Time in Range for Multiple Technologies in Type 1 Diabetes: A Systematic Review and Network Meta-analysis

BACKGROUND: Time in range is a key glycemic metric, and comparisons of management technologies for this outcome are critical to guide device selection. PURPOSE: We conducted a systematic review and network meta-analysis to compare and rank technologies for time in glycemic ranges. DATA SOURCES: We searched Evidenced-Based Medicine Reviews, CINAHL, Embase, MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, PROSPERO, PsycInfo, PubMed, and Web of Science until 24 April 2019. STUDY SELECTION: We included randomized controlled trials ≥2 weeks' duration comparing technologies for management of type 1 diabetes in adults (≥18 years of age), excluding pregnant women. DATA EXTRACTION: Data were extracted using a predefined template. Outcomes were percent time with sensor glucose levels 3.9-10.0 mmol/L (70-180 mg/dL), >10.0 mmol/L (180 mg/dL), and <3.9 mmol/L (70 mg/dL). DATA SYNTHESIS: We identified 16,772 publications, of which 14 eligible studies compared eight technologies comprising 1,043 participants. Closed-loop systems led to greater percent time in range than any other management strategy, and mean percent time in range was 17.85 (95% predictive interval 7.56-28.14) longer than with usual care of multiple daily injections with capillary glucose testing. Closed-loop systems ranked best for percent time in range or above range with use of Surface Under the Cumulative RAnking curve (SUCRA) (98.5% and 93.5%, respectively). Closed-loop systems also ranked highly for time below range (SUCRA 62.2%). LIMITATIONS: Overall risk of bias ratings were moderate for all outcomes. Certainty of evidence was very low. CONCLUSIONS: In the first integrated comparison of multiple management strategies considering time in range, we found that the efficacy of closed-loop systems appeared better than all other approaches.