Flash monitor initiation is associated with improvements in HbA1c levels and DKA rates among people with type 1 diabetes in Scotland: a retrospective nationwide observational study

Abstract

Aims/hypothesis We assessed the real-world effect of flash monitor (FM) usage on HbA1c levels and diabetic ketoacidosis (DKA) and severe hospitalised hypoglycaemia (SHH) rates among people with type 1 diabetes in Scotland and across sociodemographic strata within this population. Methods This study was retrospective, observational and registry based. Using the national diabetes registry, 14,682 individuals using an FM at any point between 2014 and mid-2020 were identified. Within-person change from baseline in HbA1c following FM initiation was modelled using linear mixed models accounting for within-person pre-exposure trajectory. DKA and SHH events were captured through linkage to hospital admission and mortality data. The difference in DKA and SHH rates between FM-exposed and -unexposed person-time was assessed among users, using generalised linear mixed models with a Poisson likelihood. In a sensitivity analysis, we tested whether changes in these outcomes were seen in an age-, sex- and baseline HbA1c-matched sample of non-users over the same time period. Results Prevalence of ever-FM use was 45.9% by mid-2020, with large variations by age and socioeconomic status: 64.3% among children aged <13 years vs 32.7% among those aged ≥65 years; and 54.4% vs 36.2% in the least-deprived vs most-deprived quintile. Overall, the median (IQR) within-person change in HbA1c in the year following FM initiation was −2.5 (−9.0, 2.5) mmol/mol (−0.2 [−0.8, 0.2]%). The change varied widely by pre-usage HbA1c: −15.5 (−31.0, −4.0) mmol/mol (−1.4 [−2.8, −0.4]%) in those with HbA1c > 84 mmol/mol [9.8%] and 1.0 (−2.0, 5.5) mmol/mol (0.1 [−0.2, 0.5]%) in those with HbA1c < 54 mmol/mol (7.1%); the corresponding estimated fold change (95% CI) was 0.77 (0.76, 0.78) and 1.08 (1.07, 1.09). Significant reductions in HbA1c were found in all age bands, sexes and socioeconomic strata, and regardless of prior/current pump use, completion of a diabetes education programme or early FM adoption. Variation between the strata of these factors beyond that driven by differing HbA1c at baseline was slight. No change in HbA1c in matched non-users was observed in the same time period (median [IQR] within-person change = 0.5 [−5.0, 5.5] mmol/mol [0.0 (−0.5, 0.5)%]). DKA rates decreased after FM initiation overall and in all strata apart from the adolescents. Estimated overall reduction in DKA event rates (rate ratio) was 0.59 [95% credible interval (CrI) 0.53, 0.64]) after FM vs before FM initiation, accounting for pre-exposure trend. Finally, among those at higher risk for SHH, estimated reduction in event rates was rate ratio 0.25 (95%CrI 0.20, 0.32) after FM vs before FM initiation. Conclusions/interpretation FM initiation is associated with clinically important reductions in HbA1c and striking reduction in DKA rate. Increasing uptake among the socioeconomically disadvantaged offers considerable potential for tightening the current socioeconomic disparities in glycaemia-related outcomes. Graphical abstract

Cohort profile: the Scottish Diabetes Research Network national diabetes cohort – a population-based cohort of people with diabetes in Scotland

“…With two recent analyses, we were able to reassure policymakers in the National Health Service in Scotland that investment in free provision of continuous subcutaneous insulin infusion (CSII) pumps and flash monitors is having an impact on important outcomes. We showed10 that flash monitor initiation was associated with clinically important reductions in HbA1c, especially in those with worst glycaemic control; an average fall of 15.5 mmol/mol (1.4% units) in those with HbA1c>84 mmol/mol (9.8%) for example. We also showed a striking 40% reduction in diabetic ketoacidosis incidence with flash monitor use.…”

Improved glucometrics in people with type 1 diabetes 1 year into the COVID-19 pandemic

“…The magnitude of the improvement that we show is larger than the HbA 1c drop of 0.2% associated with flash monitor initiation, reported by a nationwide Scottish observational study. 27 …”

Time in range following flash glucose monitoring: Relationship with glycaemic control, diabetes‐related distress and resource utilisation in the Association of British Clinical Diabetologists national audit

“…Several studies 18,19,23,25 have shown the significant benefit of isCGM on resource utilisation in people living with diabetes. For example, Jeyam et al 23 analysed data from the Scottish diabetes registry and showed a 41% reduction in DKA using isCGM in the Scottish diabetes registry. In the present study, we show similar estimates with 43% reductions in hospital admissions due to hyperglycaemia/ DKA.…”