Diabetes Tech Use On the Rise But A1c Reductions Still Lag

Medscape

3 days ago

Use of diabetes technology has dramatically increased and glycemic control has improved among people with type 1 diabetes (T1D) in the US over the past 15 years, but at the same time, overall achievement of an A1c level < 7% remains low and socioeconomic and racial disparities have widened.
These findings came from an analysis of national electronic health records of nearly 200,000 children and adults with T1D by Michael Fang, PhD, of the Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, and colleagues. The study was published online on August 11, 2025, in JAMA Network Open .
Use of continuous glucose monitors (CGMs) increased substantially from 2009-2011 to 2021-2023, from less than 5% in both children and adults to more than 80% and over half, respectively. While A1c levels did drop over the 15 years, just 1 in 5 children and slightly over a quarter of adults achieved a level < 7%. The average A1c level stayed above 8%, with ethnic minorities and low-income patients seeing the smallest gains.
'Additional opportunities for individualized patient and clinician education can help optimize the use of technologies. In our analyses, the increase in CGM and insulin pump use substantially outpaced gains in glycemic control,' Fang and colleagues wrote.
In an accompanying editorial, Diana Soliman, MD, of the Division of Endocrinology at the University of Miami Miller School of Medicine in Miami, and colleagues wrote, 'As technological innovation continues to accelerate, it is encouraging to see signs of progress in glycemic management. Ensuring that these advances benefit all individuals with T1D must remain a priority.'
Asked to comment, Anne L. Peters, MD, professor of clinical medicine and director of Clinical Diabetes Programs at the Keck School of Medicine of USC, Los Angeles, told Medscape Medical News that a key component is having staff to help with prior authorization paperwork and certified diabetes care and education specialists (CDCES) to help train patients and troubleshoot. 'These health disparities are real but fixable. However, it takes staff to make it happen.'
Tech Use On the Rise But A1c Level Hasn't Dropped Much
Fang and colleagues used the OptumLabs Data Warehouse to identify 186,590 eligible individuals with T1D, of whom 26,853 were younger than 18 years. Three quarters were White, 12% were Black, and 7% were Hispanic individuals. Few previous studies of T1D have included such representative population-based data, the authors noted.
From 2009-2011 to 2021-2023, among youths, the use of CGMs rose from 4% to 82%, insulin pumps from 16% to 50%, and the combination from 1% to 47% ( P for trend < .001 for all). Such use in 2021-2023 was higher among White youths and those with commercial insurance.
During the same period, among adults, the use of CGM rose from 5% to 57%, insulin pumps from 11% to 29%, and the combination from 1% to 22% ( P for trend < .001 for all). Throughout, adults who were White, younger, and commercially insured were more likely to use CGMs.
Overall, mean A1c levels dropped from 8.9% to 8.3% in youths and from 8.2% to 8.0% in adults from 2009-2011 to 2021-2023.
Among youths, the prevalence of achieving glycemic control, defined as an A1c level < 7%, rose from about 7% in 2009-2011 and 2014-2017 to 19% in 2021-2023 ( P for trend < .001). Glycemic control improved for all youth subgroups except for Black youths. Differences by race, ethnicity, and insurance type increased after 2018-2020.
During 2021-2023, 21% of White youths vs 17% of Hispanic and 12% of Black youths achieved glycemic control. Those with commercial health insurance also had higher rates of glycemic control than those with Medicaid insurance (22% vs 13%).
For adults with T1D, glycemic control rose from 21% in 2009-2011 to 28% in 2021-2023 ( P for trend < .001). Again, the prevalence of achieving glycemic control was higher among those who were White (30% vs 20% of Hispanic and 21% of Black patients in 2021-2023) and those who had commercial insurance (30% vs 19% of those who had Medicaid insurance).
Implications for Clinical Practice
These findings have important implications for clinical practice and policy, Soliman and colleagues said. 'Barriers to diabetes technology access, including financial costs, lack of clinician prescription, and inadequate clinical communication, continue to disproportionately affect medically underserved populations. While the increase in diabetes technology may be attributed to expanded insurance coverage, incorporation into guidelines, and improved technology, there remains a crucial need to extend this technology more widely.'
Addressing these challenges, they said, 'requires coordinated efforts that combine reduced financial barriers with clinician training, shared decision-making, and culturally competent communication to promote equitable and effective use of technology.'
Peters has one practice in the relatively wealthy west side of Los Angeles and another in an underserved area in East Los Angeles. On the west side, she has a full-time staffer who exclusively handles prior authorizations for diabetes devices and a CDCES who trains patients and follows them weekly. The patients there all speak English and have high health literacy.
On the east side, there aren't any educators and no classes on advanced technology. A prescription for an automated insulin delivery device can take months to get filled. Non-English speaking patients may have difficulty accessing manufacturer assistance and may lack smartphones compatible with their devices. Even when patients are able to start using the technology, they may not have the support they need to continue.
'The systems of care often lack what it takes to provide adequate care for under-resourced people with T1D. When we've had research funding to provide a CDCES, my patients in East LA do great. The training often takes longer than in those who are starting at a higher knowledge level, but technology is very useable by under-resourced people,' Peters said.
The study was funded by the National Heart, Lung, and Blood Institute and the National Institute of Diabetes and Digestive and Kidney Diseases. Fang had no other disclosures. Soliman had no disclosures. Peters reported recording videos for Medscape Medical News, being on the advisory board for Vertex, and having stock options for Omada Health.