ROCKET T1D Remote Patient Monitoring Program: Launching Diabetes Management Habits in New-Onset Diabetes

Abstract

ROCKET T1D (Remote Outreach and Care for Kids’ Empowerment and Technology Use in Type 1 Diabetes) is a remote patient monitoring program created to empower youth with new-onset type 1 diabetes to leverage emerging diabetes technology, improve diabetes self-management habits, and achieve their self-care goals. Youth with new-onset type 1 diabetes in the ROCKET T1D program improved key diabetes self-management habits (e.g., premeal bolusing, diabetes device use, data review, and dose adjustments) and achieved improvements in glycemic outcomes over the course of the program’s 3-month Launch phase.

Despite significant advances in therapies for type 1 diabetes, achievement of glycemic targets remains elusive, and diabetes self-management is challenging for youth with diabetes and their families. In a multicenter study from the T1D Exchange clinic registry, <20% of youth achieved a target A1C of <7%, as recommended by the American Diabetes Association (1,2). Challenges in achieving glycemic targets for youth with type 1 diabetes in the real-world setting are multifactorial (3) because type 1 diabetes is a chronic health condition that requires constant vigilance and self-management to maintain adequate glycemic control. Lee et al. (4) identified six key diabetes self-management habits associated with optimal glycemic outcomes in youth with type 1 diabetes: 1) checking glucose at least four times per day or using continuous glucose monitoring (CGM), 2) giving at least three rapid- acting insulin boluses per day, 3) using an insulin pump, 4) delivering boluses before eating, 5) reviewing glucose data outside of clinic visits, and 6) adjusting insulin doses outside of clinic visits. These diabetes management habits are centered around effective glucose monitoring, insulin delivery, and use of diabetes data (Table 1) (4).

Table 1.

The Six Diabetes Self-Management Habits

Habit	Performing Habit	Not Performing Habit
1. Glucose monitoring	Checks blood glucose four or more times per day or uses CGM ≥70% of the time	Checks blood glucose less than four times per day or uses CGM <70% of the time
2. Daily bolusing	Gives three or more rapid-acting insulin boluses per day	Gives less than three rapid-acting insulin boluses per day
3. Pump use	Uses an insulin pump	Does not use an insulin pump
4. Premeal bolusing	Delivers insulin boluses any time before meals	Delivers insulin boluses during or after meals
5. Data review	Reviews glucose data from diabetes devices at least once between clinic visits	Does not review glucose data from diabetes devices between clinic visits
6. Insulin adjustment	Adjusts insulin doses outside of clinic visits	Does not adjust insulin doses outside of clinic visits

Adapted from ref. 4.

Existing models of diabetes care delivery that rely on quarterly clinic visits neglect the reality that life with diabetes is continuous and unpredictable. To enhance support of youth with type 1 diabetes to improve diabetes management habits associated with optimal glycemic outcomes, we developed the ROCKET T1D (Remote Outreach and Care for Kids’ Empowerment and Technology Use in Type 1 Diabetes) program. The overarching aims of ROCKET T1D are to equip youth and their families to leverage emerging technology, improve diabetes self-management habits, and achieve self-care goals to thrive with type 1 diabetes.

ROCKET T1D was designed as a remote patient monitoring (RPM) program, which is a form of telemedicine that involves the collection and transmission of health data from patients to their health care team using digital health technologies (e.g., a CGM system and/or insulin delivery device) (5). In the ROCKET T1D RPM program, Cloud-based diabetes device data are aggregated and visible to the care team to enable proactive clinical management, diabetes education, and engagement of patients and families in diabetes self-management habits.

Project Methods

This institutional review board–exempt clinical innovation and quality improvement (QI) project was designed to improve diabetes care in youth with type 1 diabetes who were <18 years of age. Using QI methodology, the key drivers identified to optimize diabetes self-management habits were education, technology availability, and recruitment and retention of patients in the program (Figure 1). The ROCKET T1D program includes an initial 3-month Launch phase with RPM, tailored education, and therapy adjustments, followed by a 3- to 6-month Orbit phase with periodic data review and therapy adjustments as needed (Figure 2). Families receive an educational binder called the Rocket T1D Flight Manual, which contains pertinent family-facing content related to each of the six diabetes self-management habits in Table 1. The ROCKET T1D team includes certified diabetes care and education specialists (CDCESs) who provide education, onboard patients to diabetes technology, review diabetes device data, and make therapy adjustments under the supervision of pediatric endocrinologists. Communication with families occurs via messages in the electronic medical record (EMR) patient portal, phone calls, or text messages using a secure ROCKET T1D telephone line.

Figure 1.

Key driver diagram for increasing habits performance in youth with new-onset type 1 diabetes.

Figure 2.

Process map of the ROCKET T1D program from enrollment to completion of the program.

Since April 2023, all youth with new-onset type 1 diabetes at our diabetes center are enrolled in the 3-month Launch phase, which consists of weekly touchpoints to review diabetes self-management habits, address knowledge gaps, review Cloud-based diabetes data, and support needed insulin dose adjustments. To assess the impact of the ROCKET T1D program in optimizing diabetes self-management habits, we developed a SMART (specific, measurable, achievable, relevant, and time-limited) goal to increase performance of the six diabetes self-management habits by at least two habits from baseline to completion of the Launch phase in ≥80% of youth with new-onset diabetes enrolled in the program.

Measurements

Demographic and clinical data were extracted from the EMR. Diabetes self-management habit performance was assessed via an EMR-based flowsheet at enrollment and after completion of the Launch phase. We summed each of the six habits performed into a total habit score with a possible maximum score of 6. CGM metrics, including time in range (TIR; 70–180 mg/dL) and glucose management indicator (GMI) were obtained from Cloud-based data platforms for the first 2 weeks of participation and compared with the 2 weeks after graduation from the Launch phase.

Statistical Analysis

Clinical characteristics were summarized across the overall cohort. Continuous measures were compared across all groups and expressed as mean ± SD, median (interquartile range [IQR]), or frequency and percentage. Statistical analyses were completed with Python, v. 3.10, statistical software. All analyses were two-sided hypotheses tests, and P <0.05 was considered statistically significant.

Results

Over a nearly 1-year period from April 2023 through February 2024, 100 youth with new-onset type 1 diabetes completed the ROCKET T1D Launch phase. Of these youth, 41% were female, the mean age was 9.6 ± 4.1 years, 48% were non-Hispanic White, 25% were Hispanic White, 13% were non-Hispanic Black, 4% were Asian, 3% were Hispanic Black, and 7% had unreported race/ethnicity. A majority of the youth (72%) had private commercial health insurance, and for most (97%), English was the preferred language.

The mean total habit score at enrollment in the Launch phase was 3.2 ± 0.7. At completion of the Launch phase, the mean total habit score increased to 5.4 ± 0.6, and 84% of the youth increased the number of habits performed by two or more from baseline (Figure 3).

Figure 3.

Habit performance increased by two or more habits in 84% of patients graduating from the Launch phase of the ROCKET T1D program.

The percentage of ROCKET T1D participants performing each of the six habits at enrollment compared with after completion of the Launch phase is shown as a statistical process control chart in Figure 4. Performance of habit 1 (checking blood glucose at least four times per day or using CGM) increased from 93% at enrollment to 96% at completion of the Launch phase. Habit 2 (giving at least three rapid-acting insulin boluses per day) was performed by 99% of participants at baseline and 97% at completion of the Launch phase. Performance of habit 3 (using an insulin pump) increased from 0% at baseline to 51% at completion of the Launch phase. Habit 4 (delivering premeal boluses) was performed by 97% at enrollment and increased to 100% at completion of the Launch phase. The most substantial increases were in habit 5 (reviewing glucose data outside of clinic visits), which increased from 16% at enrollment to 100% by completion of the Launch phase, and habit 6 (adjusting insulin doses outside of clinic visits), which increased from 13% at enrollment to 95% by completion of the Launch phase.

Figure 4.

Statistical process control chart comparing habit performance at enrollment (n = 100) (A) and graduation (n = 100) (B) of the ROCKET T1D program Launch phase. The x-axis has the habits listed from left to right in ascending order of performance.

In an exploratory analysis, 65% of patients enrolled had CGM data available in both the first 2 weeks of enrollment and the 2 weeks after graduation from the Launch phase. Among these patients, the median GMI decreased by 0.35% (IQR −0.78 to −0.3%, P = 0.003), and median TIR increased by 7% (IQR −3 to 19.5, P <0.001). When CGM metrics were analyzed together with habit performance, no association was found between improvement in CGM metrics and individual habit performance. Similarly, when demographics such as sex and race/ethnicity were included in the analysis, no associations were found.

Discussion

The Launch phase of the ROCKET T1D RPM program was effective in improving diabetes self-management habits in patients with new-onset type 1 diabetes. Our multimodal, proactive interventions included tailored education, early initiation of diabetes technology (e.g., CGM systems, insulin pumps, and automated insulin delivery systems), and frequent review of diabetes device data with therapy adjustments. These interventions enabled our success in achieving our SMART goal to increase performance of the six diabetes self-management habits by at least two habits from baseline to completion of the Launch phase in >80% of patients. The most significant changes were seen in habits 5 and 6, which involve reviewing diabetes device data and making insulin dose adjustments guided by CDCESs outside of clinic visits. Conversely, performance of habit 2 (giving at least three rapid-acting insulin boluses per day) decreased by 2% from baseline to completion of the Launch phase. We speculate that this decrease was due to the nature of this cohort of children, some of whom had a robust partial remission (i.e., honeymoon period) with very low insulin requirements (6,7).

Notably, in this cohort of youth with new-onset type 1 diabetes, 51% initiated insulin pump therapy within 3 months of diagnosis, aided by the support of our remote CDCES team. Although there is no consensus on how soon to initiate insulin pump therapy, data indicate that doing so is safe and effective soon after diagnosis (8,9). Moreover, studies suggest that early initiation of insulin pump therapy results in improved glycemic control with a durable reduction in A1C (10,11). Data from the T1D Exchange Quality Improvement Collaborative show that insulin pump use has been growing steadily from 58.6% in 2017 to 66.2% in 2021 (12), although this study did not report how soon after type 1 diabetes diagnosis children were started on an insulin pump.

This is the first evaluation of diabetes self-management habit performance in youth with newly diagnosed type 1 diabetes. Data from Lee et al. (4) involving youth with established type 1 diabetes (duration ≥6 months) showed that performance of each diabetes self-management habit was associated with an A1C improvement of ∼0.7%. With our ROCKET T1D program for families of youth with new-onset type 1 diabetes, our goal was to launch these habits early in the type 1 diabetes journey to enable durable improvement in glycemic outcomes.

A large cohort study in the United Kingdom showed that A1C settles into a long-term track soon after type 1 diabetes diagnosis, prompting the need for early, targeted, and aggressive intervention (13). In a study of 261 youth with newly diagnosed type 1 diabetes over a 2.5-year period, there was a rise in A1C at 5–6 months, followed by a gradual rise by 18 months post-diagnosis (14). These data suggest that early and targeted interventions in the new-onset period of type 1 diabetes are paramount for optimizing glycemic control and may offer long-term benefits. The Teamwork, Targets, Technology, and Tight Control (4T) pilot study at Stanford Children’s Health demonstrated the benefit of early intensive interventions in youth with new-onset type 1 diabetes. In the 4T pilot study, 135 children with new-onset type 1 diabetes were enrolled, and this technology-enabled team approach to diabetes management and education resulted in lower A1C values at 6, 9, and 12 months post-diagnosis compared with a historic cohort (−0.54, −0.52, and −0.58%, respectively) (15).

As a clinical RPM program, ROCKET T1D did not routinely collect A1C measurements; however, CGM metrics were available at baseline and at the end of the Launch phase for the majority of patients. CGM metrics are validated as an acceptable clinical marker for glycemic control and correlate closely with A1C (16,17). CGM metrics in our cohort of youth with new-onset type 1 diabetes in the ROCKET T1D program showed an overall improvement in glycemic control from enrollment to completion of the Launch phase, with a significant increase in TIR and improvement in GMI. The Stanford 4T pilot study also analyzed CGM metrics over time in children recently diagnosed with diabetes and found similar results, with TIR peaking and GMI at its lowest 3 months post-diagnosis (15).

It should be noted that the glycemic improvement in TIR and GMI observed in our ROCKET T1D cohort may not necessarily reflect causality of the multimodal ROCKET T1D interventions and may be partially due to partial remission (i.e., the honeymoon phase) in some patients. The ROCKET T1D program is ongoing, and we plan to analyze CGM metrics after completion of the Orbit phase, which occurs 6–9 months post-diagnosis. Improving glycemic outcomes is only one aspect of type 1 diabetes care, and future studies should assess the effect of intensified early education and onboarding to diabetes technology on psychosocial and quality-of-life measures.

The ROCKET T1D RPM program could serve as a model for other populations in pediatric diabetes, including youth with established type 1 diabetes who are not meeting glycemic goals or who experience an episode of diabetic ketoacidosis or severe hypoglycemia. Additionally, the ROCKET T1D model could be adapted for other populations, including adults with type 2 diabetes in the primary care setting.

Diabetes imposes a significant economic burden on health systems and societies related to costs of health service use and productivity losses. For this reason, RPM programs such as ROCKET T1D may lead to cost savings when compared with usual in-person care. However, evidence for the cost-effectiveness of RPM programs in diabetes is limited. A recent systematic review evaluating the economic impact of RPM for chronic disease management demonstrated that RPM can be cost-effective depending on the clinical context and organizational processes involved (18). In a future analysis, we plan to study the cost-effectiveness of the ROCKET T1D RPM program in our diabetes center.

Conclusion

The multimodal interventions, including intensive education, onboarding to diabetes technology, and frequent therapy adjustments, provided through the ROCKET T1D Launch phase were associated with improved diabetes self-management habits and glycemic outcomes (TIR and GMI). A proactive, team-based, family- centered, and personalized approach to dynamically supporting youth with new-onset type 1 diabetes is essential to launching their course in diabetes and may offer long-term glycemic and quality-of-life benefits.

Funding Statement

This work was supported by The Leona M. and Harry B. Helmsley Charitable Trust (grant number 2206-05307).