A New Technology-Enabled Care Model for Pediatric Type 1 Diabetes

Abstract

In July 2018, pediatric type 1 diabetes (T1D) care at Stanford suffered many of the problems that plague U.S. health care. Patient outcomes lagged behind those of peer European nations, care was delivered primarily on a fixed cadence rather than as needed, continuous glucose monitors (CGMs) were largely unavailable for individuals with public insurance, and providers' primary access to CGM data was through long printouts. Stanford developed a new technology-enabled, telemedicine-based care model for patients with newly diagnosed T1D. They developed and deployed Timely Interventions for Diabetes Excellence (TIDE) to facilitate as-needed patient contact with the partially automated analysis of CGM data and used philanthropic funding to facilitate full access to CGM technology for publicly insured patients, for whom CGM is not readily available in California. A study of the use of CGM for patients with new-onset T1D (pilot Teamwork, Targets, and Technology for Tight Control [4T] study), which incorporated the use of TIDE, was associated with a 0.5%-point reduction in hemoglobin A1c compared with historical controls and an 86% reduction in screen time for providers reviewing patient data. Based on this initial success, Stanford expanded the use of TIDE to a total of 300 patients, including many outside the pilot 4T study, and made TIDE freely available as open-source software. Next steps include expanding the use of TIDE to support the care of approximately 1,000 patients, improving TIDE and the associated workflows to scale their use to more patients, incorporating data from additional sensors, and partnering with other institutions to facilitate their deployment of this care model.

FIGURE 1. Glucose Management with Fixed-Cadence Visits (Hypothetical)

Glucose management improves after fixed-cadence visits, but not enough to make up for episodes of deterioration occurring between visits. The trend illustrated is consistent with an observed decline in postdiagnosis glucose management. CGM = continuous glucose monitor. Source: Lucile Packard Children’s Hospital Stanford NEJM Catalyst (catalyst.nejm.org) © Massachusetts Medical Society

FIGURE 2. Glucose Management As-Needed Visits Based on Remote Monitoring via Continuous Glucose Monitors (Hypothetical)

Deterioration in glucose management is detected, and patients are contacted with guidance on how to improve management. The trend illustrated is consistent with a slower observed decline in postdiagnosis glucose management associated with the use of Timely Interventions for Diabetes Excellence (TIDE). CGM = continuous glucose monitor. Source: Lucile Packard Children’s Hospital Stanford NEJM Catalyst (catalyst.nejm.org) © Massachusetts Medical Society

FIGURE 3. Timely Interventions for Diabetes Excellence Population-Level View

Rows correspond to individual patient data, are ranked by the likelihood of the patient requiring contact, and display metrics exceeding predefined thresholds in red. Avg. = average, Cont = continued, 4T = Teamwork, Targets, and Technology for Tight Control, TIPs = Time in Range Program, TIR = time in range. Source: Lucile Packard Children’s Hospital Stanford NEJM Catalyst (catalyst.nejm.org) © Massachusetts Medical Society

FIGURE 4. Timely Interventions for Diabetes Excellence Individual-Level View

For the patient selected, detailed time series data reveal opportunities to improve glucose management - postprandial management for the patient shown. BG = blood glucose, CGM = continuous glucose monitor. Source: Lucile Packard Children’s Hospital Stanford NEJM Catalyst (catalyst.nejm.org) © Massachusetts Medical Society

FIGURE 5. Time Savings Associated with the Use of Timely Interventions for Diabetes Excellence

Period 1 is the baseline. Before period 2, improved algorithms reduced the average number of data reviews per patient. Before period 3, additional data displays were included in Timely Interventions for Diabetes Excellence (TIDE) to reduce the time required for data review. Source: Adapted from Ferstad JO, Vallon JJ, Jun D, et al. Population-level management of type 1 diabetes via continuous glucose monitoring and algorithm-enabled patient prioritization: precision health meets population health. Pediatr Diabetes 2021;22:982–91 with the permission of the authors NEJM Catalyst (catalyst.nejm.org) © Massachusetts Medical Society

FIGURE 6. Hemoglobin A1c for Patients in the Historical Control Group and the Teamwork, Targets, and Technology for Tight Control in Newly Diagnosed Type 1 Diabetes Phase 1 Study

Compared with 272 historical control patients, for the 135 patients in the Teamwork, Targets, and Technology for Tight Control (4T) phase 1 study, hemoglobin A1c (HbA1c) was 0.54%, 0.52%, and 0.58% points lower at months 6, 9, and 12 postdiagnosis. Source: Adapted from Prahalad P, Ding VY, Zaharieva DP, et al. Teamwork, targets, technology, and tight control in newly diagnosed type 1 diabetes: pilot 4T study. J Clin Endocrinol Metab. 2021;107:998–1008. https://academic.oup.com/jcem/advance-article-abstract/doi/10.1210/clinem/dgab859/6445182. https://doi.org/10.1210/clinem/dgab859 with the permission of the authors NEJM Catalyst (catalyst.nejm.org) © Massachusetts Medical Society

FIGURE 7. Time in Range Patients in the Pilot Teamwork, Targets, and Technology for Tight Control Study Using and Not Using Timely Interventions for Diabetes Excellence

For participants enrolled in the pilot Teamwork, Targets, and Technology for Tight Control (4T) study monitored with the use of Timely Interventions for Diabetes Excellence (TIDE), the postonset declines in glucose management and time in range (TIR) were less severe, and their TIR was 8.8% points higher at 12 months than participants monitored without the use of TIDE. CI = confidence interval. Source: Adapted from Ferstad JO, Vallon JJ, Jun D, et al. Population-level management of type 1 diabetes via continuous glucose monitoring and algorithm-enabled patient prioritization: precision health meets population health. Pediatr Diabetes 2021;22:982–91 with the permission of the authors NEJM Catalyst (catalyst.nejm.org) © Massachusetts Medical Society