Disparities in Care Delivery and Outcomes in Young Adults With Diabetes

Incidence and Risk Factors of Diagnosed Young-Adult-Onset Type 2 Diabetes in the U.S.: The National Health Interview Survey 2016-2022

OBJECTIVE

To estimate the incidence and identify risk factors for diagnosed type 2 diabetes (T2D) among young U.S. adults.

RESEARCH DESIGN AND METHODS

We analyzed 142,884 adults aged 18-79 years with self-reported diabetes type from the cross-sectional National Health Interview Survey in 2016-2022, representing the noninstitutionalized U.S. civilian population. Incidence of diagnosed T2D was calculated for three age groups: young-adult onset (18-44 years), middle-age onset (45-64 years), and older-adult onset (65-79 years); the latter two groups were included to highlight the distinct risk factor profile of young-adult-onset T2D. Multivariable logistic regressions were used to identify risk factors for young-adult-onset T2D.

RESULTS

The estimated incidence of diagnosed young-adult-onset T2D was 3.0 per 1,000 adults (95% CI 2.6-3.5). Minority groups, socioeconomically disadvantaged individuals, and people with cardiometabolic diseases or psychological conditions had a higher incidence of diagnosed young-adult-onset T2D compared with their counterparts. Lipid-lowering medication use (adjusted odds ratio [aOR] 13.15, 95% CI 8.85-19.55), antihypertensive medication use (aOR 11.89, 95% CI 7.97-17.73), and obesity (BMI ≥30 vs. <25 kg/m2, aOR 10.89, 95% CI 6.69-17.7) were the strongest risk factors for young-adult-onset T2D; these risk factors, along with hypertension, hyperlipidemia, and coronary heart disease, were more strongly associated with young-adult-onset T2D compared with later-onset T2D, with up to 4.5 times higher aORs.

CONCLUSIONS

This study quantified the incidence of diagnosed young-adult-onset T2D in U.S. adults and identified its distinct risk factor profile. Targeted prevention strategies for young-adult-onset T2D are needed for minority and socioeconomically disadvantaged people and those with cardiometabolic diseases.

Health Equity Intervention for Youth with Type 1 Diabetes and High Social Risk

BACKGROUND/OBJECTIVES

Youth with type 1 diabetes (T1D) who experience avoidable complications often have dangerously high and consistently elevated HbA1c values. Novel Interventions in Children's Healthcare (NICH), a program designed to effectively intervene with this population, has demonstrated success with reducing avoidable complications and improving HbA1c in these youth. However, prior examinations of program outcomes have not included a comparison group. This is the first study to compare electronic health record (EHR) outcomes (i.e., HbA1c values, hospital utilization) of NICH youth to a comparison group.

METHODS

Youth with T1D and avoidable complications were referred to NICH (n = 101; NICH = 40; comparison = 61) from the Pacific Northwest region of the United States. Retrospective EHR review included one year prior to and two years post NICH referral. Outcomes included hospitalization utilization and HbA1c values. There were no significant demographic differences between NICH and unserved youth (M age = 14.05 years; 50% female).

RESULTS

Within-group analyses revealed that NICH youth demonstrated a significant reduction in mean (M) admissions from one year prior to two years post-referral (M = 1.55 to M = 0.99; p = 0.011) as well as reduced HbA1c values from pre-referral to one year post-referral (M = 11.64%; 287 mg/dL; 15.9 mmol/L to M = 10.87; 265 mg/dL; 14.7 mmol/L; (p = 0.006)). Between-group analyses revealed NICH youth had lower proportions of individuals with an HbA1c over 10% (240 mg/dL; 13.3 mmol/L) (p = 0.03) compared to comparison group youth at one year post-referral. ANOVA analyses showed a significant reduction in admissions in linear interaction F (1,95) = 4.036, (p = 0.047), indicating that NICH youth demonstrated a significantly greater reduction in admissions over time compared to comparison youth.

CONCLUSIONS

This study was the first to compare the health outcomes of NICH youth to a comparison group. NICH youth demonstrated significant reductions in admissions and HbA1c values over time.

Effectiveness of the User-Centered "Healthcare CEO" App for Patients With Type 1 Diabetes Transitioning From Adolescence to Early Adulthood: Protocol for a Randomized Controlled Trial

BACKGROUND

Young patients aged 16 to 25 years with type 1 diabetes (T1D) often encounter challenges related to deteriorating disease control and accelerated complications. Mobile apps have shown promise in enhancing self-care among youth with diabetes. However, inconsistent findings suggest that further evidence is necessary to confirm the effectiveness of app-based interventions.

OBJECTIVE

This study aims to evaluate the effectiveness of the Healthcare CEO app in patients with T1D transitioning from adolescence to early adulthood.

METHODS

A 2 arms, double-blind, randomized controlled trial will be conducted over a 9-month period, with strategies designed to enhance treatment fidelity. The study expects to enroll 96 patients with T1D, aged 16 to 25 years. Participants will be randomly assigned to either the experimental or control group through central randomization. The intervention will be implemented using the Healthcare CEO app, which consists of 11 interfaces. The research will compare differences in disease control outcomes, confidence in self-management, self-care behaviors, emotional distress, quality of life, and specific diabetes-related knowledge between the 2 groups at baseline and 3, 6, and 9 months after intervention. Additionally, changes within the experimental group will be analyzed before and after the intervention.

RESULTS

The study was funded in August 2020. It was originally scheduled from August 2020 to July 2022 but was interrupted by the COVID-19 pandemic after enrolling 38 participants, with preliminary results anticipated for publication by November 2024. Recruitment resumed in August 2023, with findings expected to be finalized by July 2025.

CONCLUSIONS

The Healthcare CEO app is a comprehensive solution tailored specifically for individuals with T1D transitioning from adolescence to early adulthood. This innovative app has the potential to improve the quality of care for adolescents with T1D during this critical stage and may serve as valuable evidence in support of app-based intervention strategies.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05022875; https://www.clinicaltrials.gov/study/NCT05022875.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/59871.

Glycemic Risk Index Profiles and Predictors Among Diverse Adults With Type 1 Diabetes

BACKGROUND

The Glycemia Risk Index (GRI) was introduced as a single value derived from the ambulatory glucose profile that identifies patients who need attention. This study describes participants in each of the five GRI zones and examines the percentage of variation in GRI scores that is explained by sociodemographic and clinical variables among diverse adults with type 1 diabetes.

METHODS

A total of 159 participants provided blinded continuous glucose monitoring (CGM) data over 14 days (mean age [SD] = 41.4 [14.5] years; female = 54.1%, Hispanic = 41.5%). Glycemia Risk Index zones were compared on CGM, sociodemographic, and clinical variables. Shapley value analysis examined the percentage of variation in GRI scores explained by different variables. Receiver operating characteristic curves examined GRI cutoffs for those more likely to have experienced ketoacidosis or severe hypoglycemia.

RESULTS

Mean glucose and variability, time in range, and percentage of time in high, and very high, glucose ranges differed across the five GRI zones (P values < .001). Multiple sociodemographic indices also differed across zones, including education level, race/ethnicity, age, and insurance status. Sociodemographic and clinical variables collectively explained 62.2% of variance in GRI scores. A GRI score ≥84.5 reflected greater likelihood of ketoacidosis (area under the curve [AUC] = 0.848), and scores ≥58.2 reflected greater likelihood of severe hypoglycemia (AUC = 0.729) over the previous six months.

CONCLUSIONS

Results support the use of the GRI, with GRI zones identifying those in need of clinical attention. Findings highlight the need to address health inequities. Treatment differences associated with the GRI also suggest behavioral and clinical interventions including starting individuals on CGM or automated insulin delivery systems.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Disparities in Continuous Glucose Monitor Use Between Children With Type 1 Diabetes Living in Urban and Rural Areas

OBJECTIVE

Despite evidence that continuous glucose monitoring (CGM) use is associated with lower HbA1c among children with type 1 diabetes, uptake of this technology remains lower among those with difficulty accessing health care, including those from lower socioeconomic status backgrounds and racial and ethnic minorities. In this study, we sought to explore the impact of rural location in use of CGM technology to guide patient and provider decision making.

RESEARCH DESIGN AND METHODS

In this retrospective study of electronic health record demographic and visits data from a single diabetes program from 1 January 2018 through 31 December 2021, we compared the odds of completing a visit with (+) and without (-) CGM interpretation between rural-urban commuting area (RUCA) designations.

RESULTS

Among the 13,645 visits completed by 2,008 patients with type 1 diabetes younger than age 18 years, we found children living in small rural towns had 31% lower odds (6.3% of CGM+ visits, 8.6% of CGM- visits; adjusted odds ratio [aOR] 0.69, 95% CI 0.51-0.94) and those living in isolated rural towns had 49% lower odds (2.0% of CGM+ visits, 3.4% of CGM- visits; aOR 0.51, 95% CI 0.28-0.92) of completing a CGM-billed clinic visit compared with those living in urban areas (70.0% of CGM+ visits, 67.2% of CGM- visits). We also found significant differences in CGM-billed visits by neighborhood deprivation as well as race/ethnicity and insurance payor.

CONCLUSIONS

Geographic location presents a meaningful barrier to access to care for patients living with type 1 diabetes. Further work is needed to identify and address the needs of children and families living in rural areas to improve the care of these patients.

Emerging Technologies and Therapeutics for Type 1 Diabetes

Recent years witnessed advancements in diabetes technologies and therapeutics. People with type 1 diabetes have more options to control their blood glucose, prevent hypoglycemia, and spend more time with their loved ones. Newer diabetes technologies and therapeutics improve the quality of life and boost the confidence of people with type 1 diabetes. In parallel to changes in the diabetes technology field, stem cell research has been evolving. Gene editing and production of β cells from stem cells are ongoing. The current focus of cure studies is how to increase the survival of cells produced with stem cells. New adjunctive therapies are under development.

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

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

Views of children with diabetes from underserved communities, and their families on diabetes, glycaemic control and healthcare provision: A qualitative evidence synthesis

AIMS

Children and young people with diabetes (CYPD) from socio-economically deprived and/or ethnic minority groups tend to have poorer glucose control and greater risk of diabetes-related complications. In this systematic review of qualitative evidence (qualitative evidence synthesis, QES), we aimed to explore the experiences and views of clinical encounters in diabetes care from the perspectives of CYPD and their family/carers from underserved communities and healthcare professionals in diabetes care.

METHODS

We searched 6 databases to March 2022 with extensive search terms, and used a thematic synthesis following methods of Thomas and Harden.

RESULTS

We identified 7 studies and described 11 descriptive themes based on primary and secondary constructs. From these, three "analytical themes" were developed. (1) "Alienation of CYPD" relates to their social identity and interaction with peers, family and health service practitioners in the context of diabetes self- and family/carer management and is impacted by communication in the clinical encounter. (2) "Empowerment of CYPD and family/carers" explores families' understanding of risks and consequences of diabetes and taking responsibility for self- and family/carer management in the context of their socio-cultural background. (3) "Integration of diabetes (into self and family)" focuses on the ability to integrate diabetes self-management into the daily lives of CYPD and family/carers beyond the clinical consultation.

CONCLUSIONS

The analytical themes are interdependent and provide a conceptual framework from which to explore and strengthen the therapeutic alliance in clinical encounters and to foster greater concordance with treatment plans. Communicating the biomedical aspects of managing diabetes in the clinical encounter is important, but should be balanced with addressing socio-emotional factors important to CYPD and family/carers.

Psychosocial Factors Predicting Healthcare Usage in Young Adults with Youth-Onset Type 2 Diabetes: The TODAY2 iCount Observational Study

BACKGROUND

Established diabetes care ("diabetes home") and regular healthcare visits are important to achieve optimal health. Nothing is known about psychosocial factors that predict healthcare usage (HCU) in young adults with youth-onset type 2 diabetes, at risk for early complications.

OBJECTIVE

To identify psychosocial predictors of HCU in the Treatment Options for type 2 Diabetes in Adolescents and Youth (TODAY2) cohort.

DESIGN

Longitudinal, measured at T1 (baseline) and T2 (1 year later). Logistic and linear regressions, adjusted for potential confounders, identified predictors of sub-optimal HCU (defined as no diabetes home, 0 visits for routine care, or  ≥ 1 urgent care visit in prior 6 months).

PARTICIPANTS

N = 366 TODAY2 participants with T1 and T2 data (381 consented). Mean age = 26.0 years, 67.8% female, 37.7% non-Hispanic Black, 35.8% Hispanic, 20.2% non-Hispanic white, 6.3% "other," mean HbA1c = 9.4%.

MAIN MEASURES

HCU survey; reliable and valid measures of diabetes self-efficacy, depressive symptoms, anxiety symptoms, diabetes distress, beliefs about medicines, diabetes attitudes, material need insecurities, self-management support.

KEY RESULTS

25.4% had no diabetes home, 23.7% had 0 routine care visits, 46% had  ≥ 1 urgent care visit (prior 6 months). Beliefs in the necessity of (adjusted odds ratio [OR] = 1.28; 95% confidence interval [CI] = 1.12, 1.46, p < 0.001), and concerns about (OR = 1.29;CI = 1.08,1.54, p = 0.004), diabetes medicines, and its negative psychosocial impacts (OR = 1.57;CI = 1.04, 2.38, p = 0.03), predicted higher odds of having a diabetes home at T2. Beliefs that medicines are harmful predicted lower odds of a diabetes home (OR = 0.56;CI = 0.37,0.85, p = 0.006). Necessity beliefs (OR = 1.2;CI = 1.06,1.36, p = 0.004), and self-management support (OR = 1.5;CI = 1.08,2.07, p = 0.01) predicted higher odds of having  ≥ 1 diabetes care visit, harm beliefs predicted lower odds (OR = 0.6;CI = 0.41,0.88, p = 0.01).

CONCLUSIONS

Sub-optimal healthcare usage, common in young adults with youth-onset type 2 diabetes, is predicted by beliefs about medicines, diabetes impact, and self-management support. We must address these factors to help this vulnerable group establish stable diabetes care.

Socioeconomic inequalities in type 2 diabetes comorbidities in different population subgroups: trend analyses using German health insurance data

While socioeconomic inequalities in the prevalence and management of type 2 diabetes (T2D) are well established, little is known about whether inequalities exist in the prevalence and the temporal development of T2D comorbidities. Previous research points towards expansion of morbidity in T2D as depicted mainly by a rising trend of T2D comorbidities. Against this background, and using German claims data, this study aims to examine whether socioeconomic status (SES) inequalities exist in the rates and the temporal development of T2D comorbidities. Since previous research indicates varying risk levels for T2D prevalence in the population subgroups: working individuals, nonworking spouses and pensioners, the analyses are stratified by these three population subgroups. The study is done on a large population of statutory insured individuals with T2D in three time-periods between 2005 and 2017. Predicted probabilities of three comorbidity groups and the number of comorbidities were estimated using logistic and ordinal regression analyses among different income, education and occupation groups. Interaction analyses were applied to examine whether potential SES inequalities changed over time. The study showed that neither the cross-sectional existence, nor the temporal development of T2D comorbidities differed significantly among SES groups, ruling out SES inequalities in the prevalence and the temporal development of T2D comorbidities in Germany. In men and women of all examined population subgroups, predicted probabilities for less severe cardiovascular (CVD) comorbidities, other vascular diseases and the number of comorbidities per individual rose significantly over time regardless of SES, but little if any change took place for more severe CVD comorbidities. Another important finding is that the population subgroup of nonworking spouses had markedly higher predicted probabilities for most of the examined outcomes compared to working individuals. The study indicates that the expansion of morbidity in T2D in Germany does not appear to be SES-dependent, and applies equally to different population subgroups. Yet, the study highlights that nonworking spouses are a susceptible population subgroup that needs to be focused upon when planning and implementing T2D management interventions.

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.

Emerging Adults with Diabetes in Safety-Net Care: Self-Management Influences and Patient-Provider Interactions

Emerging adults with diabetes, particularly in underserved communities, represent a growing but less studied population whose needs may differ from older adults. This study investigated perspectives of underserved emerging adults regarding diabetes self-management influences and provider interactions. Focus groups and interviews with emerging adults in a safety-net health care setting were conducted to identify perspectives regarding self-management influences and patient-provider interactions. Diabetes was perceived as a psychological burden complicated by busy lifestyles and competing responsibilities. Lack of resources, especially financial barriers, also limited self-management. Participants often perceived diabetes visits as standardized encounters providing access to diabetes supplies but desired additional guidance appropriate to their needs and life-stage. Participants valued encouragement and positive ongoing provider relationships for tailored informational and emotional support and support from family and peers. Providers and health care systems adapting to provide or facilitate this support will be better able to optimize diabetes management at and between visits.

Diabetes Care Barriers, Use, and Health Outcomes in Younger Adults With Type 1 and Type 2 Diabetes

Importance

Treatment challenges exist for younger adults with type 1 (T1D) and type 2 diabetes (T2D). Health care coverage, access to, and use of diabetes care are not well delineated in these high-risk populations.

Objective

To compare patterns of health care coverage, access to, and use of diabetes care and determine their associations with glycemia among younger adults with T1D and with T2D.

Design, Setting, and Participants

This cohort study analyzed data from a survey that was jointly developed by 2 large, national cohort studies: the SEARCH for Diabetes in Youth (SEARCH) study, an observational study of individuals with youth-onset T1D or T2D, and the Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) study, a randomized clinical trial (2004-2011) followed by an observational study (2012-2020). The interviewer-directed survey was administered during in-person study visits in both studies between 2017 and 2019. Data analyses were performed between May 2021 and October 2022.

Main Outcomes and Measures

Survey questions addressed health care coverage, usual sources of diabetes care, and frequency of care use. Glycated hemoglobin (HbA1c) levels were assayed in a central laboratory. Patterns of health care factors and HbA1c levels were compared by diabetes type.

Results

The analysis included 1371 participants (mean [range] age, 25 [18-36] years; 824 females [60.1%]), of whom 661 had T1D and 250 had T2D from the SEARCH study and 460 had T2D from the TODAY study. Participants had a mean (SD) diabetes duration of 11.8 (2.8) years. More participants with T1D than T2D in both the SEARCH and TODAY studies reported health care coverage (94.7%, 81.6%, and 86.7%), access to diabetes care (94.7%, 78.1%, and 73.4%), and use of diabetes care (88.1%, 80.5%, and 73.6%). Not having health care coverage was associated with significantly higher mean (SE) HbA1c levels in participants with T1D in the SEARCH study (no coverage, 10.8% [0.5%]; public, 9.4% [0.2%]; private, 8.7% [0.1%]; P < .001) and participants with T2D from the TODAY study (no coverage, 9.9% [0.3%]; public, 8.7% [0.2%]; private, 8.7% [0.2%]; P = .004). Medicaid expansion vs without expansion was associated with more health care coverage (participants with T1D: 95.8% vs 90.2%; participants with T2D in SEARCH: 86.1% vs 73.9%; participants with T2D in TODAY: 93.6% vs 74.2%) and lower HbA1c levels (participants with T1D: 9.2% vs 9.7%; participants with T2D in SEARCH: 8.4% vs 9.3%; participants with T2D in TODAY: 8.7% vs 9.3%). The T1D group incurred higher median (IQR) monthly out-of-pocket expenses than the T2D group ($74.50 [$10.00-$309.00] vs $10.00 [$0-$74.50]).

Conclusions and Relevance

Results of this study suggested that lack of health care coverage and of an established source of diabetes care were associated with significantly higher HbA1c levels for participants with T1D, but inconsistent results were found for participants with T2D. Increased access to diabetes care (eg, through Medicaid expansion) may be associated with improved health outcomes, but additional strategies are needed, particularly for individuals with T2D.

Achieving Equity in Diabetes Research: Borrowing From the Field of Quality Improvement Using a Practical Framework and Improvement Tools

There are limited tools to address equity in diabetes research and clinical trials. The T1D Exchange has established a 10-step equity framework to advance equity in diabetes research. Herein, the authors outline this approach and expand on its practical application.

The association between pediatric mental health disorders and type 1 diabetes-related outcomes

OBJECTIVE

Transition from pediatric to adult healthcare systems is a difficult process for young adults with Type 1 Diabetes (T1D) and most patients experience a deterioration in disease control. Mental health (MH) disorders are common in individuals with T1D and are believed to play a role in disease control and transition of care. We evaluated the association between the presence of pediatric MH disorder and measures of success in diabetes care in young adults who recently transitioned to adult care.

RESEARCH DESIGN AND METHODS

Retrospective cohort study of young adults in a large adult endocrinology system who transitioned from a pediatric hospital system after 2009. MH disorders were diagnosed by clinical pediatric psychologists during routine care at the pediatric hospital. Measurements of Hemoglobin A1c, diabetes-related emergencies, clinic attendance and intervals in transition were assessed and compared between the pediatric and adult hospital systems.

RESULTS

237 young adults were identified and 100 (42%) of these were diagnosed with a MH disorder during pediatric care. Presence of a MH disorder was associated with higher Hemoglobin A1c levels prior to transition and increased rates of diabetes-related hospitalizations during the transition interval. Patients with a MH disorder were less likely to establish a pattern of consistent follow up after transition (p = 0.021).

CONCLUSIONS

MH disorders are common and predict greater challenges with diabetes management and less effective transition into the adult endocrinology system. Early recognition of MH disorders may allow for allocation of more proactive and intensive support for affected patients.

Diabetes Care Provider Perceptions Regarding Emerging Adults' Diabetes Self-Management Influences and Patient-Provider Visit Interactions Within a Safety-Net Hospital

The increasing number of emerging adults with diabetes (EAWD) being cared for in adult health care settings requires a better understanding of the needs of EAWD and their interactions with adult health care providers (HCPs). This article describes findings from interviews with endocrinologists and diabetes nurses from a safety-net health care system to investigate HCPs' perspectives regarding influences on EAWD self-management and HCP interactions with EAWD. HCPs frequently perceived lower EAWD engagement in diabetes management, which was complicated by barriers such as the emotional burden of diabetes, busy lives and multiple responsibilities, and limited access to resources; however, HCPs valued the role of information and communication at visits in tailoring care for EAWD. Measures to tailor care should address the psychosocial burden related to the life stage goals and priorities of EAWD, identification of resources for EAWD and HCPs, and further elucidation of effective self-management guidance and communication strategies to support EAWD in safety-net settings.

Equity in Psychosocial Outcomes and Care for Racial and Ethnic Minorities and Socioeconomically Disadvantaged People With Diabetes

The role of social determinants of health (SDOH) in promoting equity in diabetes prevalence, incidence, and outcomes continues to be documented in the literature. Less attention has focused on disparities in psychosocial aspects of living with diabetes and the role of SDOH in promoting equity in psychosocial outcomes and care. In this review, the authors describe racial/ethnic and socioeconomic disparities in psychosocial aspects of living with diabetes, discuss promising approaches to promote equity in psychosocial care, and provide future research directions.

Competing Demands of Young Adulthood and Diabetes: A Discussion of Major Life Changes and Strategies for Health Care Providers to Promote Successful Balance

Young adults (YAs) are often faced with many new transitions and major milestones specific to their life stage. For YAs with diabetes, it can be particularly difficult to balance diabetes management with the age-typical demands of young adulthood. Clinicians can play an important role in helping YAs navigate major life changes and find balance in the competing demands of young adulthood, while protecting their health and well-being.

Promoting High-Quality Health Communication Between Young Adults With Diabetes and Health Care Providers

Young adults with diabetes assume increasing responsibility for communicating with their health care providers, and engaging in high-quality health communication is an integral component of overall diabetes self-management. This article provides an overview of the main features of health communication, factors that may influence communication quality, interventions to promote communication skills, and practical strategies for clinicians working with young adults with diabetes. The review concludes with a comprehensive summary of future directions for health communication research.

Racial Disparities in Diabetes Technology Use and Outcomes in Type 1 Diabetes in a Safety-Net Hospital

BACKGROUND

Limited data exist regarding diabetes technology use among adults with type 1 diabetes (T1D) in urban racially/ethnically diverse safety-net hospitals. We examined racial/ethnic differences in the use of continuous glucose monitor (CGM) and continuous subcutaneous insulin infusion (CSII) in this setting.

METHODS

A retrospective review of 227 patients ≥ 18 years of age with T1D seen in an urban, safety-net endocrinology clinic during 2016-2017 was completed (mean age: 39; 80% English-speaking; 50% had public insurance). Diabetes technology use, defined as either CGM or CSII or both CGM and CSII, and clinical outcomes were examined by race/ethnicity.

RESULTS

Overall, 30% used CGM and 26% used CSII. After adjusting for age, language, insurance, and annual income, diabetes technology use in non-White patients was significantly lower than in White patients, predominantly lower in Black (aOR 0.25 [95% CI 0.11-0.56]) and patients identified as other race/ethnicity (aOR 0.30 [95% CI 0.11-0.77]). At the highest household income level (≥$75,000/y), Black and Hispanic individuals were significantly less likely than White individuals to use diabetes technology (P < .0007). Mean hemoglobin A1c (HbA1c) was lower in patients using any diabetes technology compared with patients using no technology (P < .0001). Use of CGM and CSII together was associated with the lowest HbA1c across all racial/ethnic groups.

CONCLUSIONS

Racial/ethnic disparities in diabetes technology use and glycemic control were observed even after adjusting for sociodemographic factors. Further research should explore barriers to accessing diabetes technology in non-White populations.

A Delphi Study on the Healthcare Needs of Patients with Type 1 Diabetes during the Transition from Adolescence to Adulthood: Consensus among Patients, Primary Caregivers, and Healthcare Providers

Patients with type 1 diabetes mellitus at the age of 16-25 face the challenges of the deterioration of disease control and accelerated exacerbation. Providing interventions that meet patient's healthcare needs can reduce the impact and improve health outcome. The purpose of this study was to identify the healthcare needs of patients with type 1 diabetes during the adolescence to adulthood transition period from the perspectives of patients, parents and healthcare providers. A two-round Delphi study was conducted among 48 participants, and included 17 patients, 16 primary caregivers, and 15 healthcare providers. The central tendency and dispersion were computed to establish a consensus. Seventy-one healthcare needs were identified across five dimensions-technology, external support, internal support, management, and healthcare-and 56 were considered as important healthcare needs and with a moderate to high level of agreement. Meanwhile, patients, primary caregivers, and healthcare providers were found to display significantly different opinions (p < 0.05) for 23 healthcare needs. This study concluded the consensus of the healthcare needs of patients with type 1 diabetes mellitus during the adolescence to adulthood transition period from a systematic investigation. The findings can serve as reference for developing transitional intervention strategies.

Outcomes for continuous subcutaneous insulin infusion users in young adults from lower socioeconomic backgrounds

Objective

Diabetes technology is available and its efficacy and safety have been demonstrated; however, there is little evidence as to how this technology is being utilized and its effectiveness in vulnerable populations. This study evaluated differences in outcomes for young adults in the United States (U.S.) from lower socioeconomic (SES) backgrounds with type 1 diabetes (T1D) managed on continuous subcutaneous insulin infusion (CSII) versus multiple daily injections (MDI) or fixed‐dose insulin (FDI).

Research design, methods and participants

Utilizing the Optum® de‐identified Electronic Health Record data set between 2008 and 2018 to perform a retrospective, cohort study, we identified 805 subjects with T1D aged 18–30 years with Medicaid. We evaluated median difference in HbA1c between CSII and MDI/FDI users for 24 months. Predictors of diabetic ketoacidosis (DKA)‐associated hospitalizations by CSII use were evaluated using logistic regression.

Results

CSII users showed statistically significant lower median HbA1c values at 24 months of follow‐up compared to individuals on MDI/FDI. Non‐white individuals were at lower odds of receiving treatment with CSII. Subjects on CSII were not more likely to be hospitalized for DKA compared to subjects treated with MDI/FDI. Older subjects were at lower odds of being hospitalized for DKA. Males and subjects followed by Endocrinologists were at higher odds of being hospitalized for DKA.

Conclusions

Young adults with T1D from lower SES backgrounds show improved glycaemic control when in CSII compared to MDI/FDI without increases in hospitalizations for DKA.

Disparities in Utilization and Outcomes With Continuous Subcutaneous Insulin Infusion in Young Adults With Type 1 Diabetes

OBJECTIVE

To evaluate which factors determine utilization patterns and outcomes of continuous subcutaneous insulin infusion (CSII) in young adults with type 1 diabetes.

METHODS

Utilizing the Optum deidentified electronic health record data set between 2008 to 2018 to perform a retrospective cohort study, we identified 2104 subjects with type 1 diabetes aged 18 to 30 years. We evaluated the effect of race on determining CSII utilization, HbA1c (%), and hospital admission for diabetic ketoacidosis (DKA). Crude and adjusted estimates were computed using logistic regression and linear mixed models.

RESULTS

There was low CSII utilization among individuals who were Black, Hispanic, male, and those with governmental insurance. These groups also demonstrated higher HbA1c levels. Subjects who were Black, Hispanic, and those with governmental insurance had higher odds of DKA. Even when commercially insured, Black and Hispanic subjects demonstrated higher HbA1c levels, and Black individuals had higher odds of DKA.

CONCLUSION

In a large electronic health record database in the U.S., there was low CSII utilization overall, particularly in Black and Hispanic minorities, despite CSII showing superior HbA1c control without an increase in DKA events.

Racial-Ethnic Disparities in Diabetes Technology use Among Young Adults with Type 1 Diabetes

Background: Recent studies highlight racial-ethnic disparities in insulin pump and continuous glucose monitor (CGM) use in people with type 1 diabetes (T1D), but drivers of disparities remain poorly understood beyond socioeconomic status (SES). Methods: We recruited a diverse sample of young adults (YA) with T1D from six diabetes centers across the United States, enrolling equal numbers of non-Hispanic (NH) White, NH Black, and Hispanic YA. We used multivariate logistic regression to examine to what extent SES, demographics, health care factors (care setting, clinic attendance), and diabetes self-management (diabetes numeracy, self-monitoring of blood glucose, and Self-Care Inventory score) explained insulin pump and CGM use in each racial-ethnic group. Results: We recruited 300 YA with T1D, aged 18-28 years. Fifty-two percent were publicly insured, and the mean hemoglobin A1c was 9.5%. Large racial-ethnic disparities in insulin pump and CGM use existed: 72% and 71% for NH White, 40% and 37% for Hispanic, and 18% and 28% for NH Black, respectively. After multiple adjustment, insulin pump and CGM use remained disparate: 61% and 53% for NH White, 49% and 58% for Hispanic, and 20 and 31% for NH Black, respectively. Conclusions: Insulin pump and CGM use was the lowest in NH Black, intermediate in Hispanic, and highest in NH White YA with T1D. SES was not the sole driver of disparities nor did additional demographic, health care, or diabetes-specific factors fully explain disparities, especially between NH Black and White YA. Future work should examine how minority YA preferences, provider implicit bias, systemic racism, and mistrust of medical systems help to explain disparities in diabetes technology use.

Racial-Ethnic Inequity in Young Adults With Type 1 Diabetes

CONTEXT

Minority young adults (YA) currently represent the largest growing population with type 1 diabetes (T1D) and experience very poor outcomes. Modifiable drivers of disparities need to be identified, but are not well-studied.

OBJECTIVE

To describe racial-ethnic disparities among YA with T1D and identify drivers of glycemic disparity other than socioeconomic status (SES).

DESIGN

Cross-sectional multicenter collection of patient and chart-reported variables, including SES, social determinants of health, and diabetes-specific factors, with comparison between non-Hispanic White, non-Hispanic Black, and Hispanic YA and multilevel modeling to identify variables that account for glycemic disparity apart from SES.

SETTING

Six diabetes centers across the United States.

PARTICIPANTS

A total of 300 YA with T1D (18-28 years: 33% non-Hispanic White, 32% non-Hispanic Black, and 34% Hispanic).

MAIN OUTCOME

Racial-ethnic disparity in HbA1c levels.

RESULTS

Non-Hispanic Black and Hispanic YA had lower SES, higher HbA1c levels, and much lower diabetes technology use than non-Hispanic White YA (P < 0.001). Non-Hispanic Black YA differed from Hispanic, reporting higher diabetes distress and lower self-management (P < 0.001). After accounting for SES, differences in HbA1c levels disappeared between non-Hispanic White and Hispanic YA, whereas they remained for non-Hispanic Black YA (+ 2.26% [24 mmol/mol], P < 0.001). Diabetes technology use, diabetes distress, and disease self-management accounted for a significant portion of the remaining non-Hispanic Black-White glycemic disparity.

CONCLUSION

This study demonstrated large racial-ethnic inequity in YA with T1D, especially among non-Hispanic Black participants. Our findings reveal key opportunities for clinicians to potentially mitigate glycemic disparity in minority YA by promoting diabetes technology use, connecting with social programs, and tailoring support for disease self-management and diabetes distress to account for social contextual factors.

The Role of Parent Self-Regulation in Youth Type 1 Diabetes Management

PURPOSE OF REVIEW

Youth with strong self-regulation (SR), or the ability to manage thoughts, emotions, and behaviors, engage in more effective type 1 diabetes (T1D) management. However, while parent support and engagement are critical to ensuring positive youth T1D outcomes, it is rarely considered that parents' SR may also influence youth T1D management. If this is the case, novel interventions to improve parents' SR or ensure adequate support for parents with SR challenges offer great potential to improve family functioning and youth T1D management.

RECENT FINDINGS

Theoretical and preliminary empirical evidence suggests that parental SR impacts family processes that support youth T1D treatment regimen adherence. Furthermore, parent and youth SR likely interact, with high parent SR enhancing the positive effects of high youth SR or compensating for low youth SR. Continued research is needed to better understand the ways in which parent SR matters to youth T1D management and identify how to support improvements in T1D management among families of parents with low SR.

Racial and Ethnic Disparities in Diabetes Care Quality among Women of Reproductive Age in an Integrated Delivery System

BACKGROUND

Diabetes is increasingly prevalent among women of reproductive age, yet little is known about quality of diabetes care for this population at increased risk of diabetes complications and poor maternal and infant health outcomes. Previous studies have identified racial/ethnic disparities in diabetes care, but patterns among women of reproductive age have not been examined.

METHODS

This retrospective cohort study analyzed 2016 data from Kaiser Permanente Northern California, a large integrated delivery system. Outcomes were quality of diabetes care measures-glycemic testing, glycemic control, and medication adherence-among women ages 18 to 44 with type 1 or type 2 diabetes (N = 9,923). Poisson regression was used to estimate the association between patient race/ethnicity and each outcome, adjusting for other patient characteristics and health care use.

RESULTS

In this cohort, 83% of participants had type 2 diabetes; 31% and 36% of women with type 2 and type 1 diabetes, respectively, had poor glycemic control (hemoglobin A1c of ≥9%), and approximately one-third of women with type 2 diabetes exhibited nonadherence to diabetes medications. Compared with non-Hispanic White women with type 2 diabetes, non-Hispanic Black women (adjusted risk ratio, 1.2; 95% confidence interval, 1.1-1.3) and Hispanic women (adjusted risk ratio, 1.2; 95% confidence interval, 1.1-1.3) were more likely to have poor control. Findings among women with type 1 diabetes were similar.

CONCLUSIONS

Our findings indicate opportunities to decrease disparities and improve quality of diabetes care for reproductive-aged women. Elucidating the contributing factors to poor glycemic control and medication adherence in this population, particularly among Black, Hispanic, and Asian women, should be a high research and practice priority.

Diabetes detachment: How cultural, contextual, and personal barriers influence low-income young women with diabetes in Appalachia

AIM

This study explored the experiences of young low-income women with type 2 diabetes (T2D) in Appalachia, Tennessee.

BACKGROUND

Diabetes care remains suboptimal across the United States particularly in underserved communities.

METHODS

The study employed a descriptive qualitative case study collecting data using in-depth interview of a group of low-income women in their 20s with T2D. Data was analyzed using qualitative content analysis.

RESULTS

The findings identified three themes: "frustration and stigma lead to detachment care," "frozen by fear and unable to overcome resource limitations" and "social support and an empowered perspective lead to a positive outlook." Cultural barriers combined with contextual and personal barriers resulted in detachment from diabetes care among study participants.

CONCLUSION

Within Appalachia, leveraging the existing familism values along with culturally congruent education and support can help alleviating the burden of diabetes care.