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Walker AF, Haller MJ, Addala A, Filipp SL, Lal R, Gurka MJ, Figg LE, Hechavarria M, Zaharieva DP, Malden KG, Hood KK, Westen SC, Wong JJ, Donahoo WT, Basina M, Bernier AV, Duncan P, Maahs DM. Not all healthcare inequities in diabetes are equal: a comparison of two medically underserved cohorts. BMJ Open Diabetes Res Care 2024; 12:e004229. [PMID: 39242122 DOI: 10.1136/bmjdrc-2024-004229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 08/15/2024] [Indexed: 09/09/2024] Open
Abstract
INTRODUCTION Diabetes disparities exist based on socioeconomic status, race, and ethnicity. The aim of this study is to compare two cohorts with diabetes from California and Florida to better elucidate how health outcomes are stratified within underserved communities according to state location, race, and ethnicity. RESEARCH DESIGN AND METHODS Two cohorts were recruited for comparison from 20 Federally Qualified Health Centers as part of a larger ECHO Diabetes program. Participant-level data included surveys and HbA1c collection. Center-level data included Healthcare Effectiveness Data and Information Set metrics. Demographic characteristics were summarized overall and stratified by state (frequencies, percentages, means (95% CIs)). Generalized linear mixed models were used to compute and compare model-estimated rates and means. RESULTS Participant-level cohort: 582 adults with diabetes were recruited (33.0% type 1 diabetes (T1D), 67.0% type 2 diabetes (T2D)). Mean age was 51.1 years (95% CI 49.5, 52.6); 80.7% publicly insured or uninsured; 43.7% non-Hispanic white (NHW), 31.6% Hispanic, 7.9% non-Hispanic black (NHB) and 16.8% other. Center-level cohort: 32 796 adults with diabetes were represented (3.4% with T1D, 96.6% with T2D; 72.7% publicly insured or uninsured). Florida had higher rates of uninsured (p<0.0001), lower continuous glucose monitor (CGM) use (18.3% Florida; 35.9% California, p<0.0001), and pump use (10.2% Florida; 26.5% California, p<0.0001), and higher proportions of people with T1D/T2D>9% HbA1c (p<0.001). Risk was stratified within states with NHB participants having higher HbA1c (mean 9.5 (95% CI 8.9, 10.0) compared with NHW with a mean of 8.4 (95% CI 7.8, 9.0), p=0.0058), lower pump use (p=0.0426) and CGM use (p=0.0192). People who prefer to speak English were more likely to use a CGM (p=0.0386). CONCLUSIONS Characteristics of medically underserved communities with diabetes vary by state and by race and ethnicity. Florida's lack of Medicaid expansion could be a factor in worsened risks for vulnerable communities with diabetes.
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Affiliation(s)
- Ashby F Walker
- University of Florida Diabetes Institute, Gainesville, Florida, USA
- Department of Health Services Research, Management and Policy, University of Florida, Gainesville, Florida, USA
| | - Michael J Haller
- University of Florida Diabetes Institute, Gainesville, Florida, USA
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA
| | - Ananta Addala
- Stanford Diabetes Research Center, Stanford, California, USA
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Stephanie L Filipp
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA
| | - Rayhan Lal
- Division of Endocrinology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Matthew J Gurka
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia, USA
| | - Lauren E Figg
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | | | - Dessi P Zaharieva
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Keilecia G Malden
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA
| | - Korey K Hood
- Stanford Diabetes Research Center, Stanford, California, USA
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Sarah C Westen
- Department of Clinical and Health Psychology, University of Florida, Gainesville, Florida, USA
| | - Jessie J Wong
- Stanford Diabetes Research Center, Stanford, California, USA
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - William T Donahoo
- University of Florida Diabetes Institute, Gainesville, Florida, USA
- Division of Endocrinology, Diabetes, & Metabolism, College of Medicine, University of Florida, Gainesville, Florida, USA
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Marina Basina
- Stanford Diabetes Research Center, Stanford, California, USA
- Division of Endocrinology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Angelina V Bernier
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA
| | - Paul Duncan
- Department of Health Services Research, Management and Policy, University of Florida, Gainesville, Florida, USA
| | - David M Maahs
- Stanford Diabetes Research Center, Stanford, California, USA
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
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Sandblom L, Kapadia C, Vaidya V, Chambers M, Gonsalves R, Holzmeister LA, Hoekstra F, Goldman S. Electronic Dashboard to Improve Outcomes in Pediatric Patients With Type 1 Diabetes Mellitus. J Diabetes Sci Technol 2024; 18:1102-1108. [PMID: 37026186 DOI: 10.1177/19322968231159401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
BACKGROUND AND OBJECTIVES Incidence of type 1 diabetes mellitus (T1DM) is increasing, and these patients often have poor glycemic control. Electronic dashboards summating patient data have been shown to improve patient outcomes in other conditions. In addition, educating patients on T1DM has shown to improve glycated hemoglobin (A1C) levels. We hypothesized that using data from the electronic dashboard to monitor defined diabetes management activities to implement population-based interventions would improve patient outcomes. METHODS Inclusion criteria included patients aged 0 to 18 years at Phoenix Children's Hospital with T1DM. Patient data were collected via the electronic dashboard, and both diabetes management activities (A1C, patient admissions, and visits to the emergency department) and patient outcomes (patient education, appointment compliance, follow-up after hospital admission) were analyzed. RESULTS This study revealed that following implementation of the electronic dashboard, the percentage of patients receiving appropriate education increased from 48% to 80% (Z-score = 23.55, P < .0001), the percentage of patients attending the appropriate number of appointments increased from 50% to 68.2%, and the percentage of patients receiving follow-up care within 40 days after a hospital admission increased from 43% to 70%. The median A1C level decreased from 9.1% to 8.2% (Z-score = -6.74, P < .0001), and patient admissions and visits to the emergency department decreased by 20%. CONCLUSIONS This study shows, with the implementation of an electronic dashboard, we were able to improve outcomes for our pediatric patients with T1DM. This tool can be used at other institutions to improve care and outcomes for pediatric patients with T1DM and other chronic conditions.
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Affiliation(s)
- Lily Sandblom
- University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
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Mohler R, Lotharius K, Moothedan E, Goguen J, Bandi R, Beaton R, Follin T, Mejia MC, Khoury M, Sacca L. Factors contributing to diabetic ketoacidosis readmission in hospital settings in the United States: A scoping review. J Diabetes Complications 2024; 38:108835. [PMID: 39137675 DOI: 10.1016/j.jdiacomp.2024.108835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2024] [Revised: 08/02/2024] [Accepted: 08/07/2024] [Indexed: 08/15/2024]
Abstract
BACKGROUND Hospitalization of patients with DKA creates a significant burden on the US healthcare system. While previous studies have identified multiple potential contributors, a comprehensive review of the factors leading to DKA readmissions within the US healthcare system has not been done. This scoping review aims to identify how access to care, treatment adherence, socioeconomic status, race, and ethnicity impact DKA readmission-related patient morbidity and mortality and contribute to the socioeconomic burden on the US healthcare system. Additionally, this study aims to integrate current recommendations to address this multifactorial issue, ultimately reducing the burden at both individual and organizational levels. METHODS The PRISMA-SCR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) was used as a reference checklist throughout this study. The Arksey and O'Malley methodology was used as a framework to guide this review. The framework methodology consisted of five steps: (1) Identify research questions; (2) Search for relevant studies; (3) Selection of studies relevant to the research questions; (4) Chart the data; (5) Collate, summarize, and report the results. RESULTS A total of 15 articles were retained for analysis. Among the various social factors identified, those related to sex/gender (n = 9) and age (n = 9) exhibited the highest frequency. Moreover, race and ethnicity (n = 8) was another recurrent factor that appeared in half of the studies. Economic factors were also identified in this study, with patient insurance type having the highest frequency (n = 11). Patient income had the second highest frequency (n = 6). Multiple studies identified a link between patients of a specific race/ethnicity and decreased access to treatment. Insufficient patient education around DKA treatment was noted to impact treatment accessibility. Certain recommendations for future directions were highlighted as recurrent themes across included studies and encompassed patient education, early identification of DKA risk factors, and the need for a multidisciplinary approach using community partners such as social workers and dieticians to decrease DKA readmission rates in diabetic patients. CONCLUSION This study can inform future policy decisions to improve the accessibility, affordability, and quality of healthcare through evidence-based interventions for patients with DM following an episode of DKA.
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Affiliation(s)
- Ryan Mohler
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, USA
| | - Kathryn Lotharius
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, USA
| | - Elijah Moothedan
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, USA
| | - Jake Goguen
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, USA
| | - Rishiraj Bandi
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, USA
| | - Ryan Beaton
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, USA
| | - Tiffany Follin
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, USA
| | - Maria C Mejia
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, USA
| | - Milad Khoury
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, USA
| | - Lea Sacca
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, USA.
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Unaka N, Kahn RS, Spitznagel T, Henize AW, Carlson D, Michael J, Quinonez E, Anderson J, Beck AF. An Institutional Approach to Equity and Improvement in Child Health Outcomes. Pediatrics 2024; 154:e2023064994. [PMID: 38953125 DOI: 10.1542/peds.2023-064994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 04/24/2024] [Accepted: 04/26/2024] [Indexed: 07/03/2024] Open
Abstract
Pediatric health inequities are pervasive. Approaches by health care institutions to address inequities often, and increasingly, focus on social needs screening without linked, robust responses. Even when actions in pursuit of health equity do occur within health care institutions, efforts occur in isolation from each other, standing in the way of cross-learning and innovation. Learning network methods hold promise when institutions are confronted with complex, multidimensional challenges. Equity-oriented learning networks may therefore accelerate action to address complex factors that contribute to inequitable pediatric health outcomes, enabling rapid learning along the way. We established an institutional Health Equity Network (HEN) in pursuit of excellent and equitable health outcomes for children and adolescents in our region. The HEN supports action teams seeking to eliminate pediatric health inequities in their clinical settings. Teams deploy targeted interventions to meet patients' and families' needs, addressing both medical and social factors affecting health and wellbeing. The primary, shared HEN measure is the equity gap in hospitalization rates between Black patients and all other patients. The HEN currently has 10 action teams and promotes rapid learning and scaling of interventions via monthly "action period calls" and "solutions labs" focused on successes, challenges, and potential common solutions (eg, scaling of existing medical-legal partnership to subspecialty clinics). In this Advocacy Case Study, we detail the design, implementation, and early outcomes from the HEN, our equity-oriented learning network.
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Affiliation(s)
- Ndidi Unaka
- Division of Hospital Medicine
- James M. Anderson Center for Health Systems Excellence
- Michael Fisher Child Health Equity Center
- Office of Population Health
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Robert S Kahn
- James M. Anderson Center for Health Systems Excellence
- Michael Fisher Child Health Equity Center
- Division of General and Community Pediatrics
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Adrienne W Henize
- Michael Fisher Child Health Equity Center
- Division of General and Community Pediatrics
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David Carlson
- James M. Anderson Center for Health Systems Excellence
- Michael Fisher Child Health Equity Center
| | - Joseph Michael
- James M. Anderson Center for Health Systems Excellence
- Michael Fisher Child Health Equity Center
| | - Elizabeth Quinonez
- James M. Anderson Center for Health Systems Excellence
- Michael Fisher Child Health Equity Center
| | - Jeffrey Anderson
- James M. Anderson Center for Health Systems Excellence
- Office of Population Health
- The Heart Institute, Cincinnati Children's, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Andrew F Beck
- Division of Hospital Medicine
- James M. Anderson Center for Health Systems Excellence
- Michael Fisher Child Health Equity Center
- Office of Population Health
- Division of General and Community Pediatrics
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Patel PM, Thomas D, Liu Z, Aldrich-Renner S, Clemons M, Patel BV. Systematic review of disparities in continuous glucose monitoring and insulin pump utilization in the United States: Key themes and evidentiary gaps. Diabetes Obes Metab 2024. [PMID: 39010293 DOI: 10.1111/dom.15774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 06/14/2024] [Accepted: 06/23/2024] [Indexed: 07/17/2024]
Abstract
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.
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Affiliation(s)
- Pranav M Patel
- University of Toledo College of Pharmacy and Pharmaceutical Sciences, Toledo, Ohio, USA
| | - Divya Thomas
- University of Toledo College of Pharmacy and Pharmaceutical Sciences, Toledo, Ohio, USA
| | - Zhixi Liu
- University of Toledo College of Pharmacy and Pharmaceutical Sciences, Toledo, Ohio, USA
| | - Sarah Aldrich-Renner
- University of Toledo General Internal Medicine Clinic and College of Pharmacy and Pharmaceutical Sciences, Toledo, Ohio, USA
| | - Marilee Clemons
- University of Toledo General Internal Medicine Clinic and College of Pharmacy and Pharmaceutical Sciences, Toledo, Ohio, USA
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Bowen AE, Holtman S, Reich J, Simon SL. Supporting healthy sleep: a qualitative assessment of adolescents with type 1 diabetes and their parents. J Pediatr Psychol 2024:jsae055. [PMID: 38994904 DOI: 10.1093/jpepsy/jsae055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 06/20/2024] [Accepted: 06/21/2024] [Indexed: 07/13/2024] Open
Abstract
OBJECTIVE Poor sleep health is common in adolescence due to a combination of physiological, psychosocial, and environmental factors. Adolescents with type 1 diabetes (T1D) may be at increased risk for poor sleep health due to physiological and behavioral aspects of diabetes and its management. This article describes a qualitative analysis of interviews with adolescents with T1D and their parents about facilitators and barriers to sleep health and family strategies to balance teens' sleep with competing demands. METHODS Separate interviews were conducted with 20 adolescents with T1D and 20 parents. Interviews were recorded and transcribed verbatim and analyzed thematically. Participants were on average 15.8 ± 1.2 years old, 45% female, and 85% non-Hispanic White. RESULTS Overnight diabetes management was the most frequently reported barrier to sleep. Families reported different strategies for taking responsibility of overnight diabetes management, which differentially impacted sleep. Families worked to balance diabetes management and sleep with other aspects of adolescent life, including school demands, social activities, and electronics use. Facilitators to healthy sleep identified by families included diabetes assistive technology and maintaining a consistent sleep/wake schedule. Both adolescents and parents voiced beliefs that their diabetes care team is not able to help with sleep health. CONCLUSIONS Pediatric psychologists should be aware of the specific sleep barriers experienced by adolescents with T1D and their parents. A focus on overnight diabetes management strategies may facilitate psychologists' support of families in the adolescent's transition to independent diabetes management. Research is needed on the impact of optimizing sleep health in adolescents with T1D.
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Affiliation(s)
- Anne E Bowen
- Division of Pediatrics, Department of Pulmonology and Sleep Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Sydney Holtman
- Division of Pediatrics, Department of Pulmonology and Sleep Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Jennifer Reich
- Department of Sociology, University of Colorado Denver, Denver, CO, United States
| | - Stacey L Simon
- Division of Pediatrics, Department of Pulmonology and Sleep Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- Department of Pulmonology and Sleep Medicine, Children's Hospital Colorado, Aurora, CO, United States
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Moore DJ, Leibel NI, Polonsky W, Rodriguez H. Recommendations for Screening and Monitoring the Stages of Type 1 Diabetes in the Immune Therapy Era. Int J Gen Med 2024; 17:3003-3014. [PMID: 39011423 PMCID: PMC11247126 DOI: 10.2147/ijgm.s438009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 06/13/2024] [Indexed: 07/17/2024] Open
Abstract
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).
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Affiliation(s)
- Daniel J Moore
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Natasha I Leibel
- Department of Pediatrics, Columbia University, New York, NY, USA
| | | | - Henry Rodriguez
- USF Diabetes and Endocrinology Center, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
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Gangqiang G, Hua C, Hongyu S. Risk predictors of glycaemic control in children and adolescents with type 1 diabetes: A systematic review and meta-analysis. J Clin Nurs 2024; 33:2412-2426. [PMID: 38661073 DOI: 10.1111/jocn.17110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 02/09/2024] [Accepted: 03/01/2024] [Indexed: 04/26/2024]
Abstract
OBJECTIVES To conduct systematic evaluation of the risk predictors of glycaemic control in children and adolescents with type 1 diabetes mellitus. METHODS Cohort studies on risk predictors of glycaemic control in children and adolescents with type 1 diabetes were retrieved from CNKI, PubMed, Web of Science, Embase databases, etc. from the construction of the repository to 3 February 2023. Literature screening was conducted according to inclusion and exclusion criteria, then data extraction of region, sample size, age, follow-up time, risk predictors, outcome indicators, etc., and quality evaluation of The Newcastle-Ottawa Scale were conducted by two researchers while the third researcher makes decisions if there are disagreements. Finally, Revman5.4 and StataMP17 were used for meta-analysis. RESULTS A total of 29 studies were included, and the results showed that insulin pump [Weighed mean difference (WMD) = -.48, 95% CI (-.73, -.24), p < .01], high-frequency sensor monitoring, early use of insulin pumps, prospective follow-up male, white race, large body mass index-standardised scoring, conscientiousness, agreeableness of mothers, eicosapentaenoic acid, leucine and protein (p < .05) were beneficial for reducing HbA1c levels in children and adolescents with diabetes. Ketoacidosis [WMD = .39, 95% CI (.28, .50), p < .01], selective admission, higher HbA1c level at one time (p < .01), higher glutamate decarboxylase antibody at 1 month after diagnosis, lower socio-economic status, non-living with biological parents, non-two-parent family, family disorder, family history of diabetes and high carbohydrate intake (p < .05) increased HbA1c levels in children and adolescents with diabetes. CONCLUSION For children and adolescents with type 1 diabetes mellitus, the use of insulin pump, high-frequency sensor monitoring, prospective follow-up, good family support and reasonable diet are conducive to blood glucose control, while selective admission and DKA are not. Disease characteristics and demographic characteristics of children are closely related to subsequent blood glucose control, and the relationship between diagnosis age and blood glucose control needs to be further explored.
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Affiliation(s)
- Gao Gangqiang
- School of Nursing, Peking University, Beijing, China
| | - Chen Hua
- School of Nursing, Peking University, Beijing, China
| | - Sun Hongyu
- School of Nursing, Peking University, Beijing, China
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Evans M, Ellis DA, Vesco AT, Feldman MA, Weissberg-Benchell J, Carcone AI, Miller J, Boucher-Berry C, Buggs-Saxton C, Degnan B, Dekelbab B, Drossos T. Diabetes distress in urban Black youth with type 1 diabetes and their caregivers: associations with glycemic control, depression, and health behaviors. J Pediatr Psychol 2024; 49:394-404. [PMID: 38216126 DOI: 10.1093/jpepsy/jsad096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 12/05/2023] [Accepted: 12/08/2023] [Indexed: 01/14/2024] Open
Abstract
OBJECTIVES Adolescents with type 1 diabetes (T1D) and their caregivers endorse high diabetes distress (DD). Limited studies have documented the impact of DD on Black youth. The aims of the present study were to (1) describe DD among a sample of Black adolescents with T1D and their caregivers, (2) compare their DD levels with published normative samples, and (3) determine how DD relates to glycemic outcomes, diabetes self-management, parental monitoring of diabetes, and youth depressive symptoms. METHODS Baseline data from a multicenter clinical trial were used. Participants (N = 155) were recruited from 7 Midwestern pediatric diabetes clinics. Hemoglobin A1c (HbA1c) and measures of DD, parental monitoring of diabetes care, youth depression and diabetes management behaviors were obtained. The sample was split into (1) adolescents (ages 13-14; N = 95) and (2) preadolescents (ages 10-12; N = 60). Analyses utilized Cohen's d effect sizes, Pearson correlations, t-tests, and multiple regression. RESULTS DD levels in youth and caregivers were high, with 45%-58% exceeding either clinical cutoff scores or validation study sample means. Higher DD in youth and caregivers was associated with higher HbA1c, lower diabetes self-management, and elevated depressive symptoms, but not with parental monitoring of diabetes management. CONCLUSIONS Screening for DD in Black youth with T1D and caregivers is recommended, as are culturally informed interventions that can reduce distress levels and lead to improved health outcomes. More research is needed on how systemic inequities contribute to higher DD in Black youth and the strategies/policy changes needed to reduce these inequities.
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Affiliation(s)
- Meredyth Evans
- Pritzker Department of Psychiatry and Behavioral Health, Ann and Robert H. Lurie Children's Hospital and Psychiatry and Behavioral Sciences, Northwestern Feinberg School of Medicine, Chicago, IL, United States
| | - Deborah A Ellis
- School of Medicine, Wayne State University, Detroit, MI, United States
| | - Anthony T Vesco
- Pritzker Department of Psychiatry and Behavioral Health, Ann and Robert H. Lurie Children's Hospital and Psychiatry and Behavioral Sciences, Northwestern Feinberg School of Medicine, Chicago, IL, United States
| | - Marissa A Feldman
- Division of Psychology, Johns Hopkins, All Children's Hospital, St Petersburg, FL, United States
| | - Jill Weissberg-Benchell
- Pritzker Department of Psychiatry and Behavioral Health, Ann and Robert H. Lurie Children's Hospital and Psychiatry and Behavioral Sciences, Northwestern Feinberg School of Medicine, Chicago, IL, United States
| | | | - Jennifer Miller
- Pritzker Department of Psychiatry and Behavioral Health, Ann and Robert H. Lurie Children's Hospital and Psychiatry and Behavioral Sciences, Northwestern Feinberg School of Medicine, Chicago, IL, United States
| | - Claudia Boucher-Berry
- Division of Pediatric Endocrinology, University of Illinois at Chicago, Chicago, IL, United States
| | | | - Bernard Degnan
- Pediatric Endocrinology, Ascension St John Children's Hospital, Detroit, MI, United States
| | - Bassem Dekelbab
- Pediatric Endocrinology, Beaumont Health Care, Royal Oak, MI, United States
| | - Tina Drossos
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL, United States
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Bergmann KR, Bjornstad P, Abuzzahab MJ, Zhong L, Collins-Dippel E, Nickel A, Watson D, Kharbanda A. Multicentre, retrospective cohort study protocol to identify racial and ethnic differences in acute kidney injuries in children and adolescents with diabetic ketoacidosis. BMJ Open 2024; 14:e086261. [PMID: 38839382 PMCID: PMC11163677 DOI: 10.1136/bmjopen-2024-086261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Accepted: 05/17/2024] [Indexed: 06/07/2024] Open
Abstract
INTRODUCTION Approximately 40% of children with diabetic ketoacidosis (DKA) develop acute kidney injury (AKI), which increases the risk of chronic kidney damage. At present, there is limited knowledge of racial or ethnic differences in diabetes-related kidney injury in children with diabetes. Understanding whether such differences exist will provide a foundation for addressing disparities in diabetes care that may continue into adulthood. Further, it is currently unclear which children are at risk to develop worsening or sustained DKA-related AKI. The primary aim is to determine whether race and ethnicity are associated with DKA-related AKI. The secondary aim is to determine factors associated with sustained AKI in children with DKA. METHODS AND ANALYSIS This retrospective, multicentre, cross-sectional study of children with type 1 or type 2 diabetes with DKA will be conducted through the Paediatric Emergency Medicine Collaborative Research Committee. Children aged 2-18 years who were treated in a participating emergency department between 1 January 2020 and 31 December 2023 will be included. Children with non-ketotic hyperglycaemic-hyperosmolar state or who were transferred from an outside facility will be excluded. The relevant predictor is race and ethnicity. The primary outcome is the presence of AKI, defined by Kidney Disease: Improving Global Outcomes criteria. The secondary outcome is 'sustained' AKI, defined as having AKI ≥48 hours, unresolved AKI at last creatinine measurement or need for renal replacement therapy. Statistical inference of the associations between predictors (ie, race and ethnicity) and outcomes (ie, AKI and sustained AKI) will use random effects regression models, accounting for hospital variation and clustering. ETHICS AND DISSEMINATION The Institutional Review Board of Children's Minnesota approved this study. 12 additional sites have obtained institutional review board approval, and all sites will obtain local approval prior to participation. Results will be presented at local or national conferences and for publication in peer-reviewed journals.
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Affiliation(s)
- Kelly R Bergmann
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, Minnesota, USA
| | - Petter Bjornstad
- Department of Medicine, UW Medicine Diabetes Institute, University of Washington, Seattle, Washington, USA
| | - M Jennifer Abuzzahab
- Department of Endocrinology and the McNeely Pediatric Diabetes Center, Children's Minnesota, St. Paul, Minnesota, USA
| | - Ling Zhong
- Department of Research and Sponsored Programs, Children's Minnesota Research Institute, Minneapolis, Minnesota, USA
| | - Elizabeth Collins-Dippel
- Department of Research and Sponsored Programs, Children's Minnesota Research Institute, Minneapolis, Minnesota, USA
| | - Amanda Nickel
- Department of Research and Sponsored Programs, Children's Minnesota Research Institute, Minneapolis, Minnesota, USA
| | - Dave Watson
- Department of Research and Sponsored Programs, Children's Minnesota Research Institute, Minneapolis, Minnesota, USA
| | - Anupam Kharbanda
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, Minnesota, USA
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Straton E, Bryant BL, Kang L, Wang C, Barber J, Perkins A, Gallant L, Marks B, Agarwal S, Majidi S, Monaghan M, Streisand R. ROUTE-T1D: A behavioral intervention to promote optimal continuous glucose monitor use among racially minoritized youth with type 1 diabetes: Design and development. Contemp Clin Trials 2024; 140:107493. [PMID: 38460913 PMCID: PMC11065587 DOI: 10.1016/j.cct.2024.107493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 02/13/2024] [Accepted: 03/05/2024] [Indexed: 03/11/2024]
Abstract
BACKGROUND Type 1 diabetes management is often challenging during adolescence, and many youth with type 1 diabetes struggle with sustained and optimal continuous glucose monitor (CGM) use. Due to racial oppression and racially discriminatory policies leading to inequitable access to quality healthcare and life necessities, racially minoritized youth are significantly less likely to use CGM. METHODS ROUTE-T1D: Research on Optimizing the Use of Technology with Education is a pilot behavioral intervention designed to promote optimal CGM use among racially minoritized youth with type 1 diabetes. Intervention strategies include problem solving CGM challenges and promoting positive caregiver-youth communication related to CGM data. RESULTS This randomized waitlist intervention provides participants with access to three telemedicine sessions with a Certified Diabetes Care and Education Specialist. Caregiver participants are also connected with a peer-parent coach. CONCLUSION Hypothesized findings and anticipated challenges are discussed. Future directions regarding sustaining and optimizing the use of diabetes technology among racially minoritized pediatric populations are reviewed.
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Affiliation(s)
- Emma Straton
- Children's National Hospital, Washington DC, United States of America
| | - Breana L Bryant
- Children's National Hospital, Washington DC, United States of America
| | - Leyi Kang
- Children's National Hospital, Washington DC, United States of America
| | - Christine Wang
- Children's National Hospital, Washington DC, United States of America
| | - John Barber
- Children's National Hospital, Washington DC, United States of America
| | - Amanda Perkins
- Children's National Hospital, Washington DC, United States of America
| | - Letitia Gallant
- Children's National Hospital, Washington DC, United States of America
| | - Brynn Marks
- Children's Hospital of Philadelphia, Philadelphia, PA, United States of America
| | - Shivani Agarwal
- Albert Einstein College of Medicine, Bronx, NY, United States of America
| | - Shideh Majidi
- Children's National Hospital, Washington DC, United States of America; The George Washington University School of Medicine, Washington, DC, United States of America
| | - Maureen Monaghan
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, United States of America
| | - Randi Streisand
- Children's National Hospital, Washington DC, United States of America; The George Washington University School of Medicine, Washington, DC, United States of America.
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Andrist E, Clarke RG, Phelps KB, Dews AL, Rodenbough A, Rose JA, Zurca AD, Lawal N, Maratta C, Slain KN. Understanding Disparities in the Pediatric ICU: A Scoping Review. Pediatrics 2024; 153:e2023063415. [PMID: 38639640 DOI: 10.1542/peds.2023-063415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/06/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Health disparities are pervasive in pediatrics. We aimed to describe disparities among patients who are likely to be cared for in the PICU and delineate how sociodemographic data are collected and categorized. METHODS Using MEDLINE as a data source, we identified studies which included an objective to assess sociodemographic disparities among PICU patients in the United States. We created a review rubric, which included methods of sociodemographic data collection and analysis, outcome and exposure variables assessed, and study findings. Two authors reviewed every study. We used the National Institute on Minority Health and Health Disparities Research Framework to organize outcome and exposure variables. RESULTS The 136 studies included used variable methods of sociodemographic data collection and analysis. A total of 30 of 124 studies (24%) assessing racial disparities used self- or parent-identified race. More than half of the studies (52%) dichotomized race as white and "nonwhite" or "other" in some analyses. Socioeconomic status (SES) indicators also varied; only insurance status was used in a majority of studies (72%) evaluating SES. Consistent, although not uniform, disadvantages existed for racial minority populations and patients with indicators of lower SES. The authors of only 1 study evaluated an intervention intended to mitigate health disparities. Requiring a stated objective to evaluate disparities aimed to increase the methodologic rigor of included studies but excluded some available literature. CONCLUSIONS Variable, flawed methodologies diminish our understanding of disparities in the PICU. Meaningfully understanding and addressing health inequity requires refining how we collect, analyze, and interpret relevant data.
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Affiliation(s)
- Erica Andrist
- Division of Pediatric Critical Care Medicine
- Departments of Pediatrics
| | - Rachel G Clarke
- Division of Pediatric Critical Care Medicine, Upstate University Hospital, Syracuse, New York
- Center for Bioethics and Humanities, SUNY Upstate Medical University, Syracuse, New York
| | - Kayla B Phelps
- Division of Pediatric Critical Care Medicine, Louisiana State University Health Sciences Center, Children's Hospital of New Orleans, New Orleans, Louisiana
| | - Alyssa L Dews
- Human Genetics, University of Michigan Medical School, Ann Arbor, Michigan
- Susan B. Meister Child Health and Adolescent Research Center, University of Michigan, Ann Arbor, Michigan
| | - Anna Rodenbough
- Division of Pediatric Critical Care Medicine, Children's Hospital of Atlanta, Atlanta, Georgia
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Jerri A Rose
- Pediatric Emergency Medicine
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Adrian D Zurca
- Division of Critical Care, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Nurah Lawal
- Stepping Stones Pediatric Palliative Care Program, C.S. Mott Children's Hospital, Ann Arbor, Michigan
- Departments of Pediatrics
| | - Christina Maratta
- Department of Critical Care, The Hospital for Sick Children, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Katherine N Slain
- Pediatric Critical Care Medicine, Rainbow Babies and Children's Hospital, Cleveland, Ohio
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio
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13
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Nwosu BU, Pellizzari M, Pavlovic MN, Ciron J, Talib R, Sohail R. Virtual insulin pump initiation is safe effective in children adolescents with type 1 diabetes. FRONTIERS IN CLINICAL DIABETES AND HEALTHCARE 2024; 5:1362627. [PMID: 38745900 PMCID: PMC11091709 DOI: 10.3389/fcdhc.2024.1362627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 04/16/2024] [Indexed: 05/16/2024]
Abstract
Objective There is no head-to-head comparison of the safety and efficacy of virtual versus in-office insulin pump initiation for youth with type 1 diabetes in the US. The study's aim was to determine the safety and efficacy of virtual versus in-office pump initiation in pediatric type 1 diabetes. Research design and methods A longitudinal retrospective study of 112 subjects: 65% (n=73), ages 11.2 ± 3.8 years(y), received in-office training; and 35% (n=39), ages 12.0 ± 4.0y, received virtual training. The number of White subjects was 40 (55%) in the in-office group, and 25 (66%) in the remote group; while Black subjects were 11 (15%) in the in-office group and 4 (10%) in the virtual group. Data were collected at pump initiation, 3 and 6 months. Results There were no significant differences in sex, race, height, weight, BMI, and the duration of diabetes between the groups at baseline. There was no significant difference in A1c between the groups at 0, 3, and 6 months. A1c correlated significantly with the glucose management indicator at 0, 3, and 6 months: baseline: r=0.49, p<0.0001; 3 months: r=0.77, p<0.0001; and 6 months: r=0.71, p<0.0001. There was no relationship between A1c or TIR and pubertal status, BMI, sex, or race. A1c was significantly elevated in the non-White individuals at 6 months only: 57.9 mmol/mol (50.8-69.4) versus 51.9 mmol/mol (46.5-59.6)], p=0.007. Conclusion Virtual insulin pump initiation is safe and effective in children with type 1 diabetes. This approach could accelerate the adoption of the use of diabetes technology in minority populations in the US.
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Affiliation(s)
- Benjamin Udoka Nwosu
- Division of Endocrinology, Department of Pediatrics, Cohen Children’s Medical Center, Hempstead, NY, United States
- Department of Pediatrics, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Queens, NY, United States
| | - Margaret Pellizzari
- Division of Endocrinology, Department of Pediatrics, Cohen Children’s Medical Center, Hempstead, NY, United States
| | - Maia N. Pavlovic
- Department of Pediatrics, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Queens, NY, United States
| | - Jason Ciron
- Division of Endocrinology, Department of Pediatrics, Cohen Children’s Medical Center, Hempstead, NY, United States
| | - Rashida Talib
- Division of Endocrinology, Department of Pediatrics, Cohen Children’s Medical Center, Hempstead, NY, United States
| | - Rubab Sohail
- Biostatistics Unit, Office of Academic Affairs, Northwell Health, NY, United States
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14
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Ellis D, Carcone AI, Templin T, Evans M, Weissberg-Benchell J, Buggs-Saxton C, Boucher-Berry C, Miller JL, Drossos T, Dekelbab MB. Moderating Effect of Depression on Glycemic Control in an eHealth Intervention Among Black Youth With Type 1 Diabetes: Findings From a Multicenter Randomized Controlled Trial. JMIR Diabetes 2024; 9:e55165. [PMID: 38593428 PMCID: PMC11040442 DOI: 10.2196/55165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 02/22/2024] [Accepted: 02/28/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND Black adolescents with type 1 diabetes (T1D) are at increased risk for suboptimal diabetes health outcomes; however, evidence-based interventions for this population are lacking. Depression affects a high percentage of youth with T1D and increases the likelihood of health problems associated with diabetes. OBJECTIVE Our aim was to test whether baseline levels of depression moderate the effects of a brief eHealth parenting intervention delivered to caregivers of young Black adolescents with T1D on youths' glycemic control. METHODS We conducted a multicenter randomized controlled trial at 7 pediatric diabetes clinics located in 2 large US cities. Participants (N=149) were allocated to either the intervention group or a standard medical care control group. Up to 3 intervention sessions were delivered on a tablet computer during diabetes clinic visits over a 12-month period. RESULTS In a linear mixed effects regression model, planned contrasts did not show significant reductions in hemoglobin A1c (HbA1c) for intervention adolescents compared to controls. However, adolescents with higher baseline levels of depressive symptoms who received the intervention had significantly greater improvements in HbA1c levels at 6-month follow-up (0.94%; P=.01) and 18-month follow-up (1.42%; P=.002) than those with lower levels of depression. Within the intervention group, adolescents had a statistically significant reduction in HbA1c levels from baseline at 6-month and 18-month follow-up. CONCLUSIONS A brief, culturally tailored eHealth parenting intervention improved health outcomes among Black adolescents with T1D and depressive symptoms. TRIAL REGISTRATION ClinicalTrials.gov NCT03168867; https://clinicaltrials.gov/study/NCT03168867.
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Affiliation(s)
- Deborah Ellis
- Department of Family Medicine and Public Health Sciences, Wayne State University School of Medicine, Detroit, MI, United States
| | - April Idalski Carcone
- Department of Family Medicine and Public Health Sciences, Wayne State University School of Medicine, Detroit, MI, United States
| | - Thomas Templin
- College of Nursing, Wayne State University, Detroit, MI, United States
| | - Meredyth Evans
- Pritzker Department of Psychiatry and Behavioral Health, Ann and Robert H Lurie Children's Hospital, Chicago, IL, United States
- Department of Psychiatry and Behavioral Sciences, Northwestern Feinberg School of Medicine, Chicago, IL, United States
| | - Jill Weissberg-Benchell
- Pritzker Department of Psychiatry and Behavioral Health, Ann and Robert H Lurie Children's Hospital, Chicago, IL, United States
- Department of Psychiatry and Behavioral Sciences, Northwestern Feinberg School of Medicine, Chicago, IL, United States
| | - Colleen Buggs-Saxton
- Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI, United States
| | - Claudia Boucher-Berry
- Department of Pediatrics, University of Illinois School of Medicine at Chicago, Chicago, IL, United States
| | - Jennifer L Miller
- Department of Pediatrics, Northwestern Feinberg School of Medicine, Chicago, IL, United States
| | - Tina Drossos
- Department of Psychiatry and Behavioral Neurosciences, University of Chicago Pritzker School of Medicine, Chicago, IL, United States
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15
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Kruger DF, Isaacs D, Hughes L, Miller E, Bailey TS. Opportunities to overcome underutilization of enhanced insulin delivery technologies in people with type 2 diabetes: a narrative review. Postgrad Med 2024; 136:246-254. [PMID: 38497381 DOI: 10.1080/00325481.2024.2331417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 03/06/2024] [Indexed: 03/19/2024]
Abstract
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.
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Affiliation(s)
- Davida F Kruger
- Division of Endocrinology, Diabetes, Bone & Mineral, Henry Ford Health System, Detroit, MI, USA
| | - Diana Isaacs
- Endocrinology and Metabolism Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Lucille Hughes
- Diabetes Education and Program Design, Catholic Health, Melville, NY, USA
| | - Eden Miller
- Endocrinology and Metabolism Institute, Diabetes and Obesity Care LLC, Bend, OR, USA
| | - Timothy S Bailey
- Endocrinology and Metabolism Institute, AMCR Institute, Escondido, CA, USA
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16
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Jacobs M, Evans E, Ellis C. Exploring the association between social determinants and aphasia impairment: A retrospective data integration approach. PLoS One 2024; 19:e0299979. [PMID: 38512886 PMCID: PMC10956803 DOI: 10.1371/journal.pone.0299979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 02/19/2024] [Indexed: 03/23/2024] Open
Abstract
INTRODUCTION Traditionally, the study of aphasia focused on brain trauma, clinical biomarkers, and cognitive processes, rarely considering the social determinants of health. This study evaluates the relationship between aphasia impairment and demographic, socioeconomic, and contextual determinants among people with aphasia (PWA). METHODS PWA indexed within AphasiaBank-a database populated by multiple clinical aphasiology centers with standardized protocols characterizing language, neuropsychological functioning, and demographic information-were matched with respondents in the Medical Expenditure Panel Survey based on response year, age, sex, race, ethnicity, time post stroke, and mental health status. Generalized log-linear regression models with bootstrapped standard errors evaluated the association between scores on the Western Aphasia Battery-Revised Aphasia Quotient (WAB-R AQ) and demographic, economic, and contextual characteristics accounting for clustering of respondents and the stratification of data collection. Region, age, and income specific models tested the sensitivity of results. RESULTS PWA over age 60 had 2.4% (SE = 0.020) lower WAB-R AQ scores compared with younger PWA. Compared to White PWA, Black and Hispanic PWA had 4.7% (SE = 0.03) and 0.81% (SE = 0.06) lower WAB-R AQ scores, respectively, as did those and living in the Southern US (-2.2%, SE = 0.03) even after controlling for age, family size, and aphasia type. Those living in larger families (β = 0.005, SE = 0.008), with income over $30,000 (β = 0.017, SE = 0.022), and a college degree (β = 0.030, SE = 0.035) had higher WAB-R AQ relative to their counterparts. Region-specific models showed that racial differences were only significant in the South and Midwest, while ethnic differences are only significant in the West. Sex differences only appeared in age-specific models. Racial and ethnic differences were not significant in the high-income group regression. CONCLUSION These findings support evidence that circumstances in which individuals live, work, and age are significantly associated with their health outcomes including aphasia impairment.
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Affiliation(s)
- Molly Jacobs
- Department of Health Services Research, Management and Policy, College of Public Health and Health Professions, University of Florida, Gainesville, FL, United States of America
| | - Elizabeth Evans
- Department of Speech, Language and Hearing Sciences, Communication Equity and Outcomes Laboratory, College of Public Health and Health Professions, University of Florida, Gainesville, FL, United States of America
| | - Charles Ellis
- Department of Speech, Language and Hearing Sciences, Communication Equity and Outcomes Laboratory, College of Public Health and Health Professions, University of Florida, Gainesville, FL, United States of America
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17
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Been RA, Lameijer A, Gans ROB, van Beek AP, Kingsnorth AP, Choudhary P, van Dijk PR. The impact of socioeconomic factors, social determinants, and ethnicity on the utilization of glucose sensor technology among persons with diabetes mellitus: a narrative review. Ther Adv Endocrinol Metab 2024; 15:20420188241236289. [PMID: 38476216 PMCID: PMC10929059 DOI: 10.1177/20420188241236289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 02/08/2024] [Indexed: 03/14/2024] Open
Abstract
Continuous glucose monitoring (CGM) usage has been shown to improve disease outcomes in people living with diabetes by facilitating better glycemic management. However, previous research has suggested that access to these devices can be influenced by nonmedical factors such as socioeconomic status and ethnicity. It is critical that equitable access to CGM devices is ensured as people from those groups experience poorer diabetes-related health outcomes. In this narrative review, we provide an overview of the various healthcare systems worldwide and how socioeconomic status, social context, and ethnicity shape device usage and the associated health outcomes. In general, we found that having a lower socioeconomic status and belonging to an ethnic minority group negatively impact CGM usage. While financial means proved to be an important mediator in this process, it was not the sole driver as disparities persisted even after adjustment for factors such as income and insurance status. Recommendations to increase CGM usage for people of a lower socioeconomic status and ethnic minorities include increasing the availability of financial, administrative, and educational support, for both patients and healthcare providers. However, recommendations will vary due to local country-specific circumstances, such as reimbursement criteria and healthcare ecosystems.
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Affiliation(s)
- Riemer A. Been
- University of Groningen, University Medical Center Groningen, Department of Endocrinology, Groningen, The Netherlands
| | - Annel Lameijer
- University of Groningen, University Medical Center Groningen, Department of Endocrinology, Groningen, The Netherlands
| | - Reinold O. B. Gans
- University of Groningen, University Medical Center Groningen, Department of Internal Medicine, Groningen, The Netherlands
| | - André P. van Beek
- University of Groningen, University Medical Center Groningen, Department of Endocrinology, Groningen, The Netherlands
| | - Andrew P. Kingsnorth
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Pratik Choudhary
- University of Leicester, Leicester General Hospital, Leicester, Leicester Diabetes Centre – Bloom, UK
| | - Peter R. van Dijk
- University of Groningen, University Medical Center Groningen, Department of Endocrinology, Hanzeplein 1, Groningen, 9713 GZ, The Netherlands
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Yayah Jones NH, Cole I, Hart KJ, Corathers S, Agarwal S, Odugbesan O, Ebekozien O, Kamboj MK, Harris MA, Fantasia KL, Mansour M. Social Determinants of Health Screening in Type 1 Diabetes Management. Endocrinol Metab Clin North Am 2024; 53:93-106. [PMID: 38272601 DOI: 10.1016/j.ecl.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
Type 1 diabetes management is intricately influenced by social determinants of health. Economic status impacts access to vital resources like insulin and diabetes technology. Racism, social injustice, and implicit biases affect equitable delivery of care. Education levels affect understanding of self-care, leading to disparities in glycemic outcomes. Geographic location can limit access to health care facilities. Stressors from discrimination or financial strain can disrupt disease management. Addressing these social factors is crucial for equitable diabetes care, emphasizing the need for comprehensive strategies that go beyond medical interventions to ensure optimal health outcomes for all individuals with type 1 diabetes.
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Affiliation(s)
- Nana-Hawa Yayah Jones
- Division of Pediatric Endocrinology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, 3333 Burnet Avenue, MLC 7012, Cincinnati, OH 45229-3039, USA.
| | - India Cole
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 15018, Cincinnati, OH 45229-3039, USA
| | - Kelsey J Hart
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 15018, Cincinnati, OH 45229-3039, USA
| | - Sarah Corathers
- Division of Pediatric Endocrinology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, 3333 Burnet Avenue, MLC 7012, Cincinnati, OH 45229-3039, USA
| | - Shivani Agarwal
- Fleischer Institute for Diabetes and Metabolism, New York Regional Center for Diabetes Translation Research, Albert Einstein College of Medicine, 1180 Morris Park Avenue, Bronx, NY 10467, USA
| | - Ori Odugbesan
- T1D Exchange, QI & Population Health Department, 101 Federal Street Suite 440, Boston, MA 02110, USA
| | - Osagie Ebekozien
- T1D Exchange, QI & Population Health Department, 101 Federal Street Suite 440, Boston, MA 02110, USA
| | - Manmohan K Kamboj
- The Ohio State University College of Medicine, Section of Endocrinology, Quality Improvement for Endocrinology, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Michael A Harris
- Oregon Health & Science University, Harold Schnitzer Diabetes Health Center, 707 SW Gaines Street, Portland, OR 97239, USA
| | - Kathryn L Fantasia
- Section of Endocrinology, Diabetes, and Nutrition, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, 72 E Concord, C3, Boston, MA 02118, USA
| | - Mona Mansour
- Division of Pediatric Endocrinology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, 3333 Burnet Avenue, MLC 7012, Cincinnati, OH 45229-3039, USA; University of Cincinnati College of Medicine, Department of Pediatrics, Population Health- CCHMC, Division of General and Community Pediatrics, Community Engagement- HealthVine, CCHMC Coordinated School Strategy, Cincinnati Children's Hospital Medical Center, University of Cincinnati, 3333 Burnet Avenue, MLC 15018, Cincinnati, OH 45229-3039, USA
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Rioles N, March C, Muñoz CE, Ilkowitz J, Ohmer A, Wolf RM. Stakeholder Engagement in Type 1 Diabetes Research, Quality Improvement, and Clinical Care. Endocrinol Metab Clin North Am 2024; 53:165-182. [PMID: 38272594 DOI: 10.1016/j.ecl.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
The integration of stakeholder engagement (SE) in research, quality improvement (QI), and clinical care has gained significant traction. Type 1 diabetes is a chronic disease that requires complex daily management and care from a multidisciplinary team across the lifespan. Inclusion of key stakeholder voices, including patients, caregivers, health care providers and community advocates, in the research process and implementation of clinical care is critical to ensure representation of perspectives that match the values and goals of the patient population. This review describes the current framework for SE and its application to research, QI, and clinical care across the lifespan.
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Affiliation(s)
| | - Christine March
- Division of Pediatric Endocrinology and Diabetes, University of Pittsburgh, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Cynthia E Muñoz
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Jeniece Ilkowitz
- Pediatric Diabetes Center, NYU Langone Health, New York, NY, USA
| | - Amy Ohmer
- International Children's Advisory Network, Atlanta, GA, USA
| | - Risa M Wolf
- Department of Pediatrics, Division of Endocrinology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Wu V, Choleva L, Wilkes M. Optimizing Glycemic Outcomes for Children with Type 1 Diabetes. Endocrinol Metab Clin North Am 2024; 53:27-38. [PMID: 38272596 DOI: 10.1016/j.ecl.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
Changes in physical growth, neurocognitive development, and pubertal maturation are some of the challenges to achieving blood glucose targets in children with type 1 diabetes mellitus. To optimize glycemic outcomes, a comprehensive approach is crucial to address psychosocial needs, expand the use of diabetes technology, and diminish health inequities.
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Affiliation(s)
- Vickie Wu
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, The Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, Box #1616, Annenberg Building, 4th Floor, New York, NY 10029, USA
| | - Lauryn Choleva
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, The Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, Box #1616, Annenberg Building, 4th Floor, New York, NY 10029, USA
| | - Meredith Wilkes
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, The Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, Box #1616, Annenberg Building, 4th Floor, New York, NY 10029, USA.
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21
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King KP, Humiston T, Gowey MA, Murdaugh DL, Dutton GR, Lansing AH. A biobehavioural and social-structural model of inflammation and executive function in pediatric chronic health conditions. Health Psychol Rev 2024; 18:24-40. [PMID: 36581801 PMCID: PMC10307927 DOI: 10.1080/17437199.2022.2162430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 12/20/2022] [Indexed: 12/31/2022]
Abstract
Evidence indicates that pediatric chronic health conditions (CHCs) often impair executive functioning (EF) and impaired EF undermines pediatric CHC management. This bidirectional relationship likely occurs due to biobehavioural and social-structural factors that serve to maintain this feedback loop. Specifically, biobehavioural research suggests that inflammation may sustain a feedback loop that links together increased CHC severity, challenges with EF, and lower engagement in health promoting behaviours. Experiencing social and environmental inequity also maintains pressure on this feedback loop as experiencing inequities is associated with greater inflammation, increased CHC severity, as well as challenges with EF and engagement in health promoting behaviours. Amidst this growing body of research, a model of biobehavioural and social-structural factors that centres inflammation and EF is warranted to better identify individual and structural targets to ameliorate the effects of CHCs on children, families, and society at large. This paper proposes this model, reviews relevant literature, and delineates actionable research and clinical implications.
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Affiliation(s)
| | - Tori Humiston
- University of Vermont, Department of Psychological Sciences
| | - Marissa A. Gowey
- University of Alabama-Birmingham School of Medicine, Department of Pediatrics
| | - Donna L. Murdaugh
- University of Alabama-Birmingham School of Medicine, Department of Pediatrics
| | - Gareth R. Dutton
- University of Alabama-Birmingham School of Medicine, Department of Preventive Medicine
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22
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Wetter-Wren SE, Himelhoch AC, Driscoll KA. A Systematic Review of the Effects of Provider Bias on Health in Youth and Young Adults with Type 1 Diabetes. Curr Diab Rep 2024; 24:45-60. [PMID: 38233705 DOI: 10.1007/s11892-023-01527-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/03/2023] [Indexed: 01/19/2024]
Abstract
PURPOSE OF REVIEW Although pervasive inequities in the health outcomes of youth and young adults with type 1 diabetes (T1D) exist, the role of provider bias in these inequities is not well-understood. The purpose of this review is to synthesize evidence from existing studies on the associations between patient characteristics, provider bias, and patient health. RECENT FINDINGS Fourteen articles were included. Determining the extent of the effects of provider bias on patient health is limited by a lack of consensus on its definition. Experiences of provider bias (e.g., shaming, criticism) negatively affects self-esteem, relationships with medical providers, and depressive symptoms. Provider bias also impacts diabetes technology recommendations, insulin regimen intensity, and risk for life-threatening T1D complications. Future studies are needed to develop questionnaires and interviews that better account for diverse experiences and interpretations of bias in T1D healthcare. More research is also needed to investigate mitigating factors to reduce provider bias as a way to improve psychological and physical health in individuals with T1D.
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Affiliation(s)
- Sara E Wetter-Wren
- Department of Clinical and Health Psychology, University of Florida, 1225 Center Dr., Gainesville, FL, 32610, USA
| | - Alexandra C Himelhoch
- Department of Clinical and Health Psychology, University of Florida, 1225 Center Dr., Gainesville, FL, 32610, USA
| | - Kimberly A Driscoll
- Department of Clinical and Health Psychology, University of Florida, 1225 Center Dr., Gainesville, FL, 32610, USA.
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23
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Tilden DR, French B, Datye KA, Jaser SS. Disparities in Continuous Glucose Monitor Use Between Children With Type 1 Diabetes Living in Urban and Rural Areas. Diabetes Care 2024; 47:346-352. [PMID: 37906202 PMCID: PMC10909681 DOI: 10.2337/dc23-1564] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 10/11/2023] [Indexed: 11/02/2023]
Abstract
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.
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Affiliation(s)
- Daniel R. Tilden
- Division of Endocrinology, Diabetes & Clinical Genetics, Department of Medicine, University of Kansas Medical Center, Kansas City, KS
| | - Benjamin French
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Karishma A. Datye
- Ian M. Burr Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Sarah S. Jaser
- Division of Pediatric Psychology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
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24
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Rosenheck S, Chen C, Regelmann MO. Pediatric Inpatient Insulin Pump Use and Glycemic Control. JAMA Netw Open 2024; 7:e2354547. [PMID: 38324317 DOI: 10.1001/jamanetworkopen.2023.54547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2024] Open
Affiliation(s)
- Sarah Rosenheck
- Division of Pediatric Endocrinology and Diabetes, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Charlotte Chen
- Division of Pediatric Endocrinology and Diabetes, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Molly O Regelmann
- Division of Pediatric Endocrinology and Diabetes, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
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25
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Kanbour S, Everett E. Addressing disparities in technology use among patients with type 1 diabetes: a review. Curr Opin Endocrinol Diabetes Obes 2024; 31:14-21. [PMID: 37882585 PMCID: PMC10841459 DOI: 10.1097/med.0000000000000840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
PURPOSE OF REVIEW The benefits of continuous glucose monitors (CGMs) and insulin pumps in the management of type 1 diabetes (T1D) are widely recognized. However, glaring disparities in access exist, particularly in marginalized and economically disadvantaged groups that stand to benefit significantly from diabetes technology use. We will review recent data describing drivers of these disparities and approaches to address the disparities. RECENT FINDINGS Several qualitative studies were published in recent years that have investigated the drivers of disparities reported over the past decades. These studies report that in addition to typical barriers seen in the diabetes technology, marginalized patients have unique challenges that make insulin pumps and CGMs less accessible. SUMMARY Barriers to technology use in these groups include stigmatization, lack of support, financial constraints, provider biases, stringent insurance policies, and clinic infrastructure. To address inequities, multifaceted strategies across community, healthcare, and provider sectors are essential. Key initiatives include enhancing public awareness, refining health policies, ensuring access to high-quality care, and emphasizing patient-centered approaches. The equitable use of technology can narrow the gap in T1D outcomes. The social and economic implications of suboptimal T1D management further underscore the urgency of these efforts for both improved health outcomes and cost-efficient care.
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Affiliation(s)
- Sarah Kanbour
- Division of Endocrinology, Diabetes, & Metabolism, AMAN Hospital, Doha, Qatar
| | - Estelle Everett
- Division of Endocrinology, Diabetes, & Metabolism, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles. California, USA
- Division of General Internal Medicine & Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles. California, USA
- VA Greater Los Angeles Healthcare System, Los Angeles. California, USA
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26
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ElSayed NA, Aleppo G, Bannuru RR, Bruemmer D, Collins BS, Ekhlaspour L, Hilliard ME, Johnson EL, Khunti K, Lingvay I, Matfin G, McCoy RG, Perry ML, Pilla SJ, Polsky S, Prahalad P, Pratley RE, Segal AR, Seley JJ, Stanton RC, Gabbay RA. 7. Diabetes Technology: Standards of Care in Diabetes-2024. Diabetes Care 2024; 47:S126-S144. [PMID: 38078575 PMCID: PMC10725813 DOI: 10.2337/dc24-s007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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27
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Addala A, Mungmode A, Ospelt E, Sanchez JE, Malik F, Demeterco-Berggren C, Butler A, Edwards C, Manukyan M, Ochoa-Maya M, Zupa M, Ebekozien O. Current Practices in Operationalizing and Addressing Racial Equity in the Provision of Type 1 Diabetes Care: Insights from the Type 1 Diabetes Exchange Quality Improvement Collaborative Health Equity Advancement Lab. Endocr Pract 2024; 30:41-48. [PMID: 37806550 DOI: 10.1016/j.eprac.2023.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 09/28/2023] [Accepted: 10/02/2023] [Indexed: 10/10/2023]
Abstract
OBJECTIVE Medical racism contributes to adverse health outcomes. Type 1 Diabetes Exchange Quality Improvement Collaborative (T1DX-QI) is a large population-based cohort engaged in data sharing and quality improvement to drive system changes in T1D care. The annual T1DX-QI survey included questions to evaluate racial equity in diabetes care and practices to promote equity. METHODS The annual T1DX-QI survey was administered to participating clinics in fall 2022 and had a 93% response rate. There were 50 responses (pediatric: 66% and adult: 34%). Questions, in part, evaluated clinical resources and racial equity. Response data were aggregated, summarized, and stratified by pediatric/adult institutions. RESULTS Only 21% pediatric and 35% adult institutions felt that all their team members can articulate how medical racism contributes to adverse diabetes outcomes. Pediatric institutions reported more strategies to address medical racism than adult (3.6 vs 3.1). Organizational strategies to decrease racial discrimination included employee trainings, equity offices/committees, patient resources, and hiring practices. Patient resources included interpreter services, transportation, insurance navigation, and housing and food assistance. Hiring practices included changing prior protocols, hiring from the community, and diversifying workforces. Most institutions have offered antiracism training in the last year (pediatric: 85% and adult: 72%) and annually (pediatric: 64% and adult: 56%). Pediatric teams felt that their antiracism training was effective more often (pediatric: 60% and adult: 45%) and more commonly, they were provided resources (pediatric: 67% and adult: 47%) to help address inequities. CONCLUSION Despite increased antiracism training, insufficient institutional support and perceived subeffective training still represent obstacles, especially in adult institutions. Sharing effective strategies to address medical racism will help institutions take steps to mitigate inequities.
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Affiliation(s)
- Ananta Addala
- Division of Pediatric Endocrinology, Department of Pediatrics, Stanford School of Medicine, California.
| | | | | | - Janine E Sanchez
- Division of Pediatric Endocrinology, University of Miami, Florida
| | - Faisal Malik
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Carla Demeterco-Berggren
- Division of Pediatric Endocrinology, University of California, San Diego, Rady Children's Hospital, San Diego, California
| | - Ashley Butler
- Division of Pediatric Endocrinology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | | | - Makaila Manukyan
- Office of Equity, Vitality, and Inclusion, Boston Medical Center, Boston, Massachusetts
| | | | - Margaret Zupa
- Divison of Endocrinology, University of Pittsburgh Medical Center, Pittsburgh
| | - Osagie Ebekozien
- T1D Exchange, Boston, Massachusetts; Deartment of Population Health, University of Mississippi School of Population Health, Mississippi
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28
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Benning TJ, Heien HC, Herges JR, Creo AL, Al Nofal A, McCoy RG. Glucagon fill rates and cost among children and adolescents with type 1 diabetes in the United States, 2011-2021. Diabetes Res Clin Pract 2023; 206:111026. [PMID: 38000667 PMCID: PMC10872944 DOI: 10.1016/j.diabres.2023.111026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 11/06/2023] [Accepted: 11/21/2023] [Indexed: 11/26/2023]
Abstract
AIMS To characterize glucagon fill rates and costs among youth with type 1 diabetes mellitus (T1DM). METHODS Claims-based analysis of commercially-insured youth with T1DM included in OptumLabs® Data Warehouse between 2011 and 2021. Glucagon fill rates and costs were calculated overall and by formulation (injectable, intranasal, autoinjector, and pre-filled syringe). Sociodemographic and clinical factors associated with glucagon fills were examined using Cox regression. RESULTS We identified 13,267 children with T1DM (76.4% non-Hispanic White). Over mean follow-up of 2.81 years (SD 2.62), 70.0% filled glucagon, with stable fill rates from 2011 to 2021. Intranasal glucagon had rapid uptake following initial approval, and it accounted for almost half (46.6%) of all glucagon fills by 2021. Family income was positively associated with glucagon fills in a stepwise fashion (HR 1.39 [95% CI 1.27-1.52] for annual household income ≥$200,000 vs. <$40,000), while Black race was negatively associated with fills (HR 0.83 [95% CI 0.76-0.91]) compared to White race). Annual mean out-of-pocket costs ranged from $21-$68 (IQR $29-$44). CONCLUSION Roughly 30% of commercially-insured youth with T1DM may lack access to unexpired glucagon, with significant disparities among Black and low-income patients. Health systems, clinicians, schools, and caregivers should work together to ensure children have reliable access to this critical medication.
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Affiliation(s)
- Tyler J Benning
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, 200 1(st) St. SW, Rochester, MN 55905, United States
| | - Herbert C Heien
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, 200 1(st) St. SW, Rochester, MN 55905, United States
| | - Joseph R Herges
- Pharmacy Services, Mayo Clinic, 200 1(st) St. SW, Rochester, MN 55905, United States
| | - Ana L Creo
- Division of Pediatric Endocrinology, Mayo Clinic, 200 1(st) St. SW, Rochester, MN 55905, United States
| | - Alaa Al Nofal
- Division of Pediatric Endocrinology, Mayo Clinic, 200 1(st) St. SW, Rochester, MN 55905, United States
| | - Rozalina G McCoy
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, 200 1(st) St. SW, Rochester, MN 55905, United States; Division of Endocrinology, Diabetes, and Nutrition, Department of Medicine, University of Maryland School of Medicine, 670 West Baltimore Street, Baltimore, MD 21201, United States; University of Maryland Institute for Health Computing, 6116 Executive Blvd, Bethesda, MD 20852, United States; OptumLabs, 11000 Optum Circle, Eden Prairie, MN 55344, United States.
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29
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Ellis DA, Naar S. Interventions Across the Translational Research Spectrum: Addressing Disparities Among Racial and Ethnic Minoritized Youth with Type 1 Diabetes. Endocrinol Metab Clin North Am 2023; 52:585-602. [PMID: 37865475 DOI: 10.1016/j.ecl.2023.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2023]
Abstract
Racial and ethnic minoritized youth with type 1 diabetes (T1D) are at elevated risk for health disparities. Few intervention studies have been conducted for these youth and evidence to support best practices to address their needs is lacking. Existing evidence supports the use of brief trials of diabetes technology with structured support from clinic staff, culturally tailored interventions such as language-congruent clinical care, and use of community health workers as promising directions to improve health outcomes. Clinicians and researchers should work collaboratively with community members to improve the quality of T1D intervention science for racial and ethnic minoritized youth.
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Affiliation(s)
- Deborah A Ellis
- Department of Family Medicine and Public Health Sciences, Wayne State University School of Medicine.
| | - Sylvie Naar
- Center for Translational Behavioral Medicine, Florida State University
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30
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Bailey R, Donthi S, Markt S, Drummond C, Cullen J. Evaluating Factors Associated With Continuous Glucose Monitoring Utilization With the Type 1 Diabetes Exchange Registry. J Diabetes Sci Technol 2023; 17:1580-1589. [PMID: 35506181 PMCID: PMC10658673 DOI: 10.1177/19322968221091299] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The 2022 American Diabetes Association (ADA) Standards of Care recommends considering use of continuous glucose monitoring (CGM) for insulin-managed diabetes mellitus (DM), but equitable access remains challenging. This study evaluates socioeconomic and demographic metrics associated with CGM use. METHODS RStudio 2021.09.1+372 was utilized to perform uni- and bivariable analysis, as well as binomial logistic regression modeling for categorical CGM use (yes/no) on the most recent cross-section from the Type 1 Diabetes Exchange (T1DX) Registry 2016-2018 cohort (n = 22 418). RESULTS Compared with White Non-Hispanic participants, Black Non-Hispanic (OR = 0.45, CI = 0.36-0.57, P < 0.001) and American Indian/Alaskan Native individuals (OR = 0.33, CI = 0.14-0.70, P = 0.008) had lower odds of CGM use. Compared with private insurance, government insurance had reduced odds of CGM use (OR = 0.59, CI = 0.52-0.66, P < 0.001). Individuals earning $100,000 or more were twice as likely to use CGMs (OR = 2.06, CI = 1.75-2.45, P < 0.001) compared with those earning <$25,000 annually. Subgroup analysis based on income bracket demonstrated that government insured individuals earning <$25,000 annually were the least likely to use CGMs (OR = 0.44, CI = 0.32-0.61, P < 0.001), as compared with private insurance. CONCLUSIONS T1DX Registry data demonstrate that CGM use follows the inverse care law, with health technology utilization inversely related to disease burden. Federal policies promoting CGM use in Medicare and Medicaid populations can facilitate the ADA's recommendation for patients with insulin-managed diabetes mellitus.
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Affiliation(s)
- Richard Bailey
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Sriya Donthi
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Sarah Markt
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Colin Drummond
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Jennifer Cullen
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH, USA
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31
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Edelman S, Cheatham WW, Norton A, Close KL. Patient Perspectives on the Benefits and Challenges of Diabetes and Digital Technology. Clin Diabetes 2023; 42:243-256. [PMID: 38666210 PMCID: PMC11040029 DOI: 10.2337/cd23-0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/28/2024]
Abstract
Diabetes technology continues to evolve, advancing with our understanding of human biology and improving our ability to treat people with diabetes. Diabetes devices are broadly classified into the following categories: glucose sensors, insulin delivery devices, and digital health care technology (i.e., software and mobile applications). When supported by education and individually tailored, technology can play a key role in optimizing outcomes. Digital devices assist in diabetes management by tracking meals, exercise, sleep, and glycemic measurements in real time, all of which can guide physicians and other clinicians in their decision-making. Here, as people with diabetes and patient advocates, as well as diabetes specialists, primary care providers, and diabetes care and education specialists, we present our perspectives on the advances, benefits, and challenges of diabetes technology in primary care practices.
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Affiliation(s)
- Steve Edelman
- University of California San Diego, Veterans Affairs Medical Center, San Diego, CA
- Taking Control of Your Diabetes, Solana Beach, CA
| | | | - Anna Norton
- National Minority Quality Forum, Washington, DC
| | - Kelly L. Close
- Close Concerns, Inc., and the diaTribe Foundation, San Francisco, CA
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32
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de Sousa Azulay RS, Rodrigues V, França de Abreu JDM, Pereira de Almeida AGF, Lago D, Tavares MDG, Nascimento G, Rocha V, Magalhães M, Facundo A, de Oliveira Neto CP, Guimarães Sá A, Parente CRV, Silva DA, Gomes MB, Faria MDS. Healthy lifestyle and genomic ancestry related to good glycemic control in type 1 diabetes patients from Northeastern Brazil: a hierarchical analysis. Front Endocrinol (Lausanne) 2023; 14:1233050. [PMID: 37900142 PMCID: PMC10611485 DOI: 10.3389/fendo.2023.1233050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 10/03/2023] [Indexed: 10/31/2023] Open
Abstract
Introduction This study aimed to investigate the sociodemographic factors, dietary adherence, regular physical activity, and genomic ancestry percentage associated with good glycemic control in Brazilian patients with type 1 diabetes (T1D) using a hierarchical approach. Methods A cross-sectional study was conducted in 152 T1D patients. Glycated hemoglobin (HbA1C) levels were measured to evaluate the glycemic control status (good, moderate, or poor). Independent factors included sex, age, self-reported skin color, educational level, family income, dietary patterns, and physical activity. The percentage of genomic ancestry (Native American, European, and African) was influenced by a panel of 46 autosomal insertion/deletion ancestry markers. Statistical analyses included receiver operating characteristic curves, and hierarchical logistic regression analysis. Results The hierarchical analysis, patients who had high dietary adherence showed a positive association with good glycemic control (adjustedOR = 2.56, 95% CI:1.18-5.59, P = 0.016). Thus, age greater than 40 years was associated with good glycemic control compared to the children and adolescents group (adjustedOR = 4.55, 95% CI:1.14-18.1, P = 0.031). Males were associated with good glycemic control (adjustedOR = 2.00, 95% CI:1.01-4.00, P =0.047). Conclusion The study findings suggest that consistent adherence to dietary regimens is associated with good glycemic control after adjusting for sociodemographic and genomic ancestry factors in an admixed population of T1D patients from Northeast Brazil.
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Affiliation(s)
- Rossana Santiago de Sousa Azulay
- Service of Endocrinology, University Hospital of the Federal University of Maranhão (HUUFMA), São Luís, Brazil
- Research Group in Clinical and Molecular Endocrinology and Metabology (ENDOCLIM), Federal University of Maranhão, São Luís, Brazil
| | - Vandilson Rodrigues
- Research Group in Clinical and Molecular Endocrinology and Metabology (ENDOCLIM), Federal University of Maranhão, São Luís, Brazil
| | - Joana D’Arc Matos França de Abreu
- Service of Endocrinology, University Hospital of the Federal University of Maranhão (HUUFMA), São Luís, Brazil
- Research Group in Clinical and Molecular Endocrinology and Metabology (ENDOCLIM), Federal University of Maranhão, São Luís, Brazil
| | | | - Débora Lago
- Service of Endocrinology, University Hospital of the Federal University of Maranhão (HUUFMA), São Luís, Brazil
- Research Group in Clinical and Molecular Endocrinology and Metabology (ENDOCLIM), Federal University of Maranhão, São Luís, Brazil
| | - Maria da Glória Tavares
- Service of Endocrinology, University Hospital of the Federal University of Maranhão (HUUFMA), São Luís, Brazil
- Research Group in Clinical and Molecular Endocrinology and Metabology (ENDOCLIM), Federal University of Maranhão, São Luís, Brazil
| | - Gilvan Nascimento
- Service of Endocrinology, University Hospital of the Federal University of Maranhão (HUUFMA), São Luís, Brazil
- Research Group in Clinical and Molecular Endocrinology and Metabology (ENDOCLIM), Federal University of Maranhão, São Luís, Brazil
| | - Viviane Rocha
- Service of Endocrinology, University Hospital of the Federal University of Maranhão (HUUFMA), São Luís, Brazil
- Research Group in Clinical and Molecular Endocrinology and Metabology (ENDOCLIM), Federal University of Maranhão, São Luís, Brazil
| | - Marcelo Magalhães
- Service of Endocrinology, University Hospital of the Federal University of Maranhão (HUUFMA), São Luís, Brazil
- Research Group in Clinical and Molecular Endocrinology and Metabology (ENDOCLIM), Federal University of Maranhão, São Luís, Brazil
| | - Alexandre Facundo
- Service of Endocrinology, University Hospital of the Federal University of Maranhão (HUUFMA), São Luís, Brazil
- Research Group in Clinical and Molecular Endocrinology and Metabology (ENDOCLIM), Federal University of Maranhão, São Luís, Brazil
| | - Clariano Pires de Oliveira Neto
- Service of Endocrinology, University Hospital of the Federal University of Maranhão (HUUFMA), São Luís, Brazil
- Research Group in Clinical and Molecular Endocrinology and Metabology (ENDOCLIM), Federal University of Maranhão, São Luís, Brazil
| | - Adriana Guimarães Sá
- Research Group in Clinical and Molecular Endocrinology and Metabology (ENDOCLIM), Federal University of Maranhão, São Luís, Brazil
| | - Conceição Ribeiro Veiga Parente
- Service of Endocrinology, University Hospital of the Federal University of Maranhão (HUUFMA), São Luís, Brazil
- Research Group in Clinical and Molecular Endocrinology and Metabology (ENDOCLIM), Federal University of Maranhão, São Luís, Brazil
| | - Dayse Aparecida Silva
- DNA Diagnostic Laboratory (LDD), Rio de Janeiro State University (UERJ), Rio de Janeiro, Brazil
| | - Marília Brito Gomes
- Diabetes Unit, Rio de Janeiro State University (UERJ), Rio de Janeiro, Brazil
| | - Manuel dos Santos Faria
- Service of Endocrinology, University Hospital of the Federal University of Maranhão (HUUFMA), São Luís, Brazil
- Research Group in Clinical and Molecular Endocrinology and Metabology (ENDOCLIM), Federal University of Maranhão, São Luís, Brazil
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Gandhi K, Ebekozien O, Noor N, McDonough RJ, Hsieh S, Miyazaki B, Dei-Tutu S, Golden L, Desimone M, Hardison H, Rompicherla S, Akturk HK, Kamboj MK. Insulin Pump Utilization in 2017-2021 for More Than 22,000 Children and Adults With Type 1 Diabetes: A Multicenter Observational Study. Clin Diabetes 2023; 42:56-64. [PMID: 38230341 PMCID: PMC10788665 DOI: 10.2337/cd23-0055] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
This large type 1 diabetes cohort study showed that insulin pump utilization has increased over time and that use differs by sex, insurance type, and race/ethnicity. Insulin pump use was associated with more optimal A1C, increased use of continuous glucose monitoring (CGM), and lower rates of diabetic ketoacidosis and severe hypoglycemia. People who used an insulin pump with CGM had lower rates of acute events than their counterparts who used an insulin pump without CGM. These findings highlight the need to improve access of diabetes technology through provider engagement, multidisciplinary approaches, and efforts to address health inequities.
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Affiliation(s)
| | - Osagie Ebekozien
- T1D Exchange, Boston, MA
- University of Mississippi School of Population Health, Jackson, MS
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Christakis NJ, Gioe M, Gomez R, Felipe D, Soros A, McCarter R, Chalew S. Determination of Glucose-Independent Racial Disparity in HbA1c for Youth With Type 1 Diabetes in the Era of Continuous Glucose Monitoring. J Diabetes Sci Technol 2023:19322968231199113. [PMID: 37700590 DOI: 10.1177/19322968231199113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Abstract
BACKGROUND The magnitude and importance of higher HbA1c levels not due to mean blood glucose (MBG) in non-Hispanic black (B) versus non-Hispanic white (W) individuals is controversial. We sought to clarify the relationship of HbA1c with glucose data from continuous glucose monitoring (CGM) in a young biracial population. METHODS Glycemic data of 33 B and 85 W, healthy youth with type 1 diabetes (age 14.7 ± 4.8 years, M/F = 51/67, duration of diabetes 5.4 ± 4.7 years) from a factory-calibrated CGM was compared with HbA1c. Hemoglobin glycation index (HGI) = assayed HbA1c - glucose management index (GMI). RESULTS B patients had higher unadjusted levels of HbA1c, MBG, MBGSD, GMI, and HGI than W patients. Percent glucose time in range (TIR) and percent sensor use (PSU) were lower for B patients. Average HbA1c in B patients 8.3% was higher than 7.7% for W (P < .0001) after statistical adjustment for MBG, age, gender, insulin delivery method, and accounting for a race by PSU interaction effect. Higher HbA1c persisted in B patients when TIR was substituted for MBG. Predicted MBG was higher in B patients at any level of PSU. The 95th percentile for HGI was 0.47 in W patients, and 52% of B patients had HGI ≥ 0.5. Time below range was similar for both. CONCLUSIONS Young B patients have clinically relevant higher average HbA1c at any given level of MBG or TIR than W patients, which may pose an additional risk for diabetes complications development. HGI ≥ 0.5 may be an easy way to identify high-risk patients.
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Affiliation(s)
- Nicholas J Christakis
- School of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Marcella Gioe
- Endocrinology and Diabetes, Children's Hospital of New Orleans, New Orleans, LA, USA
| | - Ricardo Gomez
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, School of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Dania Felipe
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, School of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Arlette Soros
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, School of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Robert McCarter
- Bioinformatics, Biostatistics and Epidemiology, Children's National Medical Center, George Washington University, Washington, DC, USA
| | - Stuart Chalew
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, School of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA, USA
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Kompala T, Wong J, Neinstein A. Diabetes Specialists Value Continuous Glucose Monitoring Despite Challenges in Prescribing and Data Review Process. J Diabetes Sci Technol 2023; 17:1265-1273. [PMID: 35403469 PMCID: PMC10563522 DOI: 10.1177/19322968221088267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Tejaswi Kompala
- Division of Endocrinology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Jenise Wong
- Division of Endocrinology, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Aaron Neinstein
- Division of Endocrinology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Center for Digital Health Innovation, University of California, San Francisco, San Francisco, CA, USA
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Bisno DI, Reid MW, Pyatak EA, Flores Garcia J, Salcedo-Rodriguez E, Torres Sanchez A, Fox DS, Hiyari S, Fogel JL, Marshall I, Bachmann G, Raymond JK. Virtual Peer Groups Reduce HbA1c and Increase Continuous Glucose Monitor Use in Adolescents and Young Adults with Type 1 Diabetes. Diabetes Technol Ther 2023; 25:589-601. [PMID: 37335751 DOI: 10.1089/dia.2023.0199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
Background: Adolescents and young adults (AYA) from diverse and marginalized backgrounds with type 1 diabetes (T1D) generally have higher hemoglobin A1c (HbA1c) levels and less frequent continuous glucose monitor (CGM) use than AYA from more privileged backgrounds. Further, scant data address the impact of virtual peer groups (VPG) on health-related outcomes for ethnically and racially diverse AYA with T1D. Methods: CoYoT1 to California was a 15-month randomized controlled trial for AYA aged 16-25 years. In this study, AYA were randomized to receive standard care (n = 28), or CoYoT1 care (n = 40), which consisted of person-centered provider visits and bimonthly VPG. VPG were AYA-driven discussions. AYA completed the Diabetes Distress Scale (DDS), Center for Epidemiologic Studies Depression (CES-D), and Diabetes Empowerment Scale-Short Form (DES-SF) scales at baseline and all study visits. Results: Participants were 50% Latinx and 75% publicly insured. Among CoYoT1 care participants, 19 attended at least 1 VPG session (VPG attendees) and 21 did not attend any VPG sessions. VPG attendees participated in 4.1 VPG sessions on average. VPG attendees had a relative reduction in HbA1C (treatment effect -1.08%, effect sizes values [ES] = -0.49, P = 0.04) and increase in CGM use (treatment effect +47%, ES = 1.00, P = 0.02) compared to standard care. VPG participation was not associated with statistically significant changes in DDS, CES-D, and DES-SF scores. Conclusions: In a 15-month randomized controlled trial, AYA with T1D who participated in VPG reported significant improvements in HbA1c and CGM use. Peer interactions may support unmet needs of AYA with T1D from diverse and marginalized backgrounds. ClinicalTrials.gov Identifier: NCT03793673.
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Affiliation(s)
- Daniel I Bisno
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Mark W Reid
- Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Elizabeth A Pyatak
- Chan Division of Occupational Science and Occupational Therapy, University of Southern California, Los Angeles, California, USA
| | | | | | | | - D Steven Fox
- School of Pharmacy, University of Southern California, Los Angeles, California, USA
| | - Sarah Hiyari
- Children's Hospital Los Angeles, Los Angeles, California, USA
| | | | - Ian Marshall
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Gloria Bachmann
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Jennifer K Raymond
- Children's Hospital Los Angeles, Los Angeles, California, USA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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Lomax KE, Taplin CE, Abraham MB, Smith GJ, Haynes A, Zomer E, Ellis KL, Clapin H, Zoungas S, Jenkins AJ, Harrington J, de Bock MI, Jones TW, Davis EA. Socioeconomic status and diabetes technology use in youth with type 1 diabetes: a comparison of two funding models. Front Endocrinol (Lausanne) 2023; 14:1178958. [PMID: 37670884 PMCID: PMC10476216 DOI: 10.3389/fendo.2023.1178958] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 07/31/2023] [Indexed: 09/07/2023] Open
Abstract
Background Technology use, including continuous glucose monitoring (CGM) and insulin pump therapy, is associated with improved outcomes in youth with type 1 diabetes (T1D). In 2017 CGM was universally funded for youth with T1D in Australia. In contrast, pump access is primarily accessed through private health insurance, self-funding or philanthropy. The study aim was to investigate the use of diabetes technology across different socioeconomic groups in Australian youth with T1D, in the setting of two contrasting funding models. Methods A cross-sectional evaluation of 4957 youth with T1D aged <18 years in the national registry was performed to determine technology use. The Index of Relative Socio-Economic Disadvantage (IRSD) derived from Australian census data is an area-based measure of socioeconomic status (SES). Lower quintiles represent greater disadvantage. IRSD based on most recent postcode of residence was used as a marker of SES. A multivariable generalised linear model adjusting for age, diabetes duration, sex, remoteness classification, and location within Australia was used to determine the association between SES and device use. Results CGM use was lower in IRSD quintile 1 in comparison to quintiles 2 to 5 (p<0.001) where uptake across the quintiles was similar. A higher percentage of pump use was observed in the least disadvantaged IRSD quintiles. Compared to the most disadvantaged quintile 1, pump use progressively increased by 16% (95% CI: 4% to 31%) in quintile 2, 19% (6% to 33%) in quintile 3, 35% (21% to 50%) in quintile 4 and 51% (36% to 67%) in the least disadvantaged quintile 5. Conclusion In this large national dataset, use of diabetes technologies was found to differ across socioeconomic groups. For nationally subsidised CGM, use was similar across socioeconomic groups with the exception of the most disadvantaged quintile, an important finding requiring further investigation into barriers to CGM use within a nationally subsidised model. User pays funding models for pump therapy result in lower use with socioeconomic disadvantage, highlighting inequities in this funding approach. For the full benefits of diabetes technology to be realised, equitable access to pump therapy needs to be a health policy priority.
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Affiliation(s)
- Kate E Lomax
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Nedlands, WA, Australia
- Children's Diabetes Centre, Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia
| | - Craig E Taplin
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Nedlands, WA, Australia
- Children's Diabetes Centre, Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia
- Centre for Child Health Research, The University of Western Australia, Perth, WA, Australia
| | - Mary B Abraham
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Nedlands, WA, Australia
- Children's Diabetes Centre, Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia
- Division of Paediatrics within the Medical School, The University of Western Australia, Perth, WA, Australia
| | - Grant J Smith
- Children's Diabetes Centre, Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia
| | - Aveni Haynes
- Children's Diabetes Centre, Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia
| | - Ella Zomer
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Katrina L Ellis
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Nedlands, WA, Australia
| | - Helen Clapin
- Children's Diabetes Centre, Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia
| | - Sophia Zoungas
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Alicia J Jenkins
- Diabetes and Vascular Medicine, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
- NHMRC Clinical Trials Centre, The University of Sydney, Sydney, NSW, Australia
| | - Jenny Harrington
- Division of Endocrinology, Women's and Children's Health Network, North Adelaide, SA, Australia
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
| | - Martin I de Bock
- Department of Paediatrics, University of Otago, Christchurch, New Zealand
| | - Timothy W Jones
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Nedlands, WA, Australia
- Children's Diabetes Centre, Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia
- Division of Paediatrics within the Medical School, The University of Western Australia, Perth, WA, Australia
| | - Elizabeth A Davis
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Nedlands, WA, Australia
- Children's Diabetes Centre, Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia
- Division of Paediatrics within the Medical School, The University of Western Australia, Perth, WA, Australia
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Ng SM, Soni A. Ten-year review of trends in children with type 1 diabetes in England and Wales. World J Diabetes 2023; 14:1194-1201. [PMID: 37664483 PMCID: PMC10473941 DOI: 10.4239/wjd.v14.i8.1194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/09/2023] [Accepted: 06/21/2023] [Indexed: 08/11/2023] Open
Abstract
This review describes the prevalence, incidence, and demographics of children and young people (CYP) with type 1 diabetes in England and Wales using data from the United Kingdom National Paediatric Diabetes Audit (NPDA) and has almost 100% submission from all paediatric diabetes centres annually. It is a powerful benchmarking tool and is an essential part of a long-term quality improvement programme for CYP with diabetes. Clinical characteristics of this population by age, insulin regimen, complication rates, health inequalities, access to diabetes technology, socioeconomic deprivation and glycaemic outcomes over the past decade is described in the review. The NPDA for England and Wales is commissioned by the United Kingdom Healthcare Quality Improvement Partnership as part of the National Clinical Audit for the United Kingdom National Service Framework for Diabetes. The rising incidence of Type 1 diabetes is evidenced in the past decade. Reduction in national median glycated hemoglobin for CYP with diabetes is observed over the last 10 years and the improvement sustained by various initiatives and quality improvement pro-grammes implemented with universal health coverage.
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Affiliation(s)
- Sze M Ng
- Department of Paediatrics, Mersey and West Lancashire Teaching Hospitals NHS Trust, Ormskirk L39 2AZ, United Kingdom
- Department of Women's and Children's Health, University of Liverpool, Liverpool L693BX, Merseyside, United Kingdom
- Faculty of Health, Social Care & Medicine, Edge Hill University, Ormskirk L39 4QP, Lancashire, United Kingdom
| | - Astha Soni
- Department of Paediatrics, Sheffield Children's Hospital, Sheffield S10 2TH, United Kingdom
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Conway RB, Gerard Gonzalez A, Shah VN, Geno Rasmussen C, Akturk HK, Pyle L, Forlenza G, Alonso GT, Snell-Bergeon J. Racial Disparities in Diabetes Technology Adoption and Their Association with HbA1c and Diabetic Ketoacidosis. Diabetes Metab Syndr Obes 2023; 16:2295-2310. [PMID: 37551339 PMCID: PMC10404403 DOI: 10.2147/dmso.s416192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 07/18/2023] [Indexed: 08/09/2023] Open
Abstract
Aim Poorer glycemic control and higher diabetic ketoacidosis (DKA) rates are seen in racial/ethnic minorities with type 1 diabetes (T1D). Use of diabetes technologies such as continuous glucose monitors (CGM), continuous subcutaneous insulin infusion (CSII) and automated insulin delivery (AID) systems has been shown to improve glycemic control and reduce DKA risk. We examined race/ethnicity differences in diabetes technology use and their relationship with HbA1c and DKA. Methods Data from patients aged ≥12 years with T1D for ≥1 year, receiving care from a single diabetes center, were examined. Patients were classified as Non-Hispanic White (n=3945), Non-Hispanic Black (Black, n=161), Hispanic (n=719), and Multiracial/Other (n=714). General linear models and logistic regression were used. Results Black (OR=0.22, 0.15-0.32) and Hispanic (OR=0.37, 0.30-0.45) patients were less likely to use diabetes technology. This disparity was greater in the pediatric population (p-interaction=0.06). Technology use associated with lower HbA1c in each race/ethnic group. Among technology users, AID use associated with lower HbA1c compared to CGM and/or CSII (HbA1c of 8.4% vs 9.2%, respectively), with the greatest difference observed for Black adult AID users. CSII use associated with a lower odds of DKA in the past year (OR=0.73, 0.54-0.99), a relationship that did not vary by race (p-interaction =0.69); this inverse association with DKA was not observed for CGM or AID. Conclusion Disparities in diabetes technology use, DKA, and glycemic control were apparent among Black and Hispanic patients with T1D. Differences in technology use ameliorated but did not fully account for disparities in HbA1c or DKA.
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Affiliation(s)
- Rebecca Baqiyyah Conway
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | - Viral N Shah
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | - Halis Kaan Akturk
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Laura Pyle
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Gregory Forlenza
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Guy Todd Alonso
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Janet Snell-Bergeon
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Walker AF, Graham S, Maple-Brown L, Egede LE, Campbell JA, Walker RJ, Wade AN, Mbanya JC, Long JA, Yajnik C, Thomas N, Ebekozien O, Odugbesan O, DiMeglio LA, Agarwal S. Interventions to address global inequity in diabetes: international progress. Lancet 2023; 402:250-264. [PMID: 37356448 PMCID: PMC10726974 DOI: 10.1016/s0140-6736(23)00914-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 04/28/2023] [Accepted: 05/04/2023] [Indexed: 06/27/2023]
Abstract
Diabetes is a serious chronic disease with high associated burden and disproportionate costs to communities based on socioeconomic, gender, racial, and ethnic status. Addressing the complex challenges of global inequity in diabetes will require intentional efforts to focus on broader social contexts and systems that supersede individual-level interventions. We codify and highlight best practice approaches to achieve equity in diabetes care and outcomes on a global scale. We outline action plans to target diabetes equity on the basis of the recommendations established by The Lancet Commission on Diabetes, organising interventions by their effect on changing the ecosystem, building capacity, or improving the clinical practice environment. We present international examples of how to address diabetes inequity in the real world to show that approaches addressing the individual within a larger social context, in addition to addressing structural inequity, hold the greatest promise for creating sustainable and equitable change that curbs the global diabetes crisis.
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Affiliation(s)
- Ashby F Walker
- Department of Health Services Research, Management and Policy, University of Florida, Gainesville, FL, USA
| | - Sian Graham
- Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Louise Maple-Brown
- Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia; Department of Endocrinology, Royal Darwin and Palmerston Hospitals, Darwin, NT, Australia
| | - Leonard E Egede
- Department of General Internal Medicine, Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jennifer A Campbell
- Department of General Internal Medicine, Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Rebekah J Walker
- Department of General Internal Medicine, Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Alisha N Wade
- MRC/Wits Rural Public Health and Health Transitions Research Unit, Wits School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; Division of Endocrinology, Diabetes and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jean Claude Mbanya
- Division of Endocrinology, Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
| | - Judith A Long
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Corporal Michael J Crescenz VA Medical Center, Philadelphia, PA, USA
| | | | - Nihal Thomas
- Department of Endocrinology, Christian Medical College, Vellore, India
| | | | | | - Linda A DiMeglio
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Shivani Agarwal
- Fleischer Institute for Diabetes and Metabolism, Department of Endocrinology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA; New York Regional Center for Diabetes Translation Research, Albert Einstein College of Medicine, Bronx, NY, USA.
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Tremblay ES, Bernique A, Garvey K, Astley CM. A Retrospective Cohort Study of Racial/Ethnic and Socioeconomic Disparities in Initiation and Meaningful Use of Continuous Glucose Monitoring among Youth With Type 1 Diabetes. J Diabetes Sci Technol 2023:19322968231183985. [PMID: 37394962 DOI: 10.1177/19322968231183985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
BACKGROUND Continuous glucose monitor (CGM) use improves type 1 diabetes (T1D) outcomes, yet children from diverse backgrounds and on public insurance have worse outcomes and lower CGM utilization. Using novel CGM data acquisition and analysis of two T1D cohorts, we test the hypothesis that T1D youth from different backgrounds experience disparities in meaningful CGM use following both T1D diagnosis and CGM uptake. METHODS Cohorts drawn from a pediatric T1D program were followed for one year beginning at diagnosis (n = 815, 2016-2020) or CGM uptake (n = 1392, 2015-2020). Using chart and CGM data, CGM start and meaningful use outcomes between racial/ethnic and insurance groups were compared using median days, one-year proportions, and survival analysis. RESULTS Publicly compared with privately insured were slower to start CGM (233, 151 days, P < .01), had fewer use-days in the year following uptake (232, 324, P < .001), and had faster first discontinuation rates (hazard ratio [HR] = 1.61, P < .001). Disparities were more pronounced among Hispanic and black compared with white subjects for CGM start time (312, 289, 149, P = .0013) and discontinuation rates (Hispanic HR = 2.17, P < .001; black HR = 1.45, P = .038), and remained even among privately insured (Hispanic/black HR = 1.44, P = .0286). CONCLUSIONS Given the impact of insurance and race/ethnicity on CGM initiation and use, it is imperative that we target interventions to support universal access and sustained CGM use to mitigate the potential impact of provider biases and systemic disadvantage and racism. By enabling more equitable and meaningful T1D technology use, such interventions will begin to alleviate outcome disparities between youth with T1D from different backgrounds.
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Affiliation(s)
- Elise Schlissel Tremblay
- Division of Endocrinology, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Allison Bernique
- Division of Endocrinology, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - Katherine Garvey
- Division of Endocrinology, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Christina M Astley
- Division of Endocrinology, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Computational Epidemiology Lab, Boston Children's Hospital, Boston, MA, USA
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
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42
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Crossen SS, Wagner DV. Narrowing the Divide: The Role of Telehealth in Type 1 Diabetes Care for Marginalized Communities. J Diabetes Sci Technol 2023; 17:901-908. [PMID: 36896887 PMCID: PMC10348000 DOI: 10.1177/19322968231157367] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
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.
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Affiliation(s)
- Stephanie S. Crossen
- Division of Pediatric Endocrinology, University of California Davis School of Medicine, Sacramento, CA, USA
| | - David V. Wagner
- Department of Pediatrics, Oregon Health & Science University, Portland, OR, USA
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Gavin JR, Abaniel RM, Virdi NS. Therapeutic Inertia and Delays in Insulin Intensification in Type 2 Diabetes: A Literature Review. Diabetes Spectr 2023; 36:379-384. [PMID: 38024219 PMCID: PMC10654128 DOI: 10.2337/ds22-0084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
Background Therapeutic inertia leading to delays in insulin initiation or intensification is a major contributor to lack of optimal diabetes care. This report reviews the literature summarizing data on therapeutic inertia and delays in insulin intensification in the management of type 2 diabetes. Methods A literature search was conducted of the Allied & Complementary Medicine, BIOSIS Previews, Embase, EMCare, International Pharmaceutical Abstracts, MEDLINE, and ToxFile databases for clinical studies, observational research, and meta-analyses from 2012 to 2022 using search terms for type 2 diabetes and delay in initiating/intensifying insulin. Twenty-two studies met inclusion criteria. Results Time until insulin initiation among patients on two to three antihyperglycemic agents was at least 5 years, and mean A1C ranged from 8.7 to 9.8%. Early insulin intensification was linked with reduced A1C by 1.4%, reduction of severe hypoglycemic events from 4 to <1 per 100 person-years, and diminution in risk of heart failure (HF) by 18%, myocardial infarction (MI) by 23%, and stroke by 28%. In contrast, delayed insulin intensification was associated with increased risk of HF (64%), MI (67%), and stroke (51%) and a higher incidence of diabetic retinopathy. In the views of both patients and providers, hypoglycemia was identified as a primary driver of therapeutic inertia; 75.5% of physicians reported that they would treat more aggressively if not for concerns about hypoglycemia. Conclusion Long delays before insulin initiation and intensification in clinically eligible patients are largely driven by concerns over hypoglycemia. New diabetes technology that provides continuous glucose monitoring may reduce occurrences of hypoglycemia and help overcome therapeutic inertia associated with insulin initiation and intensification.
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Kommareddi M, Wherry K, Vigersky RA. Racial/Ethnic Inequities in Use of Diabetes Technologies Among Medicare Advantage Beneficiaries With Type 1 Diabetes. J Clin Endocrinol Metab 2023; 108:e388-e395. [PMID: 36715293 DOI: 10.1210/clinem/dgad046] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 01/11/2023] [Accepted: 01/24/2023] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
| | - Kael Wherry
- Medtronic Diabetes, Northridge, CA 91325, USA
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Diaz-Thomas AM, Golden SH, Dabelea DM, Grimberg A, Magge SN, Safer JD, Shumer DE, Stanford FC. Endocrine Health and Health Care Disparities in the Pediatric and Sexual and Gender Minority Populations: An Endocrine Society Scientific Statement. J Clin Endocrinol Metab 2023; 108:1533-1584. [PMID: 37191578 PMCID: PMC10653187 DOI: 10.1210/clinem/dgad124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Indexed: 05/17/2023]
Abstract
Endocrine care of pediatric and adult patients continues to be plagued by health and health care disparities that are perpetuated by the basic structures of our health systems and research modalities, as well as policies that impact access to care and social determinants of health. This scientific statement expands the Society's 2012 statement by focusing on endocrine disease disparities in the pediatric population and sexual and gender minority populations. These include pediatric and adult lesbian, gay, bisexual, transgender, queer, intersex, and asexual (LGBTQIA) persons. The writing group focused on highly prevalent conditions-growth disorders, puberty, metabolic bone disease, type 1 (T1D) and type 2 (T2D) diabetes mellitus, prediabetes, and obesity. Several important findings emerged. Compared with females and non-White children, non-Hispanic White males are more likely to come to medical attention for short stature. Racially and ethnically diverse populations and males are underrepresented in studies of pubertal development and attainment of peak bone mass, with current norms based on European populations. Like adults, racial and ethnic minority youth suffer a higher burden of disease from obesity, T1D and T2D, and have less access to diabetes treatment technologies and bariatric surgery. LGBTQIA youth and adults also face discrimination and multiple barriers to endocrine care due to pathologizing sexual orientation and gender identity, lack of culturally competent care providers, and policies. Multilevel interventions to address these disparities are required. Inclusion of racial, ethnic, and LGBTQIA populations in longitudinal life course studies is needed to assess growth, puberty, and attainment of peak bone mass. Growth and development charts may need to be adapted to non-European populations. In addition, extension of these studies will be required to understand the clinical and physiologic consequences of interventions to address abnormal development in these populations. Health policies should be recrafted to remove barriers in care for children with obesity and/or diabetes and for LGBTQIA children and adults to facilitate comprehensive access to care, therapeutics, and technological advances. Public health interventions encompassing collection of accurate demographic and social needs data, including the intersection of social determinants of health with health outcomes, and enactment of population health level interventions will be essential tools.
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Affiliation(s)
- Alicia M Diaz-Thomas
- Department of Pediatrics, Division of Endocrinology, University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Sherita Hill Golden
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Dana M Dabelea
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Adda Grimberg
- Department of Pediatrics, Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Sheela N Magge
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Joshua D Safer
- Department of Medicine, Division of Endocrinology, Diabetes, and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, NY 10001, USA
| | - Daniel E Shumer
- Department of Pediatric Endocrinology, C.S. Mott Children's Hospital, University of Michigan School of Medicine, Ann Arbor, MI 48109, USA
| | - Fatima Cody Stanford
- Massachusetts General Hospital, Department of Medicine-Division of Endocrinology-Neuroendocrine, Department of Pediatrics-Division of Endocrinology, Nutrition Obesity Research Center at Harvard (NORCH), Boston, MA 02114, USA
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Loomba L, Bonanno S, Arellano D, Crossen S, Glaser N. Disparities in Insulin Pump Use Among Spanish-Speaking Children With Type 1 Diabetes Compared to Their Non-Hispanic White Peers: Mixed Methods Study. JMIR Diabetes 2023; 8:e45890. [PMID: 37294607 DOI: 10.2196/45890] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 04/28/2023] [Accepted: 05/15/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND Disparities in Insulin Pump Use Among Spanish-Speaking Children With Type 1 Diabetes Compared to Their Non-Hispanic White Peers: Mixed Methods Study. OBJECTIVE We aimed to investigate the use of insulin pumps and continuous glucose monitoring (CGM) devices among Spanish-language-preferring children in our clinic population and to identify specific barriers to technology use. METHODS First, we assessed rates and patterns of diabetes technology use (eg, insulin pumps and CGM devices) in a sample of 76 children (38 Spanish-language preferring and 38 non-Hispanic White). We compared rates of technology use, average length of time between diabetes diagnosis and initiation of insulin pump or CGM device, and rates of discontinuation of these devices between the Spanish-language-preferring and non-Hispanic White children. Second, to understand specific barriers to technology use, we compared responses to a questionnaire assessing decision-making about insulin pumps. RESULTS Spanish-language-preferring patients had lower rates of insulin pump use, even after controlling for age, gender, age at diagnosis, and type of health insurance. Spanish-language-preferring participants were more likely to report concerns over learning to use an insulin pump and were more likely to discontinue using an insulin pump after starting one. CONCLUSIONS These data confirm demographic disparities in insulin pump use among children with T1D and provide new insights about insulin pump discontinuation among Spanish-language-preferring children. Our findings suggest a need for improved patient education about insulin pump technology in general and improved support for Spanish-language-preferring families with T1D after initiation of pump therapy.
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Affiliation(s)
- Lindsey Loomba
- Department of Pediatrics, University of California, Davis, Sacramento, CA, United States
| | - Shaila Bonanno
- Department of Pediatrics, University of Washington, Seattle, WA, United States
| | - Diana Arellano
- UCSF Benioff Children's Hospital, San Francisco, CA, United States
| | - Stephanie Crossen
- Department of Pediatrics, University of California, Davis, Sacramento, CA, United States
| | - Nicole Glaser
- Department of Pediatrics, University of California, Davis, Sacramento, CA, United States
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Castellanos LE, Russell SJ, Damiano ER, Beck RW, Shah VN, Bailey R, Calhoun P, Bird K, Mauras N. The Insulin-Only Bionic Pancreas Improves Glycemic Control in Non-Hispanic White and Minority Adults and Children With Type 1 Diabetes. Diabetes Care 2023; 46:1185-1190. [PMID: 37000680 PMCID: PMC10234742 DOI: 10.2337/dc22-1478] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 03/03/2023] [Indexed: 04/01/2023]
Abstract
OBJECTIVE We evaluated the performance of the iLet bionic pancreas (BP) in non-Hispanic White individuals (here referred to as "Whites") and in Black, Hispanic, and other individuals (here collectively referred to as "Minorities"). RESEARCH DESIGN AND METHODS A multicenter, randomized controlled trial evaluated glycemic management with the BP versus standard of care (SC) in 161 adult and 165 pediatric participants with type 1 diabetes over 13 weeks. RESULTS In Whites (n = 240), the mean baseline-adjusted difference in 13-week HbA1c between the BP and SC groups was -0.45% (95% CI -0.61 to -0.29 [-4.9 mmol/mol; -6.6 to -3.1]; P < 0.001), while this difference among Minorities (n = 84) was -0.53% (-0.83 to -0.24 [-6.0 mmol/mol; -9.2 to -2.8]; P < 0.001). In Whites, the mean baseline-adjusted difference in time in range between the BP and SC groups was 10% (95% CI 7-12; P < 0.001) and in Minorities was 14% (10-18; P < 0.001). CONCLUSIONS The BP improves glycemic control in both Whites and Minorities and offers promise in decreasing health care disparities.
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Affiliation(s)
| | | | | | | | - Viral N. Shah
- Barbara Davis Center for Diabetes, University of Colorado, Aurora, CO
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Addala A, Wong JJ, Penaranda RM, Hanes SJ, Abujaradeh H, Adams RN, Barley RC, Iturralde E, Lanning MS, Tanenbaum ML, Naranjo D, Hood KK. Expanding the use of patient-reported outcomes (PROs): Screening youth with type 1 diabetes from underrepresented populations. J Diabetes Complications 2023; 37:108514. [PMID: 37263033 DOI: 10.1016/j.jdiacomp.2023.108514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 03/31/2023] [Accepted: 05/17/2023] [Indexed: 06/03/2023]
Abstract
AIM Youth from lower socioeconomic status (SES) have suboptimal type 1 diabetes (T1D) outcomes. Patient reported outcomes (PROs) measure psychosocial states and are associated with T1D outcomes, however are understudied in low SES youth. We aimed to evaluate associations between PROs and public insurance status, a proxy for low SES. METHODS We analyzed survey data from 129 youth with T1D (age 15.7 ± 2.3 years, 33 % publicly insured) screened with PROMIS Global Health (PGH, measuring global health) and Patient Health Questionnaire (PHQ-9, measuring depressive symptoms) during diabetes appointments. Correlation and regression analyses evaluated differences in PGH and PHQ-9 by insurance status. RESULTS For youth with public insurance, lower global health correlated with lower self-monitoring blood glucose (SMBG; r = 0.38,p = 0.033) and older age (r = -0.45,p = 0.005). In youth with private insurance, lower global health correlated with lower SMBG (r = 0.27,p = 0.018) and female sex (rho = 0.26,p = 0.015). For youth with private insurance, higher depressive symptoms correlated with higher body mass index (r = 0.22,p = 0.03) and fewer SMBG (r = -0.35,p = 0.04). In multivariate regression analyses, public insurance was inversely associated with global health (p = 0.027). CONCLUSION PGH is a particularly salient PRO in youth with public insurance. Global health may be an important psychosocial factor to assess in youth with T1D from low SES backgrounds.
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Affiliation(s)
- Ananta Addala
- Stanford University, Division of Pediatric Endocrinology, Stanford, CA, United States; Stanford Diabetes Research Center, United States.
| | - Jessie J Wong
- Stanford University, Division of Pediatric Endocrinology, Stanford, CA, United States
| | | | - Sarah J Hanes
- Stanford University, Division of Pediatric Endocrinology, Stanford, CA, United States
| | | | - Rebecca N Adams
- Stanford University, Division of Pediatric Endocrinology, Stanford, CA, United States
| | - Regan C Barley
- Stanford University, Division of Pediatric Endocrinology, Stanford, CA, United States
| | - Esti Iturralde
- Division of Research, Kaiser Permanente Northern California, Oakland, CA 94612, United States
| | - Monica S Lanning
- Stanford University, Division of Pediatric Endocrinology, Stanford, CA, United States
| | - Molly L Tanenbaum
- Stanford Diabetes Research Center, United States; Stanford University School of Medicine, Department of Medicine, Division of Endocrinology, Gerontology, and Metabolism, United States
| | - Diana Naranjo
- Stanford University, Division of Pediatric Endocrinology, Stanford, CA, United States
| | - Korey K Hood
- Stanford University, Division of Pediatric Endocrinology, Stanford, CA, United States
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Rikin S, Deccy S, Zhang C, Crandall J, Deng Y, Golestaneh L. Care Gaps in Sodium-Glucose Cotransporter-2 Inhibitor and Renin Angiotensin System Inhibitor Prescriptions for Patients with Diabetic Kidney Disease. J Gen Intern Med 2023; 38:1599-1605. [PMID: 36352203 PMCID: PMC10212863 DOI: 10.1007/s11606-022-07863-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 10/21/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Renin and angiotensin system inhibitors (RAASi) and sodium-glucose cotransporter-2 inhibitors (SGLT2i) are recommended for patients with diabetic kidney disease (DKD) to reduce the progression to end-stage kidney disease; however, they are under-prescribed. OBJECTIVE To evaluate the frequency of care gaps in RAASi and SGLT2i prescription by patient demographic, health system, and clinical factors in patients with DKD. DESIGN Retrospective cohort study. PARTICIPANTS Adult primary care patients with DKD at an integrated health system in Bronx, NY, with 23 primary care sites in 2021. MAIN MEASURES The odds of having a care gap for (1) SGLT2i or (2) RAASi prescription. Multivariate logistic regression models were performed for each outcome measure to evaluate associations with patient demographic, health system, and clinical factors. KEY RESULTS Of 7199 patients with DKD, 80.3% had a care gap in SGLT2i prescription and 42.0% had a care gap in RAASi prescription. For SGLT2i, patients with A1C at goal (aOR 2.32, 95% CI 1.96-2.73), Black non-Hispanic race/ethnicity (aOR 1.46, 95% CI 1.15-1.87), and Hispanic race/ethnicity (aOR 1.46, 95% CI 1.11-1.92) were more likely to experience a care gap. For RAASi, patients with blood pressure at goal (aOR 1.34, 95% CI 1.21-1.49) were more likely to experience a care gap. CONCLUSIONS The care gaps for SGLT2i and RAASi for patients with DKD with well-controlled diabetes and blood pressure suggest failure to recognize DKD as an independent indication for these medications. Racial/ethnic disparities for SGLT2i, but not for RAASi, suggest systemic racism exacerbates care gaps for novel medications. These factors can be targets for interventions to improve patient care.
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Affiliation(s)
- Sharon Rikin
- Division of General Internal Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, 3300 Kossuth Avenue, Bronx, NY, 10467, USA.
| | - Stephanie Deccy
- Montefiore Medical Center and Albert Einstein College of Medicine, 3300 Kossuth Avenue, Bronx, NY, 10467, USA
| | - Chenshu Zhang
- Division of General Internal Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, 3300 Kossuth Avenue, Bronx, NY, 10467, USA
| | - Jill Crandall
- Montefiore Medical Center and Albert Einstein College of Medicine, 3300 Kossuth Avenue, Bronx, NY, 10467, USA
| | - Yuting Deng
- Division of General Internal Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, 3300 Kossuth Avenue, Bronx, NY, 10467, USA
| | - Ladan Golestaneh
- Montefiore Medical Center and Albert Einstein College of Medicine, 3300 Kossuth Avenue, Bronx, NY, 10467, USA
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50
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Pihoker C, Braffett BH, Songer TJ, Herman WH, Tung M, Kuo S, Bellatorre A, Isganaitis E, Jensen ET, Divers J, Zhang P, Nathan DM, Drews K, Dabelea D, Zeitler PS. Diabetes Care Barriers, Use, and Health Outcomes in Younger Adults With Type 1 and Type 2 Diabetes. JAMA Netw Open 2023; 6:e2312147. [PMID: 37145592 PMCID: PMC10163384 DOI: 10.1001/jamanetworkopen.2023.12147] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 03/24/2023] [Indexed: 05/06/2023] Open
Abstract
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.
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Affiliation(s)
| | | | - Thomas J. Songer
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - William H. Herman
- Departments of Internal Medicine and Epidemiology, University of Michigan, Ann Arbor
| | - Melinda Tung
- The Biostatistics Center, George Washington University, Rockville, Maryland
| | - Shihchen Kuo
- Departments of Internal Medicine and Epidemiology, University of Michigan, Ann Arbor
| | - Anna Bellatorre
- Lifecourse Epidemiology of Adiposity and Diabetes Center, University of Colorado Anschutz Medical Campus, Aurora
| | - Elvira Isganaitis
- Research Division, Joslin Diabetes Center and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Elizabeth T. Jensen
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Jasmin Divers
- Division of Health Services Research, New York University Long Island School of Medicine, Mineola
| | - Ping Zhang
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - David M. Nathan
- Diabetes Center Massachusetts General Hospital, Harvard Medical School, Boston
| | - Kimberly Drews
- The Biostatistics Center, George Washington University, Rockville, Maryland
| | - Dana Dabelea
- Lifecourse Epidemiology of Adiposity and Diabetes Center, University of Colorado Anschutz Medical Campus, Aurora
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