When David Klonoff, MD, started practicing endocrinology more than 35 years ago, urine tests were the standard for diabetes screenings. “We had to mix chemicals with the urine to get a result—and it wasn’t very accurate,” said Klonoff, a clinical professor at the University of California, San Francisco (UCSF), School of Medicine and founding editor in chief of the Journal of Diabetes Science and Technology.
Fast-forward to 2017. Continuous glucose monitoring systems can measure blood glucose every five minutes or up to 300 times a day. Sensors built into advanced systems enable patients to sidestep the need to prick their fingers to collect blood. Klonoff, a specialist in diabetes technology, coauthored a study on the first-generation system of an artificial pancreas that can automatically send information to an insulin pump to adjust unhealthy blood glucose levels. He was lead investigator for the first in-home pivotal trial of a closed-loop product for managing type 1 diabetes, and he participated in developing the first dedicated diabetes telemedicine system cleared by the Food and Drug Administration. The system increases access to expertise for people in remote areas or without transportation.
“The new technologies for the testing and treatment of diabetes in the past few decades have been astounding and are making a major difference in improving the outcomes.”
David Klonoff, MD
University of California, San Francisco
Academic medical centers—UCSF and others—are uniquely positioned to bring together technology research and clinical care to advance diabetes care. David Armstrong, DPM, MD, PhD, professor of surgery at the University of Arizona College of Medicine and director of the Southern Arizona Limb Salvage Alliance (SALSA), is another physician who has been instrumental in introducing evidence-based strategies and devices to manage diabetes.
Armstrong has been working on “wearables” for diabetes care for 25 years—before the term became common in health care, he said. Often paired with smartphones and mobile apps, “wearables are ubiquitous now and provide astonishing data,” he observed. Smartphones can collect activity data and monitor other vital signs and indicators. “There are algorithms that can nudge patients to move so they don’t get pressure sores,” he continued. Another new tool he helped to bring to market is “smart socks,” which measure temperature and the amount of pressure applied to the ground. “They look ordinary, and they are not costly. Being that wounds heat up before they break down, they can signal inflammation and help prevent amputation.”
Armstrong’s SALSA team has worked on producing “intelligent textiles” in collaboration with an outside company. He credits novel collaborations as the basis for other technological advances such as the one he calls a “supercool bathmat,” a wireless mat that identifies foot hot spots. It was developed through a joint effort of his group, Massachusetts Institute of Technology, and Harvard Business School.
The University of Arizona Health Sciences has encouraged internal interdisciplinary collaborations in a number of ways, Armstrong added. “We’ve worked hard to give biomedical engineers a primary appointment in the surgery department. When the researcher’s office is near the clinician’s or the operating room and they bump into each other every day, everything changes. Their proximity makes a massive difference.”
Armstrong said that teaching hospitals are essential in bringing innovations into clinical practice. “The real value ultimately is the clinician asking, ‘What about this? Why am I doing this?’ Doing that and breaking down barriers between industry, academia, and government is hard but essential to make a positive difference.”
Innovation harnessed by evidence
The demand for high-quality diabetes care and improved outcomes is growing. More than 29 million people in the United States are living with diabetes and 86 million with prediabetes.
All the innovations being explored are exciting, but Scott Shipman, MD, MPH, director of primary care affairs and workforce analysis at the AAMC, advises people to temper their expectations: “Technology can certainly improve care for patients and provide physicians with better tools. But novel technology often sees slow adoption due to justifiable apprehension about the next great thing that sometimes turns out to be overhyped, as well as resistance to changing from familiar approaches to managing disease.”
And this is where academic medicine can help. “Technologies need to be backed by robust evidence to show they’re actually making a cost-effective clinical difference for individuals and their doctors,” said Shipman.
While industry has played an important role in improving glucose monitoring and insulin pump technology, clinicians at academic medical centers have served as critical partners in helping to test and assess new devices with patients and measure outcomes, said David M. Harlan, MD, William and Doris Krupp Professor of Medicine and codirector of the Diabetes Center of Excellence at the University of Massachusetts (UMass) Medical School.
“Most patients will tell you [after a diabetes diagnosis] that they got a second full-time job they don’t want.”
David Harlan, MD
University of Massachusetts Medical School
Tools that UMass clinicians are testing also make it easier for patients and more likely that they will manage their symptoms. “Most patients will tell you that [a diabetes diagnosis] is like a second full-time job they don’t want,” said Harlan. New technology eliminates some of that extra self-care time by doing the work for them. “Data about blood sugar is available to the care team seamlessly and wirelessly. And algorithms help with complex calculations like estimating how many carbs are in a meal or how much glucose will fall with exercise.” In addition, these devices also allow children and young adults to share their blood sugar levels with parents by programming a smartphone.
These tools can help the health system move away from fee-for-service care models, which are not effective in improving outcomes or controlling costs for those with chronic medical conditions such as diabetes, maintained Harlan in an article he coauthored this year.
Putting patients in the driver’s seat
Innovations that are enabling patients and their care teams to stay in constant communication are among the most important trends in diabetes care, Harlan believes. Current research at UMass is devoted to facilitating that patient–team connection, for example. A physician connected to a monitoring system can reach out to a patient who appears to be failing with high blood sugars, intervene, and prevent an emergency room visit, explained Harlan. An additional bonus is that using this technology can decrease the cost of care by preventing costly emergency care and by reducing the need for on-site visits to access patient data.
“We’ve entered an era of dynamic diabetes management,” summed up pediatric endocrinologist and certified diabetes educator Stephen Ponder, MD, with Baylor Scott & White Health in Temple, Texas. “What that means is an individual with diabetes is much more in the driver’s seat. By following their blood glucose patterns, individuals can act or not act on how to adjust their diet and treatment.”
Another innovation, remote retinal scanning that can detect diabetic retinopathy is being used widely today. This is especially advantageous for people who lack ready access to an ophthalmologist.
Looking toward the future, Harlan has been involved in studies to test a so-called bionic pancreas. Other scientists are trying to harness knowledge about immunology to prevent diabetes altogether.
A more startling technology that researchers say is within reach is a wearable robot. Armstrong has participated in early pilots and predicts the technology will take off after batteries and alloys are improved. Instead of a cane or walker, he explained, a person with diabetes or impaired mobility could step into an exoskeletal robot that would reduce stress on their extremities, improve walking efficiency, and reduce the risk of falling.
“The new technologies for the testing and treatment of diabetes in the past few decades have been astounding and are making a major difference in improving the outcomes,” said Klonoff, “All of these advancements are helping patients take more control of their diabetes and providing doctors with better information to help them better care for patients.”
Eve Glicksman contributed to this article.