'Much more convenient, just as effective': Experiences of starting continuous glucose monitoring remotely following Type 1 diabetes diagnosis.

AIM: Initiating continuous glucose monitoring (CGM) shortly after Type 1 diabetes diagnosis has glycaemic and quality of life benefits for youth with Type 1 diabetes and their families. The SARS-CoV-2 pandemic led to a rapid shift to virtual delivery of CGM initiation visits. We aimed to understand parents' experiences receiving virtual care to initiate CGM within 30 days of diagnosis. METHODS: We held focus groups and interviews using a semi-structured interview guide with parents of youth who initiated CGM over telehealth within 30 days of diagnosis during the SARS-CoV-2 pandemic. Questions aimed to explore experiences of starting CGM virtually. Groups and interviews were audio-recorded, transcribed and analysed using thematic analysis. RESULTS: Participants were 16 English-speaking parents (age 43 ± 6 years; 63% female) of 15 youth (age 9 ± 4 years; 47% female; 47% non-Hispanic White, 20% Hispanic, 13% Asian, 7% Black, 13% other). They described multiple benefits of the virtual visit including convenient access to high-quality care; integrating Type 1 diabetes care into daily life; and being in the comfort of home. A minority experienced challenges with virtual care delivery; most preferred the virtual format. Participants expressed that clinics should offer a choice of virtual or in-person to families initiating CGM in the future. CONCLUSION: Most parents appreciated receiving CGM initiation education via telehealth and felt it should be an option offered to all families. Further efforts can continue to enhance CGM initiation teaching virtually to address identified barriers.

Closing Disparities in Pediatric Diabetes Telehealth Care: Lessons From Telehealth Necessity During the COVID-19 Pandemic.

The coronavirus disease 2019 (COVID-19) pandemic necessitated using telehealth to bridge the clinical gap, but could increase health disparities. This article reports on a chart review of diabetes telehealth visits occurring before COVID-19, during shelter-in-place orders, and during the reopening period. Visits for children with public insurance and for those who were non-English speaking were identified. Telehealth visits for children with public insurance increased from 26.2% before COVID-19 to 37.3% during shelter-in-place orders and 34.3% during reopening. Telehealth visits for children who were non-English speaking increased from 3.5% before COVID-19 to 17.5% during shelter-in-place orders and remained at 15.0% during reopening. Pandemic-related telehealth expansion included optimization of workflows to include patients with public insurance and those who did not speak English. Increased participation by those groups persisted during the reopening phase, indicating that prioritizing inclusive telehealth workflows can reduce disparities in access to care.

'I was ready for it at the beginning': Parent experiences with early introduction of continuous glucose monitoring following their child's Type 1 diabetes diagnosis.

AIM: This study aimed to capture the experience of parents of youth with recent onset Type 1 diabetes who initiated use of continuous glucose monitoring (CGM) technology soon after diagnosis, which is a new practice. METHODS: Focus groups and individual interviews were conducted with parents of youth with Type 1 diabetes who had early initiation of CGM as part of a new clinical protocol. Interviewers used a semi-structured interview guide to elicit feedback and experiences with starting CGM within 30 days of diagnosis, and the benefits and barriers they experienced when adjusting to this technology. Groups and interviews were audio recorded, transcribed and analysed using content analysis. RESULTS: Participants were 16 parents (age 44.13 ± 8.43 years; 75% female; 56.25% non-Hispanic White) of youth (age 12.38 ± 4.15 years; 50% female; 50% non-Hispanic White; diabetes duration 10.35 ± 3.89 months) who initiated CGM 11.31 ± 7.33 days after diabetes diagnosis. Overall, parents reported high levels of satisfaction with starting CGM within a month of diagnosis and described a high level of reliance on the technology to help manage their child's diabetes. All participants recommended early CGM initiation for future families and were committed to continue using the technology for the foreseeable future, provided that insurance covered it. CONCLUSION: Parents experienced CGM initiation shortly after their child's Type 1 diabetes diagnosis as a highly beneficial and essential part of adjusting to living with diabetes.

Population-level management of type 1 diabetes via continuous glucose monitoring and algorithm-enabled patient prioritization: Precision health meets population health.

OBJECTIVE: To develop and scale algorithm-enabled patient prioritization to improve population-level management of type 1 diabetes (T1D) in a pediatric clinic with fixed resources, using telemedicine and remote monitoring of patients via continuous glucose monitor (CGM) data review. RESEARCH DESIGN AND METHODS: We adapted consensus glucose targets for T1D patients using CGM to identify interpretable clinical criteria to prioritize patients for weekly provider review. The criteria were constructed to manage the number of patients reviewed weekly and identify patients who most needed provider contact. We developed an interactive dashboard to display CGM data relevant for the patients prioritized for review. RESULTS: The introduction of the new criteria and interactive dashboard was associated with a 60% reduction in the mean time spent by diabetes team members who remotely and asynchronously reviewed patient data and contacted patients, from 3.2 ± 0.20 to 1.3 ± 0.24 min per patient per week. Given fixed resources for review, this corresponded to an estimated 147% increase in weekly clinic capacity. Patients who qualified for and received remote review (n = 58) have associated 8.8 percentage points (pp) (95% CI = 0.6-16.9 pp) greater time-in-range (70-180 mg/dl) glucoses compared to 25 control patients who did not qualify at 12 months after T1D onset. CONCLUSIONS: An algorithm-enabled prioritization of T1D patients with CGM for asynchronous remote review reduced provider time spent per patient and was associated with improved time-in-range.

Type of unanticipated stimulus affects lower extremity kinematics and kinetics during sidestepping.

Including an unanticipated stimulus has significant impacts on lower extremity biomechanics during dynamic movements. It is unknown how a live, human defender affects lower extremity biomechanics. The purpose of this study was thus to determine the effects of two types of unanticipated stimuli (visual stimulus; defensive opponent) on lower extremity kinematics and kinetics in males and females during 45° sidestepping trials. Eight males and eight females completed two unanticipated stimuli sidestepping conditions. Numeric visual analog scales for reaction difficulty and movement realism were collected and analysed using a 2 × 2 mixed-model ANOVA. Three-dimensional hip, knee, and ankle kinematics and kinetics were measured during the stance phase of the sidestep and analysed using statistical parametric mapping. Participants reported greater difficulty and less realistic movements with the visual stimulus. Unanticipated stimulus main effects were observed for knee abduction angle, and hip extension and adduction, and knee extension and adduction moments. Sex main effects were observed for hip flexion, hip abduction, and ankle dorsiflexion angles, as well as hip abduction, ankle plantarflexion and ankle eversion moments and vertical ground reaction forces. Participants responded differently to two unanticipated stimuli. Careful consideration should be used when determining the type of unanticipated stimulus used.

Uninterrupted continuous glucose monitoring access is associated with a decrease in HbA1c in youth with type 1 diabetes and public insurance.

OBJECTIVE: Continuous glucose monitor (CGM) use is associated with improved glucose control. We describe the effect of continued and interrupted CGM use on hemoglobin A1c (HbA1c) in youth with public insurance. METHODS: We reviewed 956 visits from 264 youth with type 1 diabetes (T1D) and public insurance. Demographic data, HbA1c and two-week CGM data were collected. Youth were classified as never user, consistent user, insurance discontinuer, and self-discontinuer. Visits were categorized as never-user visit, visit before CGM start, visit after CGM start, visit with continued CGM use, visit with initial loss of CGM, visit with continued loss of CGM, and visit where CGM is regained after loss. Multivariate regression adjusting for age, sex, race, diabetes duration, initial HbA1c, and body mass index were used to calculate adjusted mean and delta HbA1c. RESULTS: Adjusted mean HbA1c was lowest for the consistent user group (HbA1c 8.6%;[95%CI 7.9,9.3]). Delta HbA1c (calculated from visit before CGM start) was lower for visit after CGM start (-0.39%;[95%CI -0.78,-0.02]) and visit with continued CGM use (-0.29%;[95%CI -0.61,0.02]), whereas it was higher for visit with initial loss of CGM (0.40%;[95%CI -0.06,0.86]), visit with continued loss of CGM (0.46%;[95%CI 0.06,0.85]), and visit where CGM is regained after loss (0.57%;[95%CI 0.06,1.10]). CONCLUSIONS: Youth with public insurance using CGM have improved HbA1c, but only when CGM use is uninterrupted. Interruptions in use, primarily due to gaps in insurance coverage of CGM, were associated with increased HbA1c. These data support both initial and ongoing coverage of CGM for youth with T1D and public insurance.

An Evaluation of Point-of-Care HbA1c, HbA1c Home Kits, and Glucose Management Indicator: Potential Solutions for Telehealth Glycemic Assessments.

During the COVID-19 pandemic, fewer in-person clinic visits resulted in fewer point-of-care (POC) HbA1c measurements. In this sub-study, we assessed the performance of alternative glycemic measures that can be obtained remotely, such as HbA1c home kits and Glucose Management Indicator (GMI) values from Dexcom Clarity. Home kit HbA1c (n = 99), GMI, (n = 88), and POC HbA1c (n = 32) were collected from youth with T1D (age 9.7 ± 4.6 years). Bland-Altman analyses and Lin's concordance correlation coefficient (ρc) were used to characterize the agreement between paired HbA1c measures. Both the HbA1c home kit and GMI showed a slight positive bias (mean difference 0.18% and 0.34%, respectively) and strong concordance with POC HbA1c (ρc = 0.982 [0.965, 0.991] and 0.823 [0.686, 0.904], respectively). GMI showed a slight positive bias (mean difference 0.28%) and fair concordance (ρc = 0.750 [0.658, 0.820]) to the HbA1c home kit. In conclusion, the strong concordance of GMI and home kits to POC A1c measures suggest their utility in telehealth visits assessments. Although these are not candidates for replacement, these measures can facilitate telehealth visits, particularly in the context of other POC HbA1c measurements from an individual.