The right device at the right time: Optimizing the benefit
A key question for healthcare providers, payers and people with diabetes is how to match the right device to the right patient at the right time in their disease management in order to realize optimal benefit and cost-effectiveness. Decisions based solely on glycemic outcomes are insufficient, as they fail to take account of an individual’s preference, dexterity, “savviness” with technology and ability or willingness to engage with the demands of the device.
Individualized medicine, incorporating patient-reported outcome measures, as advocated by NICE, the FDA , and other regulatory bodies, are particularly relevant when prescribing a diabetes device. Individualized care and support should include an individual care plan jointly agreed between the patient with diabetes and their healthcare team, according to NICE . Any care plans produced should be reviewed annually and modified, taking into account changes in the person’s wishes, circumstances, and medical findings. Patient-centered collaborative care planning meetings are an ideal opportunity to review device prescribing for optimized outcomes.
Diabetes devices have undoubtedly revolutionized the way patients and practitioners have engaged with self-management in recent years. Developments in insulin pump therapy, smart blood glucose monitors, bolus calculators, and continuous glucose monitors (CGMs) have resulted in significant improvements to the biomedical and psychological wellbeing of people with diabetes .
Of late, closed-loop systems (also known as bionic pancreas or artificial pancreas) have garnered attention and show promise in offering tighter glycemic control whilst simultaneously reducing the burden of diabetes management. In this regard, there is much to celebrate and look forward to. However, increasing the prevalence of data to inform decision-making, improving the sharing facilities for CGMs, and creating novel data presentation platforms also present new challenges for people with diabetes and those who support them.
Technology and glycemic control
Despite technological advances, suboptimal glycemic control remains widespread, with 2016–17 data from the UK showing that only 30.2% of people with type 1 diabetes are achieving their glycated hemoglobin treatment targets, whereas 66.8% of those with type 2 diabetes are achieving their targets . These figures have remained largely unchanged in recent years, despite the proliferation of diabetes technologies.
There is considerable variability in the uptake of glycemic management technologies and their availability remains limited in some regions. For example, insulin pump use in adults with type 1 diabetes is 40–62% in the USA, whereas in Europe just 5–15% of patients are reported to manage their glucose via a pump . Further scrutiny of age group and socioeconomic status differences highlights further disparities in uptake, access, and availability, suggesting that affordability remains an issue for many.
Access to technology
Access to technologies remains challenging for some people. Self-monitoring of blood glucose, a cornerstone of management in type 1 and type 2 diabetes, is one such example of variability in provision. A 2016 Diabetes UK survey found that 27% of the 1000 respondents had, in the previous 12 months, been refused a prescription for blood glucose test strips or had the number of test strips on their prescription restricted. Of these, over half (52%) had type 1 diabetes . Reasons for refusals and restrictions included “budget constraints” and “excessive testing”. In addition, 66% of respondents were given no choice of blood glucose meter . Of these, one-quarter were not happy with the meter provided . Diabetes UK argues that rationing is unsafe and potentially puts the health of people with diabetes at risk . External factors are not always responsible for variability in uptake, however, with device design, ease of use, and ability to integrate the device into everyday life being important considerations.
Choice of technology
For those able to access diabetes technology, there is considerable choice available both between and within devices. Different devices present different features and functionality for the user, providing opportunities to tailor the device to the individual’s needs. What constitutes a strength for one person could be a weakness for another.
Important considerations include:
- The size of the device
- The presence of alarms
- Visibility of the device
- Level of functionality from basic to complex
Keeping these aspects in mind ensures that each patient is able to access a device that best meets their needs for glycemic control as well as quality of life.
The use of flash glucose monitoring versus continuous glucose monitoring is such an example. Both have been approved as non-adjunctive glucose monitoring techniques by the FDA. However, each has distinct functional differences that meet the different needs of people with diabetes.
Patient-reported outcome measures
In order to optimize the benefits to patients of diabetes devices, it will be critical to translate the experiences and expectations of individuals into meaningful measures. This, in turn, will help providers to assess the management improvements provided by such devices. To this end, patient-reported outcome measures can provide context and useful information on the preferences, facilitators, and barriers of individuals to a given diabetes device. As such, they are crucial in determining the usefulness or otherwise of a device, particularly in terms of an individual’s ability to meet the demands of the therapy in the context of their everyday life. The impact of the device on the lives of other people is often under-estimated. A CGM alarm at 2 o’clock in the morning is not only disruptive for the individual with diabetes, but also their loved ones/carers. Diabetes distress affects both the patient with diabetes and those they are close to.
In conclusion, predictors of diabetes technology uptake are varied and unique to the individual. Self-management behaviors remain the strongest predictor. However, emerging evidence on psychosocial factors and robust patient-reported outcome measures provide valuable insights into determinants and themes that may impact uptake and guide conversations between healthcare professionals and people with diabetes when making decisions about the right device at the right time for the right individual.
- Food and Drug Administration. Guidance for the industry. Patient-reported outcome measures: Use in medical product development to support labeling claims. Available at www.fda.gov/downloads/Drugs/Guidances/UCM193282.pdf. [Last accessed 16 May 2018].
- National Institute for Health and Clinical Excellence clinical guidelines. Type 1 diabetes in adults. Available at www.nice.org.uk/guidance/ng17/chapter/1-Recommendations#support-and-individualised-care. [Last accessed 16 May 2018].
- Naranjo D, Tanenbaum ML, Iturralde E, Hood KK. Diabetes technology: Uptake, outcomes, barriers and the intersection with distress. J Diabetes Sci Technol 2016; 10(4): 852-858.
- National Diabetes Audit 2016-17. Short report care processes and treatment targets: https://digital.nhs.uk/data-and-information/clinical-audits-and-registries/our-clinical-audits-and-registries/national-diabetes-audit. [Last accessed 11 Jan 2018].
- Diabetes UK. Testing times: Restrictions accessing test strips and meters for people with diabetes. Available at https://diabetes-resources-production.s3-eu-west-1.amazonaws.com/diabetes-storage/migration/pdf/1092_Testing%2520times_test%2520strips%2520and%2520meters%2520report%2520WEB%2520final.pdf. [Last accessed 9 Jan 2018].