Continuous glucose monitors (CGM) are only used by 11% of pediatric patients with type 1 diabetes, according to the Type 1 Diabetes Exchange registry report from September 2013 to December 2014.1 The Juvenile Diabetes Research Foundation (JDRF) study where patients were randomized to CGM or usual self-monitoring of blood glucose (SMBG) showed no significant improvement in hemoglobin A1c (HbA1c) for patients under 25 years old with baseline HbA1c ≥7.0.2 However, patients with HbA1c <7.0% had lower median time per day of hypoglycemia, with less severe hypoglycemia compared to the DCCT study.
We ascertained pediatric endocrinologists’ experiences with CGM using an online multiple choice survey (created using SurveyMonkey).3 An invitation to complete the survey was emailed to 973 pediatric endocrinologists in the United States with two reminder emails. Data were collected in September-October 2015. The study was approved by the Albert Einstein College of Medicine/Montefiore Medical Center IRB #2015-5372.
The survey was completed by 118 unique persons. The majority of endocrinologists (76%) responded that fewer than 25% of their pediatric patients with type 1 diabetes had ever used CGM. In all, 88% reported that the majority of their patients using CGM also used an insulin pump. Of endocrinologists, 51% reported that fewer than half of their patients used CGM one year later.
Half of clinicians (50%) saw an improvement in HbA1c in the majority of their patients since starting CGM. CGM helped in management of hypoglycemia, hyperglycemia, and understanding glucose patterns (Figure 1A). Endocrinologists reported that CGM reduced anxiety for parents of young patients and enabled a more proactive approach to diabetes management where patients could learn patterns and make insulin or food adjustments.
Figure 1.
Benefits and barriers of CGM. (A) Benefits identified by patients. (B) Barriers to CGM use in diabetes practice. “Other” includes patients don’t want to continue using it even if acknowledge information is helpful, issues with sensor and site, ongoing insurance coverage issues, reports that are difficult to interpret in a busy clinic.
Endocrinologists reported numerous reasons for patients not using CGM: not wanting a device attached (89%), too many alarms (59%), forgetting to wear (18%), and information not helpful (10%). Physicians expressed concern about insurance coverage denials, time and staff needed for data interpretation, and patients not wanting CGM (Figure 1B).
A limitation of this survey is using endocrinologists’ estimation of experience. In addition, no data were collected on practice demographics. The large number of responses from pediatric endocrinologists in the United States is a strength.
This study demonstrates that pediatric endocrinologists in the United States find data from CGM useful but state that only a minority of their patients with type 1 diabetes use CGM regularly. Children with type 1 diabetes may benefit from CGM in several situations: discrepancies between SMBG and HbA1c, keeping glucose higher than target due to fear of hypoglycemia, hypoglycemic unawareness, history of severe hypoglycemia, parental desire for monitoring overnight, changes in diabetes regimen.4
Targeting CGM to specific goals, limiting alarms, and empowering patients with the information might result in increased use of CGM.4 Continued improvements in comfort, adhesion, and sensor accuracy may help. Clinicians should consider assessing CGM comfort, goals, and data interpretation at 3 months and 6 months, as these time points have been associated with drop-off in CGM use in adults and children, respectively.5,6 There are many opportunities to improve CGM use in pediatric diabetes practice.
Footnotes
Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: RAH works with Medtronic closed-loop devices in unrelated research studies.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
Abbreviations: CGM, continuous glucose monitor; HbA1c, hemoglobin A1c; IRB, Institutional Review Board; JDRF, Juvenile Diabetes Research Foundation; SMBG, self-monitoring of blood glucose.
References
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