51
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Overcoming Barriers to Diabetes Technology in Youth with Type 1 Diabetes and Public Insurance: Cases and Call to Action. Case Rep Endocrinol 2022; 2022:9911736. [PMID: 35273814 PMCID: PMC8904094 DOI: 10.1155/2022/9911736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 02/03/2022] [Indexed: 11/21/2022] Open
Abstract
Advancements in diabetes technology such as continuous glucose monitoring (CGM), insulin pumps, and automated insulin delivery provide opportunities to improve glycemic control for youth with type 1 diabetes (T1D). However, diabetes technology use is lower in youth on public insurance, and this technology use gap is widening in the US. There is a significant need to develop effective interventions and policies to promote equitable care. The dual purpose of this case series is as follows: (1) describe success stories of the CGM Time in Range Program (CGM TIPs), which removed barriers for initiating CGM and provided asynchronous remote glucose monitoring for youth on public insurance, and (2) advocate for improving CGM coverage by public insurance. We describe a series of six youths with T1D and public insurance who obtained and sustained use of CGM with assistance from the program. Three youths had improved engagement with the care team while on CGM and the remote monitoring protocol, and three youths were able to leverage sustained CGM wear to obtain insurance coverage for automated insulin delivery systems. CGM TIPs helped these youths achieve lower hemoglobin A1c and improved time in range (TIR). Despite the successes, expansion of CGM TIPs is limited by stringent barriers for CGM approval and difficult postapproval patient workflows to receive shipments. These cases highlight the potential for combining diabetes technology and asynchronous remote monitoring to support continued use and provide education to improve glycemic control for youth with T1D on public insurance and the need to reduce barriers for obtaining CGM coverage by public insurance.
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52
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Affiliation(s)
- Klemen Dovc
- UMC-University Children's Hospital Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Bruce W Bode
- Atlanta Diabetes Associates and Emory University School of Medicine, Atlanta, GA
| | - Tadej Battelino
- Atlanta Diabetes Associates and Emory University School of Medicine, Atlanta, GA
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53
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Messer LH, Weinzimer SA. Real-World Diabetes Technology: What Do We Have? Who Are We Missing? Diabetes Technol Ther 2022; 24:S159-S172. [PMID: 35475693 DOI: 10.1089/dia.2022.2510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Laurel H Messer
- Barbara Davis Center, University of Colorado Anschutz, CO
- College of Nursing, University of Colorado Anschutz, CO
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54
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Demeterco-Berggren C, Ebekozien O, Noor N, Rompicherla S, Majidi S, Jones NHY, McDonough R, Odugbesan O, Kim A, Izquierdo R, Kamboj MK, Jacobsen LM. Factors Associated With Achieving Target A1C in Children and Adolescents With Type 1 Diabetes: Findings From the T1D Exchange Quality Improvement Collaborative. Clin Diabetes 2022; 41:68-75. [PMID: 36714245 PMCID: PMC9845079 DOI: 10.2337/cd22-0073] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The optimal care of type 1 diabetes involves consistent glycemic management to avoid short- and long-term complications. However, despite advancements in diabetes technology and standards, achieving adequate glycemic levels in children and adolescents remains a challenge. This study aimed to identify factors associated with achieving the recommended A1C target of <7% from the United States-based multicenter T1D Exchange Quality Improvement Collaborative cohort, including 25,383 children and adolescents living with type 1 diabetes.
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Affiliation(s)
- Carla Demeterco-Berggren
- Rady Children’s Hospital, University of California, San Diego, CA
- Corresponding author: Carla Demeterco-Berggren,
| | - Osagie Ebekozien
- T1D Exchange, Boston, MA
- University of Mississippi School of Population Health, Jackson, MI
| | | | | | | | | | | | | | - Ahlee Kim
- Le Bonheur Children’s Hospital, University of Tennessee, Jackson, TN
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55
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Romeo GR, Shaikh YA, Middelbeek RJW. Post-graduate medical education in the time of COVID-19: Not a remotely simple task. Front Endocrinol (Lausanne) 2022; 13:980505. [PMID: 36187134 PMCID: PMC9523131 DOI: 10.3389/fendo.2022.980505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 09/05/2022] [Indexed: 11/13/2022] Open
Abstract
The COVID-19 pandemic has stimulated a rapid shift towards telemedicine, which has had tremendous repercussions on all domains of the healthcare ecosystem. The effects of the transition to telemedicine on post-graduate medical education and on patient care provided by trainees have not been fully elucidated. Focusing on the multifaceted scope of endocrinology teaching clinics, the experience garnered by endocrinology fellows, preceptors, and patients through the adoption of virtual visits has shed new light on relevant challenges that require specific attention. First, we identified a divergent trend in glycated hemoglobin in people with type 1 diabetes according to their use of continuous glucose monitoring (CGM). Second, the patient's perspective highlighted positive aspects, including expanded options for clinical care, but also limitations in communication with clinicians for people without access to videoconferencing tools or EHR-based portals. Finally, regarding medical training evaluation and skills-based learning, academic centers, professional organizations, and clinical educators should develop new teaching curricula suitable for a telemedicine-based environment. While simultaneously facing numerous pressures, fellows can potentially spearhead new models of care delivery and innovative approaches to clinical education leveraging telemedicine.
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Affiliation(s)
- Giulio R. Romeo
- Joslin Diabetes Center, One Joslin Pl, Boston, MA, United States
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
- *Correspondence: Giulio R. Romeo, ; Roeland J. W. Middelbeek,
| | - Yousaf A. Shaikh
- Department of Medicine, UMass Memorial Medical Center, Worcester, MA, United States
| | - Roeland J. W. Middelbeek
- Joslin Diabetes Center, One Joslin Pl, Boston, MA, United States
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
- *Correspondence: Giulio R. Romeo, ; Roeland J. W. Middelbeek,
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56
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Ospelt E, Noor N, Sanchez J, Nelson G, Rioles N, Malik FS, Basina M, Indyk J, Vendrame F, Schmitt J, Scott ML, Ebekozien O. Facilitators and Barriers to Smart Insulin Pen Use: A Mixed-Method Study of Multidisciplinary Stakeholders From Diabetes Teams in the United States. Clin Diabetes 2022; 41:56-67. [PMID: 36714258 PMCID: PMC9845084 DOI: 10.2337/cd22-0068] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
This study sought to identify barriers and facilitators to successful smart insulin pen (SIP) use and gauge prescribing practices and integration into clinical practice by assessing provider and care team perspectives at participating endocrinology clinics within the T1D Exchange Quality Improvement Collaborative. The identified provider-related, patient-related, and clinic- and operational-level barriers and facilitators varied based on clinic knowledge, capacity, and resources. High-impact barriers included insurance coverage and prescribing processes; high-impact facilitators included improved diabetes clinic visit quality and use of SIPs as an alternative to insulin pump therapy. Findings indicated the need for provider and care team education and training on proper SIP features, use, and prescribing.
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Affiliation(s)
- Emma Ospelt
- T1D Exchange, Boston, MA
- Corresponding author: Emma Ospelt,
| | | | - Janine Sanchez
- University of Miami Miller School of Medicine, Miami, FL
| | | | | | | | | | | | | | | | | | - Osagie Ebekozien
- T1D Exchange, Boston, MA
- University of Mississippi School of Population Health, Jackson, MS
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57
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Pinnaro CT, Tansey MJ. The Evolution of Insulin Administration in Type 1 Diabetes. JOURNAL OF DIABETES MELLITUS 2021; 11:249-277. [PMID: 37745178 PMCID: PMC10516284 DOI: 10.4236/jdm.2021.115021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
Insulin has been utilized in the treatment of type 1 diabetes (T1D) for 100 years. While there is still no cure for T1D, insulin administration has undergone a remarkable evolution which has contributed to improvements in quality of life and life expectancy in individuals with T1D. The advent of faster-acting and longer-acting insulins allowed for the implementation of insulin regimens more closely resembling normal insulin physiology. These improvements afforded better glycemic control, which is crucial for limiting microvascular complications and improving T1D outcomes. Suspension of insulin delivery in response to actual and forecasted hypoglycemia has improved quality of life and mitigated hypoglycemia without compromising glycemic control. Advances in continuous glucose monitoring (CGM) and insulin pumps, efforts to model glucose and insulin kinetics, and the application of control theory to T1D have made the automation of insulin delivery a reality. This review will summarize the past, present, and future of insulin administration in T1D.
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Affiliation(s)
- Catherina T Pinnaro
- University of Iowa Stead Family Department of Pediatrics
- Fraternal Order of Eagles Diabetes Research Center
| | - Michael J Tansey
- University of Iowa Stead Family Department of Pediatrics
- Fraternal Order of Eagles Diabetes Research Center
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58
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Addala A, Zaharieva DP, Gu AJ, Prahalad P, Scheinker D, Buckingham B, Hood KK, Maahs DM. Clinically Serious Hypoglycemia Is Rare and Not Associated With Time-in-range in Youth With New-onset Type 1 Diabetes. J Clin Endocrinol Metab 2021; 106:3239-3247. [PMID: 34265059 PMCID: PMC8530719 DOI: 10.1210/clinem/dgab522] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Indexed: 02/06/2023]
Abstract
CONTEXT Early initiation of continuous glucose monitoring (CGM) is advocated for youth with type 1 diabetes (T1D). Data to guide CGM use on time-in-range (TIR), hypoglycemia, and the role of partial clinical remission (PCR) are limited. OBJECTIVE Our aims were to assess whether 1) an association between increased TIR and hypoglycemia exists, and 2) how time in hypoglycemia varies by PCR status. METHODS We analyzed 80 youth who were started on CGM shortly after T1D diagnosis and were followed for up to 1-year post diagnosis. TIR and hypoglycemia rates were determined by CGM data and retrospectively analyzed. PCR was defined as (visit glycated hemoglobin A1c) + (4*units/kg/day) less than 9. RESULTS Youth were started on CGM 8.0 (interquartile range, 6.0-13.0) days post diagnosis. Time spent at less than 70 mg/dL remained low despite changes in TIR (highest TIR 74.6 ± 16.7%, 2.4 ± 2.4% hypoglycemia at 1 month post diagnosis; lowest TIR 61.3 ± 20.3%, 2.1 ± 2.7% hypoglycemia at 12 months post diagnosis). No events of severe hypoglycemia occurred. Hypoglycemia was rare and there was minimal difference for PCR vs non-PCR youth (54-70 mg/dL: 1.8% vs 1.2%, P = .04; < 54mg/dL: 0.3% vs 0.3%, P = .55). Approximately 50% of the time spent in hypoglycemia was in the 65 to 70 mg/dL range. CONCLUSION As TIR gradually decreased over 12 months post diagnosis, hypoglycemia was limited with no episodes of severe hypoglycemia. Hypoglycemia rates did not vary in a clinically meaningful manner by PCR status. With CGM being started earlier, consideration needs to be given to modifying CGM hypoglycemia education, including alarm settings. These data support a trial in the year post diagnosis to determine alarm thresholds for youth who wear CGM.
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Affiliation(s)
- Ananta Addala
- Division of Endocrinology, Department of Pediatrics, Stanford University, School of Medicine, Stanford, California, USA
- Correspondence: Ananta Addala, DO, MPH, Division of Endocrinology, Department of Pediatrics, Stanford University, School of Medicine, Stanford, CA 94305, USA.
| | - Dessi P Zaharieva
- Division of Endocrinology, Department of Pediatrics, Stanford University, School of Medicine, Stanford, California, USA
| | - Angela J Gu
- Division of Endocrinology, Department of Pediatrics, Stanford University, School of Medicine, Stanford, California, USA
- Department of Management Science and Engineering, Stanford University, Stanford, California, USA
| | - Priya Prahalad
- Division of Endocrinology, Department of Pediatrics, Stanford University, School of Medicine, Stanford, California, USA
- Stanford Diabetes Research Center, Stanford, California, USA
| | - David Scheinker
- Division of Endocrinology, Department of Pediatrics, Stanford University, School of Medicine, Stanford, California, USA
- Department of Management Science and Engineering, Stanford University, Stanford, California, USA
- Stanford Diabetes Research Center, Stanford, California, USA
| | - Bruce Buckingham
- Division of Endocrinology, Department of Pediatrics, Stanford University, School of Medicine, Stanford, California, USA
- Stanford Diabetes Research Center, Stanford, California, USA
| | - Korey K Hood
- Division of Endocrinology, Department of Pediatrics, Stanford University, School of Medicine, Stanford, California, USA
- Stanford Diabetes Research Center, Stanford, California, USA
| | - David M Maahs
- Division of Endocrinology, Department of Pediatrics, Stanford University, School of Medicine, Stanford, California, USA
- Stanford Diabetes Research Center, Stanford, California, USA
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59
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Karter AJ, Gilliam LK, Dlott R. Continuous Glucose Monitoring Use and Access Disparities-Reply. JAMA 2021; 326:1438. [PMID: 34636864 PMCID: PMC9007280 DOI: 10.1001/jama.2021.13484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | - Lisa K Gilliam
- Endocrinology and Internal Medicine, Permanente Medical Group, South San Francisco, California
| | - Richard Dlott
- Endocrinology and Clinical Informatics, Permanente Medical Group, Martinez, California
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60
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Walker AF, Cuttriss N, Haller MJ, Hood KK, Gurka MJ, Filipp SL, Anez-Zabala C, Yabut K, Roque X, Wong JJ, Baer L, Figg L, Bernier A, Westen S, Lewit E, Sheehan E, Basina M, Lal R, Maizel J, Maahs DM. Democratizing type 1 diabetes specialty care in the primary care setting to reduce health disparities: project extension for community healthcare outcomes (ECHO) T1D. BMJ Open Diabetes Res Care 2021; 9:9/1/e002262. [PMID: 34244218 PMCID: PMC8268922 DOI: 10.1136/bmjdrc-2021-002262] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 06/05/2021] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Project ECHO (Extension for Community Healthcare Outcomes) is a tele-education outreach model that seeks to democratize specialty knowledge to reduce disparities and improve health outcomes. Limited utilization of endocrinologists forces many primary care providers (PCPs) to care for patients with type 1 diabetes (T1D) without specialty support. Accordingly, an ECHO T1D program was developed and piloted in Florida and California. Our goal was to demonstrate the feasibility of an ECHO program focused on T1D and improve PCPs' abilities to manage patients with T1D. RESEARCH DESIGN AND METHODS Health centers (ie, spokes) were recruited into the ECHO T1D pilot through an innovative approach, focusing on Federally Qualified Health Centers and through identification of high-need catchment areas using the Neighborhood Deprivation Index and provider geocoding. Participating spokes received weekly tele-education provided by the University of Florida and Stanford University hub specialty team through virtual ECHO clinics, real-time support with complex T1D medical decision-making, access to a diabetes support coach, and access to an online repository of diabetes care resources. Participating PCPs completed pre/post-tests assessing diabetes knowledge and confidence and an exit survey gleaning feedback about overall ECHO T1D program experiences. RESULTS In Florida, 12 spoke sites enrolled with 67 clinics serving >1000 patients with T1D. In California, 11 spoke sites enrolled with 37 clinics serving >900 patients with T1D. During the 6-month intervention, 27 tele-education clinics were offered and n=70 PCPs (22 from Florida, 48 from California) from participating spoke sites completed pre/post-test surveys assessing diabetes care knowledge and confidence in diabetes care. There was statistically significant improvement in diabetes knowledge (p≤0.01) as well as in diabetes confidence (p≤0.01). CONCLUSIONS The ECHO T1D pilot demonstrated proof of concept for a T1D-specific ECHO program and represents a viable model to reach medically underserved communities which do not use specialists.
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Affiliation(s)
- Ashby F Walker
- University of Florida Diabetes Institute, Gainesville, FL, USA
- Department of Health Services Research, Management and Policy, University of Florida, Gainesville, FL, USA
| | - Nicolas Cuttriss
- Department of Pediatrics and Division of Pediatric Endocrinology and Diabetes, Stanford University, Palo Alto, California, USA
| | - Michael J Haller
- University of Florida Diabetes Institute, Gainesville, FL, USA
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA
| | - Korey K Hood
- Department of Pediatrics and Division of Pediatric Endocrinology and Diabetes, Stanford University, Palo Alto, California, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
| | - Matthew J Gurka
- Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, Florida, USA
| | - Stephanie L Filipp
- Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, Florida, USA
| | | | - Katarina Yabut
- Department of Pediatrics and Division of Pediatric Endocrinology and Diabetes, Stanford University, Palo Alto, California, USA
| | - Xanadu Roque
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA
| | - Jessie J Wong
- Department of Pediatrics and Division of Pediatric Endocrinology and Diabetes, Stanford University, Palo Alto, California, USA
| | - Linda Baer
- Department of Pediatrics and Division of Pediatric Endocrinology and Diabetes, Stanford University, Palo Alto, California, USA
| | - Lauren Figg
- Department of Pediatrics and Division of Pediatric Endocrinology and Diabetes, Stanford University, Palo Alto, California, USA
| | - Angelina Bernier
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA
| | - Sarah Westen
- Department of Clinical and Health Psychology, University of Florida, Gainesville, Florida, USA
| | - Eugene Lewit
- Department of Health Research and Policy, Stanford, Palo Alto, California, USA
| | - Eleni Sheehan
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA
| | - Marina Basina
- Department of Pediatrics and Division of Pediatric Endocrinology and Diabetes, Stanford University, Palo Alto, California, USA
- Department of Medicine, Division of Endocrinology, Gerontology & Metabolism, Stanford University, Palo Alto, California, USA
| | - Rayhan Lal
- Department of Pediatrics and Division of Pediatric Endocrinology and Diabetes, Stanford University, Palo Alto, California, USA
- Department of Medicine, Division of Endocrinology, Gerontology & Metabolism, Stanford University, Palo Alto, California, USA
| | - Jennifer Maizel
- College of Public Health and Health Professions, University of Florida, Gainesville, Florida, USA
| | - David M Maahs
- Department of Pediatrics and Division of Pediatric Endocrinology and Diabetes, Stanford University, Palo Alto, California, USA
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