Exploring Parental Experiences of Using a Do-It-Yourself Solution for Continuous Glucose Monitoring Among Children and Adolescents With Type 1 Diabetes: A Qualitative Study

Accuracy of an Off-Label Transmitter and Data Manager Paired With an Intermittent Scanned Continuous Glucose Monitor in Adults With Type 1 Diabetes

BACKGROUND

This work evaluates the accuracy and agreement between the FreeStyle Libre sensor (FSL) and an off-label converted real-time continuous glucose monitor (c-rtCGM) device consisting of the MiaoMiao transmitter and the xDrip+ application which can be coupled to the FSL.

METHODS

Four weeks of glucose data were collected from 21 participants with type 1 diabetes using the c-rtCGM and FSL: two weeks with a single initial calibration (uncalibrated) and two weeks with a daily calibration (calibrated). Accuracy and agreement evaluation included mean absolute relative difference (MARD), the %20/20 rule, Bland-Altman plots, and the Consensus Error Grid analysis.

RESULTS

Values reported by the c-rtCGM system compared with the FSL resulted in an overall MARD of 12.06% and 84.71% of the results falling within Consensus Error Grid Zone A when the device is calibrated. For uncalibrated devices, an overall MARD of 17.49% was obtained. Decreased accuracy was shown in the hypoglycemic range and for rates of change greater than 2 mg/dL/min. The between-device bias also incremented with increasing glucose values.

CONCLUSION

Measurements recorded by the c-rtCGM were found to be accurate when compared with FSL data only when performing daily c-rtCGM device calibrations. High drops in accuracy and agreement between devices occurred when the c-rtCGM was not calibrated.

Do-it-yourself continuous glucose monitoring in people aged 16 to 69 years with type 1 diabetes: A qualitative study

AIMS

In many countries, real-time continuous glucose monitoring (rt-CGM) is not funded, and cost presents a barrier to access. A do-it-yourself conversion of intermittently scanned CGM (DIY-CGM) is a cheaper alternative. This qualitative study aimed to explore user experiences with DIY-CGM in people aged 16 to 69 years with type 1 diabetes (T1D).

METHODS

Convenience sampling was used to recruit participants for semi-structured virtual interviews exploring experiences of DIY-CGM use. Participants were recruited after completing the intervention arm of a crossover randomised controlled trial that evaluated DIY-CGM versus intermittently scanned CGM (isCGM). Participants were previously naive to DIY-CGM and rt-CGM but not isCGM. The DIY-CGM intervention consisted of a Bluetooth bridge connected to isCGM, adding rt-CGM functionality over 8 weeks. Interviews were transcribed, then thematic analysis was performed.

RESULTS

Interviews were with 12 people aged 16 to 65 years, with T1D: mean age ± SD 43 ± 14 years; baseline mean HbA1c ± SD 60 mmol/mol ± 9.9 (7.6 ± 0.9%) and time in range 59.8% ± 14.8%. Participants perceived that using DIY-CGM improved both glycaemic control and aspects of quality of life. Alarm and trend functionality allowed participants to perceive reduced glycaemic variability overnight and following meals. The addition of a smartwatch increased discrete access to glucose information. There was a high degree of trust in DIY-CGM. Challenges while using DIY-CGM included signal loss during vigorous exercise, alarm fatigue and short battery life.

CONCLUSIONS

This study suggests that for users, DIY-CGM appears to be an acceptable alternative method of rt-CGM.

The Effect of Do-It-Yourself Real-Time Continuous Glucose Monitoring on Glycemic Variables and Participant-Reported Outcomes in Adults With Type 1 Diabetes: A Randomized Crossover Trial

AIM

Real-time continuous glucose monitoring (rtCGM) has several advantages over intermittently scanned continuous glucose monitoring (isCGM) but generally comes at a higher cost. Do-it-yourself rtCGM (DIY-rtCGM) potentially has benefits similar to those of rtCGM. This study compared outcomes in adults with type 1 diabetes using DIY-rtCGM versus isCGM.

METHODS

In this crossover trial, adults with type 1 diabetes were randomized to use isCGM or DIY-rtCGM for eight weeks before crossover to use the other device for eight weeks, after a four-week washout period where participants reverted back to isCGM. The primary endpoint was time in range (TIR; 3.9-10 mmol/L). Secondary endpoints included other glycemic control measures, psychosocial outcomes, and sleep quality.

RESULTS

Sixty participants were recruited, and 52 (87%) completed follow-up. Glucose outcomes were similar in the DIY-rtCGM and isCGM groups, including TIR (53.1% vs 51.3%; mean difference -1.7% P = .593), glycosylated hemoglobin (57.0 ± 17.8 vs 61.4 ± 12.2 mmol/L; P = .593), and time in hypoglycemia <3.9 mmol/L (3.9 ± 3.8% vs 3.8 ± 4.0%; P = .947). Hypoglycemia Fear Survey total score (1.17 ± 0.52 vs 0.97 ± 0.54; P = .02) and fear of hypoglycemia score (1.18 ± 0.64 vs 0.97 ± 0.45; P = .02) were significantly higher during DIY-rtCGM versus isCGM. Diabetes Treatment Satisfaction Questionnaire status (DTSQS) score was also higher with DIY-rtCGM versus isCGM (28.7 ± 5.8 vs 26.0 ± 5.8; P = .04), whereas diabetes-related quality of life was slightly lower (DAWN2 Impact of Diabetes score: 3.11 ± 0.4 vs 3.32 ± 0.51; P = .045); sleep quality did not differ between the two groups.

CONCLUSION

Although the use of DIY-rtCGM did not improve glycemic outcomes compared with isCGM, it positively impacted several patient-reported psychosocial variables. DIY-rtCGM potentially provides an alternative, cost-effective rtCGM option.

Diabetes patient preferences for glucose-monitoring technologies: results from a discrete choice experiment in Poland and the Netherlands

INTRODUCTION

New glucose-monitoring technologies have different cost-benefit profiles compared with traditional finger-prick tests, resulting in a preference-sensitive situation for patients. This study aimed to assess the relative value adults with diabetes assign to device attributes in two countries.

RESEARCH DESIGN AND METHODS

Adults with type 1 or 2 diabetes from the Netherlands (n=226) and Poland (n=261) completed an online discrete choice experiment. Respondents choose between hypothetical glucose monitors described using seven attributes: precision, effort to check, number of finger pricks required, risk of skin irritation, information provided, alarm function and out-of-pocket costs. Panel mixed logit models were used to determine attribute relative importance and to calculate expected uptake rates and willingness to pay (WTP).

RESULTS

The most important attribute for both countries was monthly out-of-pocket costs. Polish respondents were more likely than Dutch respondents to choose a glucose-monitoring device over a standard finger prick and had higher WTP for a device. Dutch respondents had higher WTP for device improvements in an effort to check and reduce the number of finger pricks a device requires.

CONCLUSION

Costs are the primary concern of patients in both countries when choosing a glucose monitor and would likely hamper real-world uptake. The costs-benefit profiles of such devices should be critically reviewed.

Experiences of Using Wearable Continuous Glucose Monitors in Adults With Diabetes: A Qualitative Descriptive Study

PURPOSE

The purpose of the study was to understand the experiences of adults with diabetes wearing a continuous glucose monitor (CGM).

METHODS

This qualitative, descriptive study included 19 adults with type 1 diabetes or type 2 diabetes, who had used the FreeStyle Libre CGM for at least 4 weeks, from an outpatient clinic at a university-affiliated hospital in Korea. Data were collected through in-depth interviews and analyzed using an inductive content analysis approach.

RESULTS

The content analysis revealed 3 major themes-navigating glucose level fluctuations, reframing diabetes self-care and improving quality of life, and device improvement and service quality. Participants reported that CGMs offered convenient glucose level monitoring, allowed early response to rapid glucose changes, and facilitated effective patient-clinician communication. Participants expressed concerns about the financial burden and limited services, recommending improvements for devices, consumer services, and health insurance coverage.

CONCLUSIONS

Study findings indicated that using wearable CGMs could improve self-care and quality of life in adults with diabetes. Using CGMs could improve patients' understanding of how diabetes self-care management affects real-time glucose levels. Health care providers could support patients' self-care by using device data. Improvements in quality, services, and insurance coverage could increase user satisfaction and promote self-care.

Parents' experiences of using remote monitoring technology to manage type 1 diabetes in very young children during a clinical trial: Qualitative study

AIMS

To explore parents' experiences of using remote monitoring technology when caring for a very young child with type 1 diabetes during a clinical trial.

METHODS

Interviews were conducted with parents of 30 children (aged 1-7 years) participating in a trial (the KidsAP02 study) comparing hybrid closed-loop insulin delivery with sensor-augmented pump therapy. In both arms, parents had access to remote monitoring technology. Data analysis focused on identification of descriptive themes.

RESULTS

Remote monitoring technology gave parents improved access to data which helped them pre-empt and manage glucose excursions. Parents observed how, when children were in their own care, they could be more absent while present, as their attention could shift to non-diabetes-related activities. Conversely, when children were others' care, remote monitoring enabled parents to be present while absent, by facilitating oversight and collaboration with caregivers. Parents described how remote monitoring made them feel more confident allowing others to care for their children. Parents' confidence increased when using a hybrid closed-loop system, as less work was required to keep glucose in range. Benefits to children were also highlighted, including being able to play and sleep uninterrupted and attend parties and sleepovers without their parents. While most parents welcomed the increased sense of control remote monitoring offered, some noted downsides, such as lack of respite from caregiving responsibilities.

CONCLUSIONS

Remote monitoring can offer manifold benefits to both parents and very young children with type 1 diabetes. Some parents, however, may profit from opportunities to take 'time out'.

Friend or Foe: a Narrative Review of the Impact of Diabetes Technology on Sleep

PURPOSE OF REVIEW

The purpose of this review is to present a review of sleep science, the relationship between sleep and type 1 diabetes, and highlight the current literature on sleep outcomes in adult and pediatric diabetes technology research.

RECENT FINDINGS

Sleep quality is associated with glycemic outcomes, diabetes self-management, and mental health in people with type 1 diabetes. Diabetes technologies, including insulin pumps, continuous glucose monitors, and hybrid closed-loop systems improve glycemic outcomes. However, many people find this technology challenging for a variety of reasons, including increased burden and frequent alarms, especially during the night. The impact of different devices on sleep quality and quantity has been mixed. The newest technology, the hybrid closed-loop systems, offers the best opportunity for nocturnal glycemic regulation and has improved patient and family perspectives on sleep quality. However, objective sleep assessment has not shown significant improvement on sleep duration. Sleep quality and quantity in people with type 1 diabetes are widely recognized as an important component of health care, and the literature regarding the impact of diabetes devices on sleep is increasing. However, sleep disruptions are common and a barrier to device use. Despite finding minimal changes to sleep duration with device use, subjective accounts of sleep quality are overall positive, especially in those using hybrid closed-loop systems. Sleep quantity and quality are important outcomes to consider as diabetes technology continues to evolve.

Parental experiences of short term supported use of a do-it-yourself continuous glucose monitor (DIYrtCGM): A qualitative study

AIMS

To investigate the experiences of parents caring for young children with type 1 diabetes type 1 diabetes using a do-it-yourself continuous glucose monitor (DIYrtCGM) in a supported setting.

METHODS

Exit interviews were conducted with parents from 11 families at the end of the MiaoMiao study: a randomised cross-over trial focusing on parental fear of hypoglycaemia. Technical support was provided to participants while using DIYrtCGM during the trial. A convenience sampling approach was used to recruit parents. An in-depth, semi-structured interview approach was used. Thematic analysis was used to identify key themes and subthemes.

RESULTS

Parents identified that remote monitoring enabled proactive management and that overall alarms/glucose alerts were useful. Some parents reported reductions in anxiety, increased independence for their child, and improvements in the child-parent relationship. However, parents also reported regular signal loss with DIYrtCGM, along with complicated apps and challenges troubleshooting technical problems. Despite this, nine of the 11 families continued to use the system after the end of the trial.

CONCLUSIONS

Do-it-yourself continuous glucose monitoring (CGM) was on balance beneficial for the parents interviewed. However, while access to CGM shifted the burden of care experienced by parents, burden did not significantly reduce for all parents, as the improved glycaemic control that they achieved was accompanied with the responsibility for continually monitoring their child's data. Supported use of do-it-yourself CGM may be an achievable, cost-effective option for parents caring for children with type 1 diabetes in countries without funded access to CGM.

School Nurse Perspectives on Do-It-Yourself Automated Pancreas Systems in the School Setting

Do-it-yourself (DIY) artificial pancreas systems (APSs) are gaining popularity among children with type 1 diabetes. Little is known about how school systems provide care for children who use DIY APSs, and available guidance for schools is limited. This study explored school staff perspectives on DIY APSs through a national survey of school nurses about their current practices, beliefs, and attitudes toward DIY APSs. Although one-quarter (23%) of school nurses reported experience with DIY APSs in school, nearly half (46%) had no prior knowledge of this new technology. The majority (82%) reported that children should be allowed to use DIY APSs in school, although there was less consensus about school nurse responsibilities with these devices. Qualitative responses added context regarding potential barriers, including the need for more informed guidelines and training and fears of liability. Future development of school guidelines for DIY APSs is necessary and should incorporate stakeholder perspectives.

Good enough? Parental decisions to use DIY looping technology to manage type 1 diabetes in children

People are using innovative internet of things technologies to gain individualised management of their type 1 diabetes. The #WeAreNotWaiting movement supports them to build their own hybrid closed loop systems and access their real time blood sugar data via any web connected device. A small number of parents in Australia use such DIY looping systems to manage their child's type 1 diabetes, but these systems have not been approved by the Therapeutic Goods Administration in Australia, creating ethical dilemmas for clinicians about how to respond to the use of medical devices that are not registered on the Australian Register of Therapeutic Goods. This article considers whether the use of DIY looping is in the best interests of the child and, if not, whether intervention in parental decision making is justified to prevent harm to the child. It addresses the ongoing duty of healthcare professionals to provide care to children who are 'looping.' Reference is made to findings from a study, Personalised Closed Loop Systems for Childhood Diabetes, to illustrate stakeholders' perceptions of benefits and harms of DIY looping systems. I conclude that the decision of parents to use DIY looping technology could be considered to be in a child's best interests, broadly defined, and falls within the Zone of Parental Discretion, however healthcare practitioners who support parents may have professional concerns in doing so.

Data Sharing While Using a Closed-Loop System: Qualitative Study of Adolescents' and Parents' Experiences and Views

Objective: To understand and explore data sharing practices among adolescents and their parents using a closed-loop system. Methods: Eighteen adolescents (aged 11-18 years) and 19 parents were interviewed after adolescents had ∼6 months experience of using a closed-loop system, which permitted them to share glucose and insulin data with parents/caregivers. Data were analyzed thematically. Results: There was considerable variability in how parent-child dyads perceived, valued, and undertook data sharing. Parents of early adolescents (11-13 years) reported making extensive use of "real time" data to remotely manage their child's diabetes and early adolescents described needing and wanting this input. Parents of middle adolescents (14-16 years) described making greater use of retrospective data. To avoid conflict and encourage and support their son/daughter's autonomy, these individuals reported practicing watchful waiting and only intervening after concerns about a pattern of problematic behavior or their child's safety arose. Middle adolescents indicated that data sharing had been done primarily for the benefit of their parents, although they also noted quality of life benefits for themselves. Among late adolescents (17+ years), parents were simply remote because their son/daughter had not permitted access to their data. Participants recommended clear ground rules be put in place about when, and how, data sharing should be used. Conclusions: To help parent-child dyads use data sharing in ways which minimize conflict and optimize constructive parental support, we recommend tailored input and support, which takes account of family dynamics, the young person's developmental maturity, and the different ways in which data are used across the adolescent age range.

The MiaoMiao study: can do-it-yourself continuous glucose monitoring technology improve fear of hypoglycaemia in parents of children affected by type 1 diabetes?

Purpose

Type 1 diabetes (T1D) is one of the most common chronic diseases of childhood and comes with considerable management and psychological burden for children and their families. Fear of hypoglycaemia (FOH), particularly nocturnal hypoglycaemia, is a common worry. Continuous glucose monitoring (CGM) is a tool that may help reduce FOH, as well as reduce overall diabetes burden. However, CGM systems are expensive and often not publicly funded or subsidised. MiaoMiao (MM) is a novel relatively affordable third-party add-on technology to intermittently scanned CGM (isCGM). MM allows users to convert their isCGM to a form of "Do-it-yourself" (DIY)-CGM. Our hypothesis is that MM-CGM will result in significant reduction in parental fear from hypoglycaemia. The primary objective is to determine the impact of real-time DIY-CGM on parental fear of hypoglycaemia using Hypoglycaemia Fear Survey (HFS).

Methods

This is a multisite randomised cross-over study of 55 New Zealand children (ages 2-13 years) with established T1D and current users of isCGM (Abbott FreeStyle Libre). DIY-CGM will be compared to usual care with isCGM. Participants will be randomised to either arm of the study for 6 weeks followed by a 4-week wash-out period before crossing over to the other study arm for a further 6 weeks.

Discussion

The results of this study will provide much needed clinical trial data regarding DIY-CGM effectiveness in reducing parental FOH, as measured by HFS, as well as various other secondary outcomes including traditional glycaemic metrics, and child and caregiver sleep. The trial was registered with the Australian New Zealand Clinical Trials Registry (ACTRN 12619001551189) on 18 November 2019, and the World Health Organisation International Clinical Trial Registry Platform (Universal Trial Number U1111-1236-9189).