Provider Implicit Bias Impacts Pediatric Type 1 Diabetes Technology Recommendations in the United States: Findings from The Gatekeeper Study

Anticipating, experiencing, and responding to disenfranchising talk: The experiences of people with type 1 diabetes

This interpretive study applies the theory of communicative (dis)enfranchisement to analyze 290 narratives authored by people diagnosed with type 1 diabetes (T1D). Using thematic co-occurrence analysis, we identified interrelationships both among and across types of anticipated and experienced (dis)enfranchising talk (DT) and participants' responses to DT. Specifically, participants anticipated a lack of understanding and being accused of seeking pity or being incompetent in managing T1D. Participants experienced pressure from healthcare providers, unwanted intrusions, financial barriers, and negative self-talk. Participants responded to DT via denial, learning from others, and creating enfranchising messages. Utilizing a data matrix tool, we identify two theoretical relationships across types of DT and types of responses - a relationship between inability to manage T1D and experiencing unwanted intrusions from others, and between financial barriers and creating enfranchising messages. We offer theoretical implications and practical suggestions for people with T1D and their families, healthcare providers, and public health officials.

Association Between Self-Monitored Blood Glucose and Continuous Glucose Monitoring in Youth With Type 1 Diabetes and Medicaid Insurance

OBJECTIVE

Youth with type 1 diabetes (T1D) and Medicaid must demonstrate they have self-monitored their blood glucose level at least four times daily to receive continuous glucose monitors (CGMs). New California Medicaid policies eliminated this requirement and, thus, CGM access has increased. This study examines whether infrequent baseline self-monitored blood glucose (SMBG) checks result in suboptimal outcomes or nonadherence with CGM use.

RESEARCH DESIGN AND METHODS

This retrospective study included youth with T1D and Medicaid who started CGM after January 2019, when newer models no longer needed calibration, at two large health care systems. Patients were stratified by data on baseline SMBG frequency (<4 vs. ≥4 checks daily) collected at the clinic visit prior to starting CGM. Differences between SMBG groups in CGM adherence and HbA1c over time were assessed by a mixed-effects linear regression model and fixed-effect interaction term. Patients were surveyed to explore individual impact of CGM on diabetes management.

RESULTS

We followed 78 youth for 6 months. CGM adherence was similar between SMBG frequency groups at 3 months (68.7% vs. 68.4%; P = 0.97) and sustained at 6 months. HbA1c values improved in both groups at 3 months, with a larger improvement in those with SMBG <4 daily checks (1.3% vs. 0.4%), and sustained at 6 months. Patient surveys (n = 35) reported high engagement with CGM and increased insulin boluses after initiation.

CONCLUSIONS

Patients using CGM demonstrated improvement in HbA1c regardless of prior SMBG. Increased engagement with CGM likely promoted increased insulin boluses. Therefore, restriction of CGM to those with SMBG ≥4 daily checks is an unnecessary barrier, excluding those who could potentially benefit the most.

Understanding inequities in access to diabetes technologies in children and young people with type 1 diabetes: Qualitative study of healthcare professionals' perspectives and views

AIMS

We explored healthcare professionals' perceptions and understandings of the factors and considerations underlying inequities in technology access in children and young people (CYP) with type 1 diabetes.

METHODS

We interviewed (n = 29) healthcare professionals working in paediatric diabetes in England recruited from (n = 15) purposively selected sites. We analysed data thematically.

RESULTS

Interviewees highlighted multiple, often overlapping barriers to accessing technology faced by CYP with type 1 diabetes from deprived and/or ethnic minority backgrounds. They described the impacts of deprivation on technology uptake, together with the complex social, ethnic and cultural factors that could also reinforce disparities in technology access. Interviewees further highlighted staffing shortfalls as a significant barrier to supporting CYP to use technology, especially those from under-represented groups who they perceived as requiring more staff time to be trained to use technology. While interviewees suggested that unconscious bias has become less prominent, they reported being less likely to recommend technology (especially pumps) to CYP/caregivers who they feared would not use it safely and effectively (e.g. those with low literacy levels). Interviewees also highlighted geographical variability in the technology commissioning process (a 'postcode lottery').

CONCLUSIONS

Our findings suggest that without targeted interventions, technology inequities may continue to persist amongst CYP from the most and least deprived areas and from white and ethnic minority groups in the United Kingdom. Additionally, our findings suggest that closing the technology gap will require large-scale governmental and health policies aimed at fostering socioeconomic, ethnic and cultural equality alongside targeted measures to improve technology accessibility.

The Impact of Public Policy on Equitable Access to Technology for Children and Youth Living with Type 1 Diabetes in British Columbia, Canada

Objective: Structural inequities impede technology uptake in marginalized populations living with type 1 diabetes (T1D). Our objective was to describe hemoglobin A1c (HbA1c), time in range (TIR), and pump use to evaluate the impact of a universal funding policy for continuous glucose monitoring (CGM) across levels of deprivation in children with T1D in the Canadian province of British Columbia (BC). Methods: Patients with T1D and at least one outpatient visit after June 10, 2020 (1-year before universal CGM funding) who were enrolled in the BC Pediatric Diabetes Registry were included (n = 477). The Canadian Index of Multiple Deprivation (quintile 1 = least deprived; quintile 5 = most deprived) was determined using postal code. Mixed effects models were used to describe HbA1c, TIR, and pump use, and an interrupted time series generalized additive model estimated the change in CGM use pre- and postintroduction of universal coverage. Results: No differences were observed among the five levels of deprivation for HbA1c and TIR; however, for residential instability, those with the highest level of deprivation had a lower probability of pump use (-18.9%, 95% confidence interval [CI] = -26.1% to -11.7% for quintile 5 vs. 1). There was an increase in CGM uptake across all levels of deprivation 1-year after introduction of universal CGM funding. For example, the difference in sensor use from the most to least deprived situational group was -21.0% (-35.4%, -6.6%) at the time of universal coverage and shrank to -4.6% (-21.6%, 12.4%) after 12 months of coverage. However, an equity gap in CGM use persisted between the least and most deprived groups (-21.9, 95% CI = -34.5 to -9.4 for quintile 5 vs. 1 in economic dependency). Conclusions: Universal coverage of CGM improved uptake; however, equity gaps persisted. More research is needed to explore nonfinancial barriers to diabetes technology use in marginalized populations.

Discordance Between Clinician and Person-With-Diabetes Perceptions Regarding Technology Barriers and Benefits

The quality of clinician-patient relationship is integral to patient health and well-being. This article is a narrative review of published literature on concordance between clinician and patient perspectives on barriers to diabetes technology use. The goals of this manuscript were to review published literature on concordance and to provide practical recommendations for clinicians and researchers. In this review, we discuss the qualitative and quantitative methods that can be applied to measure clinician and patient concordance. There is variability in how concordance is defined, with some studies using questionnaires related to working alliance, while others use a dichotomous variable. We also explore the impact of concordance and discordance on diabetes care, barriers to technology adoption, and disparities in technology use. Published literature has emphasized that physicians may not be aware of their patients' perspectives and values. Discordance between clinicians and patients can be a barrier to diabetes management and technology use. Future directions for research in diabetes technology including strategies for recruiting and retaining representative samples, are discussed. Recommendations are given for clinical care, including shared decision-making frameworks, establishing social support groups optimizing clinician-patient communication, and using patient-reported outcomes to measure patient perspectives on outcomes of interest.

Consensus Report on the Use of Continuous Glucose Monitoring in Chronic Kidney Disease and Diabetes

This report represents the conclusions of 15 experts in nephrology and endocrinology, based on their knowledge of key studies and evidence in the field, on the role of continuous glucose monitors (CGMs) in patients with diabetes and chronic kidney disease (CKD), including those receiving dialysis. The experts discussed issues related to CGM accuracy, indications, education, clinical outcomes, quality of life, research gaps, and barriers to dissemination. Three main goals of management for patients with CKD and diabetes were identified: (1) greater use of CGMs for better glycemic monitoring and management, (2) further research evaluating the accuracy, feasibility, outcomes, and potential value of CGMs in patients with end-stage kidney disease (ESKD) on hemodialysis, and (3) equitable access to CGM technology for patients with CKD. The experts also developed 15 conclusions regarding the use of CGMs in this population related to CGMs' unique delivery of both real-time information that can guide monitoring and management of glycemia and continuous and predictive data in this population, which is at higher risk for hypoglycemia and hyperglycemia. The group noted three major clinical gaps: (1) CGMs are not routinely prescribed for patients with diabetes and CKD; (2) CGMs are not approved by the United States Food and Drug Administration (FDA) for patients with diabetes who are on dialysis; and (3) CGMs are not routinely available to all of those who need them because of structural barriers in the health care system. These gaps can be improved with greater stakeholder collaboration, education, and awareness brought to the use of CGM technology in CKD.

Addressing Inequity in Continuous Glucose Monitoring Access: Leveraging the Hospital in the Continuum of Care

BACKGROUND

While continuous glucose monitoring (CGM) has transformed the care of people with diabetes (PWD) in the ambulatory setting, there continue to be significant barriers to access. With CGM on the horizon in the acute care setting, it is important to consider the potential for this shift to improve ambulatory CGM access to those at the highest risk of morbidity and mortality.

METHODS

In this commentary, we review the existing literature on the specific barriers to CGM access for individuals with diabetes in the United States including racial disparities, provider bias, cost and shortage of specialty diabetes care. Key areas explored include the importance of CGM in diabetes management, the consequences of disparities in access to CGM, and leveraging the inpatient setting to promote equitable care and better outcomes for PWD.

RESULTS

We present a vision for a new care model, which leverages the transition of care from the hospital to successfully incorporate CGM into the discharge plan.

CONCLUSIONS

Given that CGM utilization is associated with improved outcomes and reduced rates of hospitalization and emergency department visits, a care model that facilitates CGM access upon transition from inpatient to ambulatory care can enhance health equity and quality of life for people with diabetes.

Insights from Team Clinic: A Person-Centered Virtual Peer Group Care Model Adapted for Marginalized and Historically Excluded Youth with Type 1 Diabetes (T1D)

BACKGROUND

Despite advancements in T1D care regimens, racially and ethnically diverse youth with low income continue to experience worse health outcomes, more psychosocial challenges, and higher barriers to care. Alternative care models are needed to address the needs of this population.

METHODS

Team Clinic is a person-centered virtual peer group (VPG) care model that was assessed in a 15-month, pragmatic randomized controlled trial. Youth (ages 10-17) and their families were assigned to study arms based on their clinician's group (standard care or person-centered care, PCC) and then randomized to VPGs or no groups.

RESULTS

Data from 79 youth and their families were examined. While positive outcomes were seen across all study groups, youth that participated in Team Clinic (PCC + VPG) reported the largest increases in resilience at the end of the study (+7.42, to 51.63, p = 0.009). These participants also reported the lowest levels of depressive symptoms as assessed by PHQ-8 scores (-5.07, p = 0.002) at the end of the study.

CONCLUSION

Team Clinic can serve as an alternative care model for racially and ethnically diverse youth with T1D and their families. VPGs can provide unique benefits, including an increase in resilience, a decrease in depressive symptoms, and a safe space for families to connect, learn, and receive support.

Improving equity in diabetes technology use: Voices of youth and their parents

AIMS

There are marked inequities in clinical outcomes and rates of diabetes technology use among youth with type 1 diabetes (T1D). The quantitative data from our mixed methods cohort study identified significant improvements in glycaemia and quality of life in participants. We aimed to use qualitative methods to provide further insight into our quantitative findings in the setting of underlying health disparities.

METHODS

Fifteen publicly insured, insulin pump-naïve non-Hispanic Black youth aged 6-21 years with T1D and baseline haemoglobin A1c (HbA1c) ≥86 mmol/mol (10%) and their parents participated in a mixed methods cohort study. Semi-structured interviews were conducted separately with parents and youth after completion of 6 months of HCL use. Three topic areas were explored: (1) Experience using HCL, (2) barriers to HCL and (3) facilitators to accessing HCL. Semantic content analysis and consensus coding involving two team members were used to generate themes. Thematic saturation was achieved.

RESULTS

Youth (Medianage 14.9 years, 67% female) and parents (92% female) were interviewed. Youth and their parents reported that access to HCL provides a new outlook on living with T1D, although managing T1D is still hard. They felt that diabetes technology is most helpful for those struggling with management. Participants experienced barriers to access including misconceptions of HCL systems, clinician bias and systemic racism. They suggested these barriers can be overcome by offering diabetes technology education for all people with T1D, increasing awareness of HCL in the community and providing resources to overcome barriers created by social determinants of health.

CONCLUSIONS

The voices of historically minoritised youth with suboptimal T1D control and their parents provide important, previously unreported experiences and perspectives on barriers and facilitators to using HCL that will shape interventions to improve equity in access to diabetes technology.

Technology and Continuous Glucose Monitoring Access, Literacy, and Use Among Patients at the Diabetes Center of an Inner-City Safety-Net Hospital: Mixed Methods Study

BACKGROUND

Despite the existence of an increasing array of digital technologies and tools for diabetes management, there are disparities in access to and uptake and use of continuous glucose monitoring (CGM) devices, particularly for those most at risk of poor diabetes outcomes.

OBJECTIVE

This study aims to assess communication technology and CGM access, literacy, and use among patients receiving treatment for diabetes at an inner-city safety-net hospital.

METHODS

A survey on digital technology ownership and use was self-administered by 75 adults with type 1 and type 2 diabetes at the diabetes clinic of Grady Memorial Hospital in Atlanta, Georgia. In-depth interviews were conducted with 16% (12/75) of these patient participants and 6 health care providers (HCPs) to obtain additional insights into the use of communication technology and CGM to support diabetes self-management.

RESULTS

Most participants were African American (66/75, 88%), over half (39/75, 52%) were unemployed or working part time, and 29% (22/75) had no health insurance coverage, while 61% (46/75) had federal coverage. Smartphone ownership and use were near universal; texting and email use were common (63/75, 84% in both cases). Ownership and use of tablets and computers and use and daily use of various forms of media were more prevalent among younger participants and those with type 1 diabetes, who also rated them as easier to use. Technology use specifically for diabetes and health management was low. Participants were supportive of a potential smartphone app for diabetes management, with a high interest in such an app helping them track blood sugar levels and communicate with their care teams. Younger participants showed higher levels of interest, perceived value, and self-efficacy for using an app with these capabilities. History of CGM use was reported by 56% (42/75) of the participants, although half (20/42, 48%) had discontinued use, above all due to the cost of the device and issues with its adhesive. Nonuse was primarily due to not being offered CGM by their HCP. Reasons given for continued use included convenience, improved blood glucose control, and better tracking of blood glucose. The in-depth interviews (n=18) revealed high levels of satisfaction with CGM by users and supported the survey findings regarding reasons for continued use. They also highlighted the value of CGM data to enhance communication between patients and HCPs.

CONCLUSIONS

Smartphone ownership was near universal among patients receiving care at an inner-city hospital. Alongside the need to address barriers to CGM access and continued use, there is an opportunity to leverage increased access to communication technology in combination with CGM to improve diabetes outcomes among underresourced populations.

Expansion of Medicaid Coverage of Continuous Glucose Monitor Reduces Health Disparity in Children and Young Adults With Type 1 Diabetes

BACKGROUND

Continuous glucose monitor (CGM) usage improves glycemia in people with type 1 diabetes (PWD) and is accepted as the standard of care. The CGM utilization is lower in patients with public insurance and minorized ethnicities. In 2022, California Medicaid reduced its barriers to obtaining CGM coverage for PWD. It is unknown whether this policy change is sufficient to increase CGM usage. We hypothesize that the change in Medicaid coverage improved CGM uptake in children and young adults with T1D.

METHODS

Data were extracted from electronic medical record of a large urban children's hospital in 2021 and 2022. The CGM usage was determined based on clinician documentation or the presence of CGM downloads. Kruskal-Wallis tests, Wald tests, and χ2 tests were used to test hypothesis (P < .05). Mixed effects logistical regression analyses were performed.

RESULTS

We included 878 and 892 PWD (age ≤ 21 years) in 2021 and 2022, respectively. In 2022, Medicaid insured 59.3% of patients. Between 2021 and 2022, CGM usage did not change for privately insured patients (84%) but increased from 41% to 58% for patients receiving Medicaid. In our mixed effects logistic regression model, CGM usage was higher in 2022 and in English speakers. Public insurance, black race, and patients' age were negatively associated with CGM usage.

CONCLUSION

Our results suggest that Medicaid expansion of CGM coverage increases its utilization for pediatric PWD but did not eliminate the disparity. Future studies are needed to identify barriers that preclude equity in technology uptake.

Use of diabetes technology in children

Children with type 1 diabetes and their caregivers face numerous challenges navigating the unpredictability of this complex disease. Although the burden of managing diabetes remains significant, new technology has eased some of the load and allowed children with type 1 diabetes to achieve tighter glycaemic management without fear of excess hypoglycaemia. Continuous glucose monitor use alone improves outcomes and is considered standard of care for paediatric type 1 diabetes management. Similarly, automated insulin delivery (AID) systems have proven to be safe and effective for children as young as 2 years of age. AID use improves not only blood glucose levels but also quality of life for children with type 1 diabetes and their caregivers and should be strongly considered for all youth with type 1 diabetes if available and affordable. Here, we review key data on the use of diabetes technology in the paediatric population and discuss management issues unique to children and adolescents.

Parent, child, and adolescent lived experience using the insulin-only iLet Bionic Pancreas

OBJECTIVE

Automated insulin delivery (AID) systems show great promise for improving glycemic outcomes and reducing disease burden for youth with type 1 diabetes (T1D). The current study examined youth and parent perspectives after using the insulin-only iLet Bionic Pancreas (BP) during the 13-week pivotal trial.

METHODS

Parents and youth participated in focus group interviews, with questions assessing participants' experiences in a variety of settings and were grounded in the Unified Theory of Acceptance and Use of Technology. Qualitative analysis was completed by 3 authors using a hybrid thematic analysis approach.

RESULTS

Qualitative analysis of focus groups revealed a total of 19 sub-themes falling into 5 major themes (Diabetes Burden, Freedom and Flexibility, Daily Routine, Managing Glucose Levels, and User Experience). Participants' overall experience was positive, with decreased burden and improved freedom and flexibility. Some participants reported challenges in learning to trust the system, adjusting to the user interface, and the system learning their body.

CONCLUSION

This study adds to the growing literature on patient perspectives on using AID systems and was among the first to assess caregiver and youth experiences with the BP system over an extended period (13 weeks). Patient feedback on physical experiences with the device and experiences trusting the device to manage glucose should inform future development of technologies as well as approaches to education for patients and their families.

Reducing Inequity in the Use of Automated Insulin Delivery Systems by Adults With Type 1 Diabetes: Key Learnings From a Safety Net Diabetes Clinic Program

BACKGROUND

Recent advancements in diabetes technology have significantly improved Type 1 diabetes (T1D) management, but disparities persist, particularly in the adoption of automated insulin delivery (AID) systems within minoritized communities. We aimed to improve patient access to AID system training and overcome clinical inertia to referral.

METHODS

We report on a transformative program implemented at Boston Medical Center, the largest safety-net hospital in New England, aimed at reducing disparities in AID system utilization. We employed a multidisciplinary team and quality improvement principles to identify barriers and develop solutions. Strategies included increasing access to diabetes educators, creating a referral system, and developing telemedicine education classes. We also made efforts to raise clinician awareness and confidence in recommending AID therapy.

RESULTS

At baseline, 13.5% of our clinic T1D population was using an insulin pump. The population referred included 97 people with T1D (49% female, mean A1c 8.7%, 68% public insurance beneficiaries, 25% Hispanic and 25% non-Hispanic Black). Results from the first year showed a 166% increase in AID system use rates, with 64% of referred patients starting on AID. Notably, 78% of patients with A1c >8.5% adopted AID systems, addressing a gap in representation observed in clinical efficacy trials. The initiative successfully narrowed disparities in AID use among minoritized populations.

CONCLUSIONS

The program's success among minoritized patients underscores the significance of tailored, collaborative, team-based care and targeted educational initiatives. Our experience provides a foundation for future efforts to ensure equitable access to diabetes technologies, emphasizing the potential of local quality improvement interventions.

Social deprivation and diabetic kidney disease: A European view

There is a large body of literature demonstrating a social gradient in health and increasing evidence of an association between social deprivation and diabetes complications. Diabetic kidney disease (DKD) increases mortality in people with diabetes. Socioeconomic deprivation is increasingly recognized as a modifier of risk factors for kidney disease but also an independent risk factor itself for kidney disease. This may not be truly appreciated by clinicians and warrants further attention and exploration. In this review we explore the literature to date from Europe on the relationship between social deprivation and DKD. The majority of the studies showed at least an association with microalbuminuria, an early marker of DKD, while many showed an association with overt nephropathy. This was seen across many countries in Europe using a variety of different measures of deprivation. We reviewed and considered the mechanisms by which deprivation may lead to DKD. Health related behaviors such as smoking and suboptimal control of risk factors such as hypertension, hyperglycemia and elevated body mass index (BMI) accounts for some but not all of the association. Poorer access to healthcare, health literacy, and stress are also discussed as potential mediators of the association. Addressing deprivation is difficult but starting points include targeted interventions for people living in deprived circumstances, equitable roll out of diabetes technology, and flexible outpatient clinic arrangements including virtual and community-based care.

Virtual insulin pump initiation is safe effective in children adolescents with type 1 diabetes

Objective

There is no head-to-head comparison of the safety and efficacy of virtual versus in-office insulin pump initiation for youth with type 1 diabetes in the US. The study's aim was to determine the safety and efficacy of virtual versus in-office pump initiation in pediatric type 1 diabetes.

Research design and methods

A longitudinal retrospective study of 112 subjects: 65% (n=73), ages 11.2 ± 3.8 years(y), received in-office training; and 35% (n=39), ages 12.0 ± 4.0y, received virtual training. The number of White subjects was 40 (55%) in the in-office group, and 25 (66%) in the remote group; while Black subjects were 11 (15%) in the in-office group and 4 (10%) in the virtual group. Data were collected at pump initiation, 3 and 6 months.

Results

There were no significant differences in sex, race, height, weight, BMI, and the duration of diabetes between the groups at baseline. There was no significant difference in A1c between the groups at 0, 3, and 6 months. A1c correlated significantly with the glucose management indicator at 0, 3, and 6 months: baseline: r=0.49, p<0.0001; 3 months: r=0.77, p<0.0001; and 6 months: r=0.71, p<0.0001. There was no relationship between A1c or TIR and pubertal status, BMI, sex, or race. A1c was significantly elevated in the non-White individuals at 6 months only: 57.9 mmol/mol (50.8-69.4) versus 51.9 mmol/mol (46.5-59.6)], p=0.007.

Conclusion

Virtual insulin pump initiation is safe and effective in children with type 1 diabetes. This approach could accelerate the adoption of the use of diabetes technology in minority populations in the US.

The impact of socioeconomic factors, social determinants, and ethnicity on the utilization of glucose sensor technology among persons with diabetes mellitus: a narrative review

Continuous glucose monitoring (CGM) usage has been shown to improve disease outcomes in people living with diabetes by facilitating better glycemic management. However, previous research has suggested that access to these devices can be influenced by nonmedical factors such as socioeconomic status and ethnicity. It is critical that equitable access to CGM devices is ensured as people from those groups experience poorer diabetes-related health outcomes. In this narrative review, we provide an overview of the various healthcare systems worldwide and how socioeconomic status, social context, and ethnicity shape device usage and the associated health outcomes. In general, we found that having a lower socioeconomic status and belonging to an ethnic minority group negatively impact CGM usage. While financial means proved to be an important mediator in this process, it was not the sole driver as disparities persisted even after adjustment for factors such as income and insurance status. Recommendations to increase CGM usage for people of a lower socioeconomic status and ethnic minorities include increasing the availability of financial, administrative, and educational support, for both patients and healthcare providers. However, recommendations will vary due to local country-specific circumstances, such as reimbursement criteria and healthcare ecosystems.

A Systematic Review of the Effects of Provider Bias on Health in Youth and Young Adults with Type 1 Diabetes

PURPOSE OF REVIEW

Although pervasive inequities in the health outcomes of youth and young adults with type 1 diabetes (T1D) exist, the role of provider bias in these inequities is not well-understood. The purpose of this review is to synthesize evidence from existing studies on the associations between patient characteristics, provider bias, and patient health.

RECENT FINDINGS

Fourteen articles were included. Determining the extent of the effects of provider bias on patient health is limited by a lack of consensus on its definition. Experiences of provider bias (e.g., shaming, criticism) negatively affects self-esteem, relationships with medical providers, and depressive symptoms. Provider bias also impacts diabetes technology recommendations, insulin regimen intensity, and risk for life-threatening T1D complications. Future studies are needed to develop questionnaires and interviews that better account for diverse experiences and interpretations of bias in T1D healthcare. More research is also needed to investigate mitigating factors to reduce provider bias as a way to improve psychological and physical health in individuals with T1D.

Optimizing Glycemic Outcomes for Minoritized and Medically Underserved Adults Living with Type 1 Diabetes

Individuals living with type 1 diabetes (T1D) from medically underserved communities have poorer health outcomes. Efforts to improve outcomes include a focus on team-based care, activation of behavior change, and enhancing self-management skills and practices. Advanced diabetes technologies are part of the standard of care for adults with T1D. However, health care providers often carry implicit biases and may be uncomfortable with recommending technologies to patients who have traditionally been excluded from efficacy trials or have limited real-world exposure to devices. We review the literature on this topic and provide an approach to address these issues in clinical practice.

Psychosocial Care for Youth with Type 1 Diabetes: Summary of Reviews to Inform Clinical Practice

The intensive demands of diabetes care can be difficult for youth with type 1 diabetes and their families to integrate into daily life. Standards of care in pediatric diabetes highlight the importance of evidence-based psychosocial interventions to optimize self-management behaviors and psychological well-being. The current review summarizes select systematic reviews and meta-analyses on evidence-based behavioral health interventions in pediatric diabetes. Interventions include strategies to strengthen youth psychosocial skills, improve family dynamics and caregiver mental health, enhance health and mental health equity, and address psychosocial factors related to diabetes technology use.

Addressing disparities in technology use among patients with type 1 diabetes: a review

PURPOSE OF REVIEW

The benefits of continuous glucose monitors (CGMs) and insulin pumps in the management of type 1 diabetes (T1D) are widely recognized. However, glaring disparities in access exist, particularly in marginalized and economically disadvantaged groups that stand to benefit significantly from diabetes technology use. We will review recent data describing drivers of these disparities and approaches to address the disparities.

RECENT FINDINGS

Several qualitative studies were published in recent years that have investigated the drivers of disparities reported over the past decades. These studies report that in addition to typical barriers seen in the diabetes technology, marginalized patients have unique challenges that make insulin pumps and CGMs less accessible.

SUMMARY

Barriers to technology use in these groups include stigmatization, lack of support, financial constraints, provider biases, stringent insurance policies, and clinic infrastructure. To address inequities, multifaceted strategies across community, healthcare, and provider sectors are essential. Key initiatives include enhancing public awareness, refining health policies, ensuring access to high-quality care, and emphasizing patient-centered approaches. The equitable use of technology can narrow the gap in T1D outcomes. The social and economic implications of suboptimal T1D management further underscore the urgency of these efforts for both improved health outcomes and cost-efficient care.

A scoping review of research on potential impact of implicit bias in healthcare settings for children with acquired brain injuries

PURPOSE/OBJECTIVE

Acquired brain injury (ABI) is a leading cause of disability in children and adolescents. Implicit biases within pediatric ABI healthcare settings may exert negative effects on clinical interactions and medical decision-making processes. This study aimed to conduct a scoping review of current research that examines the potential impact of implicit biases in such healthcare settings for children with ABI.

RESEARCH METHOD/DESIGN

Following PRISMA-ScR guidelines, a search among five databases (CINAHL, Cochrane CENTRAL, PubMed, PsycArticles, and PsycInfo) was conducted, followed by abstract/full-text screening and data extraction. Main characteristics of the included studies, including research design, relevance to implicit biases, and public health impact were synthesized. The risk of bias of included studies was assessed.

RESULTS

Out of the 203 articles returned from the literature search, a total of three studies met the inclusion criteria for the present review. All studies examined the relevance of racial/ethnic biases for evaluating abusive head trauma or nonaccidental trauma. The included studies had an overall unclear to low risk of biases.

CONCLUSIONS/IMPLICATIONS

This scoping review identified scarce but emerging evidence of the presence and detrimental impact of potential implicit biases on the access and quality of care received by children with ABI. More research is needed to examine the causes, process mechanisms, and consequences of implicit biases in pediatric ABI healthcare settings. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Current Practices in Operationalizing and Addressing Racial Equity in the Provision of Type 1 Diabetes Care: Insights from the Type 1 Diabetes Exchange Quality Improvement Collaborative Health Equity Advancement Lab

OBJECTIVE

Medical racism contributes to adverse health outcomes. Type 1 Diabetes Exchange Quality Improvement Collaborative (T1DX-QI) is a large population-based cohort engaged in data sharing and quality improvement to drive system changes in T1D care. The annual T1DX-QI survey included questions to evaluate racial equity in diabetes care and practices to promote equity.

METHODS

The annual T1DX-QI survey was administered to participating clinics in fall 2022 and had a 93% response rate. There were 50 responses (pediatric: 66% and adult: 34%). Questions, in part, evaluated clinical resources and racial equity. Response data were aggregated, summarized, and stratified by pediatric/adult institutions.

RESULTS

Only 21% pediatric and 35% adult institutions felt that all their team members can articulate how medical racism contributes to adverse diabetes outcomes. Pediatric institutions reported more strategies to address medical racism than adult (3.6 vs 3.1). Organizational strategies to decrease racial discrimination included employee trainings, equity offices/committees, patient resources, and hiring practices. Patient resources included interpreter services, transportation, insurance navigation, and housing and food assistance. Hiring practices included changing prior protocols, hiring from the community, and diversifying workforces. Most institutions have offered antiracism training in the last year (pediatric: 85% and adult: 72%) and annually (pediatric: 64% and adult: 56%). Pediatric teams felt that their antiracism training was effective more often (pediatric: 60% and adult: 45%) and more commonly, they were provided resources (pediatric: 67% and adult: 47%) to help address inequities.

CONCLUSION

Despite increased antiracism training, insufficient institutional support and perceived subeffective training still represent obstacles, especially in adult institutions. Sharing effective strategies to address medical racism will help institutions take steps to mitigate inequities.

Barriers and Facilitators to Uptake of Continuous Glucose Monitoring for Management of Type 2 Diabetes Mellitus in Youth

PURPOSE

The purpose of this study was to identify factors impacting the acceptability of continuous glucose monitoring (CGM) in adolescents and young adults (AYAs) with type 2 diabetes mellitus (T2DM).

METHODS

In this single-center study, semistructured interviews were conducted with AYAs with T2DM and their parents to determine attitudes about CGM, including barriers and facilitators. Interviews were audio-recorded, transcribed, and evaluated using thematic analysis.

RESULTS

Twenty AYAs and 10 parents participated (n = 30 total). AYAs were mean age 16.5 years (SD 2.2, range = 13.7-20.1) and had median diabetes duration of 1.3 years. Most were female (65%) and from minoritized background (40% non-Hispanic Black, 10% Hispanic, 5% Asian). Seven (35%) used CGM. The primary facilitator elicited was convenience over glucose meter use. Important barriers included the impact of physically wearing the device and drawing unwanted attention, desire for AYA privacy, and inadequate education about the device.

CONCLUSIONS

In this diverse sample of AYAs with T2DM and their parents, CGM was generally regarded as convenient, although concerns about worsening stigma and conflict with parents were prevalent. These findings can guide the development of patient-centered approaches to CGM for AYAs with T2DM, a critical step toward reducing inequities in diabetes technology uptake.

Interventions Across the Translational Research Spectrum: Addressing Disparities Among Racial and Ethnic Minoritized Youth with Type 1 Diabetes

Racial and ethnic minoritized youth with type 1 diabetes (T1D) are at elevated risk for health disparities. Few intervention studies have been conducted for these youth and evidence to support best practices to address their needs is lacking. Existing evidence supports the use of brief trials of diabetes technology with structured support from clinic staff, culturally tailored interventions such as language-congruent clinical care, and use of community health workers as promising directions to improve health outcomes. Clinicians and researchers should work collaboratively with community members to improve the quality of T1D intervention science for racial and ethnic minoritized youth.

Implicit or Unconscious Bias in Diabetes Care

"Implicit bias," also called "unconscious bias," refers to associations outside of conscious awareness that adversely affect one's perception of a person or group. Awareness of implicit bias has been increasing in the realm of diabetes care. Here, the authors highlight several types of unconscious bias on the part of clinicians and patients, including biases based on race, ethnicity, and obesity. They discuss how these biases can negatively affect patient-centered clinical interactions and diabetes care delivery, and they recommend implementation of evidence-based interventions and other health system policy approaches to reduce the potential impact of such biases in health care settings.

Roadmap to the Effective Use of Continuous Glucose Monitoring by Diabetes Care and Education Specialists as Technology Champions

This article describes the implementation of a diabetes technology educational program targeting continuous glucose monitoring (CGM) adoption that significantly increased utilization of CGM in the Division of Pediatric Endocrinology at the University of Florida. The author proposes that diabetes care and education specialists (DCESs) are uniquely positioned in the health care ecosystem to serve as diabetes technology champions. The article provides a step-by-step roadmap that DCESs and clinicians can use as they lead efforts to expand CGM adoption and durable use.

Benchmarking Diabetes Technology Use Among 21 U.S. Pediatric Diabetes Centers

The American Diabetes Association's Standards of Care in Diabetes recommends the use of diabetes technology such as continuous glucose monitoring systems and insulin pumps for people living with type 1 diabetes. Unfortunately, there are multiple barriers to uptake of these devices, including local diabetes center practices. This study aimed to examine overall change and center-to-center variation in uptake of diabetes technology across 21 pediatric centers in the T1D Exchange Quality Improvement Collaborative. It found an overall increase in diabetes technology use for most centers from 2021 to 2022 with significant variation.

Association of Continuous Glucose Monitor Receipt and Diabetes Care Provider Type: A Cohort Study of West Virginia Medicaid Beneficiaries With Type 1 Diabetes

OBJECTIVE

To compare the prevalence of West Virginia Medicaid (WVM) beneficiaries with type 1 diabetes (T1D) with a WVM administrative claim for continuous glucose monitoring (CGM) supplies by whether they received medical care from a board-certified endocrinologist.

METHODS

A total of 1494 WVM beneficiaries aged 20-64 with T1D were retrospectively followed from May 2018 to April 2020. The sample consisted of 2 groups: those receiving medical care from board-certified endocrinologists and those receiving medical care from other providers. CGM prevalence is compared before and after WVM started providing insurance coverage for beneficiaries with T1D to use CGM systems in May 2019 using linear regression with and without adjustments for patient characteristics.

RESULTS

Thirty-five percent of beneficiaries received care from a board-certified endocrinologist at any point during the sample period. Post-May 2019, the prevalence of WVM administrative claims for CGM supplies was significantly higher among beneficiaries receiving care from an endocrinologist compared with other providers.

CONCLUSIONS

Receiving diabetes care from a board-certified endocrinologist is positively associated with having administrative claims for CGM supplies.

Social Determinant of Health Impact on Diabetes Device Use and Clinical Outcomes in Youth with Type 1 Diabetes

Background

Youth with Type 1 diabetes (T1D) who are Black, Hispanic, or lower socioeconomic status (SES) have lower rates of diabetes device use, higher hemoglobin A1c (HbA1c), and higher rates of diabetic ketoacidosis (DKA). However, the associations of individual-level social determinants of health (SDoH) and neighborhood-level factors with device use and clinical outcomes are unknown. Area deprivation index (ADI) is a neighborhood level measure of SES reported in deciles (range 1-10 with 10 representing most deprived neighborhood).

Methods

We evaluated the association of ADI and other SDoH factors with pump/continuous glucose monitor (CGM) use, HbA1c, and DKA in 1,461 youth with T1D (50% female, age 12.8 ± 3.6 years, HbA1c 8.7 ± 2.1%, 52% pump, 70% CGM) seen between October 1, 2020 and September 30, 2021 at a large pediatric diabetes center. Multiple logistic regression and multiple linear regression analyses were used to determine statistically significant associations adjusting for potential confounders.

Results

Youth were less likely to use an insulin pump if they lived in a higher ADI neighborhood, were Black or Hispanic, had Medicaid or were uninsured, or received government assistance (e.g., Supplemental Security Income, Supplemental Nutritional Assistance Program). Youth were less likely to use a CGM if they lived in a higher ADI neighborhood, were Black or Hispanic, had Medicaid or were uninsured. Youth had higher risk of DKA event in the past year if they used government assistance, whereas pump and CGM use were associated with lower DKA risk. HbA1c (%) increased by 0.09 (95% CI: 0.05, 0.13) per unit increase in ADI. HbA1c was 0.62 lower (95% CI: -0.82, -0.42) in pump users vs. nonusers and 0.78 lower (95% CI: -0.99, -0.56) in CGM users vs. nonusers.

Conclusions

Interventions that tailor care plans to address SDoH in families living in deprived neighborhoods may be needed to increase successful technology uptake, optimize HbA1c, and prevent DKA.

Characteristics Associated With Telemonitoring Use Among Patients With Chronic Heart Failure: Retrospective Cohort Study

BACKGROUND

Chronic heart failure (HF) is a chronic disease affecting more than 64 million people worldwide, with an increasing prevalence and a high burden on individual patients and society. Telemonitoring may be able to mitigate some of this burden by increasing self-management and preventing use of the health care system. However, it is unknown to what degree telemonitoring has been adopted by hospitals and if the use of telemonitoring is associated with certain patient characteristics. Insight into the dissemination of this technology among hospitals and patients may inform strategies for further adoption.

OBJECTIVE

We aimed to explore the use of telemonitoring among hospitals in the Netherlands and to identify patient characteristics associated with the use of telemonitoring for HF.

METHODS

We performed a retrospective cohort study based on routinely collected health care claim data in the Netherlands. Descriptive analyses were used to gain insight in the adoption of telemonitoring for HF among hospitals in 2019. We used logistic multiple regression analyses to explore the associations between patient characteristics and telemonitoring use.

RESULTS

Less than half (31/84, 37%) of all included hospitals had claims for telemonitoring, and 20% (17/84) of hospitals had more than 10 patients with telemonitoring claims. Within these 17 hospitals, a total of 7040 patients were treated for HF in 2019, of whom 5.8% (409/7040) incurred a telemonitoring claim. Odds ratios (ORs) for using telemonitoring were higher for male patients (adjusted OR 1.90, 95% CI 1.50-2.41) and patients with previous hospital treatment for HF (adjusted OR 1.76, 95% CI 1.39-2.24). ORs were lower for higher age categories and were lowest for the highest age category, that is, patients older than 80 years (OR 0.30, 95% CI 0.21-0.44) compared to the reference age category (18-59 years). Socioeconomic status, degree of multimorbidity, and excessive polypharmacy were not associated with the use of telemonitoring.

CONCLUSIONS

The use of reimbursed telemonitoring for HF was limited up to 2019, and our results suggest that large variation exists among hospitals. A lack of adoption is therefore not only due to a lack of diffusion among hospitals but also due to a lack of scaling up within hospitals that already deploy telemonitoring. Future studies should therefore focus on both kinds of adoption and how to facilitate these processes. Older patients, female patients, and patients with no previous hospital treatment for HF were less likely to use telemonitoring for HF. This shows that some patient groups are not served as much by telemonitoring as other patient groups. The underlying mechanism of the reported associations should be identified in order to gain a deeper understanding of telemonitoring use among different patient groups.

Increasing Continuous Glucose Monitoring Use for Non-Hispanic Black and Hispanic People With Type 1 Diabetes: Results From the T1D Exchange Quality Improvement Collaborative Equity Study

Despite the benefits of continuous glucose monitoring (CGM), there is lower use of this technology among non-Hispanic Black and Hispanic people with type 1 diabetes compared with their non-Hispanic White counterparts. The T1D Exchange Quality Improvement Collaborative recruited five endocrinology centers to pilot an equity-focused quality improvement (QI) study to reduce racial inequities in CGM use. The centers used rapid QI cycles to test and expand interventions such as provider bias training, translation of CGM materials, provision of CGM education in multiple languages, screening for social determinants of health, and shared decision-making. After implementation of these interventions, median CGM use increased by 7% in non-Hispanic White, 12% in non-Hispanic Black, and 15% in Hispanic people with type 1 diabetes. The gap between non-Hispanic White and non-Hispanic Black patients decreased by 5%, and the gap between non-Hispanic White and Hispanic patients decreased by 8%.

Socioeconomic status and diabetes technology use in youth with type 1 diabetes: a comparison of two funding models

Background

Technology use, including continuous glucose monitoring (CGM) and insulin pump therapy, is associated with improved outcomes in youth with type 1 diabetes (T1D). In 2017 CGM was universally funded for youth with T1D in Australia. In contrast, pump access is primarily accessed through private health insurance, self-funding or philanthropy. The study aim was to investigate the use of diabetes technology across different socioeconomic groups in Australian youth with T1D, in the setting of two contrasting funding models.

Methods

A cross-sectional evaluation of 4957 youth with T1D aged <18 years in the national registry was performed to determine technology use. The Index of Relative Socio-Economic Disadvantage (IRSD) derived from Australian census data is an area-based measure of socioeconomic status (SES). Lower quintiles represent greater disadvantage. IRSD based on most recent postcode of residence was used as a marker of SES. A multivariable generalised linear model adjusting for age, diabetes duration, sex, remoteness classification, and location within Australia was used to determine the association between SES and device use.

Results

CGM use was lower in IRSD quintile 1 in comparison to quintiles 2 to 5 (p<0.001) where uptake across the quintiles was similar. A higher percentage of pump use was observed in the least disadvantaged IRSD quintiles. Compared to the most disadvantaged quintile 1, pump use progressively increased by 16% (95% CI: 4% to 31%) in quintile 2, 19% (6% to 33%) in quintile 3, 35% (21% to 50%) in quintile 4 and 51% (36% to 67%) in the least disadvantaged quintile 5.

Conclusion

In this large national dataset, use of diabetes technologies was found to differ across socioeconomic groups. For nationally subsidised CGM, use was similar across socioeconomic groups with the exception of the most disadvantaged quintile, an important finding requiring further investigation into barriers to CGM use within a nationally subsidised model. User pays funding models for pump therapy result in lower use with socioeconomic disadvantage, highlighting inequities in this funding approach. For the full benefits of diabetes technology to be realised, equitable access to pump therapy needs to be a health policy priority.

Area deprivation and demographic factors associated with diabetes technology use in adults with type 1 diabetes in Germany

Introduction

Diabetes technology improves glycemic control and quality of life for many people with type 1 diabetes (T1D). However, inequalities in access to diabetes technology exist in many countries. In Germany, disparities in technology use have been described in pediatric T1D, but no data for adults are available so far. We therefore aimed to analyze whether demographic factors and area deprivation are associated with technology use in a representative population of adults with T1D.

Materials and methods

In adults with T1D from the German prospective diabetes follow-up registry (DPV), we analyzed the use of continuous subcutaneous insulin infusion (CSII), continuous glucose monitoring (CGM), and sensor augmented pump therapy (SAP, with and without automated insulin delivery) in 2019-2021 by age group, gender, migration background, and area deprivation using multiple adjusted regression models. Area deprivation, defined as a relative lack of area-based resources, was measured by quintiles of the German index of Multiple Deprivation (GIMD 2015, from Q1, least deprived, to Q5, most deprived districts).

Results

Among 13,351 adults with T1D, the use of technology decreased significantly with older age: CSII use fell from 56.1% in the 18-<25-year age group to 3.1% in the ≥80-year age group, CGM use from 75.3% to 28.2%, and SAP use from 45.1% to 1.5% (all p for trend <0.001). The use of technology was also significantly higher in women than in men (CSII: 39.2% vs. 27.6%; CGM: 61.9% vs. 58.0%; SAP: 28.7% vs. 19.6%, all p <0.001), and in individuals without migration background than in those with migration background (CSII: 38.8% vs. 27.6%; CGM: 71.1% vs. 61.4%; SAP: 30.5% vs. 21.3%, all p <0.001). Associations with area deprivation were not linear: the use of each technology decreased only from Q2 to Q4.

Discussion

Our real-world data provide evidence that higher age, male gender, and migration background are currently associated with lower use of diabetes technology in adults with T1D in Germany. Associations with area deprivation are more complex, probably due to correlations with other factors, like the higher proportion of migrants in less deprived areas or the federal structure of the German health care system.

The Insulin-Only Bionic Pancreas Improves Glycemic Control in Non-Hispanic White and Minority Adults and Children With Type 1 Diabetes

OBJECTIVE

We evaluated the performance of the iLet bionic pancreas (BP) in non-Hispanic White individuals (here referred to as "Whites") and in Black, Hispanic, and other individuals (here collectively referred to as "Minorities").

RESEARCH DESIGN AND METHODS

A multicenter, randomized controlled trial evaluated glycemic management with the BP versus standard of care (SC) in 161 adult and 165 pediatric participants with type 1 diabetes over 13 weeks.

RESULTS

In Whites (n = 240), the mean baseline-adjusted difference in 13-week HbA1c between the BP and SC groups was -0.45% (95% CI -0.61 to -0.29 [-4.9 mmol/mol; -6.6 to -3.1]; P < 0.001), while this difference among Minorities (n = 84) was -0.53% (-0.83 to -0.24 [-6.0 mmol/mol; -9.2 to -2.8]; P < 0.001). In Whites, the mean baseline-adjusted difference in time in range between the BP and SC groups was 10% (95% CI 7-12; P < 0.001) and in Minorities was 14% (10-18; P < 0.001).

CONCLUSIONS

The BP improves glycemic control in both Whites and Minorities and offers promise in decreasing health care disparities.

Disparities in Hemoglobin A1c Levels in the First Year After Diagnosis Among Youths With Type 1 Diabetes Offered Continuous Glucose Monitoring

IMPORTANCE

Continuous glucose monitoring (CGM) is associated with improvements in hemoglobin A1c (HbA1c) in youths with type 1 diabetes (T1D); however, youths from minoritized racial and ethnic groups and those with public insurance face greater barriers to CGM access. Early initiation of and access to CGM may reduce disparities in CGM uptake and improve diabetes outcomes.

OBJECTIVE

To determine whether HbA1c decreases differed by ethnicity and insurance status among a cohort of youths newly diagnosed with T1D and provided CGM.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used data from the Teamwork, Targets, Technology, and Tight Control (4T) study, a clinical research program that aims to initiate CGM within 1 month of T1D diagnosis. All youths with new-onset T1D diagnosed between July 25, 2018, and June 15, 2020, at Stanford Children's Hospital, a single-site, freestanding children's hospital in California, were approached to enroll in the Pilot-4T study and were followed for 12 months. Data analysis was performed and completed on June 3, 2022.

EXPOSURES

All eligible participants were offered CGM within 1 month of diabetes diagnosis.

MAIN OUTCOMES AND MEASURES

To assess HbA1c change over the study period, analyses were stratified by ethnicity (Hispanic vs non-Hispanic) or insurance status (public vs private) to compare the Pilot-4T cohort with a historical cohort of 272 youths diagnosed with T1D between June 1, 2014, and December 28, 2016.

RESULTS

The Pilot-4T cohort comprised 135 youths, with a median age of 9.7 years (IQR, 6.8-12.7 years) at diagnosis. There were 71 boys (52.6%) and 64 girls (47.4%). Based on self-report, participants' race was categorized as Asian or Pacific Islander (19 [14.1%]), White (62 [45.9%]), or other race (39 [28.9%]); race was missing or not reported for 15 participants (11.1%). Participants also self-reported their ethnicity as Hispanic (29 [21.5%]) or non-Hispanic (92 [68.1%]). A total of 104 participants (77.0%) had private insurance and 31 (23.0%) had public insurance. Compared with the historical cohort, similar reductions in HbA1c at 6, 9, and 12 months postdiagnosis were observed for Hispanic individuals (estimated difference, -0.26% [95% CI, -1.05% to 0.43%], -0.60% [-1.46% to 0.21%], and -0.15% [-1.48% to 0.80%]) and non-Hispanic individuals (estimated difference, -0.27% [95% CI, -0.62% to 0.10%], -0.50% [-0.81% to -0.11%], and -0.47% [-0.91% to 0.06%]) in the Pilot-4T cohort. Similar reductions in HbA1c at 6, 9, and 12 months postdiagnosis were also observed for publicly insured individuals (estimated difference, -0.52% [95% CI, -1.22% to 0.15%], -0.38% [-1.26% to 0.33%], and -0.57% [-2.08% to 0.74%]) and privately insured individuals (estimated difference, -0.34% [95% CI, -0.67% to 0.03%], -0.57% [-0.85% to -0.26%], and -0.43% [-0.85% to 0.01%]) in the Pilot-4T cohort. Hispanic youths in the Pilot-4T cohort had higher HbA1c at 6, 9, and 12 months postdiagnosis than non-Hispanic youths (estimated difference, 0.28% [95% CI, -0.46% to 0.86%], 0.63% [0.02% to 1.20%], and 1.39% [0.37% to 1.96%]), as did publicly insured youths compared with privately insured youths (estimated difference, 0.39% [95% CI, -0.23% to 0.99%], 0.95% [0.28% to 1.45%], and 1.16% [-0.09% to 2.13%]).

CONCLUSIONS AND RELEVANCE

The findings of this cohort study suggest that CGM initiation soon after diagnosis is associated with similar improvements in HbA1c for Hispanic and non-Hispanic youths as well as for publicly and privately insured youths. These results further suggest that equitable access to CGM soon after T1D diagnosis may be a first step to improve HbA1c for all youths but is unlikely to eliminate disparities entirely.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04336969.

Use of Continuous Glucose Monitors to Manage Type 1 Diabetes Mellitus: Progress, Challenges, and Recommendations

Type 1 diabetes (T1D) management has been revolutionized with the development and routine utilization of continuous glucose monitoring (CGM). CGM technology has allowed for the ability to track dynamic glycemic fluctuations and trends over time allowing for optimization of medical therapy and the prevention of dangerous hypoglycemic events. This review details currently-available real-time and intermittently-scanned CGM devices, clinical benefits, and challenges of CGM use, and current guidelines supporting its use in the clinical care of patients with T1D. We additionally describe future issues that will need to be addressed as CGM technology continues to evolve.

Increasing Use of Diabetes Devices: What Do Health Care Professionals Need?

Despite evidence of improved diabetes outcomes with diabetes technology such as continuous glucose monitoring (CGM) systems, insulin pumps, and hybrid closed-loop (HCL) insulin delivery systems, these devices are underutilized in clinical practice for the management of insulin-requiring diabetes. This low uptake may be the result of health care providers' (HCPs') lack of confidence or time to prescribe and manage devices for people with diabetes. We administered a survey to HCPs in primary care, pediatric endocrinology, and adult endocrinology practices in the United States. Responding HCPs expressed a need for device-related insurance coverage tools and online data platforms with integration to electronic health record systems to improve diabetes technology uptake in these practice settings across the United States.

Racial Disparities in Technology Use in Children With Type 1 Diabetes: A Qualitative Content Analysis of Parents' Perspectives

PURPOSE

The purpose of the study was to describe differences in non-Hispanic Black (NHB) and non-Hispanic White (NHW) parents' perceptions of factors that influence the use of diabetes technology.

METHODS

Focus groups were conducted with parents of NHB and NHW children at a pediatric diabetes center in the Northeast United States. Kilbourne's health disparities framework informed the focus group guide and a priori coding for directed content analysis. Further analysis allowed subcategories to emerge inductively.

RESULTS

Twenty-one parents participated. Five subcategories emerged, describing differences in NHB and NHW parent decisions regarding diabetes technology: (1) child's choice, (2) shame versus pride, (3) pros and cons of technology, (4) time frame, and (5) blood glucose indications of readiness. NHB parents feared technology malfunction, worried that visible devices could worsen experienced stigma of diabetes diagnosis, and described the diabetes team as gatekeepers, who changed eligibility criteria for diabetes technology use for their research purposes. In contrast, NHW parents reported diabetes team expectation of diabetes technology use and did not report provider-related barriers.

CONCLUSION

This study adds to existing literature advancing our understanding of the patient and provider mechanisms underlying racial disparities in diabetes technology use. This understanding may guide development of interventions focused on patients, providers, and structural factors to improve equity in use of diabetes technology by youth with type 1 diabetes.

Continuous glucose monitors and virtual care in high-risk, racial and ethnic minority populations: Toward promoting health equity

Continuous glucose monitors (CGMs) have become an important tool to aid self-management of blood glucose for many patients with diabetes in the U.S., and the benefits of CGM use are well-documented. However, disparities in CGM use exist, with lower use in certain marginalized racial and ethnic groups. CGM may be an important and underutilized tool to help reduce inequities. Evidence supporting the use of CGMs as a part of virtual care is discussed, with an emphasis on designing virtual diabetes care programs to promote health equity. Recommendations for clinical practice and research are presented. In clinical practice, CGM should be an option for all people with diabetes who qualify based on clinical practice guidelines, regardless of race, ethnicity, or other individual characteristics. Future research should characterize the use of, benefit from, and preferences for CGM among individuals from racial and ethnic groups to guide interventions at the health system, clinic, provider, and patient levels to promote equitable, evidence-based, and guideline-directed CGM use in marginalized racial and ethnic groups with diabetes.

Automated insulin delivery: benefits, challenges, and recommendations. A Consensus Report of the Joint Diabetes Technology Working Group of the European Association for the Study of Diabetes and the American Diabetes Association

A technological solution for the management of diabetes in people who require intensive insulin therapy has been sought for decades. The last 10 years have seen substantial growth in devices that can be integrated into clinical care. Driven by the availability of reliable systems for continuous glucose monitoring, we have entered an era in which insulin delivery through insulin pumps can be modulated based on sensor glucose data. Over the past few years, regulatory approval of the first automated insulin delivery (AID) systems has been granted, and these systems have been adopted into clinical care. Additionally, a community of people living with type 1 diabetes has created its own systems using a do-it-yourself approach by using products commercialised for independent use. With several AID systems in development, some of which are anticipated to be granted regulatory approval in the near future, the joint Diabetes Technology Working Group of the European Association for the Study of Diabetes and the American Diabetes Association has created this consensus report. We provide a review of the current landscape of AID systems, with a particular focus on their safety. We conclude with a series of recommended targeted actions. This is the fourth in a series of reports issued by this working group. The working group was jointly commissioned by the executives of both organisations to write the first statement on insulin pumps, which was published in 2015. The original authoring group was comprised by three nominated members of the American Diabetes Association and three nominated members of the European Association for the Study of Diabetes. Additional authors have been added to the group to increase diversity and range of expertise. Each organisation has provided a similar internal review process for each manuscript prior to submission for editorial review by the two journals. Harmonisation of editorial and substantial modifications has occurred at both levels. The members of the group have selected the subject of each statement and submitted the selection to both organisations for confirmation.

Racial Disparities in Access and Use of Diabetes Technology Among Adult Patients With Type 1 Diabetes in a U.S. Academic Medical Center

OBJECTIVE

Recent studies highlight racial disparities in insulin pump (PUMP) and continuous glucose monitor (CGM) use in children and adolescents with type 1 diabetes (T1D). This study explored racial disparities in diabetes technology among adult patients with T1D.

RESEARCH DESIGN AND METHODS

This was a retrospective clinic-based cohort study of adult patients with T1D seen consecutively from April 2013 to January 2020. Race was categorized into non-Black (reference group) and Black. The primary outcomes were baseline and prevalent technology use, rates of diabetes technology discussions (CGMdiscn, PUMPdiscn), and prescribing (CGMrx, PUMPrx). Multivariable logistic regression analysis evaluated the association of technology discussions and prescribing with race, adjusting for social determinants of health and diabetes outcomes.

RESULTS

Among 1,258 adults with T1D, baseline technology use was significantly lower for Black compared with non-Black patients (7.9% vs. 30.3% for CGM; 18.7% vs. 49.6% for PUMP), as was prevalent use (43.6% vs. 72.1% for CGM; 30.7% vs. 64.2% for PUMP). Black patients had adjusted odds ratios (aORs) of 0.51 (95% CI 0.29, 0.90) for CGMdiscn and 0.61 (95% CI 0.41, 0.93) for CGMrx. Black patients had aORs of 0.74 (95% CI 0.44, 1.25) for PUMPdiscn and 0.40 (95% CI, 0.22, 0.70) for PUMPrx. Neighborhood context, insurance, marital and employment status, and number of clinic visits were also associated with the outcomes.

CONCLUSIONS

Significant racial disparities were observed in discussions, prescribing, and use of diabetes technology. Further research is needed to identify the causes behind these disparities and develop and evaluate strategies to reduce them.