Time in range use lacking among primary care providers and patients
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BALTIMORE — More than half of primary care providers are not using time in range in clinical practice, and only one-third of people with diabetes use the metric as part of their glycemic management, according to a presenter.
Research from The diaTribe Foundation presented at the Association of Diabetes Care & Educational Specialists Annual Conference revealed that while a large majority of endocrinologists and diabetes care and education specialists use time in range in practice when caring for people with diabetes, HbA1c remains a stronger fixture in diabetes care, particularly among primary care providers. Additionally, most people living with diabetes are introduced to time in range through either their continuous glucose monitoring data or their own online research and not through their health care provider. The research is guiding the mission of The diaTribe Foundation’s Time in Range Coalition, which is working to drive the adoption of time in range for use as the primary metric for daily diabetes management.
“The Time in Range Coalition is a group of members who have gathered around this idea that we need to continue to advocate and push for using time in range as the daily diabetes metric, complemented by HbA1c,” Julie K. Heverly, senior director for the Time in Range Coalition at The diaTribe Foundation in San Francisco, said during a presentation.
Heverly described time in range is an improvement over HbA1c since it provides more accurate and actionable data. While HbA1c is the mean blood glucose of a person with diabetes over a period of time, time in range measures the percentage of time a person’s glucose is between 70 mg/dL and 180 mg/dL and can provide information on glucose variability and the amount of time a person spends in hypoglycemia or hyperglycemia.
Time in range not used by most primary care providers
Despite the metric’s strengths, research from The diaTribe Foundation has revealed inconsistencies with the use of time in range in practice. From August 28 to September 10, 2021, the organization conducted interviews and surveys of health care providers caring for people with diabetes. To participate, providers had to have at least 2 years of experience and see at least 80 patients per month for endocrinologists or 30 per month for diabetes care and education specialists and primary care providers.
Diabetes care and education specialists had the highest usage rate of time in range at 94%, with endocrinologists coming in second at 88%. Primary care providers had a much lower time in range usage rate, with just 46% using the metric in practice. Additionally, only 56% of primary care providers said they were aware of time in range compared with more than 90% of endocrinologists and diabetes care and education specialists. The use among primary care providers was low even considering that about one-third of those who do not use time in range said it was an “extremely helpful” metric.
“Even the people who aren’t using time in range believe it is good,” Heverly said. “They believe it is helpful for making treatment decisions, for motivation and for changing treatment plans.”
Among those who use time in range, the metric is used most frequently for treatment decisions by people with type 1 diabetes and those with type 2 diabetes using multiple daily insulin injections or an insulin pump. However, HbA1c remains the primary metric for all other patients.
Most people with diabetes not using time in range
Additional research revealed that the majority of people with diabetes are not looking at time in range. The diaTribe Foundation conducted a 3-day online bulletin board survey of 50 people with diabetes where participants took photos, answered questions and submitted selfie videos about how time in range fits into their daily lives. In a separate, email-based survey, 1,002 people with diabetes answered questions to expand on the findings from the bulletin board survey.
Researchers found reducing HbA1c was the most common treatment goal for people with diabetes and the most common goal set by providers. With the exception of people with type 1 diabetes, the majority of participants said HbA1c was the most important metric for understanding how they were doing with diabetes self-management.
About 33% of people with diabetes said they use time in range, but the usage rate varied by type of diabetes and therapy. Time in range was used by 58% of people with type 1 diabetes and 49% of people with type 2 diabetes using multiple daily insulin injections or an insulin pump. For all other people with type 2 diabetes, fewer than one-fourth said they looked at time in range.
Most people using CGM said they discovered time in range on their own, with 44% introduced to it through their CGM data and 20% finding out about it online. Most people who did not use CGM said they also were introduced to it online and not through their health care provider.
People with diabetes who used time in range said there were several benefits, with 66% reporting the metric provided timely insight on diabetes management, 62% believing it was simple and easy to understand, 58% describing it as motivating to see immediate impact of treatment change and 51% feeling it could inform treatment decisions.
There were some drawbacks, with 24% of participants mentioning that time in range required use of a CGM, 23% saying they were unhappy their provider focused more on HbA1c than time in range, and 11% saying they were already comfortable with HbA1c. However, 41% of participants said there were no drawbacks to time in range.
Even among time in range users, many would like to receive more practical help from their providers with deciphering the metric. While 84% of time in range users said they use the metric to adjust their diabetes treatment, just 37% said they have received guidance from their provider on how to adjust their treatment on their own.
Promoting the use of time in range
Heverly said The diaTribe Foundation’s Time in Range Coalition is working to make the diabetes community more aware of time in range. The coalition consists of professional societies, industry leaders, nonprofits and patient advocates and is focusing its work on three areas. For regulatory and policy, the coalition’s goal is to identify barriers to integrate time in range as an accepted metric among regulators such as the FDA and the European Medicines Agency. Among providers and people with diabetes, the coalition is trying to develop simplified messaging for a digital campaign to increase awareness and adoption of time in range. The coalition is also trying to determine a strategy to address inconsistencies and gaps in existing practice guidelines. Heverly encouraged providers to make a concerted effort to focus more on time in range within their own practices.
“[Time in range] is the GPS, it is the Waze, it is all of those navigational tools that we need to make a difference,” Heverly said. “I just encourage you to be creative with your patients and help them see the information that is available to them.”
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Heverly JK, et al. F30. Presented at: ADCES22; Aug. 12-15, 2022; Baltimore.
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