The effects of professional continuous glucose monitoring as an adjuvant educational tool for improving glycemic control in patients with type 2 diabetes

Adding a Brief Continuous Glucose Monitoring Intervention to the National Diabetes Prevention Program: A Multimethod Feasibility Study

The National Diabetes Prevention Program (DPP) promotes lifestyle changes to prevent diabetes. However, only one-third of DPP participants achieve weight loss goals, and changes in diet are limited. Continuous glucose monitoring (CGM) has shown potential to raise awareness about the effects of diet and activity on glucose among people with diabetes, yet the feasibility of including CGM in behavioral interventions for people with prediabetes has not been explored. This study assessed the feasibility of adding a brief CGM intervention to the Arizona Cooperative Extension National DPP. Extension DPP participants were invited to participate in a single CGM-based education session and subsequent 10-day CGM wear period, during which participants reflected on diet and physical activity behaviors occurring prior to and after hyperglycemic events. Following the intervention, participants completed a CGM acceptability survey and participated in a focus group reflecting on facilitators and barriers to CGM use and its utility as a behavior change tool. A priori feasibility benchmarks included opt-in participation rates ≥ 50%, education session attendance ≥ 80%, acceptability scores ≥ 80%, and greater advantages than disadvantages of CGM emerging from focus groups, as analyzed using the Key Point Summary (KPS) method. Thirty-five DPP members were invited to participate; 27 (77%) consented, and 24 of 27 (89%) attended the brief CGM education session. Median survey scores indicated high acceptability of CGM (median = 5, range = 1-5), with nearly all (n = 23/24, 96%) participants believing that CGM should be offered as part of the DPP. In focus groups, participants described how CGM helped them make behavior changes to improve their glucose (e.g., reduced portion sizes, increased activity around eating events, and meditation). In conclusion, adding a single CGM-based education session and 10-day CGM wear to the DPP was feasible and acceptable. Future research will establish the efficacy of adding CGM to the DPP on participant health outcomes and behaviors.

A Scale for Measuring Electronic Patient Engagement Behaviors: Development and Validation

Purpose

Advancements in electronic health (eHealth) technology have profoundly impacted patient engagement. This study aimed to develop and validate the Electronic Patient Engagement Behavior (EPEB) scale to measure the conceptual and underlying framework of patient engagement behaviors in an eHealth context.

Patients and Methods

Initial measurement items were generated based on a literature review and qualitative research. Two rounds of surveys, a pilot survey and validation survey, were conducted to evaluate the psychometric properties of the scale.

Results

The EPEB scale consists of 15 items in four dimensions: disease information search, physician-patient interaction, social interaction between patients, and disease self-monitoring. In the pilot survey, the exploratory factor analysis revealed a four-factor model, explaining 69.411% of variance. In the validation survey, the Cronbach's α coefficient of each sub-scale was 0.865, 0.904, 0.904, and 0.900 respectively. The Spearman-Brown split coefficient of the scale was 0.963. The results of the cross-sex measurement equivalence test indicate that all fit indices met the measurement criteria. The confirmatory factor analysis indicated second-order 4-factor model fit the data well. The EPEB has a good reliability and validity.

Conclusion

The EPEB scale provides a reliable tool for measuring patient engagement behaviors in the eHealth context. The utilization of this scale may yield valuable insights into strategies for enhancing patient engagement and optimizing health outcomes.

Development of a Continuous Glucose Monitoring Service by Clinical Pharmacists in a Medically Underserved Population

Background: Continuous glucose monitoring (CGM) is an evolving technology that provides a wealth of information to aid in managing diabetes. Professional CGM (ProCGM) is recommended when personal CGM is not desired or available. Patients in medically underserved areas may have limited access to personal CGM devices, thus ProCGM devices can be used for short-term monitoring and medication adjustment. Clinical pharmacists are well-positioned to help set up and establish personal and professional CGM management services. Objectives: To determine the effect of ProCGM in patients with persistently uncontrolled type 2 diabetes in a medically underserved population (MUP). Methods: Pre-post intervention analysis of a single cohort of patients in a public health center. Patients with persistently uncontrolled (A1c > 9%) and taking at least one daily dose of insulin were included. Included participants wore a ProCGM sensor and met with the clinical pharmacist at least once for ProCGM data interpretation and education. The primary analysis evaluated patients who achieved an A1c <9% 1-6 months after intervention. The change in A1c was also evaluated. Participants completed a pre- and post-survey about their experience. Results: Twenty-two patients were included in the final analysis. Ten patients achieved an A1c <9% (45%). The mean A1c pre- and post-ProCGM was 11.0% and 9.8% respectively, with a decrease of -1.2% (p=0.055) overall and a decrease of -1.7% for patients who wore the sensor for at least 10 days (p=0.012; n=15). Using the CGM data 91% of participants had a change to their medication regimen and 45% achieved an A1c <9%. Six participants experienced hypoglycemia per the CGM report, but only two were aware of it. After reviewing their glucose report with the pharmacist, 95% of the respondents agreed or strongly agreed to feeling more knowledgeable about blood sugar patterns after reviewing the report with a pharmacist. Conclusion: Almost half of the patients in the study achieved an A1c <9%. This study demonstrated glycemic benefit in patients in a MUP who wore a ProCGM for at least 10 days and met with a clinical pharmacist. Data from ProCGM enabled patients to better understand glucose patterns in those with persistently uncontrolled type 2 diabetes.

Effects of Continuous Glucose Monitoring on Glycemic Control in Type 2 Diabetes: A Systematic Review and Meta-Analysis

As the prevalence of diabetes is rapidly increasing, the use of continuous glucose monitoring, which is effective in improving glycemic control in type 2 diabetes, is increasing.

METHODS

Systematic review was performed according to PRISMA criteria. The search was conducted for articles published until 31 May 2023 in PubMed, CINAHL, Cochrane Library, EMBASE, ClinicalKey, etc. The meta-analysis involved the synthesis of effect size; tests of homogeneity and heterogeneity; trim and fill plot; Egger's regression test; and Begg's test for assessing publication bias.

RESULTS

491 studies were searched, of which 17 studies that met the selection criteria were analyzed. The overall effect on HbA1c was -0.37 (95% CI, -0.63~-0.11, p < 0.001), with HbA1c decreasing significantly after CGM interventions. Sub-analyses showed that the study was statistically significant in those aged 60 years or older, when rt-CGM was used and when the study was performed in multiple centers.

CONCLUSION

The results of this study showed that intervention using CGM was effective in reducing HbA1c in type 2 diabetes. The factors identified in this study can be used as guidelines for developing future CGM intervention programs.

Expanding the Role of Continuous Glucose Monitoring in Modern Diabetes Care Beyond Type 1 Disease

Application of continuous glucose monitoring (CGM) has moved diabetes care from a reactive to a proactive process, in which a person with diabetes can prevent episodes of hypoglycemia or hyperglycemia, rather than taking action only once low and high glucose are detected. Consequently, CGM devices are now seen as the standard of care for people with type 1 diabetes mellitus (T1DM). Evidence now supports the use of CGM in people with type 2 diabetes mellitus (T2DM) on any treatment regimen, not just for those on insulin therapy. Expanding the application of CGM to include all people with T1DM or T2DM can support effective intensification of therapies to reduce glucose exposure and lower the risk of complications and hospital admissions, which are associated with high healthcare costs. All of this can be achieved while minimizing the risk of hypoglycemia and improving quality of life for people with diabetes. Wider application of CGM can also bring considerable benefits for women with diabetes during pregnancy and their children, as well as providing support for acute care of hospital inpatients who experience the adverse effects of hyperglycemia following admission and surgical procedures, as a consequence of treatment-related insulin resistance or reduced insulin secretion. By tailoring the application of CGM for daily or intermittent use, depending on the patient profile and their needs, one can ensure the cost-effectiveness of CGM in each setting. In this article we discuss the evidence-based benefits of expanding the use of CGM technology to include all people with diabetes, along with a diverse population of people with non-diabetic glycemic dysregulation.

Insight into continuous glucose monitoring: from medical basics to commercialized devices

According to the latest statistics, more than 537 million people around the world struggle with diabetes and its adverse consequences. As well as acute risks of hypo- or hyper- glycemia, long-term vascular complications may occur, including coronary heart disease or stroke, as well as diabetic nephropathy leading to end-stage disease, neuropathy or retinopathy. Therefore, there is an urgent need to improve diabetes management to reduce the risk of complications but also to improve patient's quality life. The impact of continuous glucose monitoring (CGM) is well recognized, in this regard. The current review aims at introducing the basic principles of glucose sensing, including electrochemical and optical detection, summarizing CGM technology, its requirements, advantages, and disadvantages. The role of CGM systems in the clinical diagnostics/personal testing, difficulties in their utilization, and recommendations are also discussed. In the end, challenges and prospects in future CGM systems are discussed and non-invasive, wearable glucose biosensors are introduced. Though the scope of this review is CGMs and provides information about medical issues and analytical principles, consideration of broader use will be critical in future if the right systems are to be selected for effective diabetes management.

Use of continuous glucose monitors in low- and middle-income countries: A scoping review

AIMS

The use of continuous glucose monitors (CGMs) has been shown to have positive impact on diabetes management for people with type 1 diabetes (T1DM), type 2 diabetes (T2DM) and gestational diabetes (GDM) in high-income countries. However, as useful as CGMs are, the experience in low- and middle-income countries (LMICs) is limited and has not been summarized.

METHODS

A scoping review of the scientific literature was conducted. Medline, Embase, Global Health and Scopus were used to seek original research conducted in LMICs. The search results were screened by two reviewers independently. We included studies assessing health outcomes following the use of CGMs at the individual level (e.g. glycaemic control or complications) and at the health system level (e.g. barriers, facilitators and cost-effectiveness) in English, Portuguese, Spanish and French. Results were summarized narratively.

RESULTS

From 4772 records found in database search, 27 reports were included; most of them from China (n = 7), Colombia (n = 5) and India (n = 4). Thirteen reports studied T1DM, five T2DM, seven both T1DM and T2DM and two GDM. Seven reports presented results of experimental studies (five randomized trials and two quasi-experimental); two on cost-effective analysis and the remaining 18 were observational. Studies showed that CGMs improved surrogate glycaemic outcomes (HbA_1c reduction), hard endpoints (lower hospitalization rates and diabetes complications) and patient-oriented outcomes (quality of life). However, several caveats were identified: mostly observational studies, few participants in trials, short follow-up and focused on surrogate outcomes.

CONCLUSIONS

The scoping review identified that studies about CGMs in LMICs have several limitations. Stronger study designs, appropriate sample sizes and the inclusion of patient-important outcomes should be considered to inform the evidence about CGMs for the management of people with diabetes in LMICs.

A Team-based Training for Continuous Glucose Monitoring for Diabetes Care: An Implementation Pilot in Primary Care Practices (Preprint)

BACKGROUND

The American Academy of Family Physicians (AAFP) develops and maintains continuing medical education that is relevant to modern primary care practices. One continuing medical education modality is AAFP TIPS, which are comprised of resources designed for family medicine physicians and their care teams that aid in quick and accessible practice improvement strategies, with actionable steps. Evaluating physicians' use of and satisfaction with this modality's content and implementation strategies has not been prioritized previously. Continuous glucose monitoring (CGM) plays an increasing role in the treatment of diabetes; uptake occurs more rapidly in endocrinology settings than in primary care settings. To help address such differences in CGM uptake and diabetes care, AAFP TIPS on Continuous Glucose Monitoring (AAFP TIPS CGM) was developed, using published evidence and input from content experts (family medicine faculty; AAFP staff; and an advisory group comprised of other primary care physicians, patients, a pharmacist, and a primary care practice facilitator). A pilot implementation project was conducted in 3 primary care practices.

OBJECTIVE

To evaluate AAFP TIPS CGM in primary care practices, the research team assessed use of and satisfaction with the content and assessed barriers to and facilitators for strategy and workflow implementation.

METHODS

In total, 3 primary care practices participated in a mixed methods pilot implementation of AAFP TIPS CGM between June and October 2021. Practice champions at each site completed AAFP TIPS CGM and baseline practice surveys to evaluate practice characteristics and CGM prescribing. They conducted team trainings (via webinars or in person), with the goals of implementing CGM into practice and establishing or improving CGM workflows. Practice champions and team training participants completed posttraining surveys to evaluate the training, AAFP TIPS materials, and likelihood of implementing CGM. Interviews were conducted with 6 physicians, including practice champions, 2 months after team training. Satisfaction surveys were also distributed to those who completed the AAFP TIPS CGM course via the internet during the study period.

RESULTS

Of the 3 practices, 2 conducted team trainings. The team training evaluation survey showed that practice staff understood their role in implementing CGM in practice (19/20, 95%), and most (11/20, 55%) did not have questions after the training. Insurance coverage for CGM was a remaining knowledge gap and potential barrier to implementing CGM in practice. Physicians and interdisciplinary care team members who took the AAFP TIPS CGM course via the internet, as well as those who attended in-person team training, expressed a high degree of satisfaction with the education, content, and applicability of the course.

CONCLUSIONS

This pilot implementation of AAFP TIPS CGM offers pertinent and timely information for primary care practices that desire to initiate or expand CGM use to best meet the needs of their patients with diabetes.

The Benefits of Utilizing Continuous Glucose Monitoring of Diabetes Mellitus in Primary Care: A Systematic Review

BACKGROUND

Continuous glucose monitoring (CGM) and intermittently scanned CGM (is-CGM) have shown to effectively manage diabetes in the specialty setting, but their efficacy in the primary care setting remains unknown. Does CGM/is-CGM improve glycemic control, decrease rates of hypoglycemia, and improve staff/physician satisfaction in primary care? If so, what subgroups of patients with diabetes are most likely to benefit?

METHODS

A comprehensive search in seven databases was performed in June 2021 for primary studies examining any continuous glucose monitoring system in primary care. We excluded studies with fewer than 20 participants, specialty care only, or hospitalized participants. The National Heart, Lung and Blood Institute and Grading of Recommendations Assessment, Development and Evaluation were used for the quality assessment. The weighted mean difference (WMD) of HbA1c between CGM/is-CGM and usual care with 95% confidence interval was calculated. A narrative synthesis was conducted for change of time in, above, or below range (TIR, TAR, and TBR) hypoglycemic events and staff/patient satisfaction.

RESULTS

From ten studies and 4006 participants reviewed, CGM was more effective at reducing HbA1c compared with usual care (WMD -0.43%). There is low certainty of evidence that CGM/is-CGM improves TIR, TAR, or TBR over usual care. The CGM can reduce hypoglycemic events and staff/patient satisfaction is high. Patients with intensive insulin therapy may benefit more from CGM/is-CGM.

CONCLUSIONS

Compared with usual care, CGM/is-CGM can reduce HbA1c, but most studies had notable biases, were short duration, unmasked, and were sponsored by industry. Further research needs to confirm the long-term benefits of CGM/is-CGM in primary care.