The Diabetes Technology Society Error Grid and Trend Accuracy Matrix for Glucose Monitors

David C Klonoff¹, Guido Freckmann², Stefan Pleus², Boris P Kovatchev^{3

4}, David Kerr⁵, Chui Cindy Tse⁶, Chengdong Li⁷, Michael S D Agus⁸, Kathleen Dungan⁹, Barbora Voglová Hagerf^{10

11}, Jan S Krouwer¹², Wei-An Andy Lee¹³, Shivani Misra¹⁴, Sang Youl Rhee¹⁵, Ashutosh Sabharwal¹⁶, Jane Jeffrie Seley¹⁷, Viral N Shah¹⁸, Nam K Tran¹⁹, Kayo Waki²⁰, Chris Worth²¹, Tiffany Tian²², Rachel E Aaron²², Keetan Rutledge²³, Cindy N Ho²², Alessandra T Ayers²², Amanda Adler²⁴, David T Ahn²⁵, Halis Kaan Aktürk²⁶, Mohammed E Al-Sofiani^{27

28}, Timothy S Bailey²⁹, Matt Baker³⁰, Lia Bally³¹, Raveendhara R Bannuru³², Elizabeth M Bauer³³, Yong Mong Bee³⁴, Julia E Blanchette^{35

36}, Eda Cengiz³⁷, James Geoffrey Chase³⁸, Kong Y Chen³⁹, Daniel Cherñavvsky⁴⁰, Mark Clements⁴¹, Gerard L Cote⁴², Ketan K Dhatariya^{43

44}, Andjela Drincic⁴⁵, Niels Ejskjaer^{46

47}, Juan Espinoza⁴⁸, Chiara Fabris⁴, G Alexander Fleming⁴⁹, Monica A L Gabbay⁵⁰, Rodolfo J Galindo⁵¹, Ana María Gómez-Medina⁵², Lutz Heinemann⁵³, Norbert Hermanns⁵⁴, Thanh Hoang⁵⁵, Sufyan Hussain^{56

57}, Peter G Jacobs⁵⁸, Johan Jendle⁵⁹, Shashank R Joshi⁶⁰, Suneil K Koliwad⁶¹, Rayhan A Lal⁶², Lawrence A Leiter⁶³, Marcus Lind⁶⁴, Julia K Mader⁶⁵, Alberto Maran⁶⁶, Umesh Masharani⁶¹, Nestoras Mathioudakis⁶⁷, Michael McShane⁶⁸, Chhavi Mehta⁶⁹, Sun-Joon Moon⁷⁰, James H Nichols⁷¹, David N O'Neal⁷², Francisco J Pasquel⁷³, Anne L Peters⁷⁴, Andreas Pfützner^{75

76}, Rodica Pop-Busui⁷⁷, Pratistha Ranjitkar⁷⁸, Connie M Rhee^{79

80}, David B Sacks⁸¹, Signe Schmidt⁸², Simon M Schwaighofer⁸³, Bin Sheng⁸⁴, Gregg D Simonson⁸⁵, Koji Sode^{86

87}, Elias K Spanakis⁸⁸, Nicole L Spartano⁸⁹, Guillermo E Umpierrez⁷³, Maryam Vareth^{90

91

92}, Hubert W Vesper⁶, Jing Wang⁷, Eugene Wright⁹³, Alan H B Wu⁹⁴, Sewagegn Yeshiwas⁹⁵, Mihail Zilbermint^{96

97

98}, Michael A Kohn³⁷

Affiliations

¹ Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, CA, USA.
² Institut für Diabetes-Technologie, Forschungs- und Entwicklungsgesellschaft mbH an der Universität Ulm, Ulm, Germany.
³ School of Medicine, University of Virginia, Charlottesville, VA, USA.
⁴ Center for Diabetes Technology, University of Virginia, Charlottesville, VA, USA.
⁵ Sutter Health Center for Health Systems Research, Santa Barbara, CA, USA.
⁶ Centers for Disease Control and Prevention, Atlanta, GA, USA.
⁷ College of Nursing, Florida State University, Tallahassee, FL, USA.
⁸ Divisions of Endocrinology and Medical Critical Care, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
⁹ Division of Endocrinology, Diabetes and Metabolism, Ohio State University, Columbus, OH, USA.
¹⁰ Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic.
¹¹ First Medical Faculty, Charles University, Prague, Czech Republic.
¹² Krouwer Consulting, Sherborn, MA, USA.
¹³ Division of Endocrinology, Los Angeles General Medical Center, Los Angeles, CA, USA.
¹⁴ Division of Metabolism, Digestion and Reproduction, Imperial College London, London, UK.
¹⁵ Center for Digital Health and Department of Endocrinology and Metabolism, College of Medicine, Kyung Hee University, Seoul, Republic of Korea.
¹⁶ Electrical and Computer Engineering, Rice University, Houston, TX, USA.
¹⁷ Division of Endocrinology, Diabetes & Metabolism, Weill Cornell Medicine, New York, NY, USA.
¹⁸ Division of Endocrinology and Metabolism, School of Medicine, Indiana University, Indianapolis, IN, USA.
¹⁹ University of California Davis Health, Sacramento, CA, USA.
²⁰ Department of Biomedical Informatics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
²¹ Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK.
²² Diabetes Technology Society, Burlingame, CA, USA.
²³ QuesGen, Burlingame, CA, USA.
²⁴ Diabetes Trials Unit, University of Oxford, Oxford, UK.
²⁵ Mary & Dick Allen Diabetes Center, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA.
²⁶ Barbara Davis Center for Diabetes, University of Colorado, Aurora, CO, USA.
²⁷ Division of Endocrinology, Department of Internal Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia.
²⁸ Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins University, Baltimore, MD, USA.
²⁹ Headlands AMCR Institute, Escondido, CA, USA.
³⁰ North Kansas City Hospital, North Kansas City, MO, USA.
³¹ Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland.
³² American Diabetes Association, Arlington, VA, USA.
³³ Naval Medical Center San Diego, San Diego, CA, USA.
³⁴ Singapore General Hospital, Singapore.
³⁵ University Hospitals Cleveland Medical Center, UH Diabetes and Metabolic Care Center, Cleveland, OH, USA.
³⁶ School of Medicine, Case Western Reserve University, Cleveland, OH, USA.
³⁷ University of California San Francisco, San Francisco, CA, USA.
³⁸ Centre for Bioengineering, Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand.
³⁹ National Institute of Diabetes and Digestive and Kidney Diseases Intramural Research Program, National Institutes of Health, Bethesda, MD, USA.
⁴⁰ University of Virginia, Charlottesville, VA, USA.
⁴¹ Children's Mercy Kansas City, Kansas City, MO, USA.
⁴² Center for Remote Health Technologies and Systems, Department of Biomedical Engineering and Department of Electrical and Computer Engineering, Texas A&M University, College Station, TX, USA.
⁴³ Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK.
⁴⁴ Norwich Medical School, University of East Anglia, Norwich, UK.
⁴⁵ Devision of Diabetes, Endocrinology, and Metabolism, University of Nebraska Medical Center, Omaha, NE, USA.
⁴⁶ Steno Diabetes Center North Denmark and Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark.
⁴⁷ Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark.
⁴⁸ Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
⁴⁹ Kinexum, Harpers Ferry, WV, USA.
⁵⁰ Diabetes Center, São Paulo Federal University, São Paulo, Brazil.
⁵¹ Division of Endocrinology, Miller School of Medicine, University of Miami, Miami, FL, USA.
⁵² Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogotá, Colombia.
⁵³ Science Consulting in Diabetes GmbH, Düsseldorf, Germany.
⁵⁴ Research Institute Diabetes Academy Mergentheim, Bad Mergentheim, Germany & University of Bamberg, Bamberg, Germany.
⁵⁵ Division of Endocrinology, Walter Reed National Military Medical Center, Bethesda, MD, USA.
⁵⁶ Department of Diabetes, King's College London, London, UK.
⁵⁷ Department of Diabetes and Endocrinology, Guy's and St Thomas' NHS Foundation Trust, London, UK.
⁵⁸ Department of Biomedical Engineering, Oregon Health and Science University, Portland, OR, USA.
⁵⁹ Department of Medical Sciences, School of Medicine, Örebro University, Örebro, Sweden.
⁶⁰ Joshi Clinic, Mumbai, India.
⁶¹ Division of Endocrinology and Metabolism, University of California-San Francisco, San Francisco, CA, USA.
⁶² Stanford Diabetes Research Center, Stanford University, Stanford, CA, USA.
⁶³ Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.
⁶⁴ Institute of Medicine, University of Gothenburg, Gothenburg, Sweden.
⁶⁵ Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria.
⁶⁶ Department of Medicine, University of Padua, Padua, Italy.
⁶⁷ Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA.
⁶⁸ Department of Biomedical Engineering, Department of Materials Science & Engineering, Center for Remote Health Technologies and Systems, Texas A&M University, College Station, TX, USA.
⁶⁹ Mills-Peninsula Medical Center, San Mateo, CA, USA.
⁷⁰ Division of Endocrinology and Metabolism, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
⁷¹ Vanderbilt University Medical Center, Nashville, TN, USA.
⁷² Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia.
⁷³ School of Medicine, Emory University, Atlanta, GA, USA.
⁷⁴ Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
⁷⁵ Pfützner Science & Health Institute, Mainz, Germany.
⁷⁶ University for Digital Technologies in Medicine and Dentistry, Wiltz, Luxembourg.
⁷⁷ Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI, USA.
⁷⁸ ADLM DEI Steering Committee, ADLM-Association for Diagnostics & Laboratory Medicine (formerly AACC), Washington, D.C., USA.
⁷⁹ VA Greater Los Angeles Healthcare System and David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, CA, USA.
⁸⁰ Cedars-Sinai Health Systems, Los Angeles, CA, USA.
⁸¹ National Institutes of Health, Bethesda, MD, USA.
⁸² Steno Diabetes Center Copenhagen, Herlev, Denmark.
⁸³ Diabetes Center Berne, Berne, Switzerland.
⁸⁴ Department of Computer Science and Engineering, Shanghai Jiao Tong University, Shanghai, China.
⁸⁵ International Diabetes Center, HealthPartners Institute, Minneapolis, MN, USA.
⁸⁶ Joint Department of Biomedical Engineering, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
⁸⁷ Joint Department of Biomedical Engineering, North Carolina State University, Chapel Hill, NC, USA.
⁸⁸ VA Maryland Health Care System, School of Medicine, University of Maryland, Baltimore, MD, USA.
⁸⁹ Section of Endocrinology, Diabetes, Nutrition, and Weight Management, Chobanian & Avedisian School of Medicine, Boston University, Boston, MA, USA.
⁹⁰ Berkeley Institute for Data Science, College of Computing, Data Science, and Society, UC Berkeley, Berkeley, CA, USA.
⁹¹ The Center of Intelligent Imaging (Ci2), UCSF Department of Radiology and Biomedical Imaging, San Francisco, CA, USA.
⁹² UC Berkeley/UCSF Computational Precision Health (CPH) Program, Berkeley, CA, USA.
⁹³ Department of Medicine, Duke University Medical Center, Durham, NC, USA.
⁹⁴ Department of Lab Medicine, University of California-San Francisco, San Francisco, CA, USA.
⁹⁵ Department of Pediatric Endocrinology and Child Health, College of Health Science, Addis Abeba University, Addis Ababa, Ethiopia.
⁹⁶ Division of Hospital Medicine, Johns Hopkins Community Physicians, Johns Hopkins Medicine, Baltimore, MD, USA.
⁹⁷ Suburban Hospital, Johns Hopkins Medicine, Bethesda, MD, USA.
⁹⁸ Division of Endocrinology, Diabetes, and Metabolism, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.

PMID: 39369312
PMCID: PMC11531029
DOI: 10.1177/19322968241275701

The Diabetes Technology Society Error Grid and Trend Accuracy Matrix for Glucose Monitors

David C Klonoff et al. J Diabetes Sci Technol. 2024 Nov.

. 2024 Nov;18(6):1346-1361.

doi: 10.1177/19322968241275701. Epub 2024 Oct 6.

Authors

Affiliations

¹ Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, CA, USA.
² Institut für Diabetes-Technologie, Forschungs- und Entwicklungsgesellschaft mbH an der Universität Ulm, Ulm, Germany.
³ School of Medicine, University of Virginia, Charlottesville, VA, USA.
⁴ Center for Diabetes Technology, University of Virginia, Charlottesville, VA, USA.
⁵ Sutter Health Center for Health Systems Research, Santa Barbara, CA, USA.
⁶ Centers for Disease Control and Prevention, Atlanta, GA, USA.
⁷ College of Nursing, Florida State University, Tallahassee, FL, USA.
⁸ Divisions of Endocrinology and Medical Critical Care, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
⁹ Division of Endocrinology, Diabetes and Metabolism, Ohio State University, Columbus, OH, USA.
¹⁰ Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic.
¹¹ First Medical Faculty, Charles University, Prague, Czech Republic.
¹² Krouwer Consulting, Sherborn, MA, USA.
¹³ Division of Endocrinology, Los Angeles General Medical Center, Los Angeles, CA, USA.
¹⁴ Division of Metabolism, Digestion and Reproduction, Imperial College London, London, UK.
¹⁵ Center for Digital Health and Department of Endocrinology and Metabolism, College of Medicine, Kyung Hee University, Seoul, Republic of Korea.
¹⁶ Electrical and Computer Engineering, Rice University, Houston, TX, USA.
¹⁷ Division of Endocrinology, Diabetes & Metabolism, Weill Cornell Medicine, New York, NY, USA.
¹⁸ Division of Endocrinology and Metabolism, School of Medicine, Indiana University, Indianapolis, IN, USA.
¹⁹ University of California Davis Health, Sacramento, CA, USA.
²⁰ Department of Biomedical Informatics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
²¹ Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK.
²² Diabetes Technology Society, Burlingame, CA, USA.
²³ QuesGen, Burlingame, CA, USA.
²⁴ Diabetes Trials Unit, University of Oxford, Oxford, UK.
²⁵ Mary & Dick Allen Diabetes Center, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA.
²⁶ Barbara Davis Center for Diabetes, University of Colorado, Aurora, CO, USA.
²⁷ Division of Endocrinology, Department of Internal Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia.
²⁸ Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins University, Baltimore, MD, USA.
²⁹ Headlands AMCR Institute, Escondido, CA, USA.
³⁰ North Kansas City Hospital, North Kansas City, MO, USA.
³¹ Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland.
³² American Diabetes Association, Arlington, VA, USA.
³³ Naval Medical Center San Diego, San Diego, CA, USA.
³⁴ Singapore General Hospital, Singapore.
³⁵ University Hospitals Cleveland Medical Center, UH Diabetes and Metabolic Care Center, Cleveland, OH, USA.
³⁶ School of Medicine, Case Western Reserve University, Cleveland, OH, USA.
³⁷ University of California San Francisco, San Francisco, CA, USA.
³⁸ Centre for Bioengineering, Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand.
³⁹ National Institute of Diabetes and Digestive and Kidney Diseases Intramural Research Program, National Institutes of Health, Bethesda, MD, USA.
⁴⁰ University of Virginia, Charlottesville, VA, USA.
⁴¹ Children's Mercy Kansas City, Kansas City, MO, USA.
⁴² Center for Remote Health Technologies and Systems, Department of Biomedical Engineering and Department of Electrical and Computer Engineering, Texas A&M University, College Station, TX, USA.
⁴³ Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK.
⁴⁴ Norwich Medical School, University of East Anglia, Norwich, UK.
⁴⁵ Devision of Diabetes, Endocrinology, and Metabolism, University of Nebraska Medical Center, Omaha, NE, USA.
⁴⁶ Steno Diabetes Center North Denmark and Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark.
⁴⁷ Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark.
⁴⁸ Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
⁴⁹ Kinexum, Harpers Ferry, WV, USA.
⁵⁰ Diabetes Center, São Paulo Federal University, São Paulo, Brazil.
⁵¹ Division of Endocrinology, Miller School of Medicine, University of Miami, Miami, FL, USA.
⁵² Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogotá, Colombia.
⁵³ Science Consulting in Diabetes GmbH, Düsseldorf, Germany.
⁵⁴ Research Institute Diabetes Academy Mergentheim, Bad Mergentheim, Germany & University of Bamberg, Bamberg, Germany.
⁵⁵ Division of Endocrinology, Walter Reed National Military Medical Center, Bethesda, MD, USA.
⁵⁶ Department of Diabetes, King's College London, London, UK.
⁵⁷ Department of Diabetes and Endocrinology, Guy's and St Thomas' NHS Foundation Trust, London, UK.
⁵⁸ Department of Biomedical Engineering, Oregon Health and Science University, Portland, OR, USA.
⁵⁹ Department of Medical Sciences, School of Medicine, Örebro University, Örebro, Sweden.
⁶⁰ Joshi Clinic, Mumbai, India.
⁶¹ Division of Endocrinology and Metabolism, University of California-San Francisco, San Francisco, CA, USA.
⁶² Stanford Diabetes Research Center, Stanford University, Stanford, CA, USA.
⁶³ Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.
⁶⁴ Institute of Medicine, University of Gothenburg, Gothenburg, Sweden.
⁶⁵ Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria.
⁶⁶ Department of Medicine, University of Padua, Padua, Italy.
⁶⁷ Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA.
⁶⁸ Department of Biomedical Engineering, Department of Materials Science & Engineering, Center for Remote Health Technologies and Systems, Texas A&M University, College Station, TX, USA.
⁶⁹ Mills-Peninsula Medical Center, San Mateo, CA, USA.
⁷⁰ Division of Endocrinology and Metabolism, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
⁷¹ Vanderbilt University Medical Center, Nashville, TN, USA.
⁷² Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia.
⁷³ School of Medicine, Emory University, Atlanta, GA, USA.
⁷⁴ Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
⁷⁵ Pfützner Science & Health Institute, Mainz, Germany.
⁷⁶ University for Digital Technologies in Medicine and Dentistry, Wiltz, Luxembourg.
⁷⁷ Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI, USA.
⁷⁸ ADLM DEI Steering Committee, ADLM-Association for Diagnostics & Laboratory Medicine (formerly AACC), Washington, D.C., USA.
⁷⁹ VA Greater Los Angeles Healthcare System and David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, CA, USA.
⁸⁰ Cedars-Sinai Health Systems, Los Angeles, CA, USA.
⁸¹ National Institutes of Health, Bethesda, MD, USA.
⁸² Steno Diabetes Center Copenhagen, Herlev, Denmark.
⁸³ Diabetes Center Berne, Berne, Switzerland.
⁸⁴ Department of Computer Science and Engineering, Shanghai Jiao Tong University, Shanghai, China.
⁸⁵ International Diabetes Center, HealthPartners Institute, Minneapolis, MN, USA.
⁸⁶ Joint Department of Biomedical Engineering, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
⁸⁷ Joint Department of Biomedical Engineering, North Carolina State University, Chapel Hill, NC, USA.
⁸⁸ VA Maryland Health Care System, School of Medicine, University of Maryland, Baltimore, MD, USA.
⁸⁹ Section of Endocrinology, Diabetes, Nutrition, and Weight Management, Chobanian & Avedisian School of Medicine, Boston University, Boston, MA, USA.
⁹⁰ Berkeley Institute for Data Science, College of Computing, Data Science, and Society, UC Berkeley, Berkeley, CA, USA.
⁹¹ The Center of Intelligent Imaging (Ci2), UCSF Department of Radiology and Biomedical Imaging, San Francisco, CA, USA.
⁹² UC Berkeley/UCSF Computational Precision Health (CPH) Program, Berkeley, CA, USA.
⁹³ Department of Medicine, Duke University Medical Center, Durham, NC, USA.
⁹⁴ Department of Lab Medicine, University of California-San Francisco, San Francisco, CA, USA.
⁹⁵ Department of Pediatric Endocrinology and Child Health, College of Health Science, Addis Abeba University, Addis Ababa, Ethiopia.
⁹⁶ Division of Hospital Medicine, Johns Hopkins Community Physicians, Johns Hopkins Medicine, Baltimore, MD, USA.
⁹⁷ Suburban Hospital, Johns Hopkins Medicine, Bethesda, MD, USA.
⁹⁸ Division of Endocrinology, Diabetes, and Metabolism, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.

PMID: 39369312
PMCID: PMC11531029
DOI: 10.1177/19322968241275701

Abstract

Introduction: An error grid compares measured versus reference glucose concentrations to assign clinical risk values to observed errors. Widely used error grids for blood glucose monitors (BGMs) have limited value because they do not also reflect clinical accuracy of continuous glucose monitors (CGMs).

Methods: Diabetes Technology Society (DTS) convened 89 international experts in glucose monitoring to (1) smooth the borders of the Surveillance Error Grid (SEG) zones and create a user-friendly tool-the DTS Error Grid; (2) define five risk zones of clinical point accuracy (A-E) to be identical for BGMs and CGMs; (3) determine a relationship between DTS Error Grid percent in Zone A and mean absolute relative difference (MARD) from analyzing 22 BGM and nine CGM accuracy studies; and (4) create trend risk categories (1-5) for CGM trend accuracy.

Results: The DTS Error Grid for point accuracy contains five risk zones (A-E) with straight-line borders that can be applied to both BGM and CGM accuracy data. In a data set combining point accuracy data from 18 BGMs, 2.6% of total data pairs equally moved from Zones A to B and vice versa (SEG compared with DTS Error Grid). For every 1% increase in percent data in Zone A, the MARD decreased by approximately 0.33%. We also created a DTS Trend Accuracy Matrix with five trend risk categories (1-5) for CGM-reported trend indicators compared with reference trends calculated from reference glucose.

Conclusion: The DTS Error Grid combines contemporary clinician input regarding clinical point accuracy for BGMs and CGMs. The DTS Trend Accuracy Matrix assesses accuracy of CGM trend indicators.

Keywords: accuracy; blood glucose; continuous glucose monitoring; error grid; glucose trend; surveillance.

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Conflict of interest statement

Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: D.C.K. is a consultant for Afon, Lifecare, Novo, Samsung, embecta, Glucotrack, SynchNeuro, and Thirdwayv. G.F. is CEO of IfDT. G.F./IfDT has/have received research support, speakers’ honoraria or consulting fees in the last three years from Abbott, Ascensia, Berlin Chemie, Boydsense, Dexcom, Glucoset, i-SENS, Lilly, Menarini, Novo Nordisk, Perfood, Pharmasens, Roche, Sinocare, Terumo, Ypsomed. S.P. is an employee of IfDT. B.P.K. declares patent royalties handled by UVA from: DexCom, J&J, Novo Nordisk, and Sanofi; and research support handled by UVA: Dexcom, Novo Nordisk, Tandem Diabetes Care. D.K. has received research support from Abbott Diabetes Care. M.S.D.A. is currently receiving in kind support (CGM devices) from Dexcom Inc for an investigator-initiated clinical study. K.D. receives research funding from Dexcom, Abbott, Sanofi, Viacyte, Insulet, consulting fees from Eli Lilly, Dexcom, Insulet, Oppenheimer, Elsevier, honoraria from Academy for Continued Healthcare Learning, Med Learning Group, Medscape, Impact Education, and royalties from UptoDate. S.M. is in receipt of an investigator-initiated grant from DexCom, has received speaker fees from Sanofi & Lilly, is funded by a Wellcome Trust (223024/Z/21/Z), and is supported by the NIHR Imperial Biomedical Research Centre. A.S. was supported by the NSF Engineering Research Center for Precise Advanced Technologies and Health Systems for Underserved Populations (PATHS-UP) (#1648451). V.N.S. reports receiving personal fees from Sanofi, Embecta, NovoNordisk, Dexcom, Insulet, Tandem Diabetes Care, Ascensia Diabetes Care, Genomelink and LumosFit for consulting, advising or speaking. N.K.T. is a consultant for Roche Diagnostics / Roche Molecular Systems / Radiometer. UC Davis is a Roche Diagnostics Center of Excellence. N.K.T. has received speaking honoraria for Roche Diagnostics, Nova Biomedical, Thermo Fisher, and Radiometer. N.K.T. is also Chair-Elect for the Association for Diagnostic and Laboratory Medicine (ADLM) Critical and Point-of-Care Testing Division, Co-Founder of the Machine Intelligene Learning Optimizer (MILO), Inc, and a member of the International Federation for Clinical Chemistry (IFCC) continuous glucose monitoring workgroup. T.T. is a consultant for Clinical ink. R.E.A. is a consultant for Clinical ink. D.T.A. has received speaker’s honoraria from Abbott, Ascensia Diabetes Care, Insulet, Lilly Diabetes, Mannkind, Novo Nordisk, and Xeris Pharmaceuticals. D.T.A. has received consulting fees from Ascensia Diabetes Care, Lilly Diabetes, and Senseonics. H.K.A. received research grants through University of Colorado from Dexcom, Tandem Diabetes, Medtronic, Mannkind, IM Therapeutics, IAFMS, and received honorarium through University of Colorado for consulting from Dexcom, Tandem Diabetes, and Medtronic. M.E.A.-S. has served on the advisory boards for Abbott, Medtronic, Insulet, VitalAire, Sanofi, Eli Lilly, and Dexcom; has received honoraria for speaking from Abbott, Eli Lilly, Medtronic, Novo Nordisk, Sanofi, VitalAire, and Eli Lilly; and received research support from Medtronic and Sanofi. T.S.B. has received research support from Abbott Rapid Diagnostics, Biolinq, Dexcom, Eli Lilly, Medtronic, Medtrum, Novo Nordisk, Sanofi, Senseonics, and vTv Therapeutics and consulting honoraria from Abbott Diabetes, Abbott Rapid Diagnostics, ACON, CeQur, HagarTech, Intuity Medical, Lifescan, Mannkind, Medtronic, Novo, Perspirion, Sanofi, Sequel Med Tech, and Ypsomed. M.B. currently participates on the Hospital Advisory board with Dexcom and has received research support from Dexcom. L.B. has received research/product support from Dexcom, Ypsomed, and Boehringer Ingelheim; speaker honoraria from Dexcom and Oviva; and participated in advisory boards of Dexcom, Novo Nordisk, Sanofi, Ypsomed, Oviva, and Roche Diabetes Care. Y.M.B. has received honoraria for lectures and scientific advisory from Roche and AstraZeneca in the past 12 months. J.E.B. is on the Speaker’s bureau for Insulet and on the Advisory Board for Cardinal Health and Lifescan. J.E.B. is a consultant for Embecta. J.E.B. receives research support from the Leona M. and Harry B. Helmsley Charitable Trust. E.C. is on the scientific advisory board for Novo Nordisk, Eli-Lilly, Adocia, Arecor, Proventionbio, Portal Insulin, and MannKind. D.C. was a Dexcom employee from August 2018 to May 2024. D.C. is a shareholder of Dexcom, Lilly, Abbott and Tandem. M.C. has received consulting fees from Glooko and research support from Dexcom and Abbott Diabetes Care. G.L.C. is a shareholder of BioTex, Inc., Basepair Biotechnologies Inc., Coordination Centric, Inc., and Shape Memory Medical, Inc. G.L.C. is supported by the NSF Engineering Research Center for Precise Advanced Technologies and Health Systems for Underserved Populations (PATHS-UP) (#1648451). K.K.D. has received honoraria, travel, or fees for advisory boards from AstraZeneca, Novo Nordisk, Boehringer Ingelheim, Eli Lilly, Abbott Diabetes, Menarini, and Sanofi in the last 12 months. J.E. receives federal funding from FDA, NIMHD, and NCATS and is a consultant for Sanofi. C.F. receives royalties from Dexcom and Novo Nordisk managed through her institution. G.A.F. is an advisor for 180 Life Sciences, 89bio, Adocia, Abbott, AdipoPharma, Aerami, Amolyt, Carthera, Catalyst, Cohen Global, CMC Magnetics, Diasome, Eleos, Entera Bio, Enterin, Glyscend, Hagar, Hogan Lovells, IM Therapeutics, Innoneo, Intarcia, Levicure, Lilly Asia Ventures, Lumos, Mars Symbioscience, Melior, metaLead Therapeutics, Microbiotix, MMD, Modular Medical, New Amsterdam, Northwestern, NuSirt, NuVox, Oramed, Pano, Pasithea, PhylloPharma, Pleiogenix, Recordati, Regor, Remodeless, Renaissance, RenovoRx, Rivus, RxMP, Sera Biopharma, Seraxis, Serpin, SFC Fluidics, Skinject, SROne, Stalicla, Surf Bio, TIXiMED, Veroscience, Verthermia, WaveBreak, Zealand Pharma, and Zucara. M.A.L.G. is a consultant for Abbott, Medtronic, Novonordisk, and Roche. R.J.G. received research support from Novo Nordisk, Dexcom and Eli Lilly and consulting fees/advisory fees from Abbott Diabetes Care, Aztra Zeneca, Bayer, Boehringer, Dexcom, Eli Lilly, Novo Nordisk, and Medtronic, outside of this work. R.J.G. is partially supported by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health under Award Numbers P30DK111024, K23DK123384, R03DK138255, and U2CD137135. A.M.G.-M. reports speaker fees from Novo Nordisk, Sanofi, Elli Lilly, Boehringer Ingelheim, Abbott, and Medtronic. L.H. is a consultant for a number of companies that are developing innovative solutions for the treatment of people with diabetes. N.H. reports Advisory Board member fees from Abbott Diabetes Care and Insulet as well as honoraria for lectures from Berlin-Chemie AG, Becton Dickenson, Sanofi Germany, Roche Diabetes Care, and Dexcom Germany. T.H. serves on the advisory board for Acella and Horizons Therapeutics (no financial compensation). S.H. has served on the advisory board for Tandem, Dexcom, and Medtronic, and received honoraria for nonpromotional educational and/or consultancy work from Abbott, Insulet, Dexcom, Roche, and Sanofi. P.G.J. is a shareholder of Pacific Diabetes Technologies Inc. and serves on the advisory board for Eli Lilly. P.G.J. received grant support from SFC Fluidics and research support from Eli Lilly and Dexcom. J.J. has received fees from lectures and or advisory boards from Abbott, Astra Zeneca, Boeringer Ingelheim, Eli Lilly, Medtronic, Nordic Infucare, Novo Nordisk, and Sanofi. S.R.J is a consultant for USV, Marico, Glenmark, Franco Indian, Twin Health, Biocon, and Zydus Lifesciences. S.R.J. received speaking honoraria from Abbott, Novo Nordisk, MSD, Sanofi, Boehringer Ingelheim, AstraZeneca, Lupin, Bayer Zydus, USV, DRL, Meyer Organics, Servier, Natco. R.A.L. is a consultant for Abbott Diabetes Care, Biolinq, Capillary Biomedical, Deep Valley Labs, Gluroo, PhysioLogic Devices, Portal Insulin, Sanofi, and Tidepool. R.A.L. has served on advisory boards for. ProventionBio and Lilly. R.A.L. receives research support through his institution from Insulet, Medtronic, Tandem, and Sinocare. L.A.L. has received research funding from, has provided CME on behalf of, and/or has acted as an advisor to Abbott, AstraZeneca, Boehringer Ingelheim, Eli Lilly, Lexicon, Merck, Novo Nordisk, Pfizer, and Sanofi. M.L. has been a consultant or received honoraria from Astra Zeneca, Boehringer Ingelheim, Eli Lilly, Nordic InfuCare, and Novo Nordisk, and has received research grants from Eli Lilly and Novo Nordisk, all outside of the submitted work. J.K.M. is a member of advisory boards of Abbott Diabetes Care, Becton-Dickinson, Biomea Fusion, Eli Lilly, Embecta, Medtronic, NovoNordisk A/S, Roche Diabetes Care, Sanofi-Aventis, and Viatris and received speaker honoraria from A. Menarini Diagnostics, Abbott Diabetes Care, AstraZeneca, Boehringer Ingelheim, Dexcom, Eli Lilly, Medtrust, MSD, NovoNordisk A/S, Roche Diabetes Care, Sanofi, Viatris, and Ypsomed. J.K.M. is a shareholder of decide Clinical Software GmbH and elyte Diagnostics. A.M. reports speaker fees from Novo Nordisk. M.M. has an existing research & development relationship with Scientific Bioprocessing, Inc and has been a consultant for Abbott. S.-J.M. is a consultant for Abbott, Curestream, Daewoong, EOFlow, G2e, Huons, iSense, Medtronic, Novo Nordisk, and Sanofi. D.N.O. has served on advisory boards for Abbott Laboratories, Medtronic, Merck Sharp & Dohme, Novo Nordisk, Roche, and Sanofi; received research support from Medtronic, Novo Nordisk, Roche, Eli Lilly and Company, and Sanofi; and received travel support from Novo Nordisk and Merck Sharp & Dohme. F.J.P. has received research support (to Emory University) from Dexcom, Insulet, Novo Nordisk, Tandem, and Ideal Medical Technologies, and has received consulting fees from Dexcom. A.L.P. is on the advisory board of Medscape, Vertex, and Lilly; receives research support from Insulin and Abbott; and has stock options in Omada Health. R.P.-B. receives grant support from Novo Nordisk, Lexicon Pharmaceuticals, and Medtronic and received consulting fees from Bayer, Lexicon Pharmaceuticals, Novo Nordisk, and Roche. C.M.R. has received honoraria and/or grant support from AstraZeneca, Dexcom, Fresenius, and Vifor. D.B.S. is supported by the Intramural Research Program of the National Institutes of Health. S.S. was a Novo Nordisk employee from 2022-2023. S.S. has served as advisor for Novo Nordisk and has received speaker fees from Novo Nordisk and Nordic Infucare within the past three years. G.D.S’s employer, nonprofit International Diabetes Center, HealthPartners Institute, has received educational grant funds from Abbott Diabetes Care, Medscape, and Sanofi-Aventis Groupe. G.D.S receives no personal income/honorarium from these activities. K.S. received grant supports from Arkray, Terumo, and Dexcom. E.K.S. is partly supported by the VA Merit Award (1I01CX001825) from the US Department of Veterans Affairs Clinical Sciences Research and has received unrestricted research support from Dexcom and Tandem Diabetes (to Baltimore VA Medical Center and to University of Maryland) for the conduction of clinical trials. N.L.S. received funding from Novo Nordisk for an investigator-initiated research grant unrelated to the current project. G.E.U. is partly supported by research grants from National Institutes of Health (NIH/NATS UL 3UL1TR002378-05S2) from the Clinical and Translational Science Award program, and from National Institutes of Health and National Center for Research Resources (NIH/NIDDK 2P30DK111024-06). G.E.U. has received research support (to Emory University) from Abbott, Bayer, and Dexcom; and has participated in advisory boards for Dexcom and GlyCare. E.W. has received consulting fees from Abbott Diabetes Care, Ascensia, Bayer, Boehringer, Ingelheim, Embecta, GlaxoSmithKline, Lilly, Medtronic, Renalytix, and Sanofi. E.W. has received honoraria from Abbott Diabetes Care, Bayer, Boehringer Ingelheim, GlaxoSmithKline, Lilly, Medtronic, Renalytix, and Sanofi. E.W. is on the Speakers’ Bureau from Abbott Diabetes Care, Bayer, Boehringer, Ingelheim, GlaxoSmithKline, Lilly, Renalytix, and Sanofi. M.Z. is a consultant for DexCom, Inc. M.A.K. is Chief Medical Officer of QuesGen, Inc. C.T., C.L., B.V.H., J.S.K., W.A.L., S.Y.R., J.J.S., K.W., C.W., K.R., C.N.H., A.T.A., A.A., R.R.B., E.M.B., J.G.C., K.Y.C., A.D., N.E., S.K.K., U.M., N.M., C.M., J.H.N., A.P., P.R., S.M.S., B.S., M.V., H.W.V., J.W., A.H.B.W., and S.Y. have nothing to disclose.

Figures

**Figure 1.**
The Diabetes Technology Society Error Grid for (a) BGM A, (b) BGM B, and (c) the CGM combined accuracy data set of 3952 reference/monitor data pairs. The percentage in Zone A was 89.7% for BGM A versus 99.1% for BGM B. The percentage in Zone A was 88.3% for the CGM. Abbreviations: BGM, blood glucose monitor; CGM, continuous glucose monitor.

**Figure 2.**
The mathematical relationship and line of best fit between the percent of data pairs in Zone A of the Diabetes Technology Society Error Grid and the MARD. Abbreviations: BGM, blood glucose monitor; CGM, continuous glucose monitor; MARD, mean absolute relative difference.

**Figure 3.**
The DTS Trend Accuracy Matrix for reference values from 1 to 600 mg/dL (0.0556-33.3 mmol/L) for our combined CGM data set. In 3185 (80.6%) trend accuracy records, the CGM’s trend indicator could be compared with a valid reference trend. This sample data set was based on data from nine CGM accuracy studies. It shows no trend readings in extreme trend risk categories 4 or 5. Abbreviations: CGM, continuous glucose monitor; dL, deciliter; FDA, US Food and Drug Administration; L, liter; mg, milligram; min, minutes; mmol, millimole.

**Figure 4.**
The DTS Trend Accuracy Matrix for reference values 1 to 100 mg/dL (0.0556-5.56 mmol/L) for our combined CGM data set. The Trend Accuracy Matrix has six cells corresponding to “CGM Extreme Overestimate.” Abbreviation: CGM, continuous glucose monitor; dL, deciliter; L, liter; mg, milligram; min, minutes; mmol, millimole.

**Figure 5.**
The DTS Trend Accuracy Matrix for reference values from >180 to 600 mg/dL (10.0-33.3 mmol/L) for our combined CGM data set. No combinations of reference trend and monitor trend were deemed clinically risky enough to be labeled as trend risk category 5 in the Trend Accuracy Matrix. Abbreviation: CGM, continuous glucose monitor; dL, deciliter; L, liter; mg, milligram; min, minutes; mmol, millimole.

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References

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1. Castle JR, Jacobs PG. Nonadjunctive use of continuous glucose monitoring for diabetes treatment decisions. J Diabetes Sci Technol. 2016;10(5):1169-1173. doi: 10.1177/1932296816631569. - DOI - PMC - PubMed

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The Diabetes Technology Society Error Grid and Trend Accuracy Matrix for Glucose Monitors

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The Diabetes Technology Society Error Grid and Trend Accuracy Matrix for Glucose Monitors

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