Patient Success With Continuous Glucose Monitoring Requires Knowledge and Support

Neil Osterweil

July 02, 2010

July 2, 2010 (Orlando, Florida) — Real-time (RT) continuous glucose monitoring (CGM) can significantly improve daytime and nighttime glucose control, but only if patients use it properly and get the right support, according to a psychologist who studies barriers to successful implementation of the technology.

A survey of adults with type 1 diabetes revealed that people most likely to stick with RT-CGM are those who can cope with frustrations dispassionately, use retrospective data analysis to correct their mistakes, and who have families or partners involved in their care, said Marylin D. Ritholz, PhD, here at the American Diabetes Association (ADA) 70th Scientific Sessions.

"We know that CGM success or failure is as dependent on the human experience as it is on the perfection of the technology," said Dr. Ritholz, senior psychologist at the Joslin Diabetes Center and assistant professor at Harvard Medical School, both in Boston, Massachusetts.

In a clinical trial funded by the Juvenile Diabetes Research Foundation (JDRF) and reported at the October 2009 meeting of the European Association for the Study of Diabetes, patients who used CGM at least 6 days a week had substantially lower glycosylated hemoglobin (HbA1c) levels after 6 months than patients who used it less frequently.

Despite those positive results, only a subset of adults realized benefit from RT-CGM, said Dr. Ritholz, and none of the psychosocial instruments used to determine why this was the case were able to identify predictors of compliance, she said.

A recent study (Diabetes Technol Ther. 2010;12:201-205) suggested that adults with type 1 diabetes who have less fear of hypoglycemia with CGM are more likely to be adherent, and that this compliance resulted in a decreased incidence of severe hypoglycemia and an increased sense of patient empowerment and better quality of life, Dr. Ritholz noted.

She and her colleagues conducted a qualitative study of a sample from the JDRF cohort mentioned earlier to identify psychosocial factors associated with CGM use by adults with type 1 diabetes.

They identified 20 adults from the study, and stratified them into responders and nonresponders to RT-CGM. Responders were identified as patients who had a HbA1c level of 7% or above but had a decrease during the study (mean change, –0.9% ± 0.3%; 7 patients) or those with HbA1c levels below 7% who did not go out of target range and decreased the amount of time spent in hypoglycemia (<70 mg/dL plasma glucose; 6 patients). The nonresponders had HbA1c levels above 7% and an on-study mean change of only –0.1% ± 0.2% (7 patients).

Participants had had type 1 diabetes for a mean of 25 ± 19 years, were a median of 45 ± 19 years of age, had a mean education level of 16 ± 2 years, and were equally split between men and women. Ninety percent of the patients used an insulin pump.

The patients participated in a 35 to 45 minute structured interview, with 13 questions and probes designed to elicit information such as how they felt about wearing the device, how they responded to the RT-CGM tracings of blood-glucose variations, what the most frustrating aspect of the device was, and how their spouse or significant other interacted with the device.

The investigators identified 3 overarching themes uniting responders and nonresponders: the ability to cope with frustrations arising from device alarms, sensor insertion, and calibration, and other aspects of the device; the use of information; and significant other spousal involvement.

They found that responders tended to exert self-control to cope with frustration, and had the ability to control their emotions and solve problems, whereas nonresponders tended to express themselves with angry statements and display anxiety or avoidance behaviors when coping with frustration.

When it came to information use, responders used retrospective pattern analysis and minute-to-minute data analysis in their glycemic management, whereas nonresponders used only minute-by-minute analysis techniques. In other words, nonresponders seemed unable to learn easily from their mistakes.

For example, 1 nonresponder said that he was "ready to hand the whole kit back" because of the frequency of the alarms about out-of-range glucose and the number of beeps.

Responders said they had loved ones who reported interest in their care and encouraged them in the use of the device, whereas nonresponders said their loved ones had little or no involvement. One responder noted that her husband wore the RT-CGM sensor for 5 days to get an idea of what his wife was going through.

The authors also identified a trend toward altered body image in both responders and nonresponders, with patients reporting feeling self-conscious about wearing the device, particularly in intimate situations. Some said that it made them focus on their diabetes too much, and some reported feeling "robotic" or different.

To improve results with RT-CGM, clinicians should use CGM-specific surveys to assess patient attitudes and behaviors, and educate and counsel patients to have realistic expectations about what the devices can do and about to how to download and interpret the data recorded by the device. Patients should also be counseled about how to cope with frustrations that might arise. Family members can be helped to "buy in" to the use of the devices with education about CGM and discussions of food buying and meal preparation, Dr. Ritholz said.

The study provides important information that can help target patient education efforts involving developing therapies that depend on RT-CGM, such as the artificial pancreas, said Richard M. Bergenstal, MD, president of medicine and science at the ADA and executive director of the International Diabetes Center at Park Nicollet in Minneapolis, Minnesota, in an interview with Medscape Medical News. Dr. Bergenstal was not involved in the study.

"There are always going to be issues for patients with new technology," he said. "Patients say 'it's too clunky,' or 'how will this affect my life, how does it affect my behavior?,' and Dr. Ritholz really started to focus on the issues we should address with patients, either for sorting them out and selecting them as good candidates, or helping them through challenges and barriers they can face when wearing 2 pieces of hardware."

American Diabetes Association (ADA) 70th Scientific Sessions. Presented June 27, 2010.


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