The intersection of technology, ethnicity, deprivation, and the covid-19 pandemic: Lessons from the National Diabetes Audit

Introduction: The aim was to investigate access to and the effect of intermittency scanned flash glucose monitoring (isCGM) on glycaemic control during the Covid-19 pandemic. Method(s): Data from the National Diabetes Audit from 2019 to 2021 was stratified into those who were already using isCGM on 1st April 2020 (A), those who started isCGM on or after 1st April 2020 (B), and those who did not receive isCGM (C). Logistic regression investigated the independent effects of ethnicity and deprivation on access to isCGM after adjustment for baseline covariates (age, gender, BMI, duration of diabetes, and baseline HbA1c). Ethnicity was categorized as White, Asian, Black, Mixed, and not reported. The Index of Multiple Deprivation (IMD) was divided into quintiles. Result(s): 251,620 people were identified with type 1 diabetes;88,910 (35%) had isCGM prescribed at 1st April 2020. The mean follow-up post-isCGM initiation was six months. Mean HbA1c at baseline was 67.4mmol/mol in (A), 73.6mmol/mol in (B) and 69.7mmol/mol in (C). Mean HbA1c at follow-up was 64.9mmol/mol (A) (p < 0.001), 65.5mmol/mol (p < 0.001) (B). After adjustment for age, sex, duration of diagnosis, baseline HbA1c, and BMI people with White ethnicity (OR = 1.79 p < 0.001) or in the least deprived quintile (OR = 1.54, p < 0.001) were more likely to be initiated on isCGM as compared to the black and most deprived groups. Conclusion(s): Initiating isCGM during the Covid-19 pandemic was associated with improved glycaemic control. Ethnic and socioeconomic disparities in access to isCGM were observed even during the pandemic. Ongoing work is investigating the effect of isCGM on diabetes-related hospital admissions during the pandemic.

Flash glucose monitoring: The story so far and the journey ahead

Just a few years ago FreeStyle Libre (FSL) was a rarely encountered device, used only by a select few people with type 1 diabetes who could afford to self-fund it. This small disc has a small cannula under the skin which allows for interstitial glucose measurements and remains in situ for 14 days. Over the last 4 years the number of people with access to this life-changing technology on the National Health Service (NHS) has increased rapidly. Although there were barriers to implementing access and encouraging uptake of this technology, including systems, healthcare professionals and the users themselves, innovative interventions from NHS England and diabetes organisations ensured those who stood to gain the most benefit were not impeded in their access, with a particular emphasis on enabling FSL use in those who are often the hardest to reach. This article reviews the impact of FSL on type 1 diabetes care in England, the key events to date and the lessons learnt that can be applied in the future for newer diabetes technologies. Copyright © 2022 BMJ Publishing Group. All rights reserved.

Delivering evidence-based interventions for type 1 diabetes in the virtual world - A review of UK practice during the SARS-CoV-2 pandemic.

AIMS: This review considers the impact of the SARS-CoV-2 pandemic on access to interventions for those living with type 1 diabetes and discusses the solutions which have been considered and actioned to ensure ongoing access care. METHODS: We performed a focussed review of the published literature, and the guidelines for changes that have been effected during the pandemic. We also drew from expert recommendations and information about local practice changes for areas where formal data have not been published. RESULTS: Evidence based interventions which support the achievement of improved glucose levels and/or reduction in hypoglycaemia include group structured education to support self-management, insulin pump therapy and continuous glucose monitoring. The SARS-CoV-2 pandemic had impacted the ability of diabetes services to deliver these intervention. Multiple adaptations have been put in place - transition to online delivery of education and care, and usage of diabetes technology. CONCLUSIONS: Although various adaptations have been made during the pandemic that have positively influenced uptake of services, there are many areas of delivery that need immediate improvement in the UK. We recommend a proactive approach in recognising the digital divide and inequity in distribution of these changes and we recommend introducing measures to reduce them.

COVID-19 outcomes in people with diabetes in Wales: a secondary analysis of the ABCD audit

Background: People with diabetes and coronavirus disease 2019 (COVID-19) have a significantly greater risk of death and/or intensive care unit (KU) admission. The Association of British Clinical Diabetologists (ABCD) recently audited out- comes for people hospitalised in the UK with diabetes and COVID-19. Methods: The ABCD COVID-19 and diabetes audit was a retrospective audit of patients admitted to UK hospitals with diabetes and COVID-19 between March and December 2020. Data related to patients admitted in Wales were compared with patients admitted in England and Scotland. Results: In Wales, 40/82 (48.7%) patients with diabetes had COVID-19-related mortality compared with 1,149/2,916 (39.1%) in the UK group (p=0.08). The Welsh cohort were more likely to be Caucasian, have a higher body mass index and HbA1c, be diagnosed with diabetic retinopathy and prescribed a sodium-glucose co-transporter 2 inhibitor or insulin than those in England and Scotland. Patients admitted to the ICU in Wales were more likely to be male and have type 2 diabetes. Conclusions: Patients admitted to hospital with diabetes and COVID-19 in Wales had a poorer outcome compared with England and Scotland. This disparity may reflect social inequality, differences in cardiovascular risk factors and/or differences in diabetes medications between hospitalised patients in Wales and the UK.

Time in range: A best practice guide for UK diabetes healthcare professionals in the context of the COVID-19 global pandemic.

The emergence of continuous glucose monitoring has driven improvements in glycaemic control and quality of life for people with diabetes. Recent changes in access to continuous glucose monitoring systems within UK health services have increased the number of people able to benefit from these technologies. The COVID-19 pandemic has created an opportunity for diabetes healthcare professionals to use continuous glucose monitoring technology to remotely deliver diabetes services to support people with diabetes. This opportunity can be maximized with improved application and interpretation of continuous glucose monitoring-generated data. Amongst the diverse measures of glycaemic control, time in range is considered to be of high value in routine clinical care because it is actionable and is visibly responsive to changes in diabetes management. Importantly, it is also been linked to the risk of developing complications associated with diabetes and can be understood by people with diabetes and healthcare professionals alike. The 2019 International Consensus on Time in Range has established a series of target glucose ranges and recommendations for time spent within these ranges that is consistent with optimal glycaemic control. The recommendations cover people with type 1 or type 2 diabetes, with separate targets indicated for elderly people or those at higher risk from hypoglycaemia, as well as for women with type 1 diabetes during pregnancy. The aim of this best practice guide was to clarify the intent and purpose of these international consensus recommendations and to provide practical insights into their implementation in UK diabetes care.