Inequities in Health Outcomes in Children and Adults With Type 1 Diabetes: Data From the T1D Exchange Quality Improvement Collaborative

Implementation and Evaluation of a Best Practice Advisory to Reduce Inequities in Technology Use for People With Type 1 Diabetes: Protocol for a Mixed Methods, Nonrandomized Controlled Trial

BACKGROUND

Continuous advancements in diabetes technologies have improved self-management for people with type 1 diabetes. Continuous glucose monitoring and automated insulin delivery systems have enhanced the quality of life and glycemic outcomes while reducing severe hypoglycemia and diabetes ketoacidosis hospitalizations. Despite these benefits, racial inequities in the use of advanced diabetes technology (ADT) persist.

OBJECTIVE

This study aims to develop and evaluate a best practice advisory (BPA) within the electronic medical record (EMR) to reduce racial and ethnic disparities in ADT use. We hypothesize that an EMR-based BPA designed to standardize the prescribing of ADTs will minimize racial and ethnic disparities in ADT adoption or progression in use among pediatric and adult people with type 1 diabetes.

METHODS

The Best Practice Advisories to Reduce Inequities in Technology Use (BPA-TECH) study will use a nonrandomized matched pair intervention design. Phase 1 will use qualitative methods to develop and refine the BPA, including focus groups and surveys of health care providers and people with type 1 diabetes or their caregivers. Phase 2 will evaluate the effectiveness of the BPA through a controlled before-after study of people with type 1 diabetes seen at 7 T1D Exchange Quality Improvement Collaborative (T1DX-QI) centers, with control people with type 1 diabetes matched from nonintervention T1DX-QI centers. The baseline and postintervention periods will be the 12 months before and 12 months after deployment of the BPA at the intervention centers, respectively. Eligibility criteria include people with type 1 diabetes aged ≥2 years with an EMR diagnosis of T1D during the baseline period. The primary outcome is the progression in ADT use from the baseline to postintervention periods.

RESULTS

This 3-year study began in July 2024, with data collection from key stakeholders for phase 1 qualitative research beginning in August 2024. For phase 2, we estimate approximately 3000 eligible non-Hispanic Black and Hispanic people with type 1 diabetes at the intervention centers and 15,000 matched controls. Data on ADT use, glycated hemoglobin (HbA1c), severe hypoglycemic events, and diabetes ketoacidosis events will be collected via the T1DX-QI coordinating center. The study is powered to detect a between-group difference of 15% in the proportion of patients in the intervention and control groups in meeting the primary endpoint. We anticipate the completion of this study by May 2027.

CONCLUSIONS

The BPA-TECH study aims to leverage health IT to address racial and ethnic disparities in ADT use among people with type 1 diabetes. By standardizing the approach to ADT prescribing for people with type 1 diabetes, the BPA-TECH has the potential to promote equity in diabetes management and improve clinical outcomes. The outcomes of this study will inform future efforts to reduce health care disparities.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06931275; https://clinicaltrials.gov/search?term=NCT06931275.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/71038.

Examining Medical and Demographic Associations With the Diabetes Management Questionnaire Among Racially Minoritized Youth With Type 1 Diabetes

PurposeThe purpose of this study was to examine demographic and diabetes-related factors with the Diabetes Management Questionnaire (DMQ) among racially minoritized youth with type 1 diabetes.MethodsA descriptive correlational study was employed. Youth and their caregivers were enrolled in a behavioral intervention to promote optimal continuous glucose monitoring (CGM) use along with completing the DMQ at baseline.ResultsParticipants included 60 youth ages 10 to 15 years (53% Black, 27% Hispanic/Latino/a/x, 12% another minoritized identity, 8% White; mean A1C = 10.6% ± 2.0%). Only child age was significantly associated with caregiver DMQ scores. No other demographic or medical variables, including A1C, were significantly related to DMQ scores. Mean youth DMQ scores significantly differed between samples, with the current sample reporting stronger adherence to diabetes management regimens despite higher overall A1C.ConclusionsThe lack of associations between the DMQ and demographic or medical variables in this sample compared to that of the validation sample suggest that the DMQ may have weaker psychometric properties among racially minoritized families. It is crucial that existing questionnaires like the DMQ be reexamined in a larger, more racially diverse population, where structural factors, beyond individual management behaviors, also influence A1C.

Disparities in technology utilization among youth with type 1 diabetes across diverse racial and socioeconomic backgrounds

BACKGROUND

Previous studies have demonstrated disparities in the utilization of diabetes technology among youth with type 1 diabetes (T1D) based on race and socioeconomic status (SES). Few studies have examined these differences on a national scale or among youth with commercial health insurance.

AIM

To investigate differences in the fill rates of insulin pumps and continuous glucose monitors (CGMs) among commercially insured children with T1D across diverse racial and SES groups.

METHODS

Using medical and pharmacy claims included in the OptumLabs Data Warehouse, we calculated the proportion of youth <18 years with T1D who had a fill for an insulin pump or a CGM, overall and stratified by race/ethnicity and annual household income, between 2011 and 2021.

RESULTS

Among 13,246 youth with T1D, 36.1% had CGM and 30.9% had pump fills. White youth had higher CGM and pump fills than black (CGMs: 35.8% vs 22.5%; pumps: 31.9% vs 21.2%, p<0.001) and Hispanic (CGMs: 35.8% vs 32.6%, p=0.047; pumps: 31.9% vs 25.0%, p<0.001). Youth from households with income

CONCLUSIONS

In a cohort of commercially insured youth with T1D, both race and income are important factors that can independently influence the use of diabetes technology. Racial disparities decrease with higher income and disappear at incomes ≥US$200,000. Black youth with income Collapse

Key Words

• Diabetes Mellitus, Type 1
• Disparities

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MESH Headings

• Adolescent
• Child
• Female
• Humans
• Male
• Blood Glucose Self-Monitoring/economics
• Blood Glucose Self-Monitoring/statistics & numerical data
• Diabetes Mellitus, Type 1/drug therapy
• Diabetes Mellitus, Type 1/economics
• Diabetes Mellitus, Type 1/ethnology
• Ethnicity/statistics & numerical data
• Follow-Up Studies
• Healthcare Disparities/statistics & numerical data
• Healthcare Disparities/ethnology
• Hypoglycemic Agents/administration & dosage
• Insulin/administration & dosage
• Insulin Infusion Systems/economics
• Insulin Infusion Systems/statistics & numerical data
• Prognosis
• Racial Groups/statistics & numerical data
• Social Class
• Socioeconomic Factors
• Retrospective Studies

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Grants

• K23 DK114497 NIDDK NIH HHS
• National Institute of Health Sciences
• National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)
• National Institute on Aging (NIA) of the National Institutes of Health (NIH)

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Affiliation(s)

Alaa Al Nofal Division of Pediatric Endocrinology and Metabolism, Mayo Clinic, Rochester, Minnesota, USA
Doha Hassan Department of General Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
Tamim Rajjo Department of Family Medicine, Mayo Clinic, Rochester, Minnesota, USA
Herbert C Heien Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA OptumLabs, Eden Prairie, Minnesota, USA
Rozalina G McCoy OptumLabs, Eden Prairie, Minnesota, USA Division of Endocrinology, Diabetes, and Nutrition, University of Maryland Baltimore, Baltimore, Maryland, USA University of Maryland Institute for Health Computing, North Bethesda, MD, USA

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Collaborators Collapse

Development, validation, and item bias assessment of the Self-Care Inventory-Short-Form among racially and income-diverse adolescents living with type 1 diabetes and their caregivers

OBJECTIVE

Youth with type 1 diabetes and their families engage in complex health behaviors to help manage blood glucose levels and to reduce the risk of serious health complications. Given well-documented health disparities in pediatric diabetes, rapid and equitable assessment of diabetes self-care can help identify potential areas where support is needed. This purpose of this study was to (a) develop a short-form of the Self-Care Inventory-Revised (SCI-R) and (b) evaluate validity, reliability, and differential item functioning (DIF) across several socio-illness-demographic variables of the full and short-form SCI-R.

METHODS

Participants were 181 adolescent-caregiver dyads from the Predicting Resiliency in Youth with Type 1 Diabetes (PRYDE) study who completed a 15-item version of the SCI-R. Adolescents (age: M = 14.64, SD =1.70, range 12-18 years), identifying as female (n = 92), male (n = 92), Black/AA (57%), and/or White (43%), also completed diabetes-specific measures of stress and Health-related Quality of Life (T1D-HRQoL). Youths' most recent hemoglobin A1c (HbA1c) values were extracted from their medical records.

RESULTS

Initial items selected based on the six highest factor loadings of 15 were evaluated using DIF analyses. The final 6-item youth and caregiver SCI-SF6 totals correlated with HbA1c, stress, and T1D-HRQoL. They were invariant across participant dyads at the scalar level (root mean squared error of approximation =.077, 90% CI: .056-.098; comparative fit index =.971, standardized root mean square residual = .0490). DIF analyses failed to reject the null hypothesis for item bias factor loadings or item thresholds across age, family income, HbA1c, racial category, gender, and illness duration.

CONCLUSIONS

The results support initial evidence of equitable assessment, measurement invariance, validity, and reliability for SCI-SF6 across important socio-illness-demographic variables.

Intervention to reduce barriers to type 1 diabetes self-management: Diabetes Journey study design and participant characteristics

Most adolescents with type 1 diabetes (T1D) encounter barriers to achieving optimal glycemia, including effective planning and monitoring their T1D and problem-solving, and following through with T1D treatment decisions. Thus, the overall aim of Diabetes Journey, a randomized controlled clinical trial, was to assess the feasibility, acceptability, and preliminary efficacy of a novel, amusement park-themed, web-based mobile health (mHealth) intervention tailored for adolescents who experienced barriers to T1D self-management. Secondary aims included examining post-intervention changes in T1D health-related quality of life, T1D self-management behaviors, and hemoglobin A1c (HbA1c). This article describes the study rationale, recruitment, design, and baseline characteristics of the adolescents (aged 12-17 years) who were randomized to one of two groups: Diabetes Journey or Enhanced Standard of Care. Diabetes Journey focused on reducing challenges related to stress, burnout, time pressure, and planning through the delivery of 5-8 intervention sessions using a problem-solving framework. Enhanced Standard of Care participants attended 4 education sessions focused on similar topics through the T1D Toolkit© website (educational content and brief videos about T1D). Adolescents (N = 195) were recruited with n = 162 randomized (Mage = 14.8 ± 1.6 years; 50 % female, 88 % White; HbA1c% = 8.2 ± 1.8; 86 % on insulin pumps). Diabetes Journey was impacted by COVID-19 and modifications to the study design were warranted. Future directions include examining the impact of Diabetes Journey on primary and secondary outcomes, while accounting for the impact of COVID-19.

Underresourced Youth With Diabetes in a Community-Based Intervention Show Improved Diabetes Outcomes, Technology Use, and Psychosocial Functioning

OBJECTIVE

The primary objective of this study was to evaluate the first full-scale implementation of the behavioral health program Novel Interventions in Children's Healthcare (NICH) in racially and ethnically diverse youth with diabetes and high degrees of social risk. We hypothesized that youth would demonstrate improved health outcomes and psychosocial functioning following program involvement.

METHODS

Youth with diabetes who enrolled in NICH (n = 26) and their caregivers completed measures of diabetes distress, depression, and diabetes strengths prior to and following program enrollment. Electronic health records were reviewed to describe change in hemoglobin A1C, change in continuous glucose monitoring use, and change in the number of hospital admission days from baseline to the time following program participation. Parametric and nonparametric tests were used to compare data.

RESULTS

Youth (mean age, 13.7 ± 3.5 years, 92% from historically marginalized racial or ethnic groups, 96% with public insurance) demonstrated a significant (P < .01) mean hemoglobin A1C reduction of -1.1% (-12 mmol/mol) and increase in continuous glucose monitoring use (27%-73%) 1 year following NICH enrollment, and they had significantly fewer hospital admission days over time. Youth reported significant reductions in depressive symptoms, and caregivers reported significant reductions in diabetes distress after participation in NICH (P < .05).

CONCLUSION

This study is the first to show successful full-scale implementation of NICH in a new geographic location with unique racial and ethnic diversity and social challenges, demonstrating associations with improved health and well-being.

Feasibility and acceptability of the TEAM pilot trial with African American and Latino families

OBJECTIVE

We adapted the empirically supported Family Teamwork intervention protocol to support collaborative parent involvement in type 1 diabetes (T1D) management among African American and Latino parents of children with T1D. This randomized pilot study aimed to evaluate feasibility and acceptability of the Type 1 Diabetes Empowerment and Management (TEAM) intervention.

METHODS

African American and Latino parents (n = 59; 65% recruitment rate) of youth (ages 5-10 years, M = 8.9 ± 1.6 years; 59% female, M hemoglobin A1c 9.0% ± 1.9%) with diabetes duration of ≥1 year and who were fluent in English and not planning to leave the geographic area were recruited and randomized 3:1 to the TEAM intervention (n = 44) or usual diabetes care alone (n = 15). The intervention consisted of six group-based sessions co-led by a study interventionist and a trained parent leader, plus five phone calls with the parent leader. Secondary outcomes included psychosocial questionnaires and HbA1c at baseline and 12 months post-baseline.

RESULTS

Participants attended a mean of 2.1 ± 2.0 (33%) TEAM intervention sessions. Acceptability ratings (5-point scale) among parents who completed ≥1 session (n = 28) were high: helpfulness (4.5 ± 0.75), encouraged new perspectives (4.5 ± 0.58), enjoyment (4.4 ± 0.70), learned new information/skills (4.3 ± 0.70), prompted change to diabetes management (4.6 ± 0.69), and positive impact on family (4.5 ± 0.69). Qualitative interviews (n = 35) indicated positive perspectives about emotional and informational support and suggestions for adding child intervention components. Pre-post data completion rates were 92% for questionnaires.

CONCLUSIONS

Despite feasibility challenges, the TEAM intervention was acceptable among parents who attended sessions. Reducing barriers to session attendance may be warranted to impact psychosocial and clinical outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04053504.

Patient Characteristics Associated With Annual Nutrition Visits in Children With Type 1 Diabetes

Objective

Diabetes organizations recommend nutrition education by a registered dietitian (RD) at least annually following type 1 diabetes (T1D) diagnosis in children. The study objectives were to describe differences over time in annual RD follow-up in children with T1D and to identify patient characteristics associated with RD engagement.

Research Design and Methods

Data based on 6034 completed diabetes medical visits among 1982 patients aged <18 years with T1D for ≥1 year followed at a pediatric, tertiary care, academic medical center over a 5-year period (2018-2022) were analyzed. Generalized estimating equations models assessed for differences over time in the rates of RD visit completion in the year preceding the last diabetes medical encounter and identified sociodemographic, diabetes care-related, and clinical patient characteristics associated with RD follow-up. Models were fit for the whole sample and groups subset by race and ethnicity.

Results

Observed annual RD follow-up rate over the 5-year period was 20.8%, with the lowest adjusted percentage in 2021 compared to 2018. In multivariable analysis, for each year increase in age (p = 0.004) and diabetes duration (p<0.001), there was a 3% and 15% reduction in the odds of RD follow-up, respectively. RD follow-up was associated with lower hemoglobin A1c within the subsequent year in adjusted analysis (p = 0.029), with the greatest improvement among Hispanic patients.

Conclusions

Annual RD visit frequency among children with T1D is suboptimal. Study findings provide insights for targeted intervention to improve RD engagement. RD follow-up may be associated with improved glycemic outcomes.

Project ECHO Diabetes Trial Improves Outcomes for Medically Underserved People

OBJECTIVE

The Project Extension for Community Healthcare Outcomes (ECHO) model is used in 180 countries to address chronic disease care through a provider empowerment, tele-education approach. Few studies have rigorously evaluated the impact of the program on patient outcomes using randomized designs.

RESEARCH DESIGN AND METHODS

Implementation of an ECHO Diabetes program was evaluated using a stepped-wedge design with recruitment of 20 federally qualified health centers (FQHCs) across California and Florida with randomized, phased-in intervention entry. Participating FQHCs (referred to as "spokes") provided aggregate data, including the Healthcare Effectiveness Data and Information Set (HEDIS) and diabetes technology use. Patients were recruited from spokes, and data collection involved historical and prospective HbA1c measures, HEDIS markers, and pre/post surveys. Linear mixed models were used to generate patient-level monthly HbA1c estimates and evaluate change over time; Poisson regression was used to model clinic-level technology use.

RESULTS

The spoke-level cohort included 32,796 people with type 1 diabetes (T1D; 3.4%) and type 2 diabetes (T2D; 96.6%), of whom 72.7% were publicly insured or uninsured. The patient-level cohort included 582 adults with diabetes (33.0% with T1D, 67.0% with T2D). Their mean age was 51.1 years, 80.7% were publicly insured or uninsured, 43.7% were non-Hispanic White, 31.6% were Hispanic, 7.9% were non-Hispanic Black, and 16.8% were in other race/ethnicity categories. At the spoke level, there were statistically significant reductions before and after the intervention in the proportion of people with HbA1c >9% (range 31.7% to 26.7%; P = 0.033). At the patient level, there were statistically significant increases in those using continuous glucose monitoring (range 25.1% to 36.8%; P < 0.0001) and pump use (range 15.3% to 18.3%; P < 0.001) before and after the intervention.

CONCLUSIONS

The ECHO model demonstrates promise for reducing health disparities in diabetes and contributes to our understanding of program benefits beyond the provider level.

Continuous Glucose Monitoring Attrition in Youth With Type 1 Diabetes

PURPOSE

The purpose of the study was to identify the most common reasons for and timing of continuous glucose monitoring (CGM) attrition in youth with type 1 diabetes (T1DM).

METHODS

This single center retrospective chart review included youth with T1DM <22 years seen between November 1, 2021, and October 31, 2022. Data were gathered from CGM cloud-based software and the electronic medical record.

RESULTS

Among 2663 youth, 88.3% (n = 2351) actively used CGM, and 5.9% (n = 311) had CGM attrition. Those who discontinued CGM were older (17.0 vs 14.9 years, P = .0001), had a longer T1DM duration (7.4 vs 5.1 years), higher A1C (9% vs 7.4%), and were non-Hispanic Black (NHB; 34.0% vs 11.5%). The odds of CGM attrition were 5.0 and 2.8 times higher in NHB and Latine youth, respectively, compared to non-Hispanic White youth. Median time to CGM discontinuation was 4 months, 21 days after initiation; 57% of youth who discontinued did so in the first 6 months of use. The most common reasons for CGM attrition were problems with device adhesion (18.4%), dislike device on the body (10.8%), insurance problems (9.5%), pain with device use (8.3%), and system mistrust due to inaccurate readings (8.2%). NHB and Latine youth were more likely to discontinue CGM due to insurance problems (3.2% vs 15.1% vs 16.7%).

CONCLUSIONS

To support equitable, uninterrupted CGM use, education at CGM initiation should address practical approaches to improve adhesion and wearability and provide a clear pathway to obtaining supplies. Interventions to support sustained CGM use should occur within the first 6 months of initiation.

International Society for Pediatric and Adolescent Diabetes Clinical Practice Consensus Guidelines 2024: Diabetes Technologies - Insulin Delivery

The International Society for Pediatric and Adolescent Diabetes (ISPAD) guidelines represent a rich repository that serves as the only comprehensive set of clinical recommendations for children, adolescents, and young adults living with diabetes worldwide. This chapter builds on the 2022 ISPAD guidelines, and summarizes recent advances in the technology behind insulin administration, with special emphasis on insulin pump therapy, especially on glucose-responsive integrated technology that is feasible with the use of automated insulin delivery (AID) systems in children and adolescents. The International Society for Pediatric and Adolescent Diabetes (ISPAD) guidelines represent a rich repository that serves as the only comprehensive set of clinical recommendations for children, adolescents, and young adults living with diabetes worldwide. This chapter builds on the 2022 ISPAD guidelines, and summarizes recent advances in the technology behind insulin administration, with special emphasis on insulin pump therapy, especially on glucose-responsive integrated technology that is feasible with the use of automated insulin delivery (AID) systems in children and adolescents.

The association of resilience with HbA1c and key psychosocial factors in emerging adults with type 1 diabetes

OBJECTIVE

Emerging adults (EAs) with type 1 diabetes (T1D) have difficulty meeting glycemic targets and have a high prevalence of mental health comorbidities. Resilience, the ability to harness resources needed to sustain one's emotional and physical well-being, may be a key factor impacting poor mental health and glycemic outcomes. We aimed to (a) evaluate the association between resilience, HbA1c, and key psychosocial factors and (b) explore whether resilience moderates the relationship between psychosocial factors (depression, diabetes-related distress, anxiety) and HbA1c in EAs with T1D.

METHOD

EAs with T1D (N = 233) (mean age = 19.9 years (SD = 1.6), range 16.8-24.7) seen at an EA-specific diabetes clinic completed resilience, diabetes-related distress, depression, and anxiety measures and had their HbA1c level evaluated. We used linear regression models and conducted moderation analyses for the resilience factor.

RESULTS

Resilience was strongly associated with HbA1c, depression, diabetes-related distress, and anxiety in EAs with T1D. We did not find evidence that resilience moderates the relationship between depression, anxiety, or diabetes-related distress and HbA1c.

CONCLUSIONS

This study found that resilience is a highly relevant psychological factor associated with HbA1c and a key mental health factor for EAs with T1D. Novel interventions are needed to ameliorate high diabetes-related distress and HbA1c, and bolstering resilience may be one avenue to explore. Future research on resilience should longitudinally characterize and evaluate whether resilience may be a mechanism underlying the relationship between poor psychosocial outcomes and not meeting glycemic targets in EAs with T1D.

The Supporting Emerging Adults With Diabetes (SEAD) Program: An Adult-Based Real-World Clinical Model That Improves Hospitalizations, Diabetes Technology Uptake, and Glycemic Outcomes in Underserved Young Adults With Type 1 Diabetes

OBJECTIVE

Underserved young adults (YA) with type 1 diabetes (T1D) experience the worst outcomes across the life span. We developed and integrated the Supporting Emerging Adults with Diabetes (SEAD) program into routine endocrinology care to address unmet social and medical challenges.

RESEARCH DESIGN AND METHODS

This study was designed as a longitudinal cohort study, with prospective data collection over 4 years on YA in SEAD compared with usual endocrine care. We used propensity-weighted analysis to account for differences in baseline characteristics, and multivariate regression and Cox proportional hazard models to evaluate change in outcomes over time. Primary outcomes included incidence of hospitalizations, diabetes technology uptake, and annual change in HbA1c levels.

RESULTS

We included 497 YA with T1D in SEAD (n = 332) and usual endocrine care (n = 165); mean age 25 years, 27% non-Hispanic Black, 46% Hispanic, 49% public insurance, mean HbA1c 9.2%. Comparing YA in SEAD versus usual care, 1) incidence of hospitalizations was reduced by 64% for baseline HbA1c >9% (HR 0.36 [0.13, 0.98]) and 74% for publicly insured (HR 0.26 [0.07, 0.90]); 2) automated insulin delivery uptake was 1.5-times higher (HR 1.51 [0.83, 2.77]); and 3) HbA1c improvement was greater (SEAD, -0.37% per year [-0.59, -0.15]; usual care, -0.26% per year [-0.58, 0.05]).

CONCLUSIONS

SEAD meaningfully improves clinical outcomes in underserved YA with T1D, especially for publicly insured and high baseline HbA1c levels. Early intervention for at-risk YA with T1D as they enter adult care could reduce inequity in short and long-term outcomes.

A Retrospective Cohort Study of Racial/Ethnic and Socioeconomic Disparities in Initiation and Meaningful Use of Continuous Glucose Monitoring Among Youth With Type 1 Diabetes

BACKGROUND

Continuous glucose monitor (CGM) use improves type 1 diabetes (T1D) outcomes, yet children from diverse backgrounds and on public insurance have worse outcomes and lower CGM utilization. Using novel CGM data acquisition and analysis of two T1D cohorts, we test the hypothesis that T1D youth from different backgrounds experience disparities in meaningful CGM use following both T1D diagnosis and CGM uptake.

METHODS

Cohorts drawn from a pediatric T1D program were followed for one year beginning at diagnosis (n = 815, 2016-2020) or CGM uptake (n = 1392, 2015-2020). Using chart and CGM data, CGM start and meaningful use outcomes between racial/ethnic and insurance groups were compared using median days, one-year proportions, and survival analysis.

RESULTS

Publicly compared with privately insured were slower to start CGM (233, 151 days, P < .01), had fewer use-days in the year following uptake (232, 324, P < .001), and had faster first discontinuation rates (hazard ratio [HR] = 1.61, P < .001). Disparities were more pronounced among Hispanic and black compared with white subjects for CGM start time (312, 289, 149, P = .0013) and discontinuation rates (Hispanic HR = 2.17, P < .001; black HR = 1.45, P = .038), and remained even among privately insured (Hispanic/black HR = 1.44, P = .0286).

CONCLUSIONS

Given the impact of insurance and race/ethnicity on CGM initiation and use, it is imperative that we target interventions to support universal access and sustained CGM use to mitigate the potential impact of provider biases and systemic disadvantage and racism. By enabling more equitable and meaningful T1D technology use, such interventions will begin to alleviate outcome disparities between youth with T1D from different backgrounds.

Systematic review of disparities in continuous glucose monitoring and insulin pump utilization in the United States: Key themes and evidentiary gaps

AIM

This study aims to provide a comprehensive overview of real-world evidence pertaining to disparities in the utilization of continuous glucose monitors (CGMs)/insulin pumps to highlight potential evidentiary gaps and discern emerging themes from the literature.

MATERIALS AND METHODS

A systematic review of published manuscripts and abstracts was conducted from: MEDLINE, EMBASE, Nursing and Allied Health, Web of Science and CINHAL. Attributes related to patients, outcomes, interventions (CGMs/pumps/both) and study type were captured. In addition, factors associated with disparities in device utilization were examined.

RESULTS

Thirty-six studies were included in the final analysis; the studies predominantly focused on people living with type 1 diabetes. Only two studies included individuals with type 2 diabetes. Almost two-thirds of the studies reported outcomes associated with disparities (e.g. glycated haemoglobin, diabetic ketoacidosis, resource utilization). Most studies highlighted disparities across race, ethnicity and insurance type. Evidentiary gaps were identified, particularly in the evidence for people with type 2 diabetes, the continuation of CGM/pump use and limited studies addressing disparities among Native Americans/American Indians.

CONCLUSION

This study reveals critical disparities in diabetes technology use across race, ethnicity and insurance type, particularly among people with type 1 diabetes. Evidentiary gaps assessing disparities in diabetes technology use persist, particularly concerning people with type 2 diabetes, Native American/American Indian and LGBTQ+ populations, and in outcomes related to continuation of use. Social and digital determinants of health, such as income, transportation, residential location and technological literacy, are crucial to achieving equitable access. Future research should focus on the patient journey to identify opportunities for equitable access to diabetes technology as its use grows.

Not all healthcare inequities in diabetes are equal: a comparison of two medically underserved cohorts

INTRODUCTION

Diabetes disparities exist based on socioeconomic status, race, and ethnicity. The aim of this study is to compare two cohorts with diabetes from California and Florida to better elucidate how health outcomes are stratified within underserved communities according to state location, race, and ethnicity.

RESEARCH DESIGN AND METHODS

Two cohorts were recruited for comparison from 20 Federally Qualified Health Centers as part of a larger ECHO Diabetes program. Participant-level data included surveys and HbA1c collection. Center-level data included Healthcare Effectiveness Data and Information Set metrics. Demographic characteristics were summarized overall and stratified by state (frequencies, percentages, means (95% CIs)). Generalized linear mixed models were used to compute and compare model-estimated rates and means.

RESULTS

Participant-level cohort: 582 adults with diabetes were recruited (33.0% type 1 diabetes (T1D), 67.0% type 2 diabetes (T2D)). Mean age was 51.1 years (95% CI 49.5, 52.6); 80.7% publicly insured or uninsured; 43.7% non-Hispanic white (NHW), 31.6% Hispanic, 7.9% non-Hispanic black (NHB) and 16.8% other. Center-level cohort: 32 796 adults with diabetes were represented (3.4% with T1D, 96.6% with T2D; 72.7% publicly insured or uninsured). Florida had higher rates of uninsured (p<0.0001), lower continuous glucose monitor (CGM) use (18.3% Florida; 35.9% California, p<0.0001), and pump use (10.2% Florida; 26.5% California, p<0.0001), and higher proportions of people with T1D/T2D>9% HbA1c (p<0.001). Risk was stratified within states with NHB participants having higher HbA1c (mean 9.5 (95% CI 8.9, 10.0) compared with NHW with a mean of 8.4 (95% CI 7.8, 9.0), p=0.0058), lower pump use (p=0.0426) and CGM use (p=0.0192). People who prefer to speak English were more likely to use a CGM (p=0.0386).

CONCLUSIONS

Characteristics of medically underserved communities with diabetes vary by state and by race and ethnicity. Florida's lack of Medicaid expansion could be a factor in worsened risks for vulnerable communities with diabetes.

Updates in the Management of Type 1 Diabetes in Pregnancy

The care of pregnant individuals with type 1 diabetes mellitus has experienced significant advancements in recent years. Preconception counseling has re-emerged as a core dimension of management. Continuous glucose monitoring plays an increasingly useful and beneficial role in gestational glycemic monitoring, a practice informed by improved maternofetal outcomes. While studies have not shown that continuous subcutaneous insulin infusion is superior to multiple daily injections of insulin for glycemic control, recent work has signaled that hybrid closed-loop systems with pregnancy-specific targets could meaningfully improve glycemic control and potentially ameliorate maternofetal outcomes while reducing self-care burden.

Equitable implementation of a precision digital health program for glucose management in individuals with newly diagnosed type 1 diabetes

Few young people with type 1 diabetes (T1D) meet glucose targets. Continuous glucose monitoring improves glycemia, but access is not equitable. We prospectively assessed the impact of a systematic and equitable digital-health-team-based care program implementing tighter glucose targets (HbA1c < 7%), early technology use (continuous glucose monitoring starts <1 month after diagnosis) and remote patient monitoring on glycemia in young people with newly diagnosed T1D enrolled in the Teamwork, Targets, Technology, and Tight Control (4T Study 1). Primary outcome was HbA1c change from 4 to 12 months after diagnosis; the secondary outcome was achieving the HbA1c targets. The 4T Study 1 cohort (36.8% Hispanic and 35.3% publicly insured) had a mean HbA1c of 6.58%, 64% with HbA1c < 7% and mean time in the range (70-180 mg dl-1) of 68% at 1 year after diagnosis. Clinical implementation of the 4T Study 1 met the prespecified primary outcome and improved glycemia without unexpected serious adverse events. The strategies in the 4T Study 1 can be used to implement systematic and equitable care for individuals with T1D and translate to care for other chronic diseases. ClinicalTrials.gov registration: NCT04336969 .

Investigation of geographic disparities of diabetes-related hospitalizations in Florida using flexible spatial scan statistics: An ecological study

BACKGROUND

Hospitalizations due to diabetes complications are potentially preventable with effective management of the condition in the outpatient setting. Diabetes-related hospitalization (DRH) rates can provide valuable information about access, utilization, and efficacy of healthcare services. However, little is known about the local geographic distribution of DRH rates in Florida. Therefore, the objectives of this study were to investigate the geographic distribution of DRH rates at the ZIP code tabulation area (ZCTA) level in Florida, identify significant local clusters of high hospitalization rates, and describe characteristics of ZCTAs within the observed spatial clusters.

METHODS

Hospital discharge data from 2016 to 2019 were obtained from the Florida Agency for Health Care Administration through a Data Use Agreement with the Florida Department of Health. Raw and spatial empirical Bayes smoothed DRH rates were computed at the ZCTA level. High-rate DRH clusters were identified using Tango's flexible spatial scan statistic. Choropleth maps were used to display smoothed DRH rates and significant high-rate spatial clusters. Demographic, socioeconomic, and healthcare-related characteristics of cluster and non-cluster ZCTAs were compared using the Wilcoxon rank sum test for continuous variables and Chi-square test for categorical variables.

RESULTS

There was a total of 554,133 diabetes-related hospitalizations during the study period. The statewide DRH rate was 8.5 per 1,000 person-years, but smoothed rates at the ZCTA level ranged from 0 to 101.9. A total of 24 significant high-rate spatial clusters were identified. High-rate clusters had a higher percentage of rural ZCTAs (60.9%) than non-cluster ZCTAs (41.8%). The median percent of non-Hispanic Black residents was significantly (p < 0.0001) higher in cluster ZCTAs than in non-cluster ZCTAs. Populations of cluster ZCTAs also had significantly (p < 0.0001) lower median income and educational attainment, and higher levels of unemployment and poverty compared to the rest of the state. In addition, median percent of the population with health insurance coverage and number of primary care physicians per capita were significantly (p < 0.0001) lower in cluster ZCTAs than in non-cluster ZCTAs.

CONCLUSIONS

This study identified geographic disparities of DRH rates at the ZCTA level in Florida. The identification of high-rate DRH clusters provides useful information to guide resource allocation such that communities with the highest burdens are prioritized to reduce the observed disparities. Future research will investigate determinants of hospitalization rates to inform public health planning, resource allocation and interventions.

Healthcare Professional Experiences and Opinions on Depression and Suicide in People With Diabetes

OBJECTIVE

People with diabetes have an increased risk of depression, intentional self-injury and self-harm (ISI), and suicide compared with the general population. This study aimed to explore experiences and awareness of healthcare professionals (HCPs) regarding depression, ISI, and suicide, and understand resource use and needs among HCPs who care for persons with diabetes (PWD).

METHODS

Healthcare professionals who see children and/or adults with type 1 diabetes or type 2 diabetes anonymously completed an online survey about their experiences, opinions, barriers, and needs surrounding identification and care of PWD with depression, ISI, and suicide.

RESULTS

One hundred twenty-nine HCPs participated. The majority were medical doctors (MDs) or advanced practice providers (APPs). Only a quarter of MDs and APPs felt very comfortable asking about ISI or suicidal ideation (SI), whereas 20% felt they had received appropriate training to support those with ISI or SI. The primary needs reported include more training on how to ask, respond, and support those expressing ISI and SI. Healthcare professionals reported wanting better access to resources for PWD.

DISCUSSION

The HCPs tend to underestimate SI in the diabetes population and rates of training were low. Areas to address include providing education and training to HCPs to improve identification and management of ISI and suicide risk. These data can inform the development of mechanisms to improve discussions of depression and suicide and of resources to help HCPs support PWD.

ROUTE-T1D: A behavioral intervention to promote optimal continuous glucose monitor use among racially minoritized youth with type 1 diabetes: Design and development

BACKGROUND

Type 1 diabetes management is often challenging during adolescence, and many youth with type 1 diabetes struggle with sustained and optimal continuous glucose monitor (CGM) use. Due to racial oppression and racially discriminatory policies leading to inequitable access to quality healthcare and life necessities, racially minoritized youth are significantly less likely to use CGM.

METHODS

ROUTE-T1D: Research on Optimizing the Use of Technology with Education is a pilot behavioral intervention designed to promote optimal CGM use among racially minoritized youth with type 1 diabetes. Intervention strategies include problem solving CGM challenges and promoting positive caregiver-youth communication related to CGM data.

RESULTS

This randomized waitlist intervention provides participants with access to three telemedicine sessions with a Certified Diabetes Care and Education Specialist. Caregiver participants are also connected with a peer-parent coach.

CONCLUSION

Hypothesized findings and anticipated challenges are discussed. Future directions regarding sustaining and optimizing the use of diabetes technology among racially minoritized pediatric populations are reviewed.

Prevalence of Type 1 Diabetes Among US Children and Adults by Age, Sex, Race, and Ethnicity

This study uses data from the 2019 to 2022 cycles of the National Health Interview Survey to estimate the prevalence of type 1 diabetes among US youths and adults.

Ongoing burden and recent trends in severe hospitalised hypoglycaemia events in people with type 1 and type 2 diabetes in Scotland: A nationwide cohort study 2016-2022

AIMS

We examined severe hospitalised hypoglycaemia (SHH) rates in people with type 1 and type 2 diabetes in Scotland during 2016-2022, stratifying by sociodemographics.

METHODS

Using the Scottish National diabetes register (SCI-Diabetes), we identified people with type 1 and type 2 diabetes alive anytime during 2016-2022. SHH events were determined through linkage to hospital admission and death registry data. We calculated annual SHH rates overall and by age, sex, and socioeconomic status. Summary estimates of time and stratum effects were obtained by fitting adjusted generalised additive models using R package mgcv.

RESULTS

Rates for those under 20 with type 1 diabetes reached their minimum at the 2020-2021 transition, 30% below the study period average. A gradual decline over time also occurred among 20-49-year-olds with type 1 diabetes. Overall, females had 15% higher rates than males with type 2 diabetes (rate ratio 1.15, 95% CI 1.08-1.22). People in the most versus least deprived quintile experienced 2.58 times higher rates (95% CI 2.27-2.93) in type 1 diabetes and 2.33 times higher (95% CI 2.08-2.62) in type 2 diabetes.

CONCLUSIONS

Despite advances in care, SHH remains a significant problem in diabetes. Future efforts must address the large socioeconomic disparities in SHH risks.

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.

Young Adults with Type 1 Diabetes

Young adults experience multiple developmental transitions across social, educational, vocational, residential, and financial life domains. These transitions are potential competing priorities to managing a chronic condition such as type 1 diabetes and can contribute to poor psychosocial and medical outcomes. In this narrative review, we describe population outcomes of young adult populations and the unique considerations associated with managing type 1 diabetes in young adulthood. We provide an overview of the current evidence-based strategies to improve care for young adults with type 1 diabetes and recommendations for future directions in the field.

Type 1 Diabetes and Cardiovascular Health

Type 1 diabetes (T1D) is associated with an increased risk of cardiovascular disease (CVD). CVD occurs much earlier in people with T1D than in the general population, and several risk factors have been identified some of which are modifiable. Risk prediction models and imaging tests to detect early signs of CVD have not been extensively validated. Strategies to promote cardiovascular health (CVH) in T1D include identifying risk factors, early treatment to achieve CVH targets, and improving the education of health care providers and people with T1D.

Optimizing Glycemic Outcomes for Children with Type 1 Diabetes

Changes in physical growth, neurocognitive development, and pubertal maturation are some of the challenges to achieving blood glucose targets in children with type 1 diabetes mellitus. To optimize glycemic outcomes, a comprehensive approach is crucial to address psychosocial needs, expand the use of diabetes technology, and diminish health inequities.

Improving Outcomes for People with Type 1 Diabetes Through Collaboration: Summary of Type 1 Diabetes Exchange Quality Improvement Collaborative Studies

Type 1 diabetes (T1D) management has evolved over the last decade. Innovations and groundbreaking research have paved the way for improved outcomes for people with T1D. One of the major T1D focused research network that has supported real-world research studies in the United States is the T1D Exchange Quality Improvement Collaborative (T1DX-QI) Network.T1DX-QI is a large multicenter network of 55 T1D clinics that uses quality improvement, health equity framework, and population health principles to improve outcomes for people with T1D. This article summarizes insights from T1DX-QI clinical and population health improvement studies.

Removing Barriers, Bridging the Gap, and the Changing Role of the Health Care Professional with Automated Insulin Delivery Systems

As all people with type 1 diabetes (T1D) and some with type 2 diabetes (T2D) require insulin, there is a need to develop management methods that not only achieve glycemic targets but also reduce the burden of living with diabetes. After insulin pumps and continuous glucose monitors, the next step in the evolution of diabetes technology is automated insulin delivery (AID) systems, which have transformed intensive insulin management over the past decade, as these systems address the shortcomings of previous management options. However, AID use remains fairly limited, and access represents a major barrier to use for many people with diabetes, despite these systems being standard of care. Therefore, the future of AID will necessitate addressing barriers related to social determinants of health, finances, and an expansion of the number and type of health care professionals (HCPs) prescribing AID systems. These crucial steps will be essential to ensure that everyone with intensively managed diabetes can use AID systems. The impact of implementing these changes will create a shift in the future of diabetes care that will result in achievement of more targeted glycemia and psychosocial outcomes for all people with diabetes and an expansion of the role of all HCPs in AID-related diabetes care. Even more importantly, by addressing social determinants of health and clinical inertia related to AID, the field can address disparities in outcomes across countries, race, gender, socioeconomic status, and insurance status. Furthermore, the increased use of AID system will provide more time during appointments for a shift in the discussion away from fine tuning insulin dosing and toward a focus on more topics related to behavior and conversations about general health. This will include psychosocial outcomes, and quality of life. In addition, these changes can hopefully allow for time to discuss more general issues, such as cardiovascular health, obesity prevention, diabetes-related complications, and other health-related concerns.

Hybrid Closed Loop Systems Improve Glycemic Control and Quality of Life in Historically Minoritized Youth with Diabetes

Background: We assessed changes in glycemic control and person-reported outcome measures (PROMs) with t:slim X2 insulin pump with Control-IQ technology use among historically minoritized youth who are least likely to access hybrid closed loop (HCL) technology. Methods: This single-arm, prospective pilot study enrolled 15 publicly insured, insulin pump-naïve, non-Hispanic Black youth ages 6 to <21 years with type 1 diabetes and hemoglobin A1c (HbA1c) ≥10% in a 6-month study of HCL use. The primary outcome was absolute change in time in range (TIR) (70-180 mg/dL). Secondary outcomes included other continuous glucose monitor metrics, PROMs, and diabetic ketoacidosis (DKA) incidence. Results: For 13 youth (median 14.8 years, 53.3% female, HbA1c 11.7%) who completed the study, baseline TIR of 12.3% (6.3-27.1%) increased 23.7%-points (16.9, 30.5%; P < 0.001) or 5.7 h per day. Percent time >250 mg/dL decreased 33.9%-points (-44.8, -23.1%; P < 0.001) or 8.1 h per day from a baseline of 69.4% (51.6, 84.0%). Median time in HCL was 78.3% (59.7, 87.3%). Youth received 10.1 (9.2, 11.9) boluses per day, 71.7% (63.8, 79.3%) of which were HCL-initiated autoboluses. Diabetes-specific quality of life increased among parents (P < 0.001) and youth (P = 0.004), and diabetes distress decreased in both groups (P < 0.001, P = 0.005). Improvements in glycemia did not correlate with any baseline youth or parent PROMs. DKA was high at baseline (67 episodes/100-person years) and did not increase during the intervention (72 episodes/100-person years, P = 0.78). Conclusion: Improvements in glycemic control and quality of life exceeding pivotal trial findings without increased safety risks among historically minoritized youth emphasize the need for equitable access to HCL systems. ClinicalTrials.gov: clinicaltrials.gov ID (NCT04807374).

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.

Roadmap to Continuous Glucose Monitoring Adoption and Improved Outcomes in Endocrinology: The 4T (Teamwork, Targets, Technology, and Tight Control) Program

Glucose monitoring is essential for the management of type 1 diabetes and has evolved from urine glucose monitoring in the early 1900s to home blood glucose monitoring in the 1980s to continuous glucose monitoring (CGM) today. Youth with type 1 diabetes struggle to meet A1C goals; however, CGM is associated with improved A1C in these youth and is recommended as a standard of care by diabetes professional organizations. Despite their utility, expanding uptake of CGM systems has been challenging, especially in minoritized communities. The 4T (Teamwork, Targets, Technology, and Tight Control) program was developed using a team-based approach to set consistent glycemic targets and equitably initiate CGM and remote patient monitoring in all youth with new-onset type 1 diabetes. In the pilot 4T study, youth in the 4T cohort had a 0.5% improvement in A1C 12 months after diabetes diagnosis compared with those in the historical cohort. The 4T program can serve as a roadmap for other multidisciplinary pediatric type 1 diabetes clinics to increase CGM adoption and improve glycemic outcomes.

Roadmap to Achieving Continuous Glucose Monitoring Equity: Insights From the T1D Exchange Quality Improvement Collaborative

This article describes successful interventions from the T1D Exchange Quality Improvement Collaborative (T1DX-QI) to reduce inequities in access to and use of continuous glucose monitoring (CGM). The author proposes a roadmap with recommendations for different stakeholders to achieve CGM equity using insights from the T1DX-QI experience.

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.

Real-World Glycemic Outcomes with Early Omnipod 5 Use in Youth with Type 1 Diabetes

Background: Pivotal trials of diabetes technologies have demonstrated glycemic improvements; however, these trials include patients of limited diversity and ranges of glycemic control. We assessed changes in glycemic control during the first 90 days of Omnipod 5 use in a real-world cohort of youth with type 1 diabetes (T1D). Methods: Youth 2-21 years with T1D initiating Omnipod 5 at two pediatric academic centers were included. Fourteen days of baseline (BL) continuous glucose monitoring (CGM) data were compared against data from the first 90 days of Omnipod 5 use. Outcome measures included changes in time in range (TIR), hemoglobin A1c (HbA1c), and CGM and insulin pump metrics based on the duration of Omnipod 5 use. Results: Among 195 youth (78.9% non-Hispanic White, 15.4% publicly insured, age 11.7 years, T1D duration 3.3 years) TIR increased 11%-points, from 49% to 61% (P < 0.001), and HbA1c decreased 0.5%-points, from 7.5% to 6.9% (P < 0.001). TIR improved within the first 9 days of Omnipod 5 use (p < 0.001) and did not change significantly thereafter (P = 0.1) despite decreases in user-initiated boluses (5.1 vs. 5.0, P = 0.01) and carbohydrate entries (4.2 vs. 4.1, P = 0.005) from days 1-9 to days 1-90. TIR improved 15%-points among youth with BL TIR <60% compared to a 5%-point increase for youth with BL TIR ≥60% (P < 0.001). Conclusions: Glycemic control improved within 9 days of Omnipod 5 initiation in this real-world cohort, and improvements were sustained over the first 90 days of use despite concomitant decreases in user-initiated boluses. These improvements were comparable to those observed in the pivotal trial.

Longitudinal Trends in Glycemic Outcomes and Technology Use for Over 48,000 People with Type 1 Diabetes (2016-2022) from the T1D Exchange Quality Improvement Collaborative

Objective: Previous studies revealed that hemoglobin A1c (HbA1c) increased overall in the United States in the past decade. In addition, health inequities in type 1 diabetes (T1D) outcomes by race/ethnicity and insurance type persist. This study examines the trends in HbA1c from 2016 to 2022 stratified by race/ethnicity and insurance in a large multicenter national database. Research Design and Methods: We analyzed glycemic outcomes and diabetes device use trends for >48,000 people living with type 1 diabetes (PwT1D) from 3 adult and 12 pediatric centers in the T1D Exchange Quality Improvement Collaborative (T1DX-QI), comparing data from 2016 to 2017 with data from 2021 to 2022. Results: The mean HbA1c in 2021-2022 was lower at 8.4% compared with the mean HbA1c in 2016-2017 of 8.7% (0.3% improvement; P < 0.01). Over the same period, the percentage of PwT1D using a continuous glucose monitor (CGM), insulin pump, or hybrid closed-loop system increased (45%, 12%, and 33%, respectively). However, these improvements were not equitably demonstrated across racial/ethnic groups or insurance types. Racial/ethnic and insurance-based inequities persisted over all 7 years across all outcomes; comparing non-Hispanic White and non-Hispanic Black PwT1D, disparate gaps in HbA1c (1.2%-1.6%), CGM (30%), pump (25%-35%), and hybrid-closed loop system (up to 20%) are illuminated. Conclusion: Population-level data on outcomes, including HbA1c, can provide trends and insights into strategies to improve health for PwT1D. The T1DX-QI cohort showed a significant improvement in HbA1c from 2016 to 2022. Improvements in diabetes device use are also demonstrated. However, these increases were inconsistent across all racial/ethnic groups or insurance types, an important focus for future T1D population health improvement work.

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%.

Insulin Pump Utilization in 2017-2021 for More Than 22,000 Children and Adults With Type 1 Diabetes: A Multicenter Observational Study

This large type 1 diabetes cohort study showed that insulin pump utilization has increased over time and that use differs by sex, insurance type, and race/ethnicity. Insulin pump use was associated with more optimal A1C, increased use of continuous glucose monitoring (CGM), and lower rates of diabetic ketoacidosis and severe hypoglycemia. People who used an insulin pump with CGM had lower rates of acute events than their counterparts who used an insulin pump without CGM. These findings highlight the need to improve access of diabetes technology through provider engagement, multidisciplinary approaches, and efforts to address health inequities.

Understanding temporal changes and seasonal variations in glycemic trends using wearable data

Seasonal variations in glycemic trends remain largely unstudied despite the growing prevalence of diabetes. To address this gap, our objective is to investigate temporal changes in glycemic trends by analyzing intensively sampled blood glucose data from 137 patients (ages 2 to 76, primarily type 1 diabetes) over the course of 9 months to 4.5 years. From over 91,000 days of continuous glucose monitor data, we found that glycemic control decreases significantly around the holidays, with the largest decline observed on New Year's Day among the patients with already poor glycemic control (i.e., <55% time in the target range). We also observed seasonal variations in glycemic trends, with patients having worse glycemic control in the months of November to February (i.e., mid-fall and winter, in the United States), and better control in the months of April to August (i.e., mid-spring and summer). These insights are critical to inform targeted interventions that can improve diabetes outcomes.

DiaTrend: A dataset from advanced diabetes technology to enable development of novel analytic solutions

Objective digital data is scarce yet needed in many domains to enable research that can transform the standard of healthcare. While data from consumer-grade wearables and smartphones is more accessible, there is critical need for similar data from clinical-grade devices used by patients with a diagnosed condition. The prevalence of wearable medical devices in the diabetes domain sets the stage for unique research and development within this field and beyond. However, the scarcity of open-source datasets presents a major barrier to progress. To facilitate broader research on diabetes-relevant problems and accelerate development of robust computational solutions, we provide the DiaTrend dataset. The DiaTrend dataset is composed of intensive longitudinal data from wearable medical devices, including a total of 27,561 days of continuous glucose monitor data and 8,220 days of insulin pump data from 54 patients with diabetes. This dataset is useful for developing novel analytic solutions that can reduce the disease burden for people living with diabetes and increase knowledge on chronic condition management in outpatient settings.

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 role of structural racism and geographical inequity in diabetes outcomes

Diabetes is pervasive, exponentially growing in prevalence, and outpacing most diseases globally. In this Series paper, we use new theoretical frameworks and a narrative review of existing literature to show how structural inequity (structural racism and geographical inequity) has accelerated rates of diabetes disease, morbidity, and mortality globally. We discuss how structural inequity leads to large, fixed differences in key, upstream social determinants of health, which influence downstream social determinants of health and resultant diabetes outcomes in a cascade of widening inequity. We review categories of social determinants of health with known effects on diabetes outcomes, including public awareness and policy, economic development, access to high-quality care, innovations in diabetes management, and sociocultural norms. We also provide regional perspectives, grounded in our theoretical framework, to highlight prominent, real-world challenges.

Interventions to address global inequity in diabetes: international progress

Diabetes is a serious chronic disease with high associated burden and disproportionate costs to communities based on socioeconomic, gender, racial, and ethnic status. Addressing the complex challenges of global inequity in diabetes will require intentional efforts to focus on broader social contexts and systems that supersede individual-level interventions. We codify and highlight best practice approaches to achieve equity in diabetes care and outcomes on a global scale. We outline action plans to target diabetes equity on the basis of the recommendations established by The Lancet Commission on Diabetes, organising interventions by their effect on changing the ecosystem, building capacity, or improving the clinical practice environment. We present international examples of how to address diabetes inequity in the real world to show that approaches addressing the individual within a larger social context, in addition to addressing structural inequity, hold the greatest promise for creating sustainable and equitable change that curbs the global diabetes crisis.

Narrowing the Divide: The Role of Telehealth in Type 1 Diabetes Care for Marginalized Communities

Widespread uptake of telehealth in response to the COVID-19 pandemic has highlighted geographic, demographic, and economic disparities in access to virtual care. However, research studies and clinical programs that predate the pandemic demonstrate the potential for telehealth-based interventions to improve access to and outcomes of type 1 diabetes (T1D) care for individuals in geographically or socially marginalized communities. In this expert commentary, we discuss telehealth-based care models that have been successful in improving care for marginalized T1D populations. We also outline the policy changes needed to expand access to such interventions to reduce established disparities in T1D care and promote better health equity among people living with T1D.