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

Abstract

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 minutes 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 = 0.6-16.9pp) greater time-in-range (70-180 mg/dL) glucoses compared to 25 control patients who did not qualify at twelve 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.

Advancements and future directions in the teamwork, targets, technology, and tight control—the 4T study: improving clinical outcomes in newly diagnosed pediatric type 1 diabetes

“…Novel, open-source dashboards deployed through the 4T study has allowed CDCES’ to remotely monitor patients’ CGM data, and an algorithmic backend prioritizes these patients for review and follow-up. This tool has not only improved patient care by dramatically speeding up the typical once-quarterly cadence of CGM data review, but it has increased CDCES efficiency by reducing the time spent on reviewing patient data [20,29 ▪ ,30]. Overall, our Pilot 4T data demonstrate a 0.5% reduction in HbA1c at 1-year, improved QoL, family and provider satisfaction and the challenges described above are being explored and addressed in current and future iterations of the 4T program.…”

“…First, is to document the current workflow including constraints and frictions for CDCES to review data and provide patient education at the clinic level. For example, an initial deep dive into time utilization of CDCES’ suggests additional opportunities continue to exist for algorithmic improvements in workflow, that would free up more time for them to focus on ‘top-of-license’ tasks [29 ▪ ]. Second, are the operational improvements.…”

“…We have previously developed a system for transmitting data from an individual's CGM into our electronic medical records using Apple HealthKit on iOS devices [28]. The Stanford SURF (Systems Utilization Research Force) team has also developed a glucose data dashboard to display relevant CGM data for review by a Certified Diabetes Care and Education Specialist (CDCES) [29 ▪ ]. Our team has continued to iterate and improve on the features of the dashboard.…”

“…Our team has continued to iterate and improve on the features of the dashboard. This Timely Interventions for Diabetes Excellence (TIDE) tool is a unique, open-source dashboard that has algorithm-enabled prioritization of participants who would benefit from remote CGM data review and dose adjustments by a CDCES to apply precision medicine on a population health basis [29 ▪ ,30]. It serves as an automated decision-support tool that uses CGM data to support setting personalized goals and identify a need for insulin dose adjustments in between quarterly visits.…”

“…The COVID-19 pandemic ushered in the rapid adoption and digital transformation of diabetes care delivery in a telehealth model. All study 1 participants are followed with remote monitoring and the automated-support TIDE tool [29 ▪ ] within 2–4 weeks of CGM initiation. Psychosocial and patient reported outcome surveys (PROs) are collected at baseline, 1, 3, 6, 9, and 12 months and incorporated into the clinic's psychosocial screening and treatment program.…”