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Association of real-time continuous glucose monitoring with glycemic control and acute metabolic events among patients with insulin-treated diabetes

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Karter, Andrew J., Parker, Melissa M., Moffet, Howard H., Gilliam, Lisa K., Dlott, Richard·2021·JAMA
DOI 10.1001/jama.2021.6530PMC PMC8173463
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Abstract

Importance: Continuous glucose monitoring (CGM) is recommended for patients with type 1 diabetes; observational evidence for CGM in patients with insulin-treated type 2 diabetes is lacking. Objective: To estimate clinical outcomes of real-time CGM initiation. Design, Setting, and Participants: Exploratory retrospective cohort study of changes in outcomes associated with real-time CGM initiation, estimated using a difference-in-differences analysis. A total of 41 753 participants with insulin-treated diabetes (5673 type 1; 36 080 type 2) receiving care from a Northern California integrated health care delivery system (2014-2019), being treated with insulin, self-monitoring their blood glucose levels, and having no prior CGM use were included. Exposures: Initiation vs noninitiation of real-time CGM (reference group). Main Outcomes and Measures: Ten end points measured during the 12 months before and 12 months after baseline: hemoglobin A1c (HbA1c); hypoglycemia (emergency department or hospital utilization); hyperglycemia (emergency department or hospital utilization); HbA1c levels lower than 7%, lower than 8%, and higher than 9%; 1 emergency department encounter or more for any reason; 1 hospitalization or more for any reason; and number of outpatient visits and telephone visits. Results: The real-time CGM initiators included 3806 patients (mean age, 42.4 years [SD, 19.9 years]; 51% female; 91% type 1, 9% type 2); the noninitiators included 37 947 patients (mean age, 63.4 years [SD, 13.4 years]; 49% female; 6% type 1, 94% type 2). The prebaseline mean HbA1c was lower among real-time CGM initiators than among noninitiators, but real-time CGM initiators had higher prebaseline rates of hypoglycemia and hyperglycemia. Mean HbA1c declined among real-time CGM initiators from 8.17% to 7.76% and from 8.28% to 8.19% among noninitiators (adjusted difference-in-differences estimate, -0.40%; 95% CI, -0.48% to -0.32%; P < .001). Hypoglycemia rates declined among real-time CGM initiators from 5.1% to 3.0% and increased among noninitiators from 1.9% to 2.3% (difference-in-differences estimate, -2.7%; 95% CI, -4.4% to -1.1%; P = .001). There were also statistically significant differences in the adjusted net changes in the proportion of patients with HbA1c lower than 7% (adjusted difference-in-differences estimate, 9.6%; 95% CI, 7.1% to 12.2%; P < .001), lower than 8% (adjusted difference-in-differences estimate, 13.1%; 95% CI, 10.2% to 16.1%; P < .001), and higher than 9% (adjusted difference-in-differences estimate, -7.1%; 95% CI, -9.5% to -4.6%; P < .001) and in the number of outpatient visits (adjusted difference-in-differences estimate, -0.4; 95% CI, -0.6 to -0.2; P < .001) and telephone visits (adjusted difference-in-differences estimate, 1.1; 95% CI, 0.8 to 1.4; P < .001). Initiation of real-time CGM was not associated with statistically significant changes in rates of hyperglycemia, emergency department visits for any reason, or hospitalizations for any reason. Conclusions and Relevance: In this retrospective cohort study, insulin-treated patients with diabetes selected by physicians for real-time continuous glucose monitoring compared with noninitiators had significant improvements in hemoglobin A1c and reductions in emergency department visits and hospitalizations for hypoglycemia, but no significant change in emergency department visits or hospitalizations for hyperglycemia or for any reason. Because of the observational study design, findings may have been susceptible to selection bias.

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  • Basal insulin analogs reduce hypoglycemia risk compared with NPH insulin.

    “Basal insulin analogs are preferred over NPH insulin because of a reduced risk of hypoglycemia.1066–1071”

    From American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update. (2022) · cites this paper as [1069]

    The Hypoglycemia section compares people who initiated real-time continuous glucose monitoring with those who did not. A baseline table lists long-acting and NPH insulin use, but does not compare their hypoglycemia risks. Searches for basal insulin analogs, NPH, and hypoglycemia found no passage supporting the claimed comparison; page numbers were unavailable. (LLM, conf=0.76)

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  • In adults with type 1 or type 2 diabetes treated with insulin, real-time CGM significantly lowers A1C and reduces emergency department visits or hospitalizations for hypoglycemia, but does not significantly lower overall rates of emergency department visits, hospitalizations, or hyperglycemia.

    “Retrospective data from rtCGM use in adults (87) with type 1 or type 2 diabetes treated with insulin showed that the use of rtCGM significantly lowered A1C levels and reduced rates of emergency department visits or hospitalizations for hypoglycemia but did not significantly lower overall rates of emergency department visits, hospitalizations, or hyperglycemia.”

    From 7. Diabetes Technology: Standards of Care in Diabetes—2025 (2025) · cites this paper as [87]

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Authors
Karter, A. J., Parker, M. M., Moffet, H. H., Gilliam, L. K., & Dlott, R.
Affiliations
  • Kaiser Permanente (US)
  • Kaiser Permanente South San Francisco Medical Center (US)
  • Population Care, Regional PROMPT, Regional Clinical, Thyroid Subgroup, TPMG Regional Laboratory Services, Division of Endocrinology - Diablo Service Area, Martinez, California
Corresponding author
Karter, Andrew J.
ORCID
Venue
JAMA
Publisher
American Medical Association (AMA)
Published
2021-06-08
Volume
325
Issue
22
Pages
2273
ISSN
  • 0002-9955 (ISSN-L)
  • 0098-7484
DOI
10.1001/jama.2021.6530
PMC
PMC8173463
OpenAlex
W3164469103
Cited by
191
References
46
Citations by year
2026: 25 · 2025: 49 · 2024: 42 · 2023: 32 · 2022: 28 · 2021: 15
FWCI
21.80
Type
journal article
Language
en
Open access
Locations
  • JAMA (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
Funders
  • Dexcom
  • National Institute of Diabetes and Digestive and Kidney Diseases (R01DK103721, P30DK092924)
Topics
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Treatment and Management
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Education
Keywords
continuous glucose monitoring, insulin-treated diabetes, type 1 diabetes, type 2 diabetes, glycemic control, HbA1c, hypoglycemia, hyperglycemia, emergency department utilization, hospitalization, outpatient visits, telephone visits, integrated health system, diabetes technology, self-monitoring of blood glucose
MeSH terms
Adult, Diabetes Mellitus, Type 1, Diabetes Mellitus, Type 2, Female, Health Services Needs and Demand, Glycated Hemoglobin, Hospitalization, Humans, Hyperglycemia, Hypoglycemia, Hypoglycemic Agents, Insulin, Male, Middle Aged, Retrospective Studies, Time Factors, Blood Glucose Self-Monitoring, Biosensing Techniques, Selection Bias, Confidence Intervals, Treatment Outcome, Propensity Score, Numbers Needed To Treat

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