Discussion
T1D, diabetes
DIABETES
This study reports healthcare professionals' views about the challenges and opportunities that could arise from rolling-out HCL technology to pregnant women with T1D. Our findings, alongside recommendations developed in our online workshop, offer practical ways to upskill professionals and potential ways to promote widespread and equitable access to this technology (see Summary of RecommendationsInterviewees emphasized that healthcare professionals providing training and support to pregnant HCL users would need to be proficient in the use of its constituent (CGM and insulin pump) technologies. They also raised concerns that existing disparities in insulin pump and CGM expertiseMoreover, interviewees noted how infrequent exposure to small numbers of pregnant users might limit opportunities for staff to apply their skills and retain expertise, meaning that this issue could be more pronounced when supporting HCL use in T1D pregnancy. Interviewees, however, proposed a range of “low cost” solutions, such as making webinars, videos, training resources, and succinct checklists available online to help staff refresh their skills. These recommendations were endorsed by workshop participants who noted that several of these resources are already available for healthcare professionals supporting CamAPS FX users. Such training resources would need to be updated at regular intervals to keep abreast of rapidly changing HCL technology.In keeping with interviewees' accounts, workshop participants also recommended that general hospital staff be given guidance to support HCL users who present acutely at emergency departments and maternity units. They suggested that existing mandatory training modules be updated to raise staffs' basic awareness and understanding of HCL technology and alert them to situations when they should contact diabetes specialists to seek clinical input (for further recommendations, see Box 4). In response to some interviewees' suggestion that only one HCL system initially be supported, workshop participants noted that this is not a feasible option because women are increasingly using different HCL systems before pregnancy. Participants noted that it would be unreasonable to ask existing users to switch systems and, in keeping with Sherr et al.'s recommendations,To ensure equitable access via a national rollout, our findings suggest that it will be important to provide intensive, targeted initial support to inexperienced sites and staff. There was broad consensus among workshop participants that training to use the HCL's constituent components should be provided by device manufacturers; a similar recommendation has also recently been made by Sherr et al.To this end, workshop participants reinforced interviewees' suggestions by recommending local teams or individuals who lack experience reviewing and interpreting HCL data be offered mentorship/peer support from more experienced colleagues. They also recommended implementing interviewees' suggestions to develop collaborative models of support by establishing intra- and/or intersite case-based learning sessions or HCL pregnancy “masterclasses” led by experienced colleagues. However, workshop participants suggested that further consideration should be given to whether such support is provided locally, regionally, or nationally and by whom.Moreover, they emphasized that funding may be needed to ensure that experienced staff have capacity to support less experienced colleagues/centers. Interviewees noted that such support could be provided virtually (by sharing HCL users' data with experienced colleagues); a model made logistically feasible by healthcare professionals' ability to access women's data and support glycemic management remotely.In line with interviewees' suggestions, workshop participants recommended that provision of HCL technology in routine care should include technical support for healthcare professionals, available via a 24 h telephone helpline, and similar to the support provided by insulin pump and CGM companies. Telephone support is already available for healthcare professionals supporting CamAPS FX users and as other HCL systems become available,While there may be some initial costs associated with developing the above training and support strategies, interviewees described how, in the long-term, workloads (and, hence, potentially costs) might be reduced because women using HCL might require less glycemic management input, especially during later pregnancy, than those using insulin pump or multiple daily injections regimens. This perspective mirrors that of healthcare professionals supporting adolescent HCL usersMoreover, healthcare professionals in our study observed how email reports containing summary glycemic metrics had helped them to identify and triage individuals requiring additional support. Indeed, our findings suggest that using such metrics to triage caseloads could help address concerns raised in earlier studies that more time would be required during consultations to process and interpret large volumes of HCL data.