Patient-centered, interprofessional care supports self-management.

In the United States, the incidence of diabetes continues to rise. In 2021, the Centers for Disease Control and Prevention (CDC) reported that 38.4 million people in the United States had diabetes and named it the eighth leading cause of death. (See Diabetes facts & figures.)

Over the years, several innovations (insulin, glucometers, insulin pens) have helped to improve diabetes care and management. However, many of these technologies remain out of reach for some patients. Taking a patient-centered and interprofessional approach can help diverse populations gain access to diabetes technology.

A study by Milo and Connelly suggests that knowledge and self-efficacy play a role in predicting a patients’ HbA1C, but nurses must consider other factors. For example, ElSayed and colleagues recommend considering individual patient health literacy and cultural disease awareness when discussing diabetes technology. Nurses must assess a patient’s baseline knowledge about the technology and how it improves their care. According to the American Diabetes Association (ADA), establishing a patient’s understanding and willingness to use technology before starting diabetes therapy can help ensure patient success and satisfaction.

What is digital diabetes?

Digital diabetes combines medicine, research, technology, and artificial intelligence (AI) to help transform care. Several advances—including big data, electronic health records, and digital technologies—allow researchers and engineers to use AI as an analysis tool. Research also focuses on using technology to enhance personalized care and prevent complications. Increased access to smart devices, the internet, and social media plays an essential role in changing diabetes care. (See Machine learning and data mining.)

Current technologies

The ADA Professional Practice Committee recommends that individualized devices meet patient needs. Patient and family willingness and ability to use diabetes technology helps improve adherence and prevent frustration. According to Ju and colleagues, despite advances in insulin pumps, underserved populations don’t use them. Their study suggested that ra­cial and ethnic disparities aren’t a barrier (study participants had similar insurance coverage, educational level, and history of pump use). Rather, their frustration with the pump delivery system itself presented the main barrier.

The ADA recommends using technology early in treatment to prevent long-term complications and improve patient quality of life. The International Society for Pediatric and Adolescent Diabetes (ISPAD) recommends insulin pump use in the pediatric population. The group urges many patient populations (those prone to ketosis or recurrent severe hypoglycemia, patients at risk for microvascular and macrovascular complications, young children and infants, those who experience episodes of dawn phenomenon, pregnant adolescents, competitive athletes, and children with needle phobia) to use an insulin pump with a continuous glucose monitor (CGM).

Continuous glucose monitors

Several types of CGMs exist. Professional CGMs, designed for short-term use (1 to 2 weeks), aim to improve patient understanding of their glycemic patterns. These devices can aid insulin-dosing adjustments and serve as an educational tool. Long-term use personal CGMs include real-time glucose monitoring or intermittent scanning (isCGM) capability. Some personal CGMs can be integrated with insulin pumps to create a closed-loop (hybrid) system.

Although studies demonstrate that CGMs assist in achieving target HbA1C and patient adherence, not all patients with diabetes have a CGM. A study by Rotondi and colleagues, using the Markov cost-effective model to take a population-focused approach to diabetes management, demonstrated that universal adoption of CGMs or isCGMs predicts decreased complications and mortality associated with diabetes and offers a cost-effective method for monitoring blood glucose. The study findings support universal access and equity in technology adoption of CGM and isCGM among capable adult patients.

Artificial pancreas

The two artificial pancreas device system categories are insulin-only and bi-hormonal control. The insulin-only system primarily functions based on CGM values and set thresholds. It automatically delivers basal insulin; patients manually administer mealtime insulin using the same device. The hybrid version automatically regulates basal insulin and dispenses mealtime insulin without user input. The bi-hormonal control system has hybrid features and uses two algorithms to reach a target glucose level. It’s programmed to respond to the algorithms and regulate insulin delivery in response to the patient’s HbA1c levels. Compared to the hybrid insulin-only system, the bi-hormonal control system imitates a healthy pancreas.

Automated insulin delivery

Some automated insulin delivery (AID) systems have a mode that corrects basal insulin every 5 minutes based on the patient’s CGM readings. The system helps keep HbA1c levels within the target range and reduces episodes of hypoglycemia and hyperglycemia. The manual mode with predicted low-glucose suspension preemptively addresses lows and rebound highs by automatically suspending insulin before patients reach the programmed hypoglycemia threshold. It restarts delivery when the patient recovers.

The devices, inserted just below the skin, measure glucose levels in the interstitial fluid. Tubeless and wireless systems eliminate tube kinking, which can disrupt insulin delivery. Some AID systems are waterproof. ISPAD guideline contraindications to pump therapy include a history of significant allergic reactions to the pump, tubes, and sensor; difficulty with sensor wear; and a preference not to use technology.

Before development of AID systems, patients with diabetes and their families demanded better technology for diabetes management. Some created a do-it-yourself artificial pancreas (DIYAPS) by connecting their CGM to their insulin pump. The Food and Drug Administration (FDA) doesn’t approve DIYAPS for patient use. However, according to a study by Patel and colleagues, some patients still use them because of limited access to commercial hybrid systems. The researchers compared the safety, efficacy, and patient-reported outcomes of Freestyle Libre and subcutaneous insulin infusion with DIYAPS. The study found that both groups had improved HbA1C, but participants who used DIYAPS achieved their target HbA1C as a result of their familiarity with the technology. Both groups had improved hypoglycemia awareness.

In 2023, the FDA approved the Tidepool Loop application for patients age 6 years and older. It’s the first FDA-approved application that works with DIYAPS. The fully interoperable application includes insulin dosing, glucose monitoring, and insulin delivery.

Insulin pens

Smart pens record insulin amount, dose, and timing, and they display the last dose and amount onboard. Smart device applications allow patients to calculate and track their insulin dosage. These apps also make dosing recommendations and automatically transmit data to the cloud for sharing with healthcare professionals.

Many users of insulin pens struggle to keep track of dosing, timing, and shelf-life. In 2017, the FDA approved the first Bluetooth-enabled insulin pen, Medtronic’s InPen™; in 2020, the FDA cleared it for all ages.

Supporting diabetes technology

ADA recommends individualizing the type and selection of technology and then providing appropriate training and support to help ensure patient success. Initial training should occur face-to-face with remote follow-up instruction. In addition, patients should have continued access to the technology manufacturer’s 24-hour support (usually found on the device itself or at the manufacturer’s website).

In the inpatient setting, nurses can call manufacturers directly to help troubleshoot a patient’s device. School nurses should receive technology training to ensure they can support students who use these devices.

Several smart device apps can help with diabetes management and patient independence. The mySugr app connects with Accu-Chek and Eversense glucose meters to prevent errors when patients manually log their blood glucose. It also connects with other apps such as Google Fit® and Apple Health® tracker to collect fitness data.

The One Drop app includes health coaching and a personalized content library, and the Dario app serves as a personal chronic condition management application for weight, diabetes, and hypertension self-care. It offers personalized education content for blood pressure and glycemic control, weight management, nutrition, and activity levels. The application works with the patient’s care plan. Patients can share health data collected via any of these applications with their healthcare providers and caregivers.

Nursing implications

Individualized diabetes technology therapy requires understanding a patient’s culture and preferences. When Milo and colleagues explored patient activation and self-management in a sample of Filipino Americans, they noted the role of cultural beliefs and family members in facilitating diabetes self-management. The study findings support the ADA’s clinical recommendations of a holistic approach when car­ing for patients using diabetes technology.

A study by Milo and Connelly addressed the gaps in knowledge regarding predictors of glycemic control and specific characteristics of patients with type 2 diabetes. Their evaluation of the relationships among diabetes self-management activities, perceived self-efficacy, and disease knowledge provided valuable information to support patient-centered care when implementing diabetes technology.

Patient and family education

Patient education related to diabetes technology focuses on disease self-management, glucose monitoring, and treatments (pharmacologic and nonpharmacological). Nurses and other interprofessional team members can provide education in person or via remote training, social media tools, software, smart applications, and websites. Diabetes technology education complements self-management by emphasizing patient empowerment, self-care, and improved quality of life.

Education provided by interprofessional team members (physicians, nonphysician pro­viders, nurses, diabetes educators, care coordinators, nutritionists, and technology liaisons) delivered in the patient’s preferred language plays a significant role in successful outcomes. The findings of a study by King and colleagues support the use of the interprofessional model in primary care to improve HbA1c management. A follow-up at 6 and 18 months demonstrated sustained improvement in glucose levels.

Although King and colleagues conducted their study in a primary care setting, the results support the use of the interprofessional team model for diabetes technology therapy in other settings. For example, a study by Gregory and colleagues revealed that diabetes education before discharge can reduce inpatient readmission. The transition care program included an interprofessional team approach to medication reconciliation, assessment of patient knowledge and skills in using diabetes technology, and timely follow-up phone calls and office visits with the outpatient provider within 7 days of hospital discharge. Empowering the team and transparently allocating each member demonstrated better HbA1c outcomes.

A team-based approach has challenges, including staff time and compensation, productivity, and patient adherence. Leadership can address these challenges with increased staff education and support to prevent stress and burnout. This approach to diabetes innovations has applications in other chronic conditions, such as cardiovascular disease, cancer, chronic pain, dementia, vascular ulcers, and kidney disease.

DSMES

Diabetes self-management education and support (DSMES) is the gold standard for diabetes patient education. It’s evolved from use in traditional practice settings (hospitals, primary care, pharmacies, medical homes, skilled nursing facilities, and home health) to include faith-based organizations, telehealth, community centers, and worksites. The CDC’s DSMES toolkit (cdc.gov/diabetes/dsmes-toolkit/staffing-delivery/dsmes-settings.html) provides patient education and technology resources.

DSMES provided via telehealth serves as a valuable tool for patients and providers; its use during the peak of the COVID-19 pandemic made this clear. Telehealth technology has proven effective in reaching more patients from underserved populations. Similar to any diabetes technology, the first step involves assessing patient knowledge, skills, and willingness to use telehealth. However, telehealth serves its purpose only for patients with access to the internet or a smart device.

Health coaches play an important role in diabetes management. Idris and colleagues studied the use of both clinical and nonclinical health coaches over 5 years. The coaches received training on diabetes knowledge and management, cultural competencies, data collection tools, and patient enrollment and retention. Coaching sessions included behavioral modifications, use of diabetes technology, and troubleshooting based on DSMES. The study demonstrated that patient engagement with diabetes management and technology use can improve patient outcomes.

Prioritize access

Diabetes technology promotes positive behavioral transformations and patient independence. Success requires patient comfort with the technology and patient-centered goals in each phase of treatment. However, diabetes technology won’t be a good fit for all patients, especially those with limited knowledge of technology, no access to the internet or smart devices, and those with contraindications (for example, allergies to devices, sensors, or tubes). Some patients simply prefer not to use technology. A patient-centered interprofessional team approach can help guide patients to appropriate technologies and ensure their education and management needs are met.

Although technology has proven effective in managing diabetes, some insurance may not cover its cost. This poses a challenge for patients with limited financial resources. Healthcare must develop programs that leverage access to diabetes technologies for patients in marginalized populations and lobby for policies that prioritize improving access to all patients and expanding the use of these technologies to improve disease outcomes.

Razel Bacuetes Milo is an associate professor at the University of San Diego in San Diego, California.

American Nurse Journal. 2024; 19(5). Doi: 10.51256/ANJ052419

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Key words: diabetes, digital diabetes, diabetes technology, continuous glucose monitors, artificial pancreas, automated insulin delivery, insulin pens