Consensus Recommendations for the Use of Automated Insulin Delivery (AID) Technologies in Clinical Practice

International audienceThe significant and growing global prevalence of diabetes continues to challenge people with diabetes (PwD), healthcare providers and payers. While maintaining near-normal glucose levels has been shown to prevent or delay the progression of the long-term complications of diabetes, a significant proportion of PwD are not attaining their glycemic goals. During the past six years, we have seen tremendous advances in automated insulin delivery (AID) technologies. Numerous randomized controlled trials and real-world studies have shown that the use of AID systems is safe and effective in helping PwD achieve their long-term glycemic goals while reducing hypoglycemia risk. Thus, AID systems have recently become an integral part of diabetes management. However, recommendations for using AID systems in clinical settings have been lacking. Such guided recommendations are critical for AID success and acceptance. All clinicians working with PwD need to become familiar with the available systems in order to eliminate disparities in diabetes quality of care. This report provides much-needed guidance for clinicians who are interested in utilizing AIDs and presents a comprehensive listing of the evidence payers should consider when determining eligibility criteria for AID insurance coverage

Robust estimation of bacterial cell count from optical density

Optical density (OD) is widely used to estimate the density of cells in liquid culture, but cannot be compared between instruments without a standardized calibration protocol and is challenging to relate to actual cell count. We address this with an interlaboratory study comparing three simple, low-cost, and highly accessible OD calibration protocols across 244 laboratories, applied to eight strains of constitutive GFP-expressing E. coli. Based on our results, we recommend calibrating OD to estimated cell count using serial dilution of silica microspheres, which produces highly precise calibration (95.5% of residuals <1.2-fold), is easily assessed for quality control, also assesses instrument effective linear range, and can be combined with fluorescence calibration to obtain units of Molecules of Equivalent Fluorescein (MEFL) per cell, allowing direct comparison and data fusion with flow cytometry measurements: in our study, fluorescence per cell measurements showed only a 1.07-fold mean difference between plate reader and flow cytometry data

Determining the Perception and Willingness of Primary Care Providers to Prescribe Advanced Diabetes Technologies

Advanced diabetes technologies have produced increasingly favorable outcomes compared to older treatments. Disparities in practice resources have led to a treatment disparity by clinical setting, where endocrinologists typically prescribe far more such technologies than primary care providers (PCPs). Fully automated artificial pancreas systems (APS), which combine technologies to deliver and adjust insulin dosing continuously in response to automatic and continuous glucose monitoring, may be more straightforward for PCPs to prescribe and manage, therefore extending their benefit to more patients. We aimed to assess willingness of PCPs to prescribe advanced diabetes technologies through a cross-sectional survey of PCPs from 4 geographically diverse centers. While respondents were uncomfortable initiating (63 of 72, 88%) or adjusting (64 of 72, 89%) traditional insulin pumps, their views on APS were quite different: 71 of 76 (93%) saw advantages to prescribing APS by PCPs rather than only endocrinologists. Most would consider prescribing APS for type 1 diabetes (58 of 76, 76%) and type 2 diabetes (52 of 76, 68%). No differences were seen among attendings, residents, or nurse practitioners. APS were much more acceptable than traditional insulin pumps among this primary care sample. If successful, primary care management of closed-loop APS would greatly increase access to such therapies and reduce disparities among those patients who face more difficulty accessing subspecialty care than they do primary care

Using Social Media to Broaden Understanding of the Barriers and Facilitators to Exercise in Adults With Type 1 Diabetes.

BACKGROUND: Many people with type 1 diabetes (T1D) do not achieve levels of exercise recommended by the American Diabetes Association, often due to unique barriers, including fear of hypoglycemia. This study aimed to broaden the understanding of barriers and facilitators to exercise among adults with T1D by exploring social media-specifically T1D-themed blogs-in addition to more traditional interviews and journals. METHODS: Data sources included exercise-focused T1D blog posts (n = 67) and associated comments (n = 717), as well as interviews of and journals kept by adults with T1D (n = 10). Data were analyzed using a qualitative inductive thematic approach. Shared and unique themes were identified among the three data sources. Content mapping illustrates these relationships and interplay. RESULTS: Three metathemes were identified: (1) exercise with T1D requires significant planning, (2) hypoglycemia often interrupts or causes alteration to exercise, and (3) ordinary activities can cause greater insulin sensitivity and hypoglycemia, much like planned exercise, but are often unrecognized as exercise. Unique themes found only in the blogs, only in interviews, or only in journals are also reported. CONCLUSIONS: Social media such as blogs can be a valuable addition to qualitative research, especially when combined with other sources of data. This study suggests a need for providing adults with T1D with more instruction on preventing hypoglycemia during exercise, as well as links to organized or online activities that can provide support and education. Health care providers may wish to consider strategies to help adults with T1D recognize glycemic impact from daily activities not typically recognized as exercise

A Team-Based Training for Continuous Glucose Monitoring in Diabetes Care: Mixed Methods Pilot Implementation Study in Primary Care Practices

BackgroundThe 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. ObjectiveTo 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. MethodsIn 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. ResultsOf 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. ConclusionsThis 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

Expert Panel Recommendations for a Standardized Ambulatory Glucose Profile Report for Connected Insulin Pens

Background:Connected insulin pens capture data on insulin dosing/timing and can integrate with continuous glucose monitoring (CGM) devices with essential insulin and glucose metrics into a single platform. Standardization of connected insulin pen reports is desirable to enhance clinical utility with a single report.Methods:An international expert panel was convened to develop a standardized connected insulin pen report incorporating insulin and glucose metrics into a single, clinically useful report. An extensive literature review and identification of examples of current connected insulin pen reports was performed serving as the basis for creation of a draft of a standardized connected insulin pen report. The expert panel participated in three virtual standardization meetings and online surveys.Results:The AGP Report: Connected Insulin Pen brings all clinically relevant CGM-derived glucose and connected insulin pen metrics into a single simplified two-page report. The first page contains the time in ranges bar, summary of key insulin and glucose metrics, the ambulatory glucose profile (AGP) curve, and detailed basal (long-acting) insulin assessment. The second page contains the bolus (mealtime and correction) insulin assessment periods with information on meal timing, insulin-to-carbohydrate ratio (ICR), average bolus insulin dose and number of days with bolus doses recorded. The report's second page contains daily glucose profiles with an overlay of the timing and amount of basal and bolus insulin administered.Conclusion:The AGP Report: Connected Insulin Pen is a standardized clinically useful report that should be considered by companies developing connected pen technology as part of their system reporting/output.</p