GRAPHICAL ABSTRACT

Highlights

• People with T1DM on intensive insulin therapy were studied (NHIS cohort, 2019–2022).

• Despite reimbursement, CGM prescription rates were low, especially in the elderly.

• Only 10.7% used CGM continuously, and 0.4% utilized SAP or AID systems.

• Among CGM users, HbA1c and CV decreased significantly after CGM initiation.

• More efforts are needed to increase CGM use and reduce age-related disparities.

INTRODUCTION

Continuous glucose monitoring (CGM) aids glycemic control for individuals with diabetes mellitus [1-19] by enabling continuous glucose level tracking and helping to prevent hypoglycemia and hyperglycemia. CGM also helps individuals determine accurate insulin dosing. Accordingly, clinical guidelines recommend CGM for insulin users or individuals at high risk of hypoglycemia, including those with type 1 diabetes mellitus (T1DM) [20-23]. Insulin pumps integrated with CGM, such as automated insulin delivery (AID) systems, are also recommended for T1DM management [24-28].

In South Korea, CGM devices and insulin pumps for all individuals with T1DM have been nationally reimbursed by the Korean National Health Insurance Service (NHIS) since 2019 and 2020 [29]. However, the extent of CGM and integrated insulin pump utilization in the T1DM population in South Korea remains unclear. As part of a collaborative project between the Korean Diabetes Association and NHIS, this study aimed to assess the current status of CGM use among individuals with T1DM in South Korea following reimbursement. It also sought to compare the utilization rates of CGM according to age and investigate whether there are age-related disparities in CGM use, considering that older adults may face challenges using advanced diabetes technologies. Moreover, glycemic outcomes, including glycosylated hemoglobin (HbA1c) and coefficient of variation (CV), were evaluated among CGM users.

METHODS

Data source

This study utilized the Korean NHIS Customized Database, which includes data for nearly the entire South Korean population [30-35]. This database comprises longitudinal data on demographics, diagnoses based on the International Classification of Diseases, 10th Revision (ICD-10), medication, and medical procedures. In this analysis, the NHIS database (2016–2022) and prescription data (2019–2022) for diabetes management devices, including CGM and insulin pumps, were analyzed to gain information on device start dates, usage durations, and glycemic metrics such as HbA1c, mean glucose, and CV or standard deviation (SD).

This study was approved by the Institutional Review Board (IRB) of Samsung Medical Center (IRB number: SMC 2023-04-090). Informed consent was waived as the databases did not contain any personally identifiable information.

Study population

From the NHIS database, individuals who received the ICD-10 code E10 (the standard code given for T1DM) at least once between 2019 and 2022 were included (n=300,935). Among them, those who received a minimum of three prescriptions for rapid-acting insulin were considered as undergoing intensive insulin therapy. The final cohort included 56,908 individuals with T1DM receiving intensive insulin therapy. Participants were categorized into two groups: those who had never obtained a prescription for a CGM device (n=46,086) and those who had received a prescription for CGM at least once (n=10,822).

Outcome measures

The prescription rates of CGM, sensor-augmented pump (SAP), and AID systems were examined in the total population as well as in the specific age groups (<19, 19–39, 40–59, and ≥60 years). Continuous CGM prescription was defined as CGM use for at least 70% of the follow-up period. The CGM devices used during the investigational period included the FreeStyle Libre 1 (Abbott Diabetes Care, Witney, UK), Dexcom G5 and Dexcom G6 (Dexcom, San Diego, CA, USA), and Medtronic Guardian Sensor 3 (Medtronic, Minneapolis, MN, USA). The FreeStyle Libre 1 is classified as an intermittently scanned CGM (isCGM), whereas the other devices are real-time CGM (rtCGM) systems. SAP or AID systems included Medtronic 640G, 720G, and 770G systems (Medtronic), as well as DIA:CONN G8 (G2E, Seoul, Korea).

The glycemic parameters—HbA1c and CV—among CGM users were also evaluated. These metrics were derived from physician-reported data recorded at the time of CGM prescription. CVs were computed using the formula [CV=100×SD/mean glucose], provided SD data were available. HbA1c was monitored every 3 months from baseline, and CV was tracked starting 3 months after CGM initiation, continuing for up to 24 months. The proportion of individuals achieving HbA1c <7% and CV <36% was also assessed at each time point.

Definition of clinical characteristics of participants

Baseline comorbidities of the study population were determined between 2016 and the index date. A history of severe hypoglycemia was defined as hospitalization or an emergency department visit coded with ICD-10 codes E16, E11.63, E13.63, or E14.63. Similarly, a history of diabetic ketoacidosis (DKA) was defined as hospitalization or an emergency department visit coded with ICD-10 codes E10.1, E11.1, E12.1, E13.1, E14.1, or E87.2. Hypertension and dyslipidemia were identified through the use of antihypertensive and lipid-lowering medications, respectively. Cardiovascular disease was defined as a history of myocardial infarction (ICD-10 codes I21–22), ischemic stroke (I63), or heart failure (I50). Cancer history was identified using the ICD-10 codes C00–97. End-stage kidney disease (ESKD) was identified using ICD-10 codes N18–19 with special exemption codes V001 (hemodialysis), V003 (peritoneal dialysis), or V005 (kidney transplant) [36].

Based on where insulin was prescribed within a given year, medical institutions were categorized into three categories: primary care clinics, secondary hospitals, and tertiary hospitals. A patient was classified under a higher-level institution if they received at least one insulin prescription from such an institution during the year. Income levels were categorized into four groups (lowest 30%, middle 40%, highest 30%, or unknown) according to medical insurance premiums, which were directly proportional to income [37]. Residential areas were classified as Seoul metropolitan area, other regions, or unknown.

Statistical analysis

All categorical variables were expressed as percentages, whereas continuous variables were summarized as mean±SD. An independent two-sample t-test was applied to continuous measurements, and chi-square or Fisher’s exact test was used for categorical comparisons. Analysis of variance (ANOVA) was used at each time point to compare HbA1c and CV levels across age groups (<19, 19–39, 40–59, and ≥60 years) at 3-month intervals. Within-group differences across time points were assessed using a paired t-test. All statistical analyses were performed using R version 4.0.3 (R Foundation for Statistical Computing, Vienna, Austria) and SAS Enterprise Guide 7.1 for Windows (SAS Institute, Cary, NC, USA) with a significance threshold of P<0.05.

RESULTS

Characteristics of CGM users and non-users

Table 1 summarizes participant characteristics. The mean age of CGM users was younger than non-CGM users (36.0±18.9 years vs. 56.0±18.5 years, P<0.001). The proportion of men (45.9% vs. 56.8%, P<0.001) and those newly diagnosed with T1DM (31.5% vs. 38.6%, P<0.001) were lower in CGM users than in non-CGM users, respectively. The proportion of individuals with a history of hypoglycemia was similar between both groups (8.6% vs. 8.1%, P=0.065), whereas the proportion of individuals with a history of DKA was higher among CGM users than non-CGM users (21.4% vs. 8.8%, P<0.001). The proportion of individuals with hypertension, dyslipidemia, cardiovascular disease, cancer, and ESKD was higher among non-CGM users (P<0.001 for all). On the other hand, 60.9% of CGM users visited tertiary hospitals, while 29.1% of non-CGM users visited tertiary hospitals (P<0.001 for between-group differences). The proportion of people with high income (42.5% vs. 32.8%, P<0.001) and those residing in the Seoul Metropolitan area (52.5% vs. 41.3%, P<0.001) were higher among CGM users than non-CGM users.

The comparison of CGM users and non-users among age-matched groups is provided in Supplementary Table 1. Even in age-matched groups, the prevalence of hypertension, dyslipidemia, cardiovascular disease, and ESKD was higher among non-CGM users.

Prescription rate of CGM devices

Among the total population, 19.0% received CGM at least once, and 10.7% received CGM continuously (Supplementary Table 2). The prescription rate was significantly lower for adults than for children and adolescents. While 61.4% of children and adolescents received CGM at least once, only 16.0% of adults did (P<0.001). Similarly, the continuous prescription rate was significantly lower in adults than in children (8.8% vs. 37.0%, P<0.001). However, 93.4% of patients with T1DM were adults (Fig. 1A). Among the T1DM population, only 6.6% were children and adolescents, whereas 42.7% were aged ≥60 years, 28.8% were aged 40–59 years, and 21.9% were aged 19–39 years. Despite the higher proportion of older individuals, CGM prescription rate (both for at least one prescription and continuous prescription) decreased with increasing age (P<0.001 for between-group differences) (Fig. 1B). Continuous CGM use was highest among individuals aged <19 years (37.0%), followed by those aged 19–39 years (15.8%), 40–59 years (10.7%), and ≥60 years (3.9%).

The proportions of rtCGM and isCGM utilization also varied by age. Children and adolescents were more likely to receive rtCGM than isCGM (61.5% vs. 38.5%), whereas adults received less rtCGM than isCGM (25.9% vs. 74.1%) (Supplementary Fig. 1). The utilization of rtCGM decreased with increasing age (Supplementary Table 3).

Prescription rate of SAP or AID systems

Among the total population of 56,908 individuals, only 241 (0.4%) received SAP or AID systems (Supplementary Table 2). The prescription rate of these systems was also significantly lower in adults than in children or adolescents. The highest prescription rate of the SAP or AID systems was observed among individuals aged <19 years (3.1%), followed by those aged 19–39 years (0.5%), 40–59 years (0.3%), and ≥60 years (0.1%) (P<0.001 for between-group differences) (Fig. 1C).

Change in HbA1c among CGM users

Fig. 2A illustrates the changes in HbA1c levels among CGM users. The mean±SD HbA1c decreased substantially from baseline (8.7%±2.4%) to 3 months (7.4%±1.3%) and continued to decrease gradually to 21 months (7.3%±1.2%) and 24 months (7.2%±1.2%). The proportion of users achieving HbA1c target (<7%) increased from 22.0% at baseline to 42.0% at 3 months, 45.2% at 21 months, and 50.1% at 24 months (Fig. 2B).

Table 2, Supplementary Fig. 2A detail the HbA1c levels and target achievement rates of CGM users in each age group. HbA1c levels significantly decreased from baseline in all age groups by 3 months (P<0.001 for all). After 3 months, HbA1c levels either stabilized or gradually declined. At baseline, HbA1c levels were 10.0%±2.9%, 8.3%±2.1%, 8.3%±1.7%, and 8.2%±1.8% for those aged <19, 19–39, 40–59, and ≥60 years, respectively. At 24 months, these levels had decreased to 7.3%±1.3%, 7.0%±1.1%, 7.2%±1.2%, and 7.3%±1.0%, respectively.

Change in CV among CGM users

Baseline CV data were not available on the database; therefore, CV and the proportion of users achieving CV <36% were assessed from 3 months after CGM initiation through 24 months (Fig. 2C and D). The mean±SD CV decreased from 36.6%±11.9% at 3 months to 35.5%±12.5% at 21 months and 34.1%±12.7% at 24 months. The reduction in CV was more evident in adults than in children and adolescents (Table 3). Among children and adolescents, the mean CV at 3 months was 33.8%±11.9%, remaining 33.3%±12.6% at 24 months (P=0.073 for within-group differences). Among adults, the mean CV decreased from 37.5%±11.8% at 3 months to 36.1%±12.0% at 21 months and 34.6%±12.7% at 24 months (P<0.001 for both). The differences in CV between 3 and 21 months were significant across all adult age groups (19–39, 40–59, and ≥60 years). Notably, the proportion of patients achieving CV <36% increased steadily in those aged ≥60 years, from 39.0% at 3 months to 47.9% at 21 months and 56.6% at 24 months (Supplementary Fig. 2B).

DISCUSSION

This nationwide study showed that the prescription rate of CGM in South Korea remains low despite national reimbursement of CGM devices. Only 10.7% of individuals with T1DM used CGM continuously. The prescription rate is notably lower in older adults than in younger individuals. Although 93.4% of individuals with T1DM were adults, CGM prescription rate was significantly lower in adults than in children or adolescents. The continuous CGM prescription rate was highest among individuals aged <19 years (37.0%), followed by those aged 19–39 years (15.8%), 40–59 years (10.7%), and ≥60 years (3.9%). The prescription rate of SAP and AID systems was 0.4% across the entire T1DM population, with 3.1% in children and adolescents, and only 0.2% in adults. Although the utilization rate of CGM was low, improvements in HbA1c and CV values were observed following CGM initiation.

Considering that CGM and AID systems have become standard clinical practice for individuals with T1DM, it is surprising that the prescription rates of CGM and SAP or AID systems remain so low despite national reimbursement for these devices. This low rate may be attributed to the complex reimbursement process for CGM and insulin pumps in South Korea [38]. Patients must purchase the device independently outside the hospital, unlike other medical or surgical procedures that only require copayments at the hospital. Afterward, patients submit an invoice or a receipt as a proof of purchase directly to the health insurance corporation, which reimburses a certain proportion of the costs. This cumbersome process likely acts as a barrier to CGM adoption.

The even lower prescription rate of SAP or AID systems than that of CGM could be explained by the absence of dedicated management or education fees for these systems and the higher cost of insulin pumps compared to CGM devices. In order for patients to use an insulin pump properly, physicians must adjust the pump settings and educate patients on how to use the device and make adjustments based on their blood glucose levels. This process requires a significant amount of time and effort. In many cases, hospitalization is even necessary to initiate insulin pump therapy. However, in South Korea, there is no education or management fee for insulin pumps. Without such a fee, it is challenging for physicians and hospitals to actively support patient education and prescribe SAP or AID systems.

The benefits of CGM for glycemic control in older adults have been well-documented [39,40]. The current study also showed that the mean HbA1c level decreased from 8.2% at baseline to 7.3% at 24 months among individuals aged ≥60 years. However, CGM utilization remains extremely low in this age group, with only 5.9% having used CGM at least once and 3.9% using it continuously. Older adults may face greater challenges than younger adults in adopting new technologies, including difficulties with learning new information and stress [41,42]. The lower prescription rate of rtCGM than that of isCGM in this age group may also reflect reluctance towards the additional steps involved in attaching a transmitter to the sensor. Physical limitations and comorbidities can further hinder CGM and AID system adoption in this population [43-45]. Therefore, more efforts are needed to facilitate the use of CGM among older adults.

Socioeconomic disparities were also apparent in CGM utilization, alongside age-related disparities. Among CGM users, 42.5% were high-income earners, whereas only 22.5% were low-income earners. Additionally, CGM prescriptions were more common in the Seoul metropolitan area than in other regions. Previous studies have reported health disparities associated with CGM [46,47]. Because CGM devices are expensive, societal-level interventions are necessary to reduce these disparities.

This real-world study, which encompassed nearly all CGM users with T1DM in South Korea, demonstrated improvement in glycemic control after CGM initiation. The mean HbA1c level decreased from 8.7% at baseline to 7.2% at 24 months, with a substantial reduction within the first 3 months of CGM use (from 8.7% to 7.4%). Improvements in HbA1c levels were observed across all age groups. This notable improvement may partly stem from a nationwide education program for T1DM, specifically the Korean National Home Care Pilot Program for T1DM. This program provides ongoing, structured education on insulin dose adjustments, CGM data interpretation, and carbohydrate counting [48,49]. Additionally, given the low utilization rate of CGM among the T1DM population, the study cohort likely consisted of highly motivated patients, a factor that likely contributed to the substantial improvement in HbA1c levels. Although the change in CV from baseline could not be investigated owing to the unavailability of data, we also observed a decrease in CV with CGM use.

To our knowledge, this study is the first to report the utilization rates of CGM and CGM-integrated insulin pumps in South Korea. Moreover, it highlights age-related disparities in CGM use, a subject that previous studies—that focused only on racial and ethnic disparities—have not extensively explored. This study also provides real-world evidence of CGM’s benefits for glycemic control at a population level.

However, this study has several limitations. First, it did not capture the utilization of CGM and insulin pumps outside the insurance system, as the analysis was based on the NHIS database. Second, glycemic outcomes could not be compared between CGM users and non-users due to the lack of data on the latter group. It was also not possible to track HbA1c and CV values after the discontinuation of CGM. Third, baseline CV values or other core CGM metrics, such as time in range, were unavailable. Lastly, a relatively small number of patients were followed up with for more than 1 year. In particular, the number of participants at 24 months was small, and the remarkably high rates of achieving HbA1c <7% and CV <36% at 24 months would be partly due to only well-controlled individuals continuing to be monitored at this time point. However, it is evident that even these well-controlled individuals showed improvement in HbA1c and CV compared to 3 months, as paired t-tests were performed among individuals with glycemic profiles available at both 3 and 24 months.

In conclusion, the utilization rates of CGM and CGM-integrated insulin pumps in South Korea remain low despite national reimbursement for these devices, with significant age-related disparities. Given the observed improvements in HbA1c and CV following CGM initiation, more targeted efforts are needed to enhance CGM adoption and reduce age-related disparities.

SUPPLEMENTARY MATERIALS

NOTES

CONFLICTS OF INTEREST

No potential conflict of interest relevant to this article was reported.

AUTHOR CONTRIBUTIONS

Conception or design: all authors.

Acquisition, analysis, or interpretation of data: all authors.

Drafting the work or revising: J.Y.K., S.K.

Final approval of the manuscript: J.H.K.

FUNDING

None

ACKNOWLEDGMENTS

This study was conducted as part of a special project between the Korean National Health Insurance Service (NHIS) and the Korean Diabetes Association. We extend our gratitude to the Korean NHIS for providing access to their database. The opinions expressed in this article are solely those of the authors and do not reflect the official stance of the Korean NHIS.

Fig. 1.

Prescription rate of continuous glucose monitoring (CGM) devices and insulin pumps integrated with CGM across different age groups. (A) The demographic composition of the type 1 diabetes mellitus (T1DM) population by age groups, (B) prescription rate of CGM, and (C) prescription rate of sensor-augmented pump (SAP) or automated insulin delivery (AID) systems.

Fig. 2.

Changes in glycemic status following continuous glucose monitoring utilization: (A) Mean glycosylated hemoglobin (HbA1c) levels, (B) proportion of individuals achieving HbA1c <7%, (C) coefficient of variation (CV) in glucose, and (D) proportion of individuals achieving CV <36%. Mean±standard error is shown in Fig. 2A and C. The number of participants at each time point in the HbA1c analyses (A, B) was 4,333 (baseline), 3,249 (3 months), 2,803 (6 months), 2,333 (9 months), 2,167 (12 months), 1,769 (15 months), 1,594 (18 months), 1,179 (21 months), and 687 (24 months). The number of participants at each time point in the CV analyses (C, D) was 6,257 (3 months), 5,206 (6 months), 4,623 (9 months), 4,203 (12 months), 3,662 (15 months), 3,250 (18 months), 2,537 (21 months), and 1,496 (24 months).

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Kim JY, Kim S, Kim JH. Current Status of Continuous Glucose Monitoring Use in South Korean Type 1 Diabetes Mellitus Population–Pronounced Age-Related Disparities: Nationwide Cohort Study. Diabetes Metab J. 2025 Apr 28. doi: 10.4093/dmj.2024.0804. Epub ahead of print.

Received: Dec 09, 2024; Accepted: Feb 03, 2025

DOI: https://doi.org/10.4093/dmj.2024.0804.

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