Methods
The first (A.M.), second (H.H.), and senior (O.E.) authors conducted a scoping review of published literature using terms related to diabetes, population health, and innovation on PubMed Central and Google Scholar for the period March 2020 to June 2022. To complement the review, A.M. and O.E. also reviewed abstracts from presentations at major international diabetes conferences, including the American Diabetes Association (ADA), the International Society for Pediatric and Adolescent Diabetes (ISPAD), the T1DX-QI Learning Session Conference, and the Advanced Technologies & Treatments for Diabetes (ATTD) 2020 to 2022 conferences.9-14 The authors also searched FDA.gov and ClinicalTrials.gov for relevant insights. A.M. and O.E. sorted the reviewed literature into major themes (Figure 3) from the population health improvement perspective of the T1DX-QI.
Population Health Innovations in Diabetes Management
Expansion of Telemedicine Access
Telemedicine is cost-effective for patients with diabetes,15 including those with complex cases.16 Before the COVID-19 pandemic, telemedicine and virtual care were rare in diabetes management. However, the pandemic offered a new opportunity to expand the practice of telemedicine in diabetes management. A study from the T1DX-QI showed that telemedicine visits grew from comprising <1% of visits pre-pandemic (December 2019) to 95.2% during the pandemic (August 2020).17 Additional studies, like those conducted by Phillip et al,18 confirmed the noninferiority of telemedicine practice for patients with diabetes.Telemedicine was also found to be an effective strategy to educate patients on the use of diabetes technologies.19
Real-World Data and Disease Surveillance
As the COVID-19 pandemic exacerbated outcomes for people with type 1 diabetes (T1D), a need arose to understand the immediate effects of the pandemic on people with T1D through real-world data and disease surveillance. In April 2020, the T1DX-QI initiated a multicenter surveillance study to collect data and analyze the impact of COVID-19 on people with T1D. The existing health collaborative served as a springboard for robust surveillance study, documenting numerous works on the effects of COVID-19.3,4,20-28 Other investigators also embraced the power of real-world surveillance and real-world data.29,30
Big Data, Machine Learning, and Artificial Intelligence
The past 2 years have seen a shift toward embracing the incredible opportunity to tap the large volume of data generated from routine care for practical insights.31 In particular, researchers have demonstrated the widespread application of machine learning and artificial intelligence to improve diabetes management.32 The T1DX-QI also harnessed the growing power of big data by expanding the functionality of innovative benchmarking software. The T1DX QI Portal uses electronic medical record data of diabetes patients for clinic-to-clinic benchmarking and data analysis, using business intelligence solutions.33
Health Equity
While inequities across various health outcomes have been well documented for years,34 the COVID-19 pandemic further exaggerated racial/ethnic health inequities in T1D.23,35 In response, several organizations have outlined specific strategies to address these health inequities. Emboldened by the pandemic, the T1DX-QI announced a multipronged approach to address health inequities among patients with T1D through the Health Equity Advancement Lab (HEAL).36 One of HEAL’s main components is using real-world data to champion population-level insights and demonstrate progress in QI efforts.
Multiple innovative studies have been undertaken to explore contributors to health inequities in diabetes, and these studies are expanding our understanding of the chasm.37 There have also been innovative solutions to addressing these inequities, with multiple studies published over the past 2 years.38 A source of inequity among patients with T1D is the lack of representation of racial/ethnic minorities with T1D in clinical trials.39 The T1DX-QI suggests that the equity-adapted framework for QI can be applied by research leaders to support trial diversity and representation, ensuring future device innovations are meaningful for all people with T1D.40
Diabetes Devices
Glucose monitoring and insulin therapy are vital tools to support individuals living with T1D, and devices such as CGM and insulin pumps have become the standard of care for diabetes management (Table).41 Innovations in diabetes technology and device access are imperative for a chronic disease with no cure.
The COVID-19 pandemic created an opportunity to increase access to diabetes devices in inpatient settings. In 2020, the US Food and Drug Administration expanded the use of CGM to support remote monitoring of patients in inpatient hospital settings, simultaneously supporting the glucose monitoring needs of patients with T1D and reducing COVID-19 transmission through reduced patient-clinician contact.42 This effort has been expanded and will continue in 2022 and beyond,43 and aligns with the growing consensus that supports patients wearing both CGMs and insulin pumps in ambulatory settings to improve patient health outcomes.44
Since 2020, innovations in diabetes technology have improved and increased the variety of options available to people with T1D and made them easier to use (Table). New, advanced hybrid closed-loop systems have progressed to offer Bluetooth features, including automatic software upgrades, tubeless systems, and the ability to allow parents to use their smartphones to bolus for children.45-47 The next big step in insulin delivery innovation is the release of functioning, fully closed loop systems, of which several are currently in clinical trials.48 These systems support reduced hypoglycemia and improved time in range.49
Additional innovations in insulin delivery have improved the user experience and expanded therapeutic options, including a variety of smart insulin pens complete with dosing logs50,51 and even a patch to deliver insulin without the burden of injections.52 As barriers to diabetes technology persist,53 innovations in alternate insulin delivery provide people with T1D more options to align with their personal access and technology preferences.
Innovations in CGM address cited barriers to their use, including size or overall wear.53-55 CGMs released in the past few years are smaller in physical size, have longer durations of time between changings, are more accurate, and do not require calibrations for accuracy.
New Diabetes Medications
Many new medications and therapeutic advances have become available in the past 2 years.56 Additionally, more medications are being tested as adjunct therapies to support glycemic management in patients with T1D, including metformin, sodium-glucose cotransporter 1 and 2 inhibitors, pramlintide, glucagon-like polypeptide-1 analogs, and glucagon receptor agonists.57 Other recent advances include stem cell replacement therapy for patients with T1D.58 The ultra-long-acting biosimilar insulins are one medical innovation that has been stalled, rather than propelled, during the COVID-19 pandemic.59
Diabetes Policy Advocacy
People with T1D require insulin to survive. The cost of insulin has increased in recent years, with some studies citing a 64% to 100% increase in the past decade.60,61 In fact, 1 in 4 insulin users report that cost has impacted their insulin use, including rationing their insulin.62 Lockdowns during the COVID-19 pandemic stressed US families financially, increasing the urgency for insulin cost caps.
Although the COVID-19 pandemic halted national conversations on drug financing,63 advocacy efforts have succeeded for specific populations. The new Medicare Part D Senior Savings Model will cap the cost of insulin at $35 for a 30-day supply,64 and 20 states passed legislation capping insulin pricing.62 Efforts to codify national cost caps are under debate, including the passage of the Affordable Insulin Now Act, which passed the House in March 2022 and is currently under review in the Senate.65