The new findings are from a study involving patients at the Barbara Davis Center for Diabetes Adult Clinic between January 1, 2014, and December 31, 2021. They show that as technology use has increased, A1c levels have dropped in parallel. Moreover, progression from use of stand-alone continuous glucose monitors (CGMs) to automated insulin delivery systems (AIDs), which comprise insulin pumps and connected CGMs, furthered that progress.
The findings "are in agreement with American Diabetes Association Standards of Care, and recent international consensus recommending CGM and AID for most people with type 1 diabetes, and early initiation of diabetes technology from the onset of type 1 diabetes," write Kagan E. Karakus, MD, of the Barbara Davis Center, and colleagues in the article, which was published online in Diabetes Care.
"It's very rewarding to us. We can see clearly that the uptake is going up and the A1c is dropping," lead author Viral N. Shah, MD, of the Barbara Davis Center, told Medscape Medical News.
On the flip side, A1c levels rose significantly over the study period among nonusers of technology. "We cannot rule out provider bias for not prescribing diabetes technology among those with higher A1c or from disadvantaged socioeconomic backgrounds," Karakus and colleagues write.
Also of note, even with use of the most advanced AID systems available during the study period, just under half of patients were still not achieving A1c levels below 7%. "The technology helps, but it's not perfect," Shah observed.
This study is the first to examine the relationship of A1c with technology use over time, in contrast to prior cross-sectional studies. "The intention here was to look at the landscape over a decade," Shah said.
As Overall Use of Technology Use Rose, A1c Levels Fell
The analysis included data for 4174 unique patients (mean number of patients, 1988/yr); 15,903 clinic visits were included over the 8-year study period. Technology use was defined as CGM use without an AID system or with an AID system.
Over the study period, diabetes technology use increased from 26.9% to 82.7% of the clinic population (P < .001). At the same time, the overall proportion patients who achieved the A1c goal of less than 7% increased from 32.3% to 41.7%, while the mean A1c level dropped from 7.7% to 7.5% (P < .001).
But among the technology nonusers, A1c rose from 7.85% in 2014 to 8.4% in 2021 (P < .001).
Regardless of diabetes technology use, White patients (about 80% of the total study population) had significantly lower A1c than non-White patients (7.5% vs 7.7% for technology users [P = .02]; 8.0% vs 8.3% for nontechnology users [P < .001]).
The non-White group was too small to enable the researchers to break down the data by technology type. Nonetheless, Shah said, "As a clinician, I can say that the penetration of diabetes technology in non-white populations remains low. These are also the people more vulnerable for socioeconomic and psychosocial reasons."
The A1c increase among technology nonusers may be a result of a statistical artifact, as the number of those individuals was much lower in 2021 than in 2014. It's possible that those remaining individuals have exceedingly high A1c levels, bringing the average up. "It's still not good, though," Shah said.
The More Technology, the Lower the A1c
Over the study period, the proportion of stand-alone CGM users rose from 26.9% to 44.1%, while use of AIDs rose from 0% in 2014 and 2015 to 38.6% in 2021. The latter group included patients who used first-generation Medtronic 670G and 770G devices and second-generation Tandem t:slim X2 with Control-IQ devices.
Between 2017 and 2021, AID users had significantly lower A1c levels than non-technology users: 7.4% vs 8.1% in 2017, and 7.3% vs 8.4% in 2021 (P < .001 for every year). CGM users also had significantly lower A1c levels than nonusers at all time points (P < .001 per year).
The proportions achieving an A1c less than 7% differed significantly across users of CGM, AID, and no technology (P < .01 for all years). In 2021, the percentage of people who achieved an A1c less than 7% were 50.9% with AIDs and 44.1% for CGMs, vs just 15.2% with no technology.
Work to Be Done: Why Aren't More Achieving <7% With AIDs?
Asked why only slightly more than half of patients who used AIDs achieved A1c levels below 7%, Shah listed three possibilities:
First, the 7% goal doesn't apply to everyone with type 1 diabetes, including those with multiple comorbidities or with short life expectancy, for whom the recommended goal is 7.5% to 8.0% to prevent hypoglycemia. "We didn't separate out patients by A1c goals. If we add that, the number might go up," Shah said.
Second, AID technology is continually improving, but it's not perfect. Users still must enter carbohydrate counts and signal the devices for exercise, which can lead to errors. "It's a wonderful technology for overnight control, but still, during the daytime, there are so many factors with the user interface and how much a person is engaged with the technology," Shah explained.
Third, he said, "Unfortunately, obesity is increasing in type 1 diabetes, and insulin doses are increasing. Higher BMI [body mass index] and more insulin resistance can mean higher A1c. I really think for many patients, we probably will need an adjunct therapy, such as an SGLT2 [sodium-glucose cotransporter-2] inhibitor or a GLP-1 [glucagon-like peptide-1] agonist, even though they're not approved in type 1 diabetes, for both glycemic and metabolic control including weight. I think that's another missing piece."
He also pointed out, "If someone has an A1c of 7.5%, I don't expect a huge change. But if they're at 10%, a drop to 8% is a huge change."
Overall, Shah said, the news from the study is good. "In the past, only 30% were achieving an A1c less than 7%. Now we're 20% above that.... It's a glass half full."
Karakus has disclosed no relevant financial relationships. Shah has received, through the University of Colorado, research support from Novo Nordisk, Insulet, Tandem Diabetes, and Dexcom and honoraria from Medscape, Lifescan, Novo Nordisk, and DKSH Singapore for advisory board attendance and from Insulet and Dexcom for speaking engagements.
Diabetes Care. Published online July 17, 2023. Abstract
Miriam E. Tucker is a freelance journalist based in the Washington DC area. She is a regular contributor to Medscape, with other work appearing in the Washington Post, NPR's Shots blog, and Diabetes Forecast magazine. She is on Twitter @MiriamETucker.
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Cite this: Type 1 Diabetes Management Improves as Technology Advances - Medscape - Aug 23, 2023.