Health Care Professionals’ Perspectives on Use of Diabetes Technologies for Managing Visually Impaired Patients With Diabetes

Abstract

Background:

Despite well-established safety and efficacy of diabetes technologies in management of diabetes, their utility in visually impaired patients is currently unknown. We aimed to identify providers’ preferences and challenges to prescribing diabetes technologies for visually impaired patients.

Methods:

A survey-based study among health care providers in the United States seeing visually impaired patients with diabetes and using diabetes technologies was conducted. The quantitative and qualitative responses were analyzed using Student t test and χ² tests.

Results:

Of 79 providers, 66 completed the survey and were included in the analysis. Insulin pens and hybrid closed-loop systems were preferred insulin delivery systems for managing visually impaired patients with diabetes. Despite 96% of the providers recommending continuous glucose monitoring (CGM) for their visually impaired patients with diabetes, only 55% were aware of the voice-activation feature of Dexcom G6. Voice activation to announce glucose values and audible glucose alerts were two major incentives for selecting CGM. System initialization was seen as a prevalent challenge of using CGM in visually impaired patients with diabetes. Providers who are using CGM for visually impaired patients reported benefits for patients using the voice-activation feature for six months included HbA1c reductions of >0.5% (by 87% of providers) and less hypoglycemia (by 45% of providers).

Conclusions:

The CGM is the preferred glucose monitoring method for managing visually impaired patients with diabetes. Providers face many challenges of initiating CGM in these high-risk patients. Voice-activation feature of G6 CGM is underutilized and providers who used the system reported positive outcomes in visually impaired patients.

Introduction

The use of continuous glucose monitors (CGMs) has been shown to improve glycemic control and quality of life of patients with diabetes treated with insulin.^1-3 However, the use of CGM is challenging for visually impaired patients with diabetes as they are not able to see the CGM glucose trends and be proactive to keep glucose in the target range. ⁴

Although the prevalence of visual impairment has been decreasing over time due to improved diabetes care, it is estimated that ~10% of patients with type 2 diabetes (T2D) have visual impairment. ⁵ Given 34.2 million people are living with diabetes in the United States, the number of patients living with visual impairment is large. ⁶ Despite the large population of visually impaired patients with diabetes, there are no clinical guidelines on the management of diabetes in visually impaired patients. Moreover, clinical trials with CGM and other diabetes technologies excluded visually impaired patients ⁷ and, therefore, the benefits of CGM in visually impaired patients with diabetes are unknown. Insulin delivery and glucose monitoring systems are not commonly optimized for visually impaired patients. ⁸ The safety and accuracy of currently available diabetes management tools were not assessed in this population.^9-13

Versions 1.4 and later of the Dexcom G6 app installed on iOS-based devices allow the user to request Apple’s virtual assistant (Siri) to recite the current glucose concentration and trend. This feature can be helpful in visually impaired patients with diabetes to improve glucose control. In a small proof-of-concept study by our group, the use of G6 CGM with voice-enabled Apple’s Siri significantly increased time-in-range and significantly decreased HbA1c without increasing CGM-measured hypoglycemia over 12 months in seven legally blind patients with diabetes. ¹⁴ In addition, severe hypoglycemic episodes were reduced from eight events to no events ¹⁴ This study suggested that the use of a CGM with voice activation is feasible and may help to improve glycemic control in visually impaired patients with diabetes. ¹⁴ A separate study of more than 34 000 Dexcom customers revealed that routine Siri use was associated with higher time-in-range, suggesting that the feature may contribute to appropriate diabetes management decisions. ¹⁵

Because there are no clinical guidelines on how to manage visually impaired patients with diabetes, diabetes technology use among these patients was unknown. We conducted a survey among health care professionals in the United States seeing visually impaired patients with diabetes to understand how clinicians are using newer generation CGM devices to manage diabetes in visually impaired patients.

Method

This was an online survey–based study among US health care providers (physicians, physician assistants, and nurse practitioners) who see more than 10 patients with diabetes per week, prescribe CGM in their practice, and manage visually impaired or legally blind patients with diabetes. Visual impairment was defined as not independently managing diabetes-related tasks due to low vision. The study was advertised through the Diabetes Technology Society, American Diabetes Association, and T1D Exchange members. The survey included questions about the demographics of providers, patient population, diabetes technology use among visually impaired patients, and awareness and perception of Dexcom G6 voice-enabled Apple’s Siri feature use in visually impaired patients with diabetes. Supplementary Appendix includes the full survey. REDCap (Research Electronic Data Capture), a secure, Health Insurance Portability and Accountability Act–compliant Web-based application was used for this study. Descriptive statistics were analyzed from the survey results, including means and percentages. The management differences between endocrinologists versus other providers and academic versus private practice providers were also assessed using a Student t test for continuous variables and χ² tests for categorical variables. A P value of <.05 was considered statistically significant. The Colorado Multiple Institutional Review Board approved this study under the exempt category.

Results

A total of 79 providers consented but 66 providers (70% endocrinologists, 15% physician assistants, and 15% nurse practitioners) from 23 US states completed the survey. Of the 66 providers surveyed, 55% were in private practice and 45% were in the academic field. Sixty-seven percent of providers were in practice for more than five years with 55% practicing in urban, 40% in suburban, and 5% in rural settings. Providers reported that 51% of their visually impaired patients had T2D and were using insulin, 28% had T2D and were not using insulin, and 17% had type 1 diabetes (T1D).

Provider preferences and recommendations on insulin delivery methods for visually impaired patients with diabetes were asked. Most providers preferred insulin pen and hybrid closed-loop systems (Table 1). Smart insulin pen was not often preferred by the providers for managing patients with diabetes with visual impairment.

Table 1.

Provider’s Preference for the Use of Insulin Delivery and Glucose Monitoring Devices for Visually Impaired Patients with Diabetes.

	Prescribing more in visually impaired	Prescribing at the same rate	Prescribing less in visually impaired	Not at all prescribing in visually impaired
Insulin pens	19%	27%	32%	22%
Insulin vial/syringes	1%	12%	49%	38%
Smart insulin pens	18%	27%	33%	22%
Insulin pump	17%	13%	60%	10%
HCL insulin pump	40%	15%	40%	5%
CGM	69%	16%	13%	2%
SMBG	27%	33%	39%	1%

Abbreviations: CGM, continuous glucose monitor; HCL, hybrid closed loop; SMBG, self-monitoring of blood glucose.

For glucose monitoring, 57 of 59 providers (96%) reported that they suggest CGM to their patients with diabetes with visual impairment. Of various CGMs available in the market, G6 CGM (50%) was the most preferred CGM. Providers also reported that most patients with visual impairment (65%) prefer to share CGM data with their partner/caregiver. Voice-activation and text-to-speech features are important criteria for selecting CGM for managing visually impaired patients with diabetes (Figure 1). As expected, most providers reported difficulties in setting up the CGM system for the first time for their patients with diabetes (42%). The difficulties encountered by the providers in using CGM for managing their visually impaired patients with diabetes are illustrated in Figure 2.

Figure 1.

Most important criteria when selecting continuous glucose monitoring for visually impaired patients with diabetes according to health care providers.

Figure 2.

The most common difficulties for visually impaired patients with diabetes to use diabetes technologies according to health care providers. Providers can choose multiple options in this question.

In a second part of this survey, we asked providers specific questions to understand their familiarity with G6 CGM Siri features and how they use to manage their patients with diabetes. Only 55% of providers were aware of G6 CGM Siri feature. After we provided information on G6 CGM Siri features, 97% of them felt that they would recommend it for managing their visually impaired patients with diabetes. Those providers (n = 36) who are aware of G6 CGM Siri features and used it for managing patients with diabetes with visual impairment reported HbA1c reduction of >0.5% (87%) and reduction in hypoglycemia (45%) after six months of using G6 CGM with Siri.

We also evaluated differences in diabetes technology preferences for managing visually impaired patients with diabetes between endocrinologists versus nonendocrinologists and academic versus private practice providers. There was no difference in the preference for insulin delivery systems and CGMs for managing visually impaired patients with diabetes between groups. However, the use of voice activation among G6 CGM users with visual impairment was higher among endocrinologists compared with nonendocrinologists (P = .04).

Discussion

To our knowledge, this is the first study that evaluated health care providers’ knowledge and preferences for various diabetes technologies in these patients. CGM was the most preferred glucose monitoring method to manage diabetes in visually impaired patients. CGM choice was based on various key features such as audible alerts and voice activation to obtain glucose levels and overall trend.

G6 CGM with voice-activated Apple’s Siri feature can be used by visually impaired patients using a voice command system. Patients can hear their sensor glucose value and overall trend using a voice command. High and low glucose alerts are customizable to a patient’s preferred glucose maintenance window, and once alerted, a patient can use a voice command to check their glucose level and trend.

Although G6 CGM Siri feature has been available since 2019, only 55% of the providers were aware of the Siri feature that can be used with G6 CGM. When we provided information on Siri feature, 97% of the providers would recommend this feature to their visually impaired patients with diabetes. Our study highlights the need for diabetes technology education among providers to increase the use of diabetes technologies to improve diabetes outcomes. In addition, production of getting-started guides in accessible formats would increase access to the benefits of diabetes technologies for visually impaired patients with diabetes. ¹⁶

Our study also highlights many difficulties providers face to initiate diabetes technologies in visually impaired patients with diabetes. This calls for restructuring education and supports by the industry to providers to help them successfully integrate diabetes technologies to improve outcomes among challenging patients with diabetes.

Our study had some limitations. First, the sample size was small. This may be because our study was designed for only providers who are managing visually impaired patients with diabetes. Second, generalization of the findings of this study is limited to US health care providers.

Conclusion

Our study calls for more education and supports to providers for successful integration of diabetes technologies for managing their visually impaired patients with diabetes. Future intervention studies should include visually impaired patients to address their needs and improve glycemic outcomes.