Newest Standards of Care Continue to Reflect Advances in Diabetes Technology

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Summary

Continued emphasis on diabetes management technology and patient-centered care in updated clinical management standards highlight the importance of advancing quality measurement.

Overview of Standards 

In December 2023, the American Diabetes Association (ADA) released its 2024 Standards of Care in Diabetes (2024 SOC). For 35 years, the ADA has developed and disseminated evidence-based clinical practice recommendations. These standards are updated annually and serve as a foundational resource for patients, providers, payers, researchers, policymakers, and other stakeholders seeking to provide quality care for people with diabetes (PWD).  

Since 2022, the ADA has recommended continuous glucose monitoring (CGM) beginning with diagnosis of type 1 diabetes (T1D) and type 2 diabetes (T2D) requiring insulin management. This is intended to promote detailed tracking and to allow for appropriate lifestyle modifications to improve disease management.  

In the latest guidance, the ADA underscores the benefit of emerging technologies, recommending that all PWD be offered any type of diabetes device, regardless of insulin use status. Furthermore, the 2024 SOC was updated to highlight device integration between CGM and automated insulin delivery systems (AIDs), outline the benefits of real-world data, and provide recommendations for facilitating the interpretation of CGM data.  

Overall, the 2024 SOC:  

  • Highlights the importance of cultural sensitivity within the framework of person-centered care 
  • Enhances language to provide healthcare providers with actionable insights (Section 12. Retinopathy, Neuropathy, and Foot Care) 
  • Emphasizes the heterogeneity in older adult populations and corresponding need for personalized treatment goals 
  • Includes costs of insulin and glucose monitoring devices, along with information on lowered insulin prices (Section 1. Cost Considerations for Medication-Taking Behaviors)   
  • Centers language on the actions of healthcare professionals, rather than PWD 

The 2024 SOC includes several recommendations that will impact quality measurement and emerging technologies (Table 1).  Notably, there are 10 new recommendations, further highlighting the potential impact of diabetes technology on real-world clinical management for PWD. 

Table 1. 2024 SOC Updates Impacting Quality Measurement and Emerging Technologies 

Recommendation Grade of Evidence
6.11d: Use of CGM is beneficial and recommended for individuals at high risk for hypoglycemia (New) A
7.1: Diabetes devices should be offered to PWD (New)  A
7.2: Initiation of CGM should be offered to people with T1D early in the disease, even at time of diagnosis (New)  A
7.3: Consider establishing competencies based on role in practice setting for healthcare professionals working with diabetes technology (New)  E  
7.8: Initiation of continuous subcutaneous insulin infusion CSII and/or AID early, even at diagnosis, in the treatment of diabetes can be beneficial depending on a person or caregiver’s needs and preferences (New)  C
7.14: Real-time CGM or intermittently scanned CGM should be offered for diabetes management in adults with diabetes on basal insulin who are capable of using the devices safely (either by themselves or with a caregiver). The choice of device should be made based on the individual’s circumstances, preferences, and needs (Updated)  A,B
7.24: Insulin pens or insulin injection aids are recommended for people with limited dexterity  or vision impairment or when decided by shared decision making to facilitate the accurate dosing and administration of insulin (Refined)  C
7.33: In people with diabetes using personal CGM, the use of CGM should be continued when clinically appropriate during hospitalization, with confirmatory point-of-care glucose measurements for insulin dosing and hypoglycemia assessment and treatment under an institutional protocol (New)  B
8.17: In PWD and overweight or obesity, the preferred pharmacotherapy should be a glucagon-like peptide-1 (GLP-1) receptor agonist or dual glucagon-like peptide (GIP) and GLP-1 receptor agonist with greater weight loss efficacy (i.e., semaglutide or tirzepatide), especially considering their added weight-independent benefits (e.g., glycemic and cardiometabolic) (New)  A
9.3: Early use of CGM is recommended for adults with T1D to improve glycemic outcomes and quality of life and minimize hypoglycemia (New)  B
9.4: AIDS should be considered for all adults with T1D (New)  A
13.6: For older adults with T2D on insulin therapy, CGM should be considered to improve glycemic outcomes and reduce hypoglycemia (Updated)  B
16.7: For people with diabetes using an AID system along with CGM, the use of AID and CGM should be continued during hospitalization if clinically appropriate, with confirmatory point-of-care blood glucose measurements for insulin dosing decisions and hypoglycemia assessment, if resources and training are available, and according to an institutional protocol (New)  C

 

Table 2. ADA Grading System  

Grade Evidence Level 
A Clear evidence from well-conducted, generalizable randomized controlled trials that are adequately powered  
B Supportive evidence from well-conducted cohort studies 
C Supportive evidence from poorly controlled or uncontrolled studies 
E Expert consensus or clinical experience  

 

The Evidence Cycle: Standards of Care and Quality Measurement 

There is a symbiotic relationship between standards of care and quality measurement. Both rely on a well-established evidence base. Given the lag between evidence and implementation, quality measures can serve as a fulcrum to encourage and incentivize best practices. Quality improvement efforts and quality measures data can in turn generate new evidence, upon which standards can be refined, modified, and updated. Quality measures are developed based on evidence-based guidelines like the 2024 SOC, and thus should reinforce the guidelines. However, there are few existing diabetes quality measures that reflect the guideline’s increasing focus on technological advancements, patient education, and patient-centered care.  

Guidelines are critical in informing policy and coverage decisions, and strongly influence clinical practice. While the 2024 SOC account for emerging technologies and patient preferences for PWD more than previous iterations, there is more work to be done in establishing updated measures that improve diabetes quality of care. 

Piloting Novel CGM Measures 

The Improving Diabetes Quality Initiative (iDQI), established in 2021 by Avalere, Beyond Type 1, and the Association of Diabetes Care & Education Specialists, is a national effort to improve diabetes care in the era of emerging technologies.  

iDQI’s initial phase of work involves the launch of a mixed-methods pilot study in a large academic medical center. The primary objective of this study is to test the feasibility of collecting data on a set of three new CGM-related measure concepts through completion of a feasibility scorecard that assesses data availability, standardization, and ease of extraction. Secondarily, the study aims to understand CGM workflow and standards of care through qualitative interviews with staff. This data will inform refinements to the measure specifications and elucidate current practices related to diabetes technology.  

iDQI’s measure concepts align closely to recommendations in the 2024 SOC. Several of the added recommendations and text related to personalized treatment goals, cultural sensitivity, and education emphasize the importance of shared decision making, while the focus on improving CGM interpretation highlights the importance of CGM data review. While iDQI is currently focusing on a specific subset of standards related to CGMs, the initiative plans to explore measurement for a broader range of innovative technologies in the future. 

Preliminary results of the pilot study will be shared at the upcoming International Conference for Advanced Technologies & Treatments for Diabetes.

To learn more about iDQI is’ activities or to get involved, please email Naila Wahid. To learn more about diabetes or quality improvement, connect with us. 

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