Standards of Care Begin to Reflect Advances in Diabetes Technology

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Changes to standards related to diabetes technology indicate a corresponding opportunity to evolve quality measurements.


Traditional methods of assessing diabetes management—blood glucose monitoring (BGM) and A1C— are average measurements that do not reflect glycemic variability or hypoglycemic events. Newer technologies like continuous glucose monitoring (CGM) devices and automated insulin delivery systems that pair with CGMs can provide longitudinal data that depict glucose variability and other valuable metrics, including percentage of time spent in, above, and below target ranges.

Evidence suggests that wearing a CGM that assesses real-time blood sugar results may be beneficial for improving glycemic control, understanding variability, and promoting lifestyle changes. However, standards of care for diabetes have not yet been updated to reflect this evidence.

Overview of Standards

On December 12, the American Diabetes Association (ADA) released its 2023 Standards of Care in Diabetes (Standards of Care). For over 30 years, ADA has played a major role in the development and dissemination of the latest evidence-based clinical practice recommendations. Updated annually, the Standards of Care are considered the gold standard for healthcare stakeholders (e.g., patients, providers, payers, researchers, policymakers) seeking to provide quality care for people with diabetes. The Standards of Care offers recommendations for diabetes prevention, screening, diagnosis, treatment, and optimal management of related complications, with each recommendation assigned a rating of A, B, C, or E (expert opinion) based on the quality of the evidence reviewed. Evidence-based guidelines are critical in developing quality measures, making relevant policy decisions, influencing coverage decisions, and changing clinical practice.

Since 2021, the ADA has recommended CGM access from the outset of a diabetes diagnosis (e.g., type 1 diabetes, type 2 diabetes requiring insulin management) to promote detailed tracking and to allow for appropriate lifestyle modifications. The ADA has also recommended uninterrupted access to CGM devices to prevent worsening of outcomes.

Below is a summary of revisions that are most relevant to quality measurement and emerging technologies in the 2023 edition:

Table 1. Summary of Relevant Revisions
Recommendation Grade of Evidence
People with diabetes should have uninterrupted access to their supplies to minimize gaps in continuous glucose monitoring (CGM) use (New) A
CGM users should be educated on potential interfering substances and other factors that may affect accuracy (New) C
Setting a glycemic goal during consultations is likely to improve patient outcomes (New) E
For older adults with type 1 diabetes, CGM is recommended to reduce hypoglycemia (Language strengthened) A
For older adults with type 1 diabetes, consider the use of automated insulin delivery systems and other devices such as connected pens to reduce risk of hypoglycemia (New) B, E
For older adults with type 2 diabetes on multiple daily doses of insulin, consider CGM to improve glycemic outcomes and decrease glucose variability (New) C
Use of personal CGM and automated insulin delivery devices should be supported during hospitalization (Evidence added)

The inclusion of recommendations related to CGMs and automated insulin delivery systems in the 2023 Standards of Care provides a starting point for evidence-based progress in diabetes care.

Translating Standards into Quality Measures and Initiatives

When designing quality measures, measure developers (e.g., the Centers for Medicare & Medicaid Services, the National Committee for Quality Assurance) may refer to evidence-based recommendations like the ADA Standards of Care. However, existing diabetes measures do not reflect the recent shift in clinical recommendations accounting for technological advancements and patient preferences.

The healthcare sector has been slow to adapt to changes in technology because clinical practice, reimbursement, and measurement tend to follow evidence-based guidelines. The lag between the development of new technologies and changes to the standards suggests a need to generate evidence to account for emerging technologies and other innovations in care delivery. As diabetes stakeholders call for updated measures to improve diabetes management and quality assessment, the most recent Standards of Care editions have started to reflect emerging technology for people with diabetes.

Along those lines, several initiatives have been launched in an effort to match the changing diabetes landscape. For example, the National Committee for Quality Assurance recently revealed plans to update its diabetes recognition program and develop new diabetes measures.

Introducing the Improving Diabetes Quality Initiative

Following the example set by leading diabetes stakeholders, in 2021, Avalere Health—along with Beyond Type 1 and the Association of Diabetes Care & Education Specialists—launched the Improving Diabetes Quality Initiative (iDQI). The iDQI is a national effort to improve diabetes care in the era of emerging technology, such as CGMs.

As an initial phase of work, the iDQI is testing the feasibility of a set of CGM-related quality measures in a pilot study to identify individuals who may benefit from emerging technologies for diabetes management, elucidate disparities in access and uptake of diabetes technology, and encourage patient-provider shared-decision making.

iDQI’s measure concepts align closely to recommendations in the 2023 Standards of Care. For example, the ADA’s recommendation for patients to choose a CGM device based on their circumstances, preferences, and needs supports the shared-decision making measure. While the iDQI is currently focusing on a specific subset of standards relevant to evolving the landscape of diabetes care, the initiative plans to explore measurement for a broader range of innovative technologies in the future.

The iDQI seeks to advance care delivery and quality that is reflective of the current diabetes technology environment. Generating real world evidence on the barriers and facilitators to diabetes technology use can support a shift in recommended standards, which will likely have downstream effects on payers and providers regarding the adoption of modern diabetes technology.

Additional information about the iDQI can be found in the program invitation. If you have any questions about iDQI or are interested in learning more about ways to get involved, please email Naila Wahid.

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