If Diabetes Technologies Improve Outcomes and Quality of Life, Why Aren’t They More Broadly Adopted?— Barriers and Facilitators for Clinicians to Consider

Hope Warshaw MMSc, RD, CDCES, BC-ADM, FADCES
Category: Tips & Guidelines

Today, in the U.S. alone, roughly seven million people with diabetes require insulin to manage their glucose levels. This includes 1.5 million people with type 1 diabetes1 and about 6 million people with type 2 diabetes who require insulin.2 The American Diabetes Association (ADA) states that diabetes technology can lead to a reduced disease burden and greater quality of life for patients.3 Though the number of people who use technology-enabled insulin delivery devices is slowly increasing, roughly half of people who take insulin, including people with type 14,5 and type 2 diabetes,5 continue to take it using a syringe or traditional pen.

Why?

From the vantage point of a person with diabetes and/or their caregivers, they may not be aware of newer devices and thus don’t inquire about them or advocate for their use. Some people rely on their clinicians to provide this knowledge. For others, even when they’re aware of newer devices for insulin delivery that may reduce disease burden, they can have an, “If it ain’t broke don’t fix it,” perspective after having taken insulin a certain way for years. Other reasons may relate to the time and energy it takes to master a new device, an unsuccessful prior experience, and/or lack of desire to wear an on-body device 24/7.

From the vantage of clinicians, if you’re not steeped in diabetes care day to day, it can be challenging to keep up with the rapid evolution of all types of technology-enabled insulin delivery devices.3,6 It’s also time consuming, within the realm of daily patient care, to take time to introduce and review the array of devices, determine starting settings, get a person started on a device, and continually evaluate and tweak device settings. And above and beyond these challenges, there may be hurdles in the healthcare system to help patients obtain device coverage.

Barriers and Facilitators to Diabetes Device Adoption

In a recent review, two well respected diabetes psychologists, Tanenbaum from Stanford, and Commissariat from Joslin Diabetes Center, explore barriers and facilitators to diabetes technology adoption.7 Below is a high-level summary of their key points that clinicians should keep in mind to help people with diabetes and to ensure we don’t inadvertently put up barriers to their technology adoption.

  • Provider-level barrier: the role of gatekeeper  
    The authors note that, “Providers are responsible for the introduction, education and prescription of new technologies.” In this role providers are in the position of “gatekeepers” for device use. As gatekeepers, providers may without intention, create obstacles to device adoption or withhold the recommendation of a certain technology. The review cites studies that have found providers may have preconceived notions about who is a, “good candidate,” for certain diabetes technologies. For example, a person who has higher education and/or is tech-savvy is a good candidate vs. a person without these characteristics. Evidence from Agarwal, et al., cited in this review, report racial and ethnic disparities in the use of diabetes technologies among 300 young adults with type 1 diabetes.8  
    Let’s reflect and think about whether we, as providers, apply an implicit bias when we think about the characteristic of a “good candidate” for an array of diabetes technologies.
     
  • Provider-level barrier: learning a new device and/or creating necessary workflows to promote device adoption and sustained use  
    The authors cite research that found older providers and those who practice outside of an academic medical center had fewer positive attitudes about diabetes technologies. They also had less exposure to and were less likely to work with people with diabetes who use these technologies. These providers reported needing other experts to support their patients’ successful use of these technologies.

  • Provider-level facilitators: using educational resources to increase device uptake and sustained  
    The authors state, “Healthcare providers have influence on decisions to use diabetes technology through comprehensive education and individualized support.” They add, that, “Providers are responsible for educating patients on their available options.” The authors note that patients with diabetes increasingly want information, education and support on diabetes technologies.” With obvious shortages of time and resources, clinicians can access reliable resources about various diabetes technologies and guidelines to stay up to date. Consider recommending the following resources to people with diabetes and caregivers as well.


    Reliable resources include:

    • American Diabetes Association: ADA maintains a Consumer Guide that contains up to date information about all diabetes technologies. In addition, annually ADA updates their Standards of Care which includes a section on diabetes technology.3
    • Association for Diabetes Care and Education Specialists (ADCES): ADCES maintains an online resource for all things diabetes technology, called danatech. This resource includes information about devices, including a quick overview of current AID systems, as well as diabetes-focused apps. In addition, access online training and education including certificate programs, webinars, and device training. There are also resources on coverage for various diabetes technologies.
    • DiabetesWise: This resource was developed by diabetes experts at Stanford University School of Medicine with support from the Helmsley Charitable Trust. DiabetesWise has a side of their website for people with diabetes and caregivers, as well as the DiabetesWise website for clinicians.
       
  • Provider-level facilitator: using the power of the patient-provider relationship   
    Authors of this review cite research that shows people with diabetes have endorsed a desire for support specifically from their providers. Regarding diabetes technologies, this includes information on getting started on technologies, how to self-advocate with device companies’ customer support, how to manage glucose data, and consideration and discussion about the emotional challenges of using devices. In addition, research the authors share suggests that “provider enthusiasm about technology and tailored discussion of how technology could meet an individual’s needs may facilitate technology uptake.” They share data from a qualitative study in young adults with type 1 diabetes by Agarwal et al.9 Subjects in this study discussed the lack of shared decision-making with providers and feeling that they were not provided with sufficient information on their options for devices as barriers to not being fully exposed to the variety of devices accessible to them.   
    The authors cite research that shows use of an insulin pump can, “change the nature of patient-provider relationship by increasing collaboration and thus the individual’s sense of empowerment and control over their diabetes.”9 A publication authored by Polonsky, that focuses on the psychological aspects of diabetes technology in adults, is cited by the authors. It underscores the important point that, “Providers may be able to increase technology acceptance by addressing concerns and emphasizing person-specific benefits, and providing ongoing personalized support. Polonsky, in his publication adds, “For diabetes technologies to more effectively and/or more easily [help people with diabetes] achieve glycemic management while also enhancing (or at least not reducing) quality of life and make good use of it (integrate it into care), the person with diabetes needs to want the technology and accept it as part of their diabetes self-care.”10

In conclusion, taking insulin (typically several times a day or more), along with managing all aspects of daily diabetes self-care is challenging and burdensome. Completing these tasks on top of all the ins and outs of living life today is a lot of work for most people with diabetes. Today we have an increasing array of available diabetes technologies. Though recommended by ADA in their 2023 Standards of Care3 and AACE in their clinical practice guideline,6 these devices remain woefully underutilized.

As the review article cited emphasizes,7 it’s incumbent upon us as clinicians to explore our implicit biases about who we believe may want, be able to use and benefit from diabetes technologies. It’s also our responsibility as clinicians who care for and counsel people with diabetes to determine how we can better facilitate the successful use of these technologies to help our patients improve clinical outcomes, reduce disease burden, improve quality of life and make taking care of diabetes just a bit easier day to day.

The author was compensated for this article.

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References:

  1. JDRF. https://www.jdrf.org/about/facts-about-jdrf/. Accessed May 1, 2023.
  2. Saydah SH, Cowie CC, Casagrande SS, et al. Medication use and self-care practices in persons with diabetes. In: Diabetes in America. 3rd ed. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases (US); 2018 Aug. CHAPTER 39. PMID: 33651554. https://www.ncbi.nlm.nih.gov/books/NBK567996/#ch39.sum. Accessed May 1, 2023.
  3. American Diabetes Association. Standards of Care in Diabetes – 2023. 7. Diabetes technology. Diabetes Care. 2023;(Supp 1):S111-S127.
  4. Foster NC, Beck RW, Miller KM, et al. State of type 1 diabetes management and outcomes from the T1D exchange in 2016-2018. Diabetes Technol Ther. 2019;21(2):66-72.
  5. Umpierrez GE, Klonoff DC. Diabetes technology Update: Use of insulin pumps and continuous glucose monitoring in the hospital. Diabetes Care. 2018;41(8:1579-1589.
  6. Grunberger G, Sherr J, Allende M, et al. AACE clinical practice guideline: the use of advanced technology in the management of persons with diabetes. Endocr Pract. 2021;27:505-537.
  7. Tanenbaum ML, Commissariat PV. Barriers and facilitators to diabetes device adoption for people with type 1 diabetes. Cur Diabetes Rep. 2022;22:291-299.
  8. Agarwal S, Schechter C, Gonzalez J, Long JA. Racial-Ethnic disparities in diabetes technology use among young adults with type 1 diabetes. Diabetes Technol Ther. 2021;23(4):306-313.
  9. Agarwal S, Crespo-Ramos G, Long JA, Miller VA. “I didn’t really have a choice”: qualitative analysis of racial-ethnic disparities in diabetes technology use among young adults with type 1 diabetes. Diabetes Technol Ther. 2021;23(9):616-622.
  10. Polonsky WH. Psychosocial aspects of diabetes technology: adult perspective. Endocrinol Metab Clinic. 2020;49(1):143-155.

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