Pediatric endocrine society survey of diabetes practices in the United States: What is the current state?

Access to Specialty Care for Commercially Insured Youths With Type 1 and Type 2 Diabetes

Importance

Youths with type 2 diabetes are at higher risk for complications compared with peers with type 1 diabetes, though few studies have evaluated differences in access to specialty care.

Objective

To compare claims with diabetes specialists for youths with type 1 vs type 2 diabetes and the association between specialist claims with multidisciplinary and acute care utilization.

Design, Setting, and Participants

This cross-sectional study used Optum Clinformatics Data Mart commercial claims. Individuals included in the study were youths younger than 19 years with type 1 or 2 diabetes as determined by a validated algorithm and prescription claims. Data were collected for youths with at least 80% enrollment in a commercial health plan from December 1, 2018, to December 31, 2019. Statistical analysis was performed from September 2022 to January 2024.

Main Outcomes and Measures

The primary outcome was the number of ambulatory claims from an endocrine and/or diabetes physician or advanced practice clinician associated with a diabetes diagnosis code; secondary outcomes included multidisciplinary and acute care claims.

Results

Claims were analyzed for 4772 youths (mean [SD] age, 13.6 [3.7] years; 4300 [90.1%] type 1 diabetes; 472 [9.9%] type 2 diabetes; 2465 [51.7%] male; 128 [2.7%] Asian, 303 [6.4] Black or African American, 429 [9.0%] Hispanic or Latino, 3366 [70.5%] non-Hispanic White, and 546 [11.4%] unknown race and ethnicity). Specialist claims were lower in type 2 compared with type 1 diabetes (incidence rate ratio [IRR], 0.61 [95% CI, 0.52-0.72]; P < .001) in propensity score-weighted analyses. The presence of a comorbidity was associated with increased specialist claims for type 1 diabetes (IRR, 1.07 [95% CI, 1.03-1.10]) and decreased claims for type 2 diabetes (IRR, 0.77 [95% CI, 0.67-0.87]). Pooling diagnosis groups and adjusted for covariates, each additional specialist claim was associated with increased odds of a claim with a diabetes care and education specialist (odds ratio [OR], 1.31 [95% CI, 1.25-1.36]), dietitian (OR, 1.14 [95% CI, 1.09-1.19]), and behavioral health clinician (OR, 1.16 [95% CI, 1.12-1.20]). For acute care claims, each additional specialist claim was associated with increased odds of admission (OR, 1.17 [95% CI, 1.11-1.24]) but not for emergency claims (OR, 1.03 [95% CI, 0.98-1.82]).

Conclusions and Relevance

This cross-sectional study found that youths with type 2 diabetes were significantly less likely to have specialist claims despite insurance coverage, indicating other barriers to care, which may include medical complexity. Access to diabetes specialists influences engagement with multidisciplinary services. The association between increasing ambulatory clinician services and admissions suggests high utilization by a subgroup of patients at greater risk for poor outcomes.

Psychosocial Staffing and Implementation of the International Society for Pediatric and Adolescent Diabetes Psychological Care Guidelines in U.S. Pediatric Diabetes Clinics

Background

Few studies have examined the implementation of the International Society for Pediatric and Adolescent Diabetes (ISPAD) Clinical Practice Consensus Guidelines for the Psychological Care of Children and Adolescents with Type 1 Diabetes.

Objective

To collect benchmark data on psychosocial staffing and implementation of the ISPAD guidelines across U.S. pediatric diabetes clinics.

Methods

Medical (n = 95; 77 endocrinologists and 18 advance practice providers) and psychosocial (n = 86; 43 social workers and 43 psychologists) providers from 98 of 115 contacted clinics completed an online survey (85% response rate). Providers reported the number of psychosocial staff and rated the adequacy of psychosocial staffing, quality of psychosocial care, and adherence to the ISPAD guidelines in their clinics. χ2 Tests and ANOVA were used to examine differences across clinic size and across medical and psychosocial providers.

Results

Clinics averaged a total of ∼4 hours per week of psychosocial provider time per 100 patients with type 1 diabetes. Only 27% of providers agreed that psychosocial staffing was adequate, and 35% described their psychosocial care as comprehensive. Implementation of the ISPAD guidelines varied across clinics, with minimal differences across clinic size. Medical providers reported that evidence-based psychological assessment and interventions were delivered consistently by <55% of clinics. Psychosocial, compared with medical, providers were more likely to report frequent implementation of psychosocial assessment and intervention guidelines.

Conclusion

Psychological care in U.S. pediatric type 1 diabetes clinics does not consistently meet the ISPAD guidelines, and many clinics lack adequate psychosocial staff. These benchmark data are a foundational step to improve psychosocial care for pediatric patients with type 1 diabetes.

A centennial review of discoveries and advances in diabetes: Children and youth

Diabetes is an increasingly common chronic metabolic disorder in children worldwide. The discovery of insulin in 1921 resulted in unprecedented advancements that improved the lives of children and youth with diabetes. The purpose of this article is to review the history of diabetes in children and youth over the last century and its implications for future developments in the field. We identified 68 relevant events between 1921 and 2021 through literature review and survey of pediatric endocrinologists. Basic research milestones led to the discovery of insulin and other regulatory hormones, established the normal physiology of carbohydrate metabolism and pathophysiology of diabetes, and provided insight into strategies for diabetes prevention. While landmark clinical studies were initially focused on adult diabetes populations, later studies assessed etiologic factors in birth cohort studies, evaluated technology use among children with diabetes, and investigated pharmacologic management of youth type 2 diabetes. Technological innovations culminated in the introduction of continuous glucose monitoring that enabled semi-automated insulin delivery systems. Finally, professional organizations collaborated with patient groups to advocate for the needs of children with diabetes and their families. Together, these advances transformed type 1 diabetes from a terminal illness to a manageable disease with near-normal life expectancy and increased our knowledge of type 2 diabetes and other forms of diabetes in the pediatric population. However, disparities in access to insulin, diabetes technology, education, and care support remain and disproportionately impact minority youth and communities with less resources. The overarching goal of diabetes management remains promoting a high quality of life and improving glycemic management without undermining the psychological health of children and youth living with diabetes.

Role of Psychologists in Pediatric Endocrinology

The care of youth managed within pediatric endocrine clinics is complex and requires a multi- or interdisciplinary approach. Psychosocial aspects of chronic health conditions are well-documented. Clinical practice guidelines outline the importance of routine psychosocial screening and support for youth with diabetes and obesity. This article outlines the diverse role of psychologists in pediatric endocrinology, including screening, in-clinic intervention, outpatient psychological services, and inpatient consultation. Although research exists documenting the effectiveness of behavioral interventions to improve adherence and health-related quality of life, cost analysis research is emerging.

Feasibility, Acceptability, and Preliminary Efficacy of an Intensive Clinic-Based Intervention for Children with Poorly Controlled Type 1 Diabetes

OBJECTIVE

To evaluate the feasibility, acceptability and preliminary efficacy of a team-based intervention for youth with type 1 diabetes (T1D) with suboptimal glycemia as measured by hemoglobin A1c (HbA1c).

METHODS

40 participants with T1D >1 year and HbA1c ≥9.5% (80mmol/mol) enrolled in a multidisciplinary intervention that included pediatric endocrinology, pediatric psychology, and a Certified Diabetes Care and Education Specialist (CDCES). The CDCES integrated medical management while reinforcing physical, emotional, and behavioral health, connected with families to set and monitor goals, and reviewed medication adjustments. Feasibility was assessed by enrollment targets, acceptability by retention rates, and preliminary efficacy by changes in HbA1c, quality of life (QoL), diabetes strengths and resilience, and hospital admissions, emergency room visits, and school days missed.

RESULTS

Of the 43 patients and families approached, 40 agreed to participate, 36 completed the 4-month intervention and 31 completed full 8-month follow-up data collection. The CDCES coach averaged 6.8 contacts per participant during the 8-month study period. HbA1c was reduced significantly from baseline to 4-months (12.1±1.6% to 11.0±1.9%, p=0.001) and sustained at 8-months (10.7±1.9%, p<0.001). Participants reported significant increases in diabetes-specific QoL (p<0.05) and diabetes strength and resilience (p=0.003). School days missed was reduced from 7.23±7.5 days to 1.55±1.9 days (p <0.001) and diabetes-related hospitalizations decreased from 0.4±0.6 to 0.1±0.3 (p=0.009).

CONCLUSIONS

Preliminary data suggest that a multidisciplinary intervention leveraging a team approach with a physician, psychologist and CDCES can support improvements in glycemic control and psychosocial outcomes among youth with type 1 diabetes with HbA1c above target.

Self-reported insulin pump prescribing practices in pediatric type 1 diabetes

INTRODUCTION

Disadvantaged and minority youth with type 1 diabetes are less likely to be on insulin pump therapy compared to the majority population. Little is known about how pediatric endocrinology providers determine eligibility for insulin pump. We aimed to identify provider factors influencing the decision to initiate insulin pump therapy.

METHODS

We conducted a survey of Pediatric Endocrine Society members who prescribe insulin pump therapy to pediatric patients with type 1 diabetes. The survey collected information about prescriber characteristics, use and adherence to guidelines, eligibility criteria, and objective and subjective factors that influence insulin pump prescription.

RESULTS

The survey was completed by 192 individuals who met eligibility criteria (14.1% response rate). The majority of respondents were attending providers, and were white, non-Hispanic females. A minority of providers (22%) reported following written insulin pump guidelines, and many (70%) reported using personal guidelines to guide patient selection. Most providers had no objective eligibility criteria, aside from standard glucose monitoring. Providers identified patient lifestyle and increased risk of hypoglycemia, as well as patient and family factors such as motivation, realistic expectations of insulin pump use, ability to demonstrate carbohydrate counting, patient request, and ability to communicate as important in the decision to initiate insulin pump.

CONCLUSION

Pediatric endocrinology providers place significant importance on subjective factors and utilize few objective criteria in determining eligibility for insulin pump. In the setting of the known disparities in insulin pump use, providers should utilize objective, consistent criteria to determine which patients are safe to initiate insulin pump.

Screening for Mental Health Comorbidities in a Pediatric Diabetes Clinic Setting

Quality Improvement Success Stories are published by the American Diabetes Association in collaboration with the American College of Physicians and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes an effort to improve mental health screening of patients at a pediatric diabetes clinic in Seattle, WA.

Discrepancies in Assessing Symptoms of Depression in Adolescents With Diabetes Using the Patient Health Questionnaire and Semi-Structured Interviews

Adolescents with diabetes have a higher prevalence of depression compared with their peers. The American Diabetes Association recommends routine mental health screening for youth with diabetes. This screening is often conducted through accessible and free depression screeners, such as the nine-item Patient Health Questionnaire (PHQ-9). Although the PHQ-9 has been validated for use in adolescents and with other medical conditions, it has yet to be validated for use in pediatric diabetes. This study evaluated adolescents' depression symptom endorsement through retrospective review of PHQ-9 screening and semi-structured interviews with a mental health provider in a multidisciplinary diabetes clinic (patients with type 1 or type 2 diabetes). Adolescent participants (n = 96) screened during one to three separate visits (n = 148) endorsed some depressive symptoms in 56% of visits (n = 84) and moderate to severe symptoms in 6% of visits on the PHQ-9. Approximately 95% of study participants did not meet the clinic cutoff for further evaluation, but greater rates of depression were endorsed in youth with type 1 diabetes. Low mood was endorsed at a higher rate during a semi-structured interview with embedded mental health providers than on the PHQ-9. Symptoms specific to low mood, including anhedonia, sleep disturbance, concentration disturbance, motor disturbance, and thoughts of death/self-harm, were more frequently endorsed on the PHQ-9 than during the interview. Although the PHQ-9 is a good screening tool, the availability of mental health providers in diabetes clinics is important to address specific endorsed symptoms and place them in perspective based on specialized training. Until more definitive research is available on the sensitivity and specificity of this measure in this population and setting, a two-part screening approach that includes both the screening questionnaire and a brief semi-structured interview is warranted.

Trends in pediatric obesity management, a survey from the Pediatric Endocrine Society Obesity Committee

Background In the United States, 18.5% of children are obese. Dietary and lifestyle modifications are key, but often ineffective. There are limited approved pediatric pharmacotherapies. The objective of this study was to evaluate current treatment practices for pediatric obesity among members of the Pediatric Endocrine Society (PES, n = 1300) and the Pediatric Obesity Weight Evaluation Registry (POWER, n = 42) consortium. Methods A 10-question online survey on treatment of children with obesity in clinical practice was conducted. Results The response rates were 19% for PES and 20% for POWER members. The majority were female (65%) and board certified in pediatric endocrinology (81%). Most practitioners saw 5-10 patients with obesity/week and 19% prescribed weight-loss medications. POWER participants were more likely to prescribe weight-loss medications than PES participants (46% vs. 18%, p =  0.02). Metformin was the most commonly prescribed medication. Response to medication was poor. Use of dietary non-pharmacological treatment options was uncommon. Over half of the respondents (56%) referred patients for bariatric surgery and 53% had local access to pediatric bariatric surgery. Conclusions Metformin was the most common drug prescribed among respondents, but successful weight-loss responses were uncommon. Among practitioners who are using pharmacological interventions, therapeutic strategies vary widely. Targeted research in pharmacologic and surgical treatment for pediatric obesity is urgently needed.

Small Interventions for Big Change: Brief Strategies for Distress and Self-Management Amongst Youth with Type 1 Diabetes

PURPOSE OF REVIEW

Diabetes self-management and diabetes distress are complex processes implicated in glycemic control and other health outcomes for youth with type 1 diabetes. Growing integration of medical and behavioral care provides opportunities for brief psychosocial interventions during routine diabetes care. This review focuses on interventions for self-management and diabetes distress that can be delivered alongside usual medical care or via a single-patient encounter.

RECENT FINDINGS

Recent research underscores the potential of brief interventions delivered by both medical providers and integrated behavioral health professionals, but little is known regarding the comparative effectiveness of different interventions or the factors that impact dissemination and implementation. This article asserts that brevity is critical to maximizing the reach, scalability, and impact of psychosocial interventions for youth with type 1 diabetes. The authors review existing evidence for brief interventions, describe several untested clinical strategies, and make recommendations for accelerating the translational study of brief interventions.

Neurodevelopmental and Mental Health Screening for Patients with Turner Syndrome in Pediatric Endocrine Clinics: Results of a Pediatric Endocrine Society Survey

INTRODUCTION

International Turner syndrome (TS) Clinical Practice Guidelines recommend screening for neurodevelopmental (ND) and mental health (MH) concerns in girls with TS; however, it remains unclear whether this is implemented in current practice. The objective of this mixed methods study was to assess screening practices for ND and MH in girls with TS from the perspective of pediatric endocrinologists.

METHODS

Pediatric Endocrine Society members who provide care for girls with TS were invited to complete an electronic survey on screening practices. Descriptive statistics were used to summarize quantitative results concurrently with thematic analysis of free-text survey responses.

RESULTS

A total of 124 surveys were completed (86% attending pediatric endocrinologists, 81% at academic institutions). Overall, 25% of providers reported their patients with TS received both ND and MH screenings. Only 9 (9%) respondents endorsed screening for ND concerns themselves, while more providers (26%) reported they screen for MH concerns. Multiple barriers to screening for ND and MH concerns within the clinical setting were endorsed. Nearly all providers (>93%) reported they would consider using a short, validated screening tool for ND and MH concerns if such tools were available.

DISCUSSION

A minority of pediatric endocrinologists currently perform ND or MH screening for patients with TS, however, many would be interested in implementing a brief screening tool into their clinical practice. Given almost all girls with a TS diagnosis receive care from pediatric endocrinologists at least annually, this may be an effective method to increase the proportion of girls with TS who receive recommended screenings.