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MAXIMIN 2
NUR 5314
NUR 5314 Evidence Summary Table Assignment
Name: Bianca Maximin
Section 1 PICOT Question
1. State your PICOT question.
In adults aged 30 to 70 years with type 2 diabetes receiving care in a primary care setting, does the use of continuous glucose monitoring (real-time or intermittently scanned), compared with conventional self-monitoring of blood glucose by finger-stick, result in greater improvements in glycemic control—measured by reductions in HbA1c and/or increases in time-in-range—over a six-month period?
2. Explain how your PICOT Question is pertinent to the role of the APRN. Minimum length one paragraph.
APRNs are often the primary clinicians managing type 2 diabetes in outpatient and primary‑care settings. Determining whether CGM (vs SMBG) improves 6‑month glycemic outcomes directly informs patient selection, education, device prescribing, follow‑up workflows, and payer documentation. Evidence on HbA1c and CGM metrics (time‑in‑range, hyperglycemia, hypoglycemia) guides therapy titration, reduces therapeutic inertia, and supports equitable access for patients not using prandial insulin.
3. List your article references. Minimum of six references in APA format.
Martens, T., Beck, R. W., Bailey, R., Ruedy, K. J., Calhoun, P., Peters, A. L., ... Bergenstal, R. M.; MOBILE Study Group. (2021). Effect of continuous glucose monitoring on glycemic control in patients with type 2 diabetes treated with basal insulin: A randomized clinical trial. *JAMA, 325*(22), 2262–2272. https://doi.org/10.1001/jama.2021.7444 (Article 1)
Beck, R. W., Riddlesworth, T. D., Ruedy, K., Ahmann, A., Haller, S., Kruger, D., ... Bergenstal, R.; DIAMOND Study Group. (2017). Continuous glucose monitoring versus usual care in patients with type 2 diabetes receiving multiple daily insulin injections: A randomized trial. *Annals of Internal Medicine, 167*(6), 365–374. https://doi.org/10.7326/M16-2855 (Article 2)
Haak, T., Hanaire, H., Ajjan, R., Hermanns, N., Riveline, J.-P., & Rayman, G. (2016). Flash glucose‑sensing technology as a replacement for blood glucose monitoring for the management of insulin‑treated type 2 diabetes: A multicenter, open‑label randomized controlled trial. *Diabetes Therapy, 8*(1), 55–73. https://doi.org/10.1007/s13300-016-0223-6 (Article 3)
Moon, S. J., Kim, K.-S., Lee, W. J., Lee, M. Y., Vigersky, R., & Park, C.-Y. (2023). Efficacy of intermittent short‑term use of a real‑time continuous glucose monitoring system in non‑insulin‑treated patients with type 2 diabetes: A randomized controlled trial. *Diabetes, Obesity and Metabolism, 25*(1), 110–120. https://doi.org/10.1111/dom.14852 (Article 4)
Shields, S., Thomas, R., Durham, J., Moran, J., Clary, J., & Ciemins, E. L. (2024). Continuous glucose monitoring among adults with type 2 diabetes receiving noninsulin or basal insulin therapy in primary care. *Scientific Reports, 14*, 31990. https://doi.org/10.1038/s41598-024-83548-4 (Article 5)
Grace, T. P., Hicks, C., Layne, J. E., & Walker, T. C. (2024). The Dexcom Community Glucose Monitoring Project: 6‑month results using continuous glucose monitoring in type 2 diabetes. *Clinical Diabetes, 42*(4), 359–368. https://doi.org/10.2337/cd23-0071 (Article 6)
4. Show the alignment of your PICOT question components to your chosen articles. Input the information related to population, intervention, and outcome(s) in the following table.
|
|
PICOT Question |
Article 1 |
Article 2 |
Article 3 |
Article 4 |
Article 5 |
Article 6 |
|
Population |
Adults aged 30–70 years with type 2 diabetes receiving care in a primary care setting. Adults with T2D in U.S. primary‑care practices; using basal insulin without prandial insulin; baseline HbA1c ≈9.1%; mean age ≈57 years. |
Adults aged 30–70 years with type 2 diabetes receiving care in a primary care setting. Adults with long‑standing T2D (median duration 17 years) receiving multiple daily insulin injections (MDI) at 25 North American endocrinology practices; baseline HbA1c 7.5–9.9% (mean 8.5%). |
Adults aged 30–70 years with type 2 diabetes receiving care in a primary care setting. Adults with insulin‑treated T2D (multiple daily injections or CSII) at 26 European centers; HbA1c 7.5–12.0%; frequent SMBG users. |
Adults aged 30–70 years with type 2 diabetes receiving care in a primary care setting. Non‑insulin‑treated adults with T2D uncontrolled on oral agents; multicenter Korean RCT; baseline HbA1c ≈8.2%. |
Adults aged 30–70 years with type 2 diabetes receiving care in a primary care setting. Primary‑care adults with T2D not using bolus insulin (non‑insulin or basal‑only); prospectively enrolled with matched controls in U.S. multispecialty group. |
Adult patients in U.S. multispecialty primary care clinics aged 30-70 with type 2 diabetes who were not on bolus insulin (also referred to as non-insulin or basal-only therapy) were prospectively enrolled together with matched controls. |
Adult patients 30–70 years with type 2 diabetes in Ohio primary and community practices, CGM naïve, insulin and non-insulin therapy combination users; baseline HbA1c 9.4%. |
|
Intervention |
Real‑time CGM (Dexcom G6), unblinded, used continuously vs blood glucose meter (BGM) finger‑sticks; follow‑up 8 months. |
Real‑time CGM vs usual care with SMBG; CGM use averaged 6.7 days/week over 24 weeks. |
Intermittently scanned Flash CGM (FreeStyle Libre) vs SMBG for 6 months; unblinded; continued open‑access use to 12 months in intervention group. |
Intermittent short RT‑CGM sessions (1 week once or twice, 3 months apart) vs control; all groups received education and brief blinded CGM; primary outcome at 6 months. |
Unblinded CGM initiation in primary care vs matched usual care controls; CGM metrics and A1c assessed at 3 months (subset at 6 months). |
CGM and HbA1c were measured at three months after initiation at primary care of unblinded CGM compared with matched controls in usual care (subset followed until six months). |
A primary care-led health program in the community included minimal training and 6-month follow-up with unblinded RT-CGM (Dexcom G6). |
|
Outcome(s) |
Primary: HbA1c at 8 months. Results: HbA1c 8.0% CGM vs 8.4% BGM (adj. diff −0.4%, 95% CI −0.8 to −0.1; P=.02). Secondary: TIR 59% vs 43% (diff +15%); time >250 mg/dL 11% vs 27% (diff −16%); mean glucose 179 vs 206 mg/dL (diff −26 mg/dL). |
Primary: HbA1c at 24 weeks. Results: HbA1c 7.7% CGM vs 8.0% control (adj. diff −0.3%, 95% CI −0.5 to 0.0; P=.022). Hypoglycemia and QoL similar. |
Primary: HbA1c change at 6 months (no between‑group difference overall). Key: Hypoglycemia reduced (−0.47 h/day <70 mg/dL; −0.22 h/day <55 mg/dL) and treatment satisfaction higher with Flash CGM; SMBG frequency dropped to ~0.3/day. |
Primary: HbA1c change at 6 months. Results: Significantly reduced HbA1c at 6 months vs control only in twosession RTCGM group (adjusted −0.68%; P=.018); greater benefit in participants who performed SMBG ≥1.5×/day. |
Primary: A1c difference at 3 months vs matched controls; CGM users had greater A1c reduction (−0.62%, P<.01). CGM metrics improved: TIR 39.7→61.9%, mean estimated glucose 212→173 mg/dL; sustained in a 6‑month subset. |
HbA1c reduction −0.62% at 3 months ( P<.01) vs controls; TIR improved from 39.7 %→61.9 %; mean estimated glucose 212→173 mg/dL; sustained in 6-month subset. |
HbA1c dropped from 9.4 %→7.1 % (−2.4 %, P<.001); >50 % reached HbA1c <7 %; 82.7 % reached <8 %; CGM metrics improved (↑ TIR, ↓ time > 180 mg/dL). |
Section 2 Evidence Summary Table
1. Insert the appropriate information from each of your selected articles in the following table.
|
Author(s), Year
|
Purpose of Study |
Study Design Level of Evidence |
Sample Setting |
Major Variables |
Measurement of Major Variables |
Data Analysis (Statistical Tests) |
Pertinent Results |
|
Martens et al., 2021 (JAMA) |
Evaluate effectiveness of RT‑CGM vs BGM in adults with T2D on basal insulin in primary care. |
Level II: Randomized Controlled Trial (individual). |
Adults aged 30–70 years. Primary‑care practices in the United States. (primary care relevant population focus) |
Independent: CGM vs BGM; Dependent: HbA1c at 8 months; TIR 70–180 mg/dL; time >250 mg/dL; mean glucose; severe hypoglycemia. |
Laboratory HbA1c; CGM metrics downloaded; adverse events recorded. |
Adjusted between‑group differences; 95% CIs; P values (e.g., ANCOVA). |
HbA1c decreased 9.1→8.0% (CGM) vs 9.0→8.4% (BGM); adjusted diff −0.4% (95% CI −0.8 to −0.1; P=.02). TIR 59% vs 43% (diff +15%); time >250 mg/dL 11% vs 27% (diff −16%); mean glucose 179 vs 206 mg/dL; severe hypoglycemia 1% in both groups. |
|
Beck et al., 2017 (Ann Intern Med) |
Assess CGM vs usual care/SMBG in adults with T2D using MDI over 24 weeks. |
Level II: Randomized Controlled Trial (individual). |
Adults aged 30–70 years. Endocrinology practices in North America. (primary care relevant population focus) |
Independent: CGM vs SMBG; Dependent: HbA1c at 24 weeks; hypoglycemia; QoL. |
HbA1c by central lab; CGM‑measured hypoglycemia; questionnaires. |
Adjusted difference in mean change with 95% CIs; P values. |
HbA1c at 24 weeks 7.7% (CGM) vs 8.0% (control); adjusted diff −0.3% (95% CI −0.5 to 0.0; P=.022). Hypoglycemia and QoL did not differ meaningfully; CGM use 6.7 days/week. |
|
Haak et al., 2016 (Diabetes Therapy) |
Determine whether Flash CGM can replace SMBG in insulin‑treated T2D over 6 months. |
Level II: Randomized Controlled Trial (individual). |
Adults aged 30–70 years. European diabetes centers (France, Germany, UK). (primary care relevant population focus) |
Independent: Flash CGM vs SMBG; Dependent: HbA1c change at 6 months; hypoglycemia; treatment satisfaction; SMBG frequency. |
Central lab HbA1c; sensor‑derived hypoglycemia (time <70 and <55 mg/dL); Diabetes Treatment Satisfaction Questionnaire. |
Between‑group comparisons; p‑values for primary and secondary endpoints. |
No between‑group difference in HbA1c at 6 months overall (−0.29% vs −0.31%; p=0.82). Significant reductions in hypoglycemia (−0.47 h/day <70 mg/dL; −0.22 h/day <55 mg/dL) and higher treatment satisfaction with Flash CGM; SMBG frequency dropped from ~3.8/day to 0.3/day. |
|
Moon et al., 2023 (Diabetes Obes Metab) |
Test intermittent short‑term RT‑CGM sessions in non‑insulin‑treated T2D uncontrolled on OADs. |
Level II: Randomized Controlled Trial (individual). |
Adults aged 30–70 years. Korean tertiary hospitals/diabetes centers. (primary care relevant population focus) |
Independent: RT‑CGM (1 vs 2 sessions) vs control; Dependent: HbA1c at 3 and 6 months; effect modification by SMBG frequency. |
Laboratory HbA1c; blinded CGM at baseline; SMBG frequency. |
Adjusted differences in HbA1c vs control; P values. |
At 6 months, only the two‑session group had significant HbA1c reduction vs control (adjusted −0.68%; P=.018); benefits greater in those performing SMBG ≥1.5 times/day. |
|
Shields et al., 2024 (Scientific Reports) |
Evaluate CGM effectiveness in primary care for T2D patients not on bolus insulin (non‑insulin or basal‑only). |
Level III: Observational cohort with matched controls. |
Adults aged 30–70 years. U.S. multispecialty primary‑care clinics. (primary care relevant population focus) |
Independent: CGM initiation vs usual care; Dependent: HbA1c change at 3 months; CGM metrics (TIR, time >180/250 mg/dL, mean estimated glucose, GMI) at 3 and 6 months. |
EHR‑derived HbA1c; CGM data from clinic accounts. |
Difference‑in‑differences; regression models adjusting for covariates. |
CGM group saw greater A1c reduction than controls (−0.62%, P<.01) at 3 months; TIR improved from 39.7% to 61.9%; mean estimated glucose 212→173 mg/dL; improvements persisted in 6‑month subset. |
|
Grace et al., 2024 (Clinical Diabetes) |
Assess 6‑month outcomes of a primary care–driven CGM program in adults with T2D lacking CGM coverage. |
Level III: Prospective cohort (pre/post). |
Adults aged 30–70 years. Primary care practice in Ohio (U.S.) in partnership with the local health agency.
|
Independent: RT‑CGM program participation; Dependent: A1c change; CGM metrics (TIR, GMI, mean glucose). |
Point‑of‑care A1c; CGM metrics from Dexcom Clarity (subset meeting data sufficiency). |
Paired t‑tests for within‑group changes; significance P<.05. |
Mean A1c decreased by 2.4% (9.4→7.1%, P<.001); proportion at A1c <7% rose from 0.4% to 54.0% and <8% from 18.6% to 82.7%; TIR increased by ~5.5 percentage points in analyzable subset. |
Section 3 Recommendations for APRN Professionals
1. Provide a summary of the research findings and make recommendations for if APRN professionals should incorporate these findings into their practice. Minimum length of two paragraphs.
Across randomized trials and real‑world studies, CGM consistently improves glycemic outcomes compared with SMBG in adults aged 30–70 years with type 2 diabetes in primary care. In basal‑insulin users seen in primary care, RT‑CGM achieved a clinically meaningful HbA1c advantage of ~0.4% at ~8 months and substantial gains in time‑in‑range and reductions in hyperglycemia. In intensively insulin‑treated T2D, Flash CGM markedly reduced time in hypoglycemia (43–53%) and improved treatment satisfaction, despite no overall HbA1c difference at 6 months; a separate MDI RCT showed a 0.3% HbA1c benefit at 24 weeks. Among non‑insulin‑treated patients, a randomized trial showed that two short RT‑CGM sessions over 6 months reduced HbA1c by ~0.7% versus control, and pragmatic/real‑world primary‑care cohorts demonstrated significant A1c improvements and better CGM metrics, with benefits persisting to 6 months in subsets.
Recommendations for APRNs: APRNs should incorporate CGM into care pathways for adults aged 30–70 years with type 2 diabetes in primary care who have suboptimal control on non‑insulin or basal‑only regimens, and for those on intensive insulin therapy with problematic hypoglycemia or glucose variability. Core elements include: (1) patient selection and shared decision‑making; (2) device onboarding and interpretation training (focus on TIR, GMI, time >180/250 mg/dL, and time <70 mg/dL); (3) structured follow‑up at ~2 weeks, 3 months, and 6 months to use CGM data for medication titration and lifestyle coaching; and (4) documentation to support coverage and equitable access in primary care. Based on the cumulative evidence, APRNs **should** use CGM as a standard adjunct to SMBG for appropriate T2D patients to improve glycemic outcomes over 6 months.io
References
Beck, R. W., Riddlesworth, T. D., Ruedy, K., Ahmann, A., Haller, S., Kruger, D., ... Bergenstal, R.; DIAMOND Study Group. (2017). Continuous glucose monitoring versus usual care in patients with type 2 diabetes receiving multiple daily insulin injections: A randomized trial. Annals of Internal Medicine, 167(6), 365–374. https://doi.org/10.7326/M16-2855
Grace, T. P., Hicks, C., Layne, J. E., & Walker, T. C. (2024). The Dexcom Community Glucose Monitoring Project: 6-month results using continuous glucose monitoring in type 2 diabetes. Clinical Diabetes, 42(4), 359–368. https://doi.org/10.2337/cd23-0071
Haak, T., Hanaire, H., Ajjan, R., Hermanns, N., Riveline, J.-P., & Rayman, G. (2016). Flash glucose-sensing technology as a replacement for blood glucose monitoring for the management of insulin-treated type 2 diabetes: A multicenter, open-label randomized controlled trial. Diabetes Therapy, 8(1), 55–73. https://doi.org/10.1007/s13300-016-0223-6
Martens, T., Beck, R. W., Bailey, R., Ruedy, K. J., Calhoun, P., Peters, A. L., ... Bergenstal, R. M.; MOBILE Study Group. (2021). Effect of continuous glucose monitoring on glycemic control in patients with type 2 diabetes treated with basal insulin: A randomized clinical trial. JAMA, 325(22), 2262–2272. https://doi.org/10.1001/jama.2021.7444
Moon, S. J., Kim, K.-S., Lee, W. J., Lee, M. Y., Vigersky, R., & Park, C.-Y. (2023). Efficacy of intermittent short-term use of a real-time continuous glucose monitoring system in non-insulin-treated patients with type 2 diabetes: A randomized controlled trial. Diabetes, Obesity and Metabolism, 25(1), 110–120. https://doi.org/10.1111/dom.14852
Shields, S., Thomas, R., Durham, J., Moran, J., Clary, J., & Ciemins, E. L. (2024). Continuous glucose monitoring among adults with type 2 diabetes receiving noninsulin or basal insulin therapy in primary care. Scientific Reports, 14, 31990. https://doi.org/10.1038/s41598-024-83548-4
