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

Digital health technologies and inequalities: A scoping review of potential impacts and policy recommendations

Digital health technologies hold promises for reducing health care costs, enhancing access to care, and addressing labor shortages. However, they risk exacerbating inequalities by disproportionately benefitting a subset of the population. Use of digital technologies accelerated during the Covid-19 pandemic. Our scoping review aimed to describe how inequalities related to their use were conceptually assessed during and after the pandemic and understand how digital strategies and policies might support digital equity. We used the PRISMA Extension for scoping reviews, identifying 2055 papers through an initial search of 3 databases in 2021 and complementary search in 2022, of which 41 were retained. Analysis was guided by the eHealth equity framework. Results showed that digital inequalities were reported in the U.S. and other high-income countries and were mainly assessed through differences in access and use according to individual sociodemographic characteristics. Health disparities related to technology use and the interaction between context and technology implementation were more rarely documented. Policy recommendations stressed the adoption of an equity lens in strategy development and multilayered and intersectoral collaboration to align interventions with the needs of specific subgroups. Finally, findings suggested that evaluations of health and wellbeing distribution related to the use of digital technologies should inform digital strategies and health policies.

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.

Recommendations for Screening and Monitoring the Stages of Type 1 Diabetes in the Immune Therapy Era

Type 1 diabetes (T1D) is a complex, chronic autoimmune disease that affects over 1.6 million people in the United States. It is now understood that T1D may be undetected for many years while the disease progresses quietly without producing symptoms. T1D can be identified through diabetes-related autoantibody screening and staged accordingly, enabling healthcare providers to identify high-risk individuals in the early stages of the disease and either provide a stage-specific intervention or offer clinical trial opportunities to preserve beta cell function and anticipate the onset of clinical T1D. Evidence-based clinical practice guidelines currently do not exist for routine diabetes-related autoantibody screening of individuals at risk of developing T1D or of the general population. The purpose of this article is to help clinicians acquire an understanding of the rationale and protocols recommended for identifying patients at risk of developing T1D and monitoring such patients for autoimmune markers and progression of disease from Stage 1 to Stage 3 (clinical disease).

Assessing Patterns of Continuous Glucose Monitoring Use and Metrics of Glycemic Control in Type 1 Diabetes and Type 2 Diabetes Patients in the Veterans Health Care System: Integrating Continuous Glucose Monitoring Device Data with Electronic Health Records Data

Objective: To integrate long-term daily continuous glucose monitoring (CGM) device data with electronic health records (EHR) for patients with type 1 and type 2 diabetes (T1D and T2D) in the national Veterans Affairs Healthcare System to assess real-world patterns of CGM use and the reliability of EHR-based CGM information. Research Design and Methods: This observational study used Dexcom CGM device data linked with EHR (from 2015 to 2020) for a large national cohort of patients with diabetes. We tracked the initiation and consistency of CGM use, assessed concordance of CGM use and measures of glucose control between CGM device data and EHR records, and examined results by age, ethnicity, and diabetes type. Results: The time from pharmacy release of CGM to patients to initiation of uploading CGM data to Dexcom servers averaged 3 weeks but demonstrated wide variation among individuals; importantly, this delay decreased markedly over the later years. The average daily wear time of CGM exceeded 22 h over nearly 3 years of follow-up. Patterns of CGM use were generally consistent across age, race/ethnicity groups, and diabetes type. There was strong concordance between EHR-based estimates of CGM use and Dexcom CGM wear time and between estimates of glucose control from both sources. Conclusions: The study demonstrates our ability to reliably integrate CGM devices and EHR data to provide valuable insights into CGM use patterns. The results indicate in the real-world environment that CGM is worn consistently over many years for both patients with T1D and T2D within the Veterans Affairs Healthcare System and is similar across major race/ethnic groups and age-groups.

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.

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.

Opportunities to overcome underutilization of enhanced insulin delivery technologies in people with type 2 diabetes: a narrative review

Use of innovative technologies such as continuous glucose monitoring (CGM) and insulin delivery systems have been shown to be safe and effective in helping patients with diabetes achieve significantly improved glycemic outcomes compared to their previous therapies. However, these technologies are underutilized in many primary care practices. This narrative review discusses some of the clinical and economic benefits of tubeless insulin delivery devices and discusses how this technology can overcome the main obstacles inherent to use of conventional insulin delivery devices.

Diabetes Technology Meeting 2023

Diabetes Technology Society hosted its annual Diabetes Technology Meeting from November 1 to November 4, 2023. Meeting topics included digital health; metrics of glycemia; the integration of glucose and insulin data into the electronic health record; technologies for insulin pumps, blood glucose monitors, and continuous glucose monitors; diabetes drugs and analytes; skin physiology; regulation of diabetes devices and drugs; and data science, artificial intelligence, and machine learning. A live demonstration of a personalized carbohydrate dispenser for people with diabetes was presented.

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.

Patterns and Trends in Continuous Glucose Monitoring Utilization Among Commercially Insured Individuals With Type 1 Diabetes: 2010-2013 to 2016-2019

Prior studies suggest that only ∼30% of patients with type 1 diabetes use continuous glucose monitoring (CGM), but most studies to date focused on children and young adults seen by endocrinologists or in academic centers. This study examined national trends in CGM utilization among commercially insured children and adults with type 1 diabetes. Overall, CGM utilization was 20.12% in 2010-2013 and 49.78% in 2016-2019, reflecting a 2.5-fold increase in utilization within a period of <10 years. Identifying populations with low CGM use is a necessary first step in developing targeted interventions to increase CGM uptake.

Diabetes Specialists Value Continuous Glucose Monitoring Despite Challenges in Prescribing and Data Review Process

BACKGROUND

Diabetes clinicians are key facilitators of continuous glucose monitoring (CGM) provision, but data on provider behavior related to CGM use and CGM generated data are limited.

METHODS

We conducted a national survey of providers caring for people with diabetes on CGM-related opinions, facilitators and barriers to prescription, and data review practices.

RESULTS

Of 182 survey respondents, 73.2% worked at academic centers, 70.6% were endocrinologists, and 70.7% practiced in urban settings. Nearly 70% of providers reported CGM use in the majority of their patients with type 1 diabetes. Half of the providers reported CGM use in 10% to 50% of their patients with type 2 diabetes. All respondents believed CGM improved quality of life and could optimize diabetes control. We found no differences in reported rates of CGM use based on providers' years of experience, patient volume, practice setting, or clinic type. Most providers reviewed CGM data each visit (97.7%) and actively involved patients in the data interpretation (98.8%). Only 14.1% of clinicians reported reviewing CGM data without any prompting from patients or their family members outside of visits. Most providers (80.7%) reported their CGM data review was valued by patients although only half reported having adequate time (45.1%) or an efficient process (56.1%) to do so.

CONCLUSIONS

Despite uniform support for CGM by providers, ongoing challenges related to cost, insurance coverage, and difficulties with prescription were major barriers to CGM use. Increased use of CGM in appropriate populations will necessitate improvements in data access and integration, clearly defined workflows, and decreased administrative burden to obtain CGM.

Greater Telehealth Use Results in Increased Visit Frequency and Lower Physician Related-Distress in Adolescents and Young Adults With Type 1 Diabetes

BACKGROUND

Type one diabetes (T1D) management is challenging for adolescents and young adults (AYAs) due to physiological changes, psychosocial challenges, and increasing independence, resulting in increased diabetes distress and hemoglobin A1c (HbA1c). Alternative care models that engage AYAs and improve diabetes-related health outcomes are needed.

METHODS

A 15-month study evaluated an adaptation of the Colorado Young Adults with T1D (CoYoT1) Care model. CoYoT1 Care includes person-centered care, virtual peer groups, and physician training delivered via telehealth. AYAs (aged 16-25 years) were partially randomized to CoYoT1 or standard care, delivered via telehealth or in-person. As the study was ending, the COVID-19 pandemic forced all AYAs to transition to primarily telehealth appointments. This secondary analysis compares changes in clinic attendance, T1D-related distress, HbA1c, and device use between those who attended more than 50% of diabetes clinic visits via telehealth and those who attended more sessions in-person throughout the course of the study.

RESULTS

Out of 68 AYA participants, individuals (n = 39, 57%) who attended most (>50%) study visits by telehealth completed more diabetes care visits (3.3 visits) than those (n = 29, 43%) who primarily attended visits in-person (2.5 visits; P = .007). AYAs who primarily attended visits via telehealth maintained stable physician-related distress, while those who attended more in-person visits reported increases in physician-related distress (P = .03).

CONCLUSIONS

Greater usage of telehealth improved AYA engagement with their care, resulting in increased clinic attendance and reduced physician-related diabetes distress. A person-centered care model delivered via telehealth effectively meets the needs of AYAs with T1D.

Racial/Ethnic Inequities in Use of Diabetes Technologies Among Medicare Advantage Beneficiaries With Type 1 Diabetes

CONTEXT

Racial/ethnic inequities have been observed in diabetes care.

OBJECTIVE

To measure changes in prevalence of continuous glucose monitoring (CGM) and insulin pump therapy among Medicare Advantage beneficiaries with type 1 diabetes by race/ethnicity and to determine the impact of socioeconomic factors on racial/ethnic inequities.

DESIGN

The prevalence of CGM and pump use was assessed by race/ethnicity for Medicare Advantage beneficiaries annually from 2017 through 2020. Models predicting technology use by year, race/ethnicity, age, sex, endocrinology visits, and measures of socioeconomic status were fit.

SETTING

Community.

PATIENTS OR OTHER PARTICIPANTS

Beneficiaries with type 1 diabetes and 2 or more claims with a diabetes diagnosis in the coverage year.

INTERVENTION(S)

Insulin pump or CGM therapy.

MAIN OUTCOME MEASURE(S)

Use of diabetes technology by racial/ethnic group.

RESULTS

Technology use increased from 2017 through 2020 in all racial/ethnic groups. The absolute difference in use between White and Black beneficiaries from 2017 to 2020 remained stable for insulin pumps (10.7% to 10.8%) and increased for CGM (2.6% to 11.1%). The differences in pump use from 2017 to 2020 narrowed between White and Hispanic beneficiaries (12.3% to 11.4%) and White and Asian beneficiaries (9.7% to 6.6%), whereas the opposite occurred for CGM use (3.0% to 15.5% for White vs Hispanic beneficiaries; 1.5% to 8.0% for White vs Asian beneficiaries). Racial/ethnic inequities persisted (P < .0001) after adjusting for other characteristics.

CONCLUSIONS

Differences in diabetes technology use between racial/ethnic groups often persisted from 2017 through 2020 and could not be explained by demographics, socioeconomic status, or endocrinology visits.

At the intersection of trust and mistrust: A qualitative analysis of motivators and barriers to research participation at a safety-net hospital

INTRODUCTION

The underrepresentation of Black, Indigenous, and People of Color (BIPOC) individuals in healthcare research limits generalizability and contributes to healthcare inequities. Existing barriers and attitudes toward research participation must be addressed to increase the representation of safety net and other underserved populations.

METHODS

We conducted semi-structured qualitative interviews with patients at an urban safety net hospital, focusing on facilitators, barriers, motivators, and preferences for research participation. We conducted direct content analysis guided by an implementation framework and used rapid analysis methods to generate final themes.

RESULTS

We completed 38 interviews and identified six major themes related to preferences for engagement in research participation: (1) wide variation in research recruitment preferences; (2) logistical complexity negatively impacts willingness to participate; (3) risk contributes to hesitation toward research participation; (4) personal/community benefit, interest in study topic, and compensation serve as motivators for research participation; (5) continued participation despite reported shortcomings of informed consent process; and (6) mistrust could be overcome by relationship or credibility of information sources.

CONCLUSION

Despite barriers to participation in research studies among safety-net populations, there are also facilitators that can be implemented to increase knowledge and comprehension, ease of participation, and willingness to join research studies. Study teams should vary recruitment and participation methods to ensure equal access to research opportunities.

PATIENT/PUBLIC CONTRIBUTION

Our analysis methods and study progress were presented to individuals within the Boston Medical Center healthcare system. Through this process community engagement specialists, clinical experts, research directors, and others with significant experience working with safety-net populations supported data interpretation and provided recommendations for action following the dissemination of data.

Disparities in Continuous Glucose Monitoring Use Among Women of Reproductive Age with Type 1 Diabetes in the T1D Exchange

We identified characteristics associated with continuous glucose monitoring (CGM) use in women of reproductive age with type 1 diabetes (T1D) in the T1D Exchange clinic registry from 2015 to 2018. Among 6643 assessed women, the frequency of CGM increased from 2015 to 2018 (20.6% vs. 30.0%; adjusted odds ratios [aOR]: 1.72; confidence interval [95% CI]: 1.51-1.95) and was more likely with recent pregnancy (45.3% vs. 25.8%; aOR: 1.63; 95% CI: 1.23-2.16). Non-Hispanic Black and Hispanic race and ethnicity, younger age, lower educational attainment, lower income, and Medicaid insurance were associated with lower odds of CGM. The use of CGM was associated with lower odds of diabetic ketoacidosis and lower hemoglobin A1c without any difference in the odds of symptomatic severe hypoglycemia. In conclusion, although CGM use was associated with better glycemic control, the majority of reproductive-age women still did not use it. Those who did not use CGM were more likely to be those at greatest risk of adverse pregnancy outcomes.

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

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

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

OBJECTIVE

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

RESEARCH DESIGN AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Racial and Ethnic Disparities in Diabetes Clinical Care and Management: A Narrative Review

Diabetes affects nearly 37 million Americans, with disproportionately higher disease burden amongst those from minoritized communities. The result of this is greater rates of diabetic complications and mortality. To close this gap in care, it is important to assess the differences in both diagnosis and care between White and ethnic/racial minoritized persons with diabetes. The purpose of this narrative review is to explore this further by assessing the differences in diagnosis, management, diabetes education, and complications.

The impact of socio-economic deprivation on access to diabetes technology in adults with type 1 diabetes

BACKGROUND

With advances in technology, there is an emerging concern that inequalities exist in provision and diabetes outcomes in areas of greater deprivation. We assess the relationship between socio-economic status and deprivation with access to diabetes technology and their outcomes in adults with type 1 diabetes.

METHODS

Retrospective, observational analysis of adults attending a tertiary centre, comprising three urban hospitals in the UK. Socio-economic deprivation was assessed by the English Indices of Deprivation 2019. Data analysis was performed using one-way ANOVAs and chi-squared tests.

RESULTS

In total, 1631 adults aged 44 ± 15 years and 758 (47%) women were included, with 391 (24%) using continuous subcutaneous insulin infusion, 312 (19%) using real-time continuous glucose monitoring and 558 (34%) using intermittently scanned continuous glucose monitoring. The highest use of diabetes technology was in the least deprived quintile compared to the most deprived quintile (67% vs. 45%, respectively; p < 0.001). HbA_1c outcomes were available in 400 participants; no association with deprivation was observed (p = 0.872). Participation in structured education was almost twice as high from the most deprived to the least deprived groups (23% vs. 43%; p < 0.001). Adults with white or mixed ethnicity were more likely to use technology compared to black ethnicity (60% vs. 40%; p < 0.001).

CONCLUSIONS

Adults living in the most deprived quintile had less technology use. Irrespective of socio-economic status or ethnicity, glycaemia was positively affected in all groups. It is imperative that health disparities are further addressed.

Delays in Continuous Glucose Monitoring Device Initiation: A Single Center Experience and a Call to Change

Background: Continuous glucose monitoring (CGM) has been increasingly shown to be beneficial in patients with both types 1 and 2 diabetes using insulin. Despite this, challenges remain in obtaining coverage for these devices. We sought to define the process of initiation of CGM and better understand factors associated with successful initiation. Methods: A single-center retrospective cohort study of 271 patients seen over a 3-year period from 2017 to 2020 in the adult endocrinology clinic at Boston Medical Center who were prescribed CGM was performed. The primary outcome was time to CGM initiation. Secondary outcomes included factors associated with initiation and continued use of CGMs and glycemic control. Results: Obtaining CGM through pharmacy benefit was significantly faster than through durable medical equipment companies (78 days vs. 152 days, P < 0.0001). Factors associated with initiation of CGM were younger age, private insurance, and education with a clinical diabetes educator. Identifying as black or Hispanic was significantly associated with decreased initiation of CGM. Glycemic control as represented by hemoglobin A1c improved in patients initiated on CGM from 9.06% to 8.22% (P < 0.001). Conclusion: Prescribing CGM as a pharmacy benefit significantly reduces the time to initiation, but on average, still takes several months, delaying potentially life-saving care for patients living with diabetes. Barriers to CGM initiation must be addressed to ensure timely delivery of optimal care to our patients.

Advanced Diabetes Technology Remains Underutilized in Underserved Populations: Early Hybrid Closed-Loop System Experience at an Academic Safety Net Hospital

We retrospectively evaluated outcomes of the Minimed Medtronic 670G system in an academic urban safety-net population of adults with type 1 diabetes, between September 2016 and January 2020. Among 32 patients prescribed the 670G, the majority were female (69%), white (69%), achieved advanced degrees (56%), were commercially insured (94%), and were experienced pump users (84%). Patients who initiated auto-mode demonstrated significant improvement in A1c after 1 year. However, 31% of patients never initiated auto-mode. Black and Hispanic patients comprised 50% of this group, despite similar insurance coverage, diabetes duration, educational level, and prior pump use. Hence, traditional barriers to technology use do not explain these racial/ethnic disparities. Of 22 patients who initiated auto-mode, 5 discontinued within 1 year. The most common reason for discontinuation was frustration with pump-sensor interactions. Future studies identifying barriers to and strategies for increasing use of advanced insulin delivery systems in underserved populations are needed.

Equity in Medical Care for People Living With Diabetes

Disparities and inequities exist for individuals with diabetes in marginalized communities of color, especially among people with low socioeconomic status. Although these barriers are apparent, only a few care models have been designed for and examined in racially and ethnically diverse individuals. This article reviews models that have been developed and examined in a variety of different populations and focuses on how to implement elements from these programs in clinical practice. Health equity-promoting ideas and approaches that can be applied throughout the life span (children to seniors) are also included. As diabetes health care providers, researchers, educators, policymakers, and advocates, we must now combine our efforts and focus on historically excluded populations to bridge the gap to essential diabetes care.

The Evolution of Insulin Administration in Type 1 Diabetes

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.

Help when you need it: Perspectives of adults with T1D on the support and training they would have wanted when starting CGM

AIMS

The purpose of this study was to explore preferences that adults with type 1 diabetes (T1D) have for training and support to initiate and sustain optimal use of continuous glucose monitoring (CGM) technology.

METHODS

Twenty-two adults with T1D (M age 30.95 ± 8.32; 59.1% female; 90.9% Non-Hispanic; 86.4% White; diabetes duration 13.5 ± 8.42 years; 72.7% insulin pump users) who had initiated CGM use in the past year participated in focus groups exploring two overarching questions: (1) What helped you learn to use your CGM? and (2) What additional support would you have wanted? Focus groups used a semi-structured interview guide and were recorded, transcribed and analyzed.

RESULTS

Overarching themes identified were: (1) "I got it going by myself": CGM training left to the individual; (2) Internet as diabetes educator, troubleshooter, and peer support system; and (3) domains of support they wanted, including content and format of this support.

CONCLUSION

This study identifies current gaps in training and potential avenues for enhancing device education and CGM onboarding support for adults with T1D. Providing CGM users with relevant, timely resources and attending to the emotional side of using CGM could alleviate the burden of starting a new device and promote sustained device use.