Why Stanford Wants to Make CGM a Standard of Care for Diabetic Kids

With interest in remote patient monitoring skyrocketing, providers are exploring the various uses of this technology for different conditions. One arena where it could be a game-changer? Management of type 1 diabetes among children.

In 2018, there were 187,000 children and adolescents younger than 20 years with type 1 diabetes, according to the latest data from the Centers for Disease Control and Prevention. This figure may have already increased amid the COVID-19 pandemic, as new research shows that those younger than 18 years are at an increased risk of developing diabetes, including type 1, following COVID-19 infection.

Stanford Children's Health in Palo Alto, California, recently conducted a study that showed encouraging results related to the use of continuous glucose monitors (CGMs), even among young patients. Not only that, but the technology-based approach did not worsen the care experience for either patients or their families.

"There has been debate in the medical community about when is too early to start diabetes technology," said Dr. Priya Prahalad, Stanford Children's Health pediatric endocrinologist and member of the Maternal and Child Health Research Institute at Stanford Medicine, in a phone interview. "And I think what we are able to show is that starting diabetes technology early does not have any adverse effects on patients and families. It does not decrease their quality of life."

The study and its results

Published in the Journal of Clinical Endocrinology and Metabolism, the study assessed glycated hemoglobin A1c outcomes in children with type 1 diabetes who received a CGM soon after being diagnosed.

"A majority of youth with type 1 diabetes do not achieve the A1c targets that are set by the American Diabetes Association or the International Society for Pediatric and Adolescent Diabetes," said Prahalad, one of the study authors. "And what we find is that the age group that we see, those who are between zero and 18, have the highest A1c and those who are adolescents have even higher A1c."

Researchers examined outcomes for 135 children and teenagers diagnosed with diabetes between 2018 and 2020 and compared them with 272 children diagnosed between 2014 and 2016. Among the more recent cohort, 124 patients began using continuous glucose monitors within a month of diagnosis, while the remaining 11 started more than a month after diagnosis. In the 2014-16 cohort, about half of patients eventually used the monitors, but only 1.8 percent began in the first month post-diagnosis.

A CGM is a wireless sensor that automatically and continuously tracks blood glucose levels. The data is then transmitted to a monitor, smartphone or tablet.

Without a CGM, patients have to use glucometers and check their blood sugar six to 10 times a day by poking their fingers. But with the continuous monitoring device, patients can get a glucose reading every five minutes.

"So that's about 288 readings a day," said Prahalad. "And not only that, the sensor can give you alerts for high and low glucoses and can also tell patients and families which direction their glucoses are trending."

"And the really nice feature about this as well is, if you're able to connect it to the internet, we as providers can see the data remotely," Prahalad added.

Every week, a certified diabetes care and education specialist at Stanford would review the data for the study participants with CGMs and message the patients or their families to inform them about the insulin dose adjustments that need to be made to keep their glucose levels in tight control.

A year after being diagnosed, 66% of participants in the 2018-20 CGM group reached the then standard of care goal of having an A1c below 7.5 percent, as compared with 43% in the 2014-16 cohort.

During the study, the standard of care target changed to A1c levels less than 7 percent. At 12 months post-diagnosis, 53 percent of patients in the 2018-20 CGM cohort met the goal versus only 28 percent in the earlier group. 

CGM's impact on patient experience

Getting diagnosed with type 1 diabetes is life-changing, for both pediatric patients and their families, Prahalad said.

She and her fellow researchers were worried that a device that provided 200-plus glucose readings a day would overwhelm patients and their loved ones, resulting in them discontinuing use.

"But what we were able to find was that families really wanted this device," Prahalad said. "They really liked using this device early on. And we had very few discontinuations and we did not see a worsening quality of life."

The CGM also enabled clinicians to adjust doses when needed, which has been shown to help tighten glucose control and improve outcomes, without patients having to come into the clinic frequently.

Researchers who conducted the above study collaborated with colleagues in Stanford's engineering and management sciences departments to build a dashboard that helped clinicians prioritize patients who would benefit from having their CGM data reviewed by a certified diabetes care and education specialist. Eighty-nine patients from the 2018-20 cohort participated in the remote patient monitoring aspect of the study.

"We made this part of our diabetes educator workflows, and we were able to operationalize remote patient monitoring," said Prahalad.

This helped provide patients and their families with the support that they needed without the disruption to daily life that in-person visits can cause.

Key considerations for implementing CGM

Providers interested in deploying CGM devices among their own pediatric populations must take several factors into account, including accessibility.

"CGM technology may not be accessible for all people," Prahalad said. "It's accessible to those who have the ability to get it covered through insurance or who have the means of paying for it out of pocket. But for those who lack the coverage or who lack the means to pay for it, these are people who can miss out from this tech-driven approach."

For the study, Stanford was able to provide uninsured kids with supplies through philanthropic funding by the Lucile Packard Children's Health Auxiliaries Endowment Fund.

This consideration goes hand-in-hand with another potential hurdle that type 1 diabetic patients may face: lack of internet connectivity. Patients and their families may not have smartphones or computers, and in some cases, broadband, and may miss out on the benefits CGM can provide.

"Fortunately, we found that even if children don't have smartphones, their parents tend to have smartphones or they're able to access Wi-Fi at school," Prahalad said. "So, this could be a potential way of mitigating the concern for internet access."

The barriers facing patients is just one aspect of the key considerations for providers interested in CGM. The other is clinician buy-in.

Patients need consistent messaging about their newly diagnosed type 1 diabetes from their physicians, nurse practitioners and diabetes educators. Consistent messaging will help patients retain the information provided on diabetes management, Prahalad explained. 

Luckily, Prahalad has found that the technology-based CGM approach is an easy sell for diabetes care and educational specialists.

"We rely very heavily on our certified diabetes care and education specialists to make this a successful program," she said. "They are often the ones who are starting the CGM on our patients. They are the ones who are reviewing the data every week. Our diabetes care and educational specialists have really enjoyed this part of their work. They feel like they're doing a lot more clinical work and they're getting to establish relationships with patients."

Together, the human component of chronic disease management support and devices like CGM have the potential to change what 'usual' care looks like for kids with type 1 diabetes.

Prahalad envisions a future where instead of kids being handed a glucometer when they are diagnosed, they get a CGM.

"We are hopeful that our data can encourage more people to make CGM a standard of care for diabetes," she said.