The Science of Diabetes Self-Management and Care2024, Vol. 50(5) 394–405© The Author(s) 2024Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/26350106241268479journals.sagepub.com/home/tde
AbstractPurpose: The purpose of this study was to examine the impact of continuous blood glucose monitoring (CGM) on transitions of care as patients with diabetes are discharged from the hospital on insulin.
Methods: This is a descriptive study with 2 cohorts of patients (transition to home with CGM and transition to home without CGM) who were assessed prior to discharge (baseline) and 30 days post discharge (follow-up). The key outcome measures were satisfaction with diabetes management, diabetes-related quality of life, frequency of blood glucose monitoring, and 30-day readmission rates.
Results: Patients in the CGM group reported significantly higher levels of satisfaction with diabetes self-care management and higher levels of diabetes-related quality of life compared to those patients discharged without CGM.
Conclusion: The results of this study suggest that CGM enables a smoother transition from hospital to home for patients with diabetes placed on insulin at discharge. CGM was associated with higher satisfaction and diabetesrelated quality of life, perhaps as a result of timely, ongoing information about glucose levels without the burden and pain of finger sticks. CGM may provide greater confidence in self-care decisions regarding insulin dosing, food intake, and exercise. Further research is needed to confirm our results and explore the additional factors associated with greater quality of life and satisfaction.
Diabetes is a chronic disease that affects approximately 37.3 million (11.3%) persons in the United States,1 with 6% of diagnosed cases being type 1 (T1) and 91% of cases being type 2 (T2).2,3 The diabetes self-care regimen can be challenging with the need to balance diet, exercise, and medications in ways that maintain near-normal blood glucose levels. To do this successfully, individuals must regularly monitor blood sugar levels through self-testing with test strips or, more recently, use of continuous blood glucose monitoring (CGM).4 Timely information about blood glucose levels enables patients to safely adjust medication dosing, exercise, and diet to optimize glycemic control. Strong glycemic control is a critical factor in preventing or delaying both the short- and long-term complications of diabetes.5,6
Transitioning patients to home following a hospitalization is a particularly vulnerable time for problems with the regimen and glucose control to emerge.7,8 This is especially true for patients on insulin, which places them at higher risk of hypoglycemia and hyperglycemia as well as hospital readmission and quality of life challenges.9,10
Self-monitoring of blood glucose (SMBG) is a key part of diabetes management plans for all patients with diabetes and on insulin. However, it is often inconsistently performed by patients for a number of reasons, including insurance coverage, cost, inconvenience, and pain.11-13 Effective SMBG can involve 1 to 6 finger sticks daily, which amplifies these challenges. Inconsistent SMBG is known to be a significant factor associated with poor glucose control and related health challenges. It is also a strong predictor of rehospitalization and diabetic complications and has been shown to be particularly detrimental for individuals already in poor control.
First released in the United States in 2004, continuous glucose monitoring (CGM) has increased in utilization significantly in the past 5 years. Medicare began covering CGM with restrictions in 2017 and without restrictions in 2021. Most insurance companies now also have expanded coverage. This has made CGM accessible to a much larger proportion of the US population than in the past. The benefits of CGM in terms of self-care behaviors, glucose control, satisfaction, and health consequences have been well established.14-17 To our knowledge, however, no study has examined the impact CGM has on the transition from hospital to home for patients newly placed on insulin.
The purpose of this study is to examine the impact of CGM on transitions of care as patients with diabetes are discharged from the hospital with insulin. This is a particularly vulnerable and anxiety-provoking time for patients. Being placed on insulin requires close monitoring by patients to determine dosing and avoid the frightening and dangerous side effects of hypoglycemia and hyperglycemia. Our hypothesis is that patients discharged home with CGM will have higher diabetes-related quality of life, closer monitoring of glucose levels, and higher satisfaction with their self-care.
Study participants were recruited through convenience sampling based on A1C reports that the inpatient diabetes team reviewed daily in the hospital. To be eligible for participation, patients had to be hospitalized with T1 or T2 diabetes, have commercial insurance coverage, be placed on insulin during the respective hospitalization, and be discharged to home. Individuals were excluded from participation if they were prisoners, pregnant, older than 65, had Medicaid or Medicare coverage, were in end-stage renal disease, were non-English speaking, or were cognitively impaired. Every hospitalized patient meeting the inclusion/exclusion criteria from 2018 to 2020 was invited to participate in the study. Because of logistical issues, the first 50 patients were placed into the CGM group, and an additional goal of 50 patients were to be recruited into the control group. As a result of the significant challenges during COVID with staffing and patient access to the hospital, the study concluded with 50 patients in the CGM group and only 12 patients in the control group. The analysis approach has been adjusted accordingly. Prior to the formal analysis, analysis was conducted to ensure these 2 groups were equivalent with respect to gender, race/ethnicity, diabetes duration, diabetes type, oral drug usage, and insulin usage at baseline. No significant differences between groups at baseline were observed. All participants consented, and their admitting physicians were contacted to obtain orders for the diabetes coordinators and CGM.
Participants in both groups received diabetes standard of care and education about critical self-care behaviors (diet, exercise, foot care, medications, and blood glucose monitoring), survival skills for navigating life with diabetes (self-care, hypoglycemia, hypoglycemia, sick care), and information about when to call the primary care provider.
Participants in the control group were instructed to check their blood sugars as ordered by the discharging MD, and a prescription for a glucose meter was given if they did not already have one at home.
Participants in the CGM group were given a FreeStyle Libre CGM by the diabetes coordinator and were educated on the appropriate application and use of the sensor. The first sensor was applied prior to discharge. Participants were also provided with instructional materials and had ready access to diabetes coordinators whenever they had questions or problems (a call-line number was provided). Patient questions regarding management/treatment related to diabetes were addressed, and patients were told to call the primary care provider for detailed diabetes management questions. Participants were instructed to apply a new sensor on day 14 after discharge. They were encouraged to call if assistance was needed.
Participants in both groups completed the Diabetes Quality of Life Brief Clinical Inventory (DQOL-BCI), diabetes management satisfaction questionnaire, and questions about the blood glucose monitoring behaviors. These assessments were completed at baseline and again at follow-up. All patients were called 1 week after discharge to answer questions and, for the CGM group, to ensure they were actively using the CGM. In the CGM group, participants who failed to continue using the sensors were removed from the study and are not included in the analyses.
The outcomes measures were DQOL-BCI scores (individual item and total), satisfaction with diabetes management, and 30-day readmissions.
The DQOL-BCI 15 items was used to assess individual components and overall quality of life. The instrument has been widely used in research and clinical practice and translated into more than 15 languages. The instrument was first developed in 2004 through a multistage developmental and testing process. Psychometric testing has demonstrated strong reliability and validity in English and other languages.18 Items were rated on a 5-point Likert scale for the satisfaction questions (5 = very satisfied, 4 = moderately satisfied, 3 = neither, 2 = moderately dissatisfied, 1 = very dissatisfied) and for the frequency of concerns/behaviors questions (5 = never, 4 = very seldom, 3 = sometimes, 2 = often, 1 = all the time). The DQOL-BCI total score was calculated as the average of the 15 individual items, with higher scores indicating stronger quality of life. We analyzed the DQOL-BCI total score and the 15 individual-item scores to better understand how continuous glucose monitoring was related to specific aspects of quality of life (see Table 1).
Diabetes satisfaction was assessed by 2 questions utilizing a 10-point Likert scale (1 = not satisfied, 10 = most satisfied). These were analyzed separately. The items were: (1) How satisfied are you with your overall diabetes control? and (2) How satisfied are you with your diabetes self-care regimen?
The 30-day readmission rates were assessed using hospital admissions data and patient interviews. No study participants in either group were readmitted to the hospital, so this variable was not included in any analysis.
Descriptive statistical methods and Chi-square testing were used to examine the demographic, diabetes care, and medication regimen (oral vs insulin). A 3-step process was used to examine the effect of continuous glucose monitoring compared to the control group: (1) test for baseline differences between each group for each outcomes variable, (2) test for changes between baseline and follow-up for each group (dependent means t-tests with change scores), and (3) test for differences between the groups in their change scores from baseline to follow-up (independent means t-tests). Outcome variables included the two satisfaction items, the DQOL-BCI individual items/components and the DQOL-BCI total score.
This is a longitudinal cohort study of 2 groups: the CGM group, standard of care with CGM, and the control group, standard of care without CGM, where all participants were assessed prior to discharge (baseline) and at 30 to 60 days postdischarge (follow-up). The longitudinal cohort design provided valuable information about both the short-term and long-term impacts of CGM use on patient outcomes. It also tested for preexisting differences between the 2 groups and assessed how well CGM use was sustained following discharge. A disadvantage to any longitudinal design is the potential for participant attrition. In this study, however, participants remained engaged and provided data throughout the duration of the study.
A total of 50 participants were in the CGM group. Of these, there were 30 (60%) male, 18 (36%) female, and 2 (4%) unknown gender. The type of diabetes in participants was split (T1: n = 11, 22%; T2: n = 39, 78%), with most not taking an oral drug (n = 36, 72%), the majority on insulin (n = 49, 98%), and most on other injectables (n = 44, 88%). All 50 participants responded to the first call, and 34 (68%) responded to the second call.
A total of 12 participants were in the control group. There were 3 (25%) male, 4 (33%) female, and 5 (41%) with unspecified gender. The type of diabetes in participants was split (T1: n = 3, 25%; T2: n = 9, 75%), with most not taking an oral drug (n = 11, 92%), the majority on insulin (n = 11, 92%), and most on other injectables (n = 9, 75%). All 12 participants responded to the first call, and 7 (58%) responded to the second call. The small sample size in the control group prevented us from conducting further multivariate analyses (eg, analysis of variance) to examine the role of sample characteristics when examining differences in change scores between the CGM and control groups.
Sample characteristics at baseline. To determine if there were any significant differences in demographic and background variables between the control and CGM groups at baseline, a Chi-square test of independence was utilized to formally evaluate each variable and cross-tables as references. The variables to be evaluated are gender, race/ethnicity, diabetes duration, diabetes type, oral drug usage, and insulin usage. Diabetes duration refers to how long a participant has been diagnosed with diabetes. Table 2 shows that there were no differences between groups for gender, race/ethnicity, diabetes duration, diabetes type, oral drug usage, and insulin usage.
Diabetes quality of life at baseline. Independent means t-tests (2-sided) were used to determine whether each outcome variable differed between the 2 groups at baseline. Table 3 shows that DQOL-BCI questions 1, 4, 5, 9, and 14 were significantly different such that the control group had higher levels of satisfaction and behaviors than did the CGM group. These items reflect overall satisfaction with diabetes treatment, time required to determine sugar levels, time spent getting checkups, often worrying about missing work, and concerns about diabetes limiting career.
Diabetes satisfaction questions at baseline. As shown in Table 4, independent means t-tests (2-sided) found no difference between groups at baseline for the question, “How satisfied are you with your overall diabetes management? ‘1’ not satisfied and ‘10’ most satisfied?” The analysis did, however, find a significant difference between the groups for the item, “How satisfied are you with your current diabetes treatment?”
Following testing for baseline differences between groups, testing was then done related to significant changes in quality of life and satisfaction between baseline and follow-up for both groups.
Paired t-tests (2-sided) tested whether each group achieved significant changes in DQOL-BCI between baseline and follow-up. As shown in Table 5, the results indicate that the CGM group had significant increases in all DQOL-BCI items except for questions 8, 9, and 13. The control group, in contrast, had no significant changes. These results suggest that the CGM device was associated with significant improvement on all aspects of quality of life except for their satisfaction in their sex life, career limitations, and concern about passing out. Although not reaching statistical significance, these 3 items all trended in a positive direction.
The same pattern of results was seen when examining the DQOL-BCI total score such that the CGM group had a 28.6% increase in total diabetes-related quality of life, but the control group saw only a 3.07% increase. The increases in individual DQOL-BCI items are displayed in Figure 1. Similar graphs for the total DQOL-BCI score are provided in Figures 2 through 4.
Paired t-tests (1-sided) examined whether each group achieved significant changes on the 2 diabetes satisfaction items between baseline and time. As shown in Table 6, for satisfaction with overall diabetes management, the CGM group saw a statistically significant increase in scores (41% improvement, P = 0.0001), whereas the control group saw no statistically significant change in satisfaction levels (7.25% decrease, P = 0.191). This is even more notable because satisfaction at baseline was significantly higher than the CGM group. Similarly, “satisfaction with diabetes treatment” increased by 71% (P = 0.0001) for the CGM group and 22% for the control group (P = 0.356). These changes are displayed in Figures 5 through 8.
Continuous glucose monitoring has become the standard of care for most cases of diabetes. With the expanded eligibility criteria announced by CMS in March 2023 and the increasing coverage by commercial insurance, this technology is now available to a larger proportion of individuals with diabetes. CGM provides physical, psychological, safety, and quality-of-life benefits that are well-established. These benefits will likely increase with the rapid advancements in technology, including integration with insulin pumps, automated insulin delivery, algorithmic alerts for high and low blood glucose levels, and the ability to view results on a smart device and share them real time with family caregivers.
For patients transitioning from hospital to home on insulin, CGM can provide an increased sense of security and confidence in managing diabetes. It can provide valuable real-time information to help guide insulin adjustments, diet, and exercise. It also eliminates the hassle of finger sticks, which can be particularly challenging in work and social settings. Prior research has shown significant clinical benefits of CGM in terms of improved glycemic control as well as patient satisfaction with using CGM, increased confidence in diabetes self-care, and a reduction in diabetes distress.14,15,19-21
Although considerable prior research has examined the accuracy, clinical benefits, and patient satisfaction with continuous glucose monitoring, there is no published research examining the benefits of CGM use during the transition from hospital to home. Our research found significant improvements in quality of life and satisfaction with diabetes control and treatment for those patients on CGM. The magnitude of these improvements is worth noting. The total DQOL-BCI score increased by nearly 30% for the CGM group, yet saw no improvement for the control group. Similarly, in the CGM group, satisfaction with overall diabetes management increased 41%, and satisfaction with diabetes treatment increased 71%. No significant increases were observed for the control group. These results are consistent with earlier research that found similar benefits in the context of everyday life for patients. It is not surprising that results would be particularly pronounced at the point of being discharged to home, where clinical staff are not present as support.
These results suggest that providers place inpatients with diabetes, particularly those with newly initiated insulin, on continuous glucose monitoring prior to discharge. The data shows that continuous glucose monitoring will provide greater satisfaction with treatment, overall diabetes management, and quality of life during this transition. Although this study did not examine the outpatient setting, it is reasonable that similar benefits might occur for patients initiated on insulin in an outpatient setting and those initiated on combinations of oral agents.
For inpatients being placed on a CGM at the point of discharge, there may also be benefit to initiating CGM earlier in the hospitalization. This would provide time for patients to learn to use the device for real-time adjustments in medications, diet, and exercise while still being under the care of providers. The COVID-19 pandemic expedited temporary approval of CGM in hospitals (which was accompanied by finger sticks to validate results) to save personal protective equipment, provide continuous monitoring of patients in isolation, and help reduce the workload of healthcare personnel. Because inpatient use of CGM still awaits FDA approval, the temporary allowances made for hospital use during the COVID-19 pandemic required some workarounds that would not be required once patients were at home, for instance, individual patient monitors that were kept in the patient’s rooms and readings needed to be manually documented. Once regulatory approval is in place, consideration should be given to initiating CGM use early in the hospital stay.
A cursory data review shows that this decision improved patient care and satisfaction and saved nurses’ time. Patients received more timely insulin administration and expressed increased overall satisfaction. Meanwhile, nursing staff reduced the need to frequently locate and clean glucose meters and, subsequently, the need for personal protective equipment. Continuous glucose monitoring is not the standard of care in hospital settings, and additional research is needed to substantiate its ongoing benefits for hospital use.
Emergency inpatient use of CGM suggests significant benefits of integrating this technology into computerized medical records and even of displaying CGM data on the monitors beside O2 saturation, pulse, and blood pressure. Patients have already shown how this technology is revolutionizing an ever-changing health care environment where time, efficiency, and safety are of the utmost importance.
There are several limitations to this research that should be noted. The largest is the relatively small sample size in the control group, where enrollment had to be stopped prematurely due to COVID-19. This sample size limited the specific analyses that could be conducted and may have influenced some findings. It should be noted, however, that this would not have impacted the magnitude of improvements that were observed in the CGM group. A second limitation was the operational issues that emerged working with pharmacies and physicians. Although the patients did not deal with these firsthand, they were aware that they were happening. This may have contributed to the diverging responses to outpatient diabetes management satisfaction.
Providers should consider CGM for inpatients being discharged to home after initiating insulin therapy. Our results suggest significantly higher satisfaction with diabetes management, diabetes treatment, and overall quality of life for individuals discharged with a CGM compared to those not. There are a number of benefits of CGM that are particularly valuable during this transition. This real-time glucose feedback can be used by the patient to make decisions about upcoming meals, physical activity, and medication adjustments. It can also increase a patient’s comfort and confidence in starting insulin therapy by reducing the risk of undetected hypoglycemia or hyperglycemia. With the recent expansion of insurance coverage, some of the barriers providers faced in the past with continuous glucose monitoring are not as common.
Individuals discharged from hospitals should maintain ongoing SMBG. But the challenges associated with SMBG, which include obtaining blood through 1 to 6 daily finger pricks, can be a painful barrier to successful diabetes management. This remains a serious point of concern because inconsistent or worse, a lack of regular SMBG predicts hospitalization for diabetes-related concerns. However, continuous glucose monitoring virtually eliminates the pain barrier and enables more convenient and easier monitoring of blood glucose levels. The findings from this research accentuate the need for diabetes self-management tools that not only provide accurate and timely results but also offer fewer diabetes management challenges. Quality of life is a predictor of success in diabetes management and thus should not be ignored. Further research is needed to validate this practice. However, this study shows evidence that CGM is a powerful tool for those with diabetes and one that should be utilized more routinely.
Acknowledgment is expressed to the Cone Health Inpatient DM program for supporting and helping with the completion of this important research project. Special thanks to Marie Byrd, RN, MSN, CDCES, Shannon Willis, RN, MSN, BC-ADM, and Clanford Johnson, MD.
The authors declare that there is no conflict of interest.
Institutional Support.
Cone Health Institutional Review Board, approval No. 1192583-2.
Marjorie Jenkins https://orcid.org/0000-0001-7893-4012
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From Cone Health, Greensboro, North Carolina (Dr Jenkins, Ms Simpson, Mr Ursuy, Ms Hanks); and St. Louis University, St. Louis, Missouri (Dr Burroughs).
Corresponding Author:Marjorie Jenkins, Cone Health, 706 Green Valley Road, Suite 223, Greensboro, NC 27408, USA.Email: Marjorie.Jenkins@conehealth.com