Health Care Informatics
Type 1 diabetes (T1D) refers to a chronic condition when the pancreas fails to produce insulin, thus hindering the transfer of glucose from the blood to cells. The treatment involves the administration of insulin several times a day or by using an insulin pump continuously injecting the hormone into the body (Vettoretti & Facchinetti, 2019). Although T1D is supposed to be treated by endocrinologists, patients having this disease often turn to primary care for medical help.
To treat patients with T1D effectively, primary care specialists may need information about patients’ blood glucose levels throughout the day. These data are necessary to determine correct doses, which is crucial for preventing severe complications (Vettoretti & Facchinetti, 2019).
As a solution to this problem in primary care settings, continuous glucose monitoring (CGM) may be proposed. CGM is a technology allowing patients to monitor their blood glucose levels in real-time and notice patterns of changes depending on performed activities (Alcántara-Aragón, 2019). This paper aims at proving that the use of CGM in primary care would allow physicians to choose better treatment options and help patients decrease negative disease outcomes due to facilitated self-care.
Literature Review
Researchers exploring promising medical technologies for diabetes pay attention to CGM. Alcántara-Aragón (2019), in her review of emerging diabetes technologies, identified the characteristics that patients and clinicians expect from innovative devices and described such options as different types of CGM, telemedicine, and smartphone applications. According to Alcántara-Aragón (2019), patients want diabetes technologies to be adaptive so that they could easily use them in their everyday lives, while clinicians are concerned about costs and the ease of adherence and learning.
Prahalad et al. (2018) explored potential complications of T1D and technologies designed to prevent these complications. Researchers noted that CGM could replace traditional self-monitoring of blood glucose (SMBG) using finger sticks (Prahalad et al., 2018). Prahalad et al. (2018) also noted the possibility of using the internet for educating patients about T1D, telemedicine for providing healthcare in distant areas, and big data for personalized care delivery. Vettoretti and Facchinetti (2019) focused on the opportunity of the combined use of CGM and insulin pumps and reviewed algorithms used to automatically tune the dosage of injected insulin based on the CGM measurements. Thus, CGM is one of the major developments in diabetes technologies.
CGM has already been tested in multiple clinical trials that proved its potential in decreasing negative outcomes of diabetes. For example, Beck et al. (2017) aimed at investigating whether CGM improved the level of hemoglobin A1c (HbA1c) compared to SMBG. This randomized clinical trial involved 158 participants with T1D who used multiple daily injections, 105 of whom were provided with CGM, and 53 were assigned to usual care (Beck et al., 2017). The results of the trial that lasted 24 weeks showed that the use of CGM led to a more considerable decrease in HbA1c levels compared to usual care (Beck et al., 2017).
These findings concur with the results of various studies reviewed by Slattery and Choudhary (2017). Researchers also concluded that the combined use of CGM and systems that automatically suspended insulin delivery when hypoglycemia was expected resulted in the reduction of the frequency of hypoglycemia (Slattery & Choudhary, 2017). Bando et al. (2018) conducted a study in which they identified glucose profiles of a 57-year-old woman with T1D. The findings indicated that CGM lets patients notice the relationship between glucose levels and their lifestyles and adjust their treatment.
Description of the Patient Condition
T1D is a chronic illness resulting from the inability of the pancreas to produce insulin. The number of individuals with diabetes is rising around the globe (Bando et al., 2018). The treatment of the disease is directed toward maintaining adequate levels of blood glucose, which is about 70–180 mg/dl (Vettoretti & Facchinetti, 2019). To reach this target range, proper doses of insulin should be administered. Otherwise, there is a high risk of various complications of diabetes.
If the doses of insulin are too low, it leads to hyperglycemia, which may result in diabetes ketoacidosis, cardiovascular diseases, diabetic foot, kidney disease, neurological damage, or retinopathy (Vettoretti & Facchinetti, 2019). In the case of insulin overdose, hypoglycemia occurs, and it may lead to unconsciousness, seizures, or death if it remains untreated (Vettoretti & Facchinetti, 2019). Therefore, patients with T1D should always be aware of their blood glucose levels to estimate the necessary dosage of insulin.
Individuals with T1D encounter several barriers to care, most of which are related to the necessity of continuous adherence to self-care. For example, young people with T1D are more subject to depression than those without diabetes, and this psychiatric disorder prevents them from the regular self-monitoring of blood glucose (Prahalad et al., 2018). People with T1D undergoing intensive insulin therapy often suffer from obesity (Prahalad et al., 2018).
As a result, girls with T1D sometimes refuse to inject insulin and develop eating disorders to lose weight, which leads them to have microvascular complications (Prahalad et al., 2018). Furthermore, individuals, especially adolescents, have difficulties in adhering to self-care because it requires multiple actions regularly (Alcántara-Aragón, 2019). Thus, patients with T1D feel the need for technology that would facilitate their self-care and lighten their burden of life-long adherence to insulin therapy.
Description of the Technology
CGM is a technology intended to help individuals to monitor their levels of blood glucose. Generally, CGM is a small sensor that is implanted right under the skin of the arm or the abdomen (Vettoretti & Facchinetti, 2019). This sensor measures the concentration of glucose in the subcutaneous tissue at short intervals, for example, five minutes (Vettoretti & Facchinetti, 2019). The sensor is attached to a transmitter, which sends the measurements to a portable receiver that displays the glucose levels and trends (Vettoretti & Facchinetti, 2019). There are two types of CGM: blinded retrospective CGM and real-time CGM.
The first category shows retrospective data and is helpful for physicians adjusting treatment plans (Slattery & Choudhary, 2017). The second type measures interstitial glucose in real-time and activates alarms if hypo- or hyperglycemia is expected so that a patient could quickly respond with appropriate actions (Slattery & Choudhary, 2017). Since real-time CGM measures interstitial glucose, it needs several calibration tests with finger sticks to ensure precision (Slattery & Choudhary, 2017). Recently introduced flash glucose monitoring systems also show real-time data but do not need to be calibrated by patients.
Monitoring blood glucose levels is essential for patients with T1D, and CGM provides several advantages of this process compared to finger sticks. First of all, CGM allows for frequent testing, which helps to prevent hypoglycemia (Slattery & Choudhary, 2017). Although traditional blood glucose monitoring also can be conducted frequently, people often avoid it because of pain, inconvenience, and social uneasiness (Slattery & Choudhary, 2017).
Alarms are also a useful feature because they urge patients to take the necessary measures before their condition worsens. Yet, although alarms are effective, users sometimes feel uncomfortable when their devices make noise in such environments as school or workplace (Alcántara-Aragón, 2019). Finally, CGM is useful for treatment adjustments and the diagnosis of glucose fluctuations due to its capability of identifying trends (Slattery & Choudhary, 2017). The efficiency of CGM has been proved by many clinical trials. For example, the study conducted by Beck et al. (2017) demonstrated that the application of CGM resulted in a larger decrease in HbA1c level in contrast with the control group. The technology is still being improved in terms of accuracy, safety, and ease of use.
One of the most promising benefits of CGM is the possibility of its integration with insulin pumps. Scientists have developed algorithms that allow for attenuating or suspending basal insulin delivery based on the CGM readings (Vettoretti & Facchinetti, 2019).
If an attenuation or suspension method is based on the detection of hypoglycemia, insulin infusion is decreased when current CGM measurements reach a certain threshold (Vettoretti & Facchinetti, 2019). In the prediction-based method, basal insulin delivery depends on the measurements predicted by CGM rather than current ones (Vettoretti & Facchinetti, 2019). The second method is considered more reliable because it prevents a hypoglycemic event, while the detection-based method only reduces its duration (Vettoretti & Facchinetti, 2019).
Such algorithms have already been employed in medical devices, such as MiniMed 640G, and proved to be effective in reducing hypoglycemia events in clinical trials (Vettoretti & Facchinetti, 2019). Scholars are still working on improving the performance of these devices and developing algorithms that would allow for increasing automatic basal insulin infusion in response to hyperglycemia.
The Integration of the Technology
CGM may become a proper solution for patients with T1D turning to primary care for medical help. For such patients, it is crucial to be aware of their blood glucose levels to prevent the incidence of hypo- or hyperglycemia. Therefore, primary care specialists may suggest that these individuals should implant a CGM sensor to monitor their glucose levels and watch the trends. The use of CGM in primary care is likely to facilitate the provision of care. Once physicians get precise information about the patient’s blood glucose dynamics, they will be able to adjust insulin dosages as required by the patient’s condition.
CGM has great potential to integrate treatment and monitoring from the primary care setting to the patient’s home. Healthcare professionals should explain to patients with T1D what advantages CGM has as a tool for monitoring glucose levels. If patients are educated about how to check CGM measurements, how to interpret them, and how to respond to those readings, they will be able to improve their well-being and prevent complications.
CGM seems to be especially suitable for children because they are usually less likely to adhere to routine tasks, and their parents cannot always keep their eyes on them. Furthermore, primary care specialists may recommend the use of flash glucose monitoring systems for children with T1D. Since these systems do not need to be calibrated with finger sticks, they will allow for frequent and painless testing of glucose levels in children.
Finally, CGM is a useful tool for integrating communication between a healthcare professional and a patient from primary care to the home and then to ongoing care. Since CGM registers the patient’s data and notices trends, this information is of great value for primary care specialists because it demonstrates the patient’s situation more accurately than the patient would report orally.
For example, in the study by Bando et al. (2018), CGM allowed researchers to identify how different activities, such as moving, eating, and omitting insulin injections, influenced the patient’s glucose fluctuations. Moreover, recent developments, such as the Dexcom G4 and G5 systems, enable transmitters to send data to the cloud so that information can be accessed via web resources and shared with the patient’s physician (Slattery & Choudhary, 2017). These technologies facilitate the communication between patients and healthcare professionals and allow for providing care at a distance.
Conclusion
To sum up, primary care specialists should be aware of diabetes technologies to treat patients with T1D. One of the existing options is CGM, a system that automatically measures glucose levels at short intervals. CGM ensures frequent measurements of glucose levels, which is often unattainable using traditional testing with finger sticks. The use of CGM in primary care would allow physicians to supply patients with a powerful monitoring tool and choose better treatment options to reduce hypo- and hyperglycemia and avoid complications. CGM facilitates the communication between patients and healthcare professionals by providing specific data about glucose levels and allowing for sharing patients’ information remotely.
References
Alcántara-Aragón, V. (2019). Improving patient self-care using diabetes technologies. Therapeutic Advances in Endocrinology and Metabolism, 10, 1-11. Web.
Bando, H., Ebe, K., Kato, Y., Bando, M., & Yonei, Y. (2018) Investigation of blood glucose profile by continuous glucose monitoring (CGM). Endocrinology Research and Metabolism, 2(1), 1-4.
Beck, R. W., Riddlesworth, T., Ruedy, K., Ahmann, A., Bergenstal, R., Haller, S., Kollman, C., Kruger, D., McGill, J. B., Polonsky, W., Toschi, E., Wolpert, H., & Price, D. (2017). Effect of continuous glucose monitoring on glycemic control in adults with type 1 diabetes using insulin injections. JAMA, 317(4), 371-378. Web.
Prahalad, P., Tanenbaum, M., Hood, K., & Maahs, D. M. (2018). Diabetes technology: Improving care, improving patient‐reported outcomes and preventing complications in young people with type 1 diabetes. Diabetic Medicine, 35(4), 419-429. Web.
Slattery, D., & Choudhary, P. (2017). Clinical use of continuous glucose monitoring in adults with type 1 diabetes. Diabetes Technology & Therapeutics, 19(S2), 55-61. Web.
Vettoretti, M., & Facchinetti, A. (2019). Combining continuous glucose monitoring and insulin pumps to automatically tune the basal insulin infusion in diabetes therapy: A review. BioMedical Engineering OnLine, 18(37), 1-17. Web.