Intensive education improves glycemic outcomes in new-onset type 1 diabetes
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Intensive diabetes education with early initiation of continuous glucose monitoring is associated with improvements in HbA1c for children with type 1 diabetes, according to study data.
Researchers at Stanford University implemented the 4T program — teamwork, targets, technology and tight control — to put a closer focus on diabetes management for children with new-onset type 1 diabetes. Participants in the 4T program had a lower mean HbA1c at 6, 9 and 12 months after diagnosis compared with a group of children with type 1 diabetes receiving standard diabetes education.
“Early initiation of CGM soon after diagnosis of type 1 diabetes was well received by patients and families and resulted in a 0.5% lower HbA1c compared to historic controls,” David M. Maahs, MD, division chief of pediatric endocrinology at Stanford Children’s Health, told Healio. “Use of remote monitoring and a population dashboard allowed certified diabetes educators to asynchronously monitor glucose values and provide diabetes education and dose adjustments in between clinical visits.”
Maahs and colleagues enrolled 135 children newly diagnosed with type 1 diabetes at Stanford Children’s Health between July 2018 and June 2020 into the 4T program (median age, 9.7 years; 52.6% boys; 37% white). Those who chose to start CGM had a follow-up visit with a certified diabetes care and education specialist to start the technology. Those diagnosed in March 2019 or later were also allowed to take part in remote monitoring (n = 89). CGM data were transferred to electronic health records and reviewed weekly. Certified diabetes care and education specialists recommended insulin dose adjustments, if needed. HbA1c changes from 4 to 12 months after diagnosis in the 4T program cohort were compared with a historical cohort of 272 children diagnosed with type 1 diabetes between June 2014 and December 2016 who received standard diabetes education and had quarterly clinic visits (median age, 9.7 years; 50.4% boys; 42.6% white).
The findings were published in The Journal of Clinical Endocrinology & Metabolism.
4T program improves glycemic outcomes
The 4T program group had a higher HbA1c at baseline compared with the historical group (12.2% vs. 10.7%), but there were no other significant differences between the cohorts. The historical group had a rise in HbA1c at 4 months, with HbA1c steadily increasing over time, whereas the 4T program group had a more gradual increase in HbA1c. The 4T program cohort had a mean HbA1c 0.54% lower at 6 months, 0.52% lower at 9 months and 0.58% lower at 12 months compared with the historical cohort. Mean HbA1c increased between 4 and 12 months by 1.47% in the historical group compared with 1.32% in the 4T program group (P < .001).
Within the 4T program cohort, children who did not participate in remote monitoring had an earlier and quicker HbA1c increase compared with those who had remote monitoring, though both groups had lower HbA1c at 12 months compared with the historical cohort. Those who had remote monitoring had a mean HbA1c 0.14% lower at 6 months, 0.18% lower at 9 months and 0.14% lower at 12 months compared with 4T participants with no remote monitoring.
At 3 months, the historical cohort had a higher proportion of children meeting an HbA1c target of less than 7.5%. At 12 months, the 4T program cohort had a greater percentage of children with an HbA1c less than 7.5% compared with the historical group (66% vs. 43%; P < .01).
“I was not surprised, but gratified [by] how much of a positive impact early access and education on CGM made for children and families,” Maahs said. “We were also very pleased that all patients, whether on private or public insurance, English-speaking or not, were able to participate and benefit from the program.”
Overcoming barriers
Glucose management indicator was calculated at 2-week intervals due to some participants missing HbA1c data due to the COVID-19 pandemic. Glucose management indicator patterns in the 4T program group were similar to those observed with HbA1c, with the lowest value coming 10 to 20 weeks after diagnosis. Time in range was also highest between 10 and 20 weeks and decreased slowly during the study. Mean time in range for the 4T program group was 66% throughout the study and 63% at 12 months.
The findings showed that the 4T program can lead to improvements in glycemic outcomes, but Maahs said there are several barriers that must be addressed to allow the program to be implemented in other clinics.
“The transfer of the data for use can be a big challenge, and we are fortunate to have an excellent group of engineers and data scientists at Stanford who are essential to the program,” Maahs said. “We aim to develop and share this dashboard system, Timely Interventions for Diabetes Excellence, with other programs. In addition, many programs do not have sufficient support from certified diabetes care and education specialists to provide as much education as they would like. Likewise, certified diabetes care and education specialists spend way too much time on insurance related paperwork, instead of educating and caring for patients.”
For more information:
David M. Maahs, MD, can be reached at dmaahs@stanford.edu.
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