Glucose monitoring is a cornerstone of diabetes care. The 4T program – Teamwork, Targets, Technology, and Tight Control – offers a roadmap for improving outcomes in young people with type 1 diabetes through early continuous glucose monitoring, remote patient monitoring, and consistent glycaemic targets, aiming to replicate the benefits of intensive therapy seen in historic trials. The model also prioritizes equitable access to technology and addressing care disparities, leveraging tools to streamline monitoring and support targeted interventions.
Glucose monitoring is recognized as an essential component of diabetes care. This practice has evolved significantly over the last century, moving from urine glucose monitoring (introduced in 1908) to home blood glucose monitoring in the 1980s, which helped revolutionize diabetes care by enabling more precise insulin dosing.
Today, the paradigm has shifted to continuous glucose monitoring, which received its first U.S. Food and Drug Administration approval in 1999.
Modern continuous glucose monitoring systems gather interstitial glucose values every 1–15 minutes, display these readings on a receiver, and alert users to episodes of hypoglycemia – low blood sugar – or hyperglycemia – high blood sugar. While early systems required calibration via blood glucose monitoring, the first factory-calibrated control glucose monitoring system was introduced in 2016. These modern devices facilitate data sharing to clinics and other individuals through cloud-based platforms and smartphone applications.
Despite these technological advances, many people with diabetes—especially paediatric patients—still struggle to achieve recommended A1C targets. In most cases, the goal is to maintain HbA1c levels below 7%, reflecting good long-term glucose control, although specific targets may vary by age and health status. HbA1c is formed when glucose binds to haemoglobin in red blood cells, so higher levels indicate higher average blood sugar.
The success of tight glycemic control in historic trials was partly driven by frequent insulin dose adjustments made by the study care team—an approach that remains largely underutilized in routine clinical practice.
While cloud-based platforms have facilitated data sharing for remote patient monitoring, staffing limitations continue to hinder the widespread implementation of these programs.
The 4T Program Roadmap
The 4T (Teamwork, Targets, Technology, and Tight Control) program was designed using a team-based approach to set consistent glycemic targets, and initiate continuous glucose monitoring and remote patient control equitably in young people with new-onset type 1 diabetes. The program serves as a roadmap to improve long-term outcomes by intensifying management in the first year after diagnosis.
The cornerstone of the 4T program is the early initiation of continuous glucose monitoring within the first month of diagnosis. This aligns with the rationale that the new-onset period is when individuals are most receptive to education. The program also sought to sustain the intensive insulin adjustment approach from the Diabetes Control and Complications Trial by developing a sustainable, asynchronous remote patient monitoring system.
Teamwork is the foundation of the 4T program. The clinical diabetes team, including physicians, registered dietitians, nurse practitioners, certified diabetes care and education specialists, and social workers, collaborated in planning and fine-tuning the program iteratively.
The initial approach to remote patient monitoring—reviewing each patient’s continuous glucose monitoring data directly from the manufacturer’s website—quickly became unsustainable. To address this, the team collaborated with engineers to create a system that prioritizes youth most in need of intervention. This led to the development of the Timely Interventions for Diabetes Excellence (TIDE) dashboard, a data visualization tool. TIDE uses an algorithm based on continuous glucose monitoring consensus guidelines to flag and prioritize patients for closer review. Implementing the TIDE dashboard reduced review time by 60% compared with evaluating each tracing individually.
Before the 4T program, newly diagnosed youth attended a 4–6 hour outpatient education session, followed by quarterly visits for insulin dose adjustments, without a standardized approach to initiating diabetes technology. During the pilot 4T study (July 2018–June 2020), which targeted an A1C of <7.5% (equivalent to an average glucose of <169 mg/dL), participants in the 4T cohort achieved a 0.5% greater reduction in A1C at 12 months post-diagnosis compared with a historical cohort. Although a 0.5% difference may appear modest, it is clinically meaningful in diabetes management. Landmark studies, such as the Diabetes Control and Complications Trial, have demonstrated that tighter glycemic control significantly reduces microvascular complications (those affecting small blood vessels in the eyes, kidneys, and nerves). Thus, an intervention that achieves a measurable and sustained A1C improvement—like the 0.5% reduction seen here—provides participants with better long-term protection.
Promoting Equity in Technology Access
Equitable access was a core principle of the 4T program. Philanthropic and research funding ensured uninterrupted access to continuous glucose monitoring and provided a safety net for participants facing insurance disruptions. To address disparities in device access for data sharing, participants received iPod Touch devices to upload glucose data and access remote monitoring messages via the secure patient portal. Recognizing gaps in internet availability, the team partnered with local schools to enable students to use school internet for data sharing during school hours. While the program achieved similar A1C reductions across ethnic and insurance groups, some disparities persisted, likely reflecting broader social determinants of health beyond the program’s scope.
Conclusion and Future Roadmap
The program demonstrates that combining a team-based approach with early technology initiation and remote patient monitoring, can successfully improve outcomes in young people with newly diagnosed type 1 diabetes.
Moving forward, careful attention must be paid to ensure technology implementation does not widen disparities. Advocacy is needed for equitable access to technology and for free basic Internet service to facilitate medical data sharing. While collaboration with schools assists currently, integrating wi-fi or cellular connectivity directly into diabetes devices would eliminate the requirement for users to own a separate smart device for data-sharing.
The ongoing challenges associated with the streamlining of remote patient monitoring can be attributed to two key factors. Firstly, there is limited access to device data, and secondly, there is an absence of integrated continuous glucose monitoring within electronic health records. In this context, wearable devices have the potential to play a crucial role by providing real-time data. This data could be used to make timely adjustments to insulin levels, thereby supporting individualised care. Monitoring dashboards must be adaptable to integrate these technologies, including automated insulin delivery systems.
Successfully expanding the 4T program will require strong collaboration among industry, hospital leadership, payers, and clinics. Continued innovation, advocacy, and partnership will be key to sustaining these advances and translating them into lasting improvements in diabetes care.
- Laura Avogaro FRESCI
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References
- Prahalad, P., & Maahs, D. M. (2023). Roadmap to Continuous Glucose Monitoring Adoption and Improved Outcomes in Endocrinology: The 4T (Teamwork, Targets, Technology, and Tight Control) Program. Diabetes spectrum: a publication of the American Diabetes Association, 36(4), 299–305.
- Laura Avogaro from FRESCI
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