions (CGMs/pumps/both) and study type were captured. In addition, factors associated with disparities in device utilization were examined. RESULTS Thirty-six studies were included in the final analysis; the studies predominantly focused on people living with type 1 diabetes. Only two studies included individuals with type 2 diabetes. Almost two-thirds of the studies reported outcomes associated with disparities (e.g. glycated haemoglobin, diabetic ketoacidosis, resource utilization). Most studies highlighted disparities across race, ethnicity and insurance type. Evidentiary gaps were identified, particularly in the evidence for people with type 2 diabetes, the continuation of CGM/pump use and limited studies addressing disparities among Native Americans/American Indians. CONCLUSION This study reveals critical disparities in diabetes technology use across race, ethnicity and insurance type, particularly among people with type 1 diabetes. Evidentiary gaps assessing disparities in diabetes technology use persist, particularly concerning people with type 2 diabetes, Native American/American Indian and LGBTQ+ populations, and in outcomes related to continuation of use. Social and digital determinants of health, such as income, transportation, residential location and technological literacy, are crucial to achieving equitable access. Future research should focus on the patient journey to identify opportunities for equitable access to diabetes technology as its use grows.
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Affiliation(s)
- Pranav M Patel
- University of Toledo College of Pharmacy and Pharmaceutical Sciences, Toledo, Ohio, USA
| | - Divya Thomas
- University of Toledo College of Pharmacy and Pharmaceutical Sciences, Toledo, Ohio, USA
| | - Zhixi Liu
- University of Toledo College of Pharmacy and Pharmaceutical Sciences, Toledo, Ohio, USA
| | - Sarah Aldrich-Renner
- University of Toledo General Internal Medicine Clinic and College of Pharmacy and Pharmaceutical Sciences, Toledo, Ohio, USA
| | - Marilee Clemons
- University of Toledo General Internal Medicine Clinic and College of Pharmacy and Pharmaceutical Sciences, Toledo, Ohio, USA
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Steenkamp D, Brouillard E, Aia C, Fantasia K, Sullivan C, Atakov-Castillo A, Wolpert H. Reducing Inequity in the Use of Automated Insulin Delivery Systems by Adults With Type 1 Diabetes: Key Learnings From a Safety Net Diabetes Clinic Program. Endocr Pract 2024; 30:558-563. [PMID: 38583773 DOI: 10.1016/j.eprac.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 03/28/2024] [Accepted: 04/01/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Recent advancements in diabetes technology have significantly improved Type 1 diabetes (T1D) management, but disparities persist, particularly in the adoption of automated insulin delivery (AID) systems within minoritized communities. We aimed to improve patient access to AID system training and overcome clinical inertia to referral. METHODS We report on a transformative program implemented at Boston Medical Center, the largest safety-net hospital in New England, aimed at reducing disparities in AID system utilization. We employed a multidisciplinary team and quality improvement principles to identify barriers and develop solutions. Strategies included increasing access to diabetes educators, creating a referral system, and developing telemedicine education classes. We also made efforts to raise clinician awareness and confidence in recommending AID therapy. RESULTS At baseline, 13.5% of our clinic T1D population was using an insulin pump. The population referred included 97 people with T1D (49% female, mean A1c 8.7%, 68% public insurance beneficiaries, 25% Hispanic and 25% non-Hispanic Black). Results from the first year showed a 166% increase in AID system use rates, with 64% of referred patients starting on AID. Notably, 78% of patients with A1c >8.5% adopted AID systems, addressing a gap in representation observed in clinical efficacy trials. The initiative successfully narrowed disparities in AID use among minoritized populations. CONCLUSIONS The program's success among minoritized patients underscores the significance of tailored, collaborative, team-based care and targeted educational initiatives. Our experience provides a foundation for future efforts to ensure equitable access to diabetes technologies, emphasizing the potential of local quality improvement interventions.
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Affiliation(s)
- Devin Steenkamp
- Section of Endocrinology, Diabetes and Nutrition, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, and Boston Medical Center, Boston, Massachusetts.
| | - Elizabeth Brouillard
- Section of Endocrinology, Diabetes and Nutrition, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, and Boston Medical Center, Boston, Massachusetts
| | - Corinne Aia
- Section of Endocrinology, Diabetes and Nutrition, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, and Boston Medical Center, Boston, Massachusetts
| | - Kathryn Fantasia
- Section of Endocrinology, Diabetes and Nutrition, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, and Boston Medical Center, Boston, Massachusetts; Evans Center for Implementation and Improvement Sciences, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Catherine Sullivan
- Section of Endocrinology, Diabetes and Nutrition, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, and Boston Medical Center, Boston, Massachusetts
| | - Astrid Atakov-Castillo
- Section of Endocrinology, Diabetes and Nutrition, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, and Boston Medical Center, Boston, Massachusetts
| | - Howard Wolpert
- Section of Endocrinology, Diabetes and Nutrition, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, and Boston Medical Center, Boston, Massachusetts
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Auzanneau M, Eckert AJ, Meyhöfer SM, Heni M, Gillessen A, Schwettmann L, Jehle PM, Hummel M, Holl RW. Area deprivation and demographic factors associated with diabetes technology use in adults with type 1 diabetes in Germany. Front Endocrinol (Lausanne) 2023; 14:1191138. [PMID: 37600703 PMCID: PMC10433185 DOI: 10.3389/fendo.2023.1191138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 06/30/2023] [Indexed: 08/22/2023] Open
Abstract
Introduction Diabetes technology improves glycemic control and quality of life for many people with type 1 diabetes (T1D). However, inequalities in access to diabetes technology exist in many countries. In Germany, disparities in technology use have been described in pediatric T1D, but no data for adults are available so far. We therefore aimed to analyze whether demographic factors and area deprivation are associated with technology use in a representative population of adults with T1D. Materials and methods In adults with T1D from the German prospective diabetes follow-up registry (DPV), we analyzed the use of continuous subcutaneous insulin infusion (CSII), continuous glucose monitoring (CGM), and sensor augmented pump therapy (SAP, with and without automated insulin delivery) in 2019-2021 by age group, gender, migration background, and area deprivation using multiple adjusted regression models. Area deprivation, defined as a relative lack of area-based resources, was measured by quintiles of the German index of Multiple Deprivation (GIMD 2015, from Q1, least deprived, to Q5, most deprived districts). Results Among 13,351 adults with T1D, the use of technology decreased significantly with older age: CSII use fell from 56.1% in the 18-<25-year age group to 3.1% in the ≥80-year age group, CGM use from 75.3% to 28.2%, and SAP use from 45.1% to 1.5% (all p for trend <0.001). The use of technology was also significantly higher in women than in men (CSII: 39.2% vs. 27.6%; CGM: 61.9% vs. 58.0%; SAP: 28.7% vs. 19.6%, all p <0.001), and in individuals without migration background than in those with migration background (CSII: 38.8% vs. 27.6%; CGM: 71.1% vs. 61.4%; SAP: 30.5% vs. 21.3%, all p <0.001). Associations with area deprivation were not linear: the use of each technology decreased only from Q2 to Q4. Discussion Our real-world data provide evidence that higher age, male gender, and migration background are currently associated with lower use of diabetes technology in adults with T1D in Germany. Associations with area deprivation are more complex, probably due to correlations with other factors, like the higher proportion of migrants in less deprived areas or the federal structure of the German health care system.
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Affiliation(s)
- Marie Auzanneau
- Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
- German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
| | - Alexander J. Eckert
- Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
- German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
| | - Sebastian M. Meyhöfer
- German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
- Institute for Endocrinology and Diabetes, University of Lübeck, Lübeck, Germany
| | - Martin Heni
- Division of Endocrinology and Diabetology, Department of Internal Medicine 1, University Hospital Ulm, Ulm, Germany
- Department for Diagnostic Laboratory Medicine, Institute for Clinical Chemistry and Pathobiochemistry, University Hospital Tübingen, Tübingen, Germany
| | - Anton Gillessen
- Department of Internal Medicine, Sacred Heart Hospital, Muenster, Germany
| | - Lars Schwettmann
- Division of Health Economics, Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| | - Peter M. Jehle
- Department of Internal Medicine I, University Medicine, Academic Hospital Paul-Gerhardt-Stift, Martin-Luther-University Halle-Wittenberg, Lutherstadt Wittenberg, Germany
| | - Michael Hummel
- Research Group Diabetes e.V., Helmholtz Center Munich, Munich-Neuherberg, Germany
| | - Reinhard W. Holl
- Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
- German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
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Malone SK, Matus AM, Flatt AJ, Peleckis AJ, Grunin L, Yu G, Jang S, Weimer J, Lee I, Rickels MR, Goel N. Prolonged Use of an Automated Insulin Delivery System Improves Sleep in Long-Standing Type 1 Diabetes Complicated by Impaired Awareness of Hypoglycemia. J Diabetes Sci Technol 2023:19322968231182406. [PMID: 37449426 DOI: 10.1177/19322968231182406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
BACKGROUND This study assessed changes in actigraphy-estimated sleep and glycemic outcomes after initiating automated insulin delivery (AID). METHODS Ten adults with long-standing type 1 diabetes and impaired awareness of hypoglycemia (IAH) participated in an 18-month clinical trial assessing an AID intervention on hypoglycemia and counter-regulatory mechanisms. Data from eight participants (median age = 58 years) with concurrent wrist actigraph and continuous glucose monitoring (CGM) data were used in the present analyses. Actigraphs and CGM measured sleep and glycemic control at baseline (one week) and months 3, 6, 9, 12, 15, and 18 (three weeks) following AID initiation. HypoCount software integrated actigraphy with CGM data to separate wake and sleep-associated glycemic measures. Paired sample t-tests and Cohen's d effect sizes modeled changes and their magnitude in sleep, glycemic control, IAH (Clarke score), hypoglycemia severity (HYPO score), hypoglycemia exposure (CGM), and glycemic variability (lability index [LI]; CGM coefficient-of-variation [CV]) from baseline to 18 months. RESULTS Sleep improved from baseline to 18 months (shorter sleep latency [P < .05, d = 1.74], later sleep offset [P < .05, d = 0.90], less wake after sleep onset [P < .01, d = 1.43]). Later sleep onset (d = 0.74) and sleep midpoint (d = 0.77) showed medium effect sizes. Sleep improvements were evident from 12 to 15 months after AID initiation and were preceded by improved hypoglycemia awareness (Clarke score [d = 1.18]), reduced hypoglycemia severity (HYPO score [d = 2.13]), reduced sleep-associated hypoglycemia (percent time glucose was < 54 mg/dL, < 60 mg/dL,< 70 mg/dL; d = 0.66-0.81), and reduced glucose variability (LI, d = 0.86; CV, d = 0.62). CONCLUSION AID improved sleep initiation and maintenance. Improved awareness of hypoglycemia, reduced hypoglycemia severity, hypoglycemia exposure, and glucose variability preceded sleep improvements.This trial is registered with ClinicalTrials.gov NCT03215914 https://clinicaltrials.gov/ct2/show/NCT03215914.
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Affiliation(s)
- Susan Kohl Malone
- Rory Meyers College of Nursing, New York University, New York, NY, USA
| | - Austin M Matus
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - Anneliese J Flatt
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, and Institute for Diabetes, Obesity, and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Amy J Peleckis
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, and Institute for Diabetes, Obesity, and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Laura Grunin
- Rory Meyers College of Nursing, New York University, New York, NY, USA
| | - Gary Yu
- Rory Meyers College of Nursing, New York University, New York, NY, USA
| | - Sooyong Jang
- PRECISE Center, Department of Computer and Information Science, School of Engineering and Applied Sciences, University of Pennsylvania, Philadelphia, PA, USA
| | - James Weimer
- PRECISE Center, Department of Computer and Information Science, School of Engineering and Applied Sciences, University of Pennsylvania, Philadelphia, PA, USA
| | - Insup Lee
- PRECISE Center, Department of Computer and Information Science, School of Engineering and Applied Sciences, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael R Rickels
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, and Institute for Diabetes, Obesity, and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Namni Goel
- Biological Rhythms Research Laboratory, Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, IL, USA
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Kanbour S, Jones M, Abusamaan MS, Nass C, Everett E, Wolf RM, Sidhaye A, Mathioudakis N. Racial Disparities in Access and Use of Diabetes Technology Among Adult Patients With Type 1 Diabetes in a U.S. Academic Medical Center. Diabetes Care 2023; 46:56-64. [PMID: 36378855 PMCID: PMC9797654 DOI: 10.2337/dc22-1055] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 10/07/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Recent studies highlight racial disparities in insulin pump (PUMP) and continuous glucose monitor (CGM) use in children and adolescents with type 1 diabetes (T1D). This study explored racial disparities in diabetes technology among adult patients with T1D. RESEARCH DESIGN AND METHODS This was a retrospective clinic-based cohort study of adult patients with T1D seen consecutively from April 2013 to January 2020. Race was categorized into non-Black (reference group) and Black. The primary outcomes were baseline and prevalent technology use, rates of diabetes technology discussions (CGMdiscn, PUMPdiscn), and prescribing (CGMrx, PUMPrx). Multivariable logistic regression analysis evaluated the association of technology discussions and prescribing with race, adjusting for social determinants of health and diabetes outcomes. RESULTS Among 1,258 adults with T1D, baseline technology use was significantly lower for Black compared with non-Black patients (7.9% vs. 30.3% for CGM; 18.7% vs. 49.6% for PUMP), as was prevalent use (43.6% vs. 72.1% for CGM; 30.7% vs. 64.2% for PUMP). Black patients had adjusted odds ratios (aORs) of 0.51 (95% CI 0.29, 0.90) for CGMdiscn and 0.61 (95% CI 0.41, 0.93) for CGMrx. Black patients had aORs of 0.74 (95% CI 0.44, 1.25) for PUMPdiscn and 0.40 (95% CI, 0.22, 0.70) for PUMPrx. Neighborhood context, insurance, marital and employment status, and number of clinic visits were also associated with the outcomes. CONCLUSIONS Significant racial disparities were observed in discussions, prescribing, and use of diabetes technology. Further research is needed to identify the causes behind these disparities and develop and evaluate strategies to reduce them.
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Affiliation(s)
- Sarah Kanbour
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Marissa Jones
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Mohammed S. Abusamaan
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Caitlin Nass
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Estelle Everett
- Division of Endocrinology, Diabetes, & Metabolism, University of California, Los Angeles, Los Angeles, CA
| | - Risa M. Wolf
- Division of Pediatric Endocrinology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Aniket Sidhaye
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nestoras Mathioudakis
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD
- Corresponding author: Nestoras Mathioudakis,
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Tanenbaum ML, Commissariat PV. Barriers and Facilitators to Diabetes Device Adoption for People with Type 1 Diabetes. Curr Diab Rep 2022; 22:291-299. [PMID: 35522355 PMCID: PMC9189072 DOI: 10.1007/s11892-022-01469-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/14/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE OF REVIEW Diabetes technology (insulin pumps, continuous glucose monitoring, automated insulin delivery systems) has advanced significantly and provides benefits to the user. This article reviews the current barriers to diabetes device adoption and sustained use, and outlines the known and potential facilitators for increasing and sustaining device adoption. RECENT FINDINGS Barriers to diabetes device adoption continue to exist at the system-, provider-, and individual-level. Known facilitators to promote sustained adoption include consistent insurance coverage, support for providers and clinics, structured education and support for technology users, and device user access to support as needed (e.g., through online resources). Systemic barriers to diabetes device adoption persist while growing evidence demonstrates the increasing benefits of newest devices and systems. There are ongoing efforts to develop evidence-based structured education programs to support device adoption and sustained use.
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Affiliation(s)
- Molly L Tanenbaum
- Department of Pediatrics, Division of Endocrinology and Diabetes, Stanford University School of Medicine, Stanford, CA, USA.
| | - Persis V Commissariat
- Pediatric, Adolescent and Young Adult Section, Joslin Diabetes Center, Boston, MA, USA
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Modzelewski KL, Murati J, Charoenngam N, Rehm C, Steenkamp DW. Delays in Continuous Glucose Monitoring Device Initiation: A Single Center Experience and a Call to Change. Diabetes Technol Ther 2022; 24:390-395. [PMID: 35099277 DOI: 10.1089/dia.2021.0557] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Background: Continuous glucose monitoring (CGM) has been increasingly shown to be beneficial in patients with both types 1 and 2 diabetes using insulin. Despite this, challenges remain in obtaining coverage for these devices. We sought to define the process of initiation of CGM and better understand factors associated with successful initiation. Methods: A single-center retrospective cohort study of 271 patients seen over a 3-year period from 2017 to 2020 in the adult endocrinology clinic at Boston Medical Center who were prescribed CGM was performed. The primary outcome was time to CGM initiation. Secondary outcomes included factors associated with initiation and continued use of CGMs and glycemic control. Results: Obtaining CGM through pharmacy benefit was significantly faster than through durable medical equipment companies (78 days vs. 152 days, P < 0.0001). Factors associated with initiation of CGM were younger age, private insurance, and education with a clinical diabetes educator. Identifying as black or Hispanic was significantly associated with decreased initiation of CGM. Glycemic control as represented by hemoglobin A1c improved in patients initiated on CGM from 9.06% to 8.22% (P < 0.001). Conclusion: Prescribing CGM as a pharmacy benefit significantly reduces the time to initiation, but on average, still takes several months, delaying potentially life-saving care for patients living with diabetes. Barriers to CGM initiation must be addressed to ensure timely delivery of optimal care to our patients.
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Affiliation(s)
- Katherine L Modzelewski
- Department of Medicine, Section of Endocrinology, Diabetes, Nutrition and Weight Management, Boston Medical Center, Boston, Massachusetts, USA
| | - Jonila Murati
- Department of Medicine, Section of Endocrinology, Diabetes, Nutrition and Weight Management, Boston Medical Center, Boston, Massachusetts, USA
| | - Nipith Charoenngam
- Department of Medicine, Section of Endocrinology, Diabetes, Nutrition and Weight Management, Boston Medical Center, Boston, Massachusetts, USA
| | - Cassie Rehm
- Department of Medicine, Section of Endocrinology, Diabetes, Nutrition and Weight Management, Boston Medical Center, Boston, Massachusetts, USA
| | - Devin W Steenkamp
- Department of Medicine, Section of Endocrinology, Diabetes, Nutrition and Weight Management, Boston Medical Center, Boston, Massachusetts, USA
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Nefs G. The Psychological Implications of Automated Insulin Delivery Systems in Type 1 Diabetes Care. FRONTIERS IN CLINICAL DIABETES AND HEALTHCARE 2022; 3:846162. [PMID: 36992780 PMCID: PMC10012062 DOI: 10.3389/fcdhc.2022.846162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 03/25/2022] [Indexed: 01/15/2023]
Abstract
Automated insulin delivery (AID) systems have brought important glycemic benefits to type 1 diabetes management. The present paper provides an overview of their psychological implications. Trials and real-world observational studies report improvements in diabetes-specific quality of life, with qualitative work describing reduced management burden, increased flexibility and improved relationships. Not all experiences are positive, however, evidenced by dropping algorithm use soon after device initiation. Apart from finance and logistics, reasons for discontinuation include technology frustrations, wear-related issues and unmet glycemic and work load expectations. New challenges include distrust in proper AID functioning, overreliance and deskilling, compensatory behaviors to override or trick the system and optimize time in range, and concerns related to wearing multiple devices on the body. Research efforts may focus on incorporating a diversity perspective, updating existing person-reported outcome measures according to new technology developments, addressing implicit or explicit health professional bias in technology access, examining the merits of incorporating stress reactivity in the AID algorithm, and developing concrete approaches for psychological counseling and support related to technology use. An open dialogue with health professionals and peers about expectations, preferences and needs may foster the collaboration between the person with diabetes and the AID system.
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Affiliation(s)
- Giesje Nefs
- Department of Medical Psychology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, Netherlands
- Diabeter, National Treatment and Research Center for Children, Adolescents and Adults With Type 1 Diabetes, Rotterdam, Netherlands
- Department of Medical and Clinical Psychology, Center of Research On Psychological Disorders and Somatic Diseases (CoRPS), Tilburg University, Tilburg, Netherlands
- *Correspondence: Giesje Nefs,
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