Awareness and access to Time in Range – Opportunities for improvement
At the 2022 ADA Scientific Sessions, diaTribe staff members Julia Kenney and Andrew Briskin presented two posters on the awareness of, and access to,
Time in Range (TIR) among healthcare providers (HCPs) in the US. TIR can be a valuable tool in diabetes care. However, the reality is that many HCPs don’t know about the metric and don’t have the resources to effectively use TIR for their patients.
To understand the level of TIR awareness among HCPs, and the barriers they might face in using the metric, diaTribe and dQ&A (a market research company focused on people with diabetes), conducted a survey of 303 HCPs made up of primary care providers, certified diabetes care and education specialists (CDCES), and endocrinologists in the dQ&A US provider panel.
Awareness of TIR
Overall, more CDCES (96%) and endocrinologists (92%) were aware of TIR compared to primary care providers (56%). Primary care providers (PCPs) were also least likely to be familiar with CGM metrics for diabetes care such as Time in Range, Time Above Range, and Time Below Range.
Among the HCPs who were aware of TIR, CDCES were more likely to use TIR to educate (94%) and motivate (77%) their patients and to increase people’s engagement in their own care (82%). Endocrinologists were more likely to use TIR to make treatment decisions (87%). Primary care providers were least likely to use TIR for any of these purposes.
This data indicates that there is a lack of TIR awareness and use among primary care providers. This is particularly concerning given that for many people with diabetes, their primary care provider is their main HCP (or only HCP). Future efforts to increase HCP engagement with TIR should be focused on the need for education and resources among primary care providers.
Access to CGM
The second poster focused on barriers to using TIR. 80% of HCPs identified access to CGM as a critical obstacle to expanded use. Providers said that access to CGM, getting the people that they treat to use it, and the time and infrastructure it takes to download and interpret CGM data are all important issues.
When asked what would improve their care of people with diabetes, HCPs said getting more people on a CGM (39%) and the ability to use TIR data with more people (28%) as the top two solutions. In addition, 41% of HCPs who do not use TIR said that increased access to CGM would convince them to use the metric in their practice.
The data highlights the importance of access to CGM in helping more providers use TIR in their diabetes care. Comprehensive and readily available CGM data would make it easier for HCPs to use TIR with their patients and track their day-to-day glucose variability. The data also shows that TIR non-users are open to using the metric as long as they have the necessary tools and resources.
“We’re excited to present this data, which suggests several potential paths to improve the awareness and use of TIR,” Briskin said. “Increased access to CGM can support the use of TIR by more healthcare providers, potentially improving the lives of millions of people with diabetes.”
Severe hypoglycemia persists despite advances in diabetes technology
Most adults with type 1 diabetes have trouble achieving their glucose managmentgoals. Diabetes technology has the potential to improve Time in Range (TIR) and reduce diabetes complications. Dr. Jeremy Pettus, Associate Professor Of Clinical medicine, UCSD School of Medicine and author at Taking Control of Your Diabetes (TCOYD), studied whether continuous glucose monitoring (CGM) and other diabetes technologies have helped reduce the amount of hypoglycemia in people with type 1 diabetes.
The study evaluated type 1 diabetes management in terms of HbA1C, impaired awareness of hypoglycemia (IAH), and severe hypoglycemic events (SHEs).
Over 2,000 adults with type 1 diabetes participated in the trial and were split into groups based on whether they used CGM or not. Pettus also considered whether the CGM users combined multiple daily doses of insulin (MDI), a pump, or hybrid closed loop systems with their device.
Despite improvement in glucose management with CGM, 40% of overall participants on CGM did not reach their target A1C.Despite improvement in glucose management with CGM, 40% of overall participants on CGM did not reach their target A1C. Even worse, 61.3% of non-CGM users did not reach their targets. Comparatively, 35.6% of those using a pump and CGM (or hybrid closed loop systems) did not reach their target A1C.
Additionally, about 30% of participants had IAH, which was similar regardless of CGM usage (including people using a hybrid closed loop system).
Looking at SHEs, the average number was lower among those using CGM, but events still occurred even among people with hybrid closed loop systems. Non-CGM users experience an average of 1.83 SHEs per year, compared to hybrid closed loop users’ average of 0.82. Ultimately, despite using a CGM, a substantial proportion of people with diabetes experience SHEs. However, 34.3% of non-CGM users experienced at least one SHE per year, compared to 18.5% in CGM users.
Although people with diabetes are increasingly adopting diabetes technology, “there exists a substantial unmet need for innovative approaches to improve both glycemic control and decrease severe hypoglycemic events for people with type 1 diabetes,” said Dr. Pettus
Getting CGM Data Into Electronic Health Records
An electronic health record (EHR) is a way for healthcare providers to digitally upload, access and analyze their patient’s data. This record typically includes medical history, medications, lab reports from blood work, and other essential information about a person’s health.
This data in the EHR allows doctors to more easily optimize care so that they are providing as personalized care as possible. The EHR also enables providers to assess population health.
Although 48% of people with type 1 diabetes in USA rely on a continuous glucose monitor (CGM), this data is not yet integrated into the EHR. This information gap can complicate the data review process for doctors as they have to log into several different websites and platforms and piece together all the information in the relatively short time they have with their patient.
“We’ve always thought diabetes is complicated enough,” said Dr. Richard Bergenstal MD, executive director of the International Diabetes Center (IDC). “The data shouldn’t be the complicated part.”
Bergenstal has worked on a way to integrate CGM data into the EMR at the International Diabetes Center in Minneapolis, Minnesota. “Easy access allows more time to review and discuss the data,” he said.
Bergenstal also reviewed the evolving impact of CGM data:
- Standardize CGM data
- Organize CGM data into a useable report
- Integrate CGM data Directly into the EHR
- Analyze a CGM report in a systematic way
- Act on the CGM report to optimize glucose
Dr. Juan Espinoza an Informatics Physician at the Children’s Hospital of Los Angeles has also been working on integrating CGM and other devices into the EHR. A group of stakeholders has started working on iCoDE, an effort to help integrate CGM data into the EHR. iCoDE will meet throughout 2022 and beyond to create a set of data standards and guidelines for this purpose.
“We don’t do this because it’s fun,” said Espinoza, “we do this to take better care of our patients.”
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