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Tanenbaum ML, Commissariat PV, Wilmot EG, Lange K. Navigating the Unique Challenges of Automated Insulin Delivery Systems to Facilitate Effective Uptake, Onboarding, and Continued Use. J Diabetes Sci Technol 2024:19322968241275963. [PMID: 39212371 DOI: 10.1177/19322968241275963] [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] [Indexed: 09/04/2024]
Abstract
Advances in diabetes technologies have enabled automated insulin delivery (AID) systems, which have demonstrated benefits to glycemia, psychosocial outcomes, and quality of life for people with type 1 diabetes (T1D). Despite the many demonstrated benefits, AID systems come with their own unique challenges: continued user attention and effort, barriers to equitable access, personal costs vs benefits, and integration of the system into daily life. The purpose of this narrative review is to identify challenges and opportunities for supporting uptake and onboarding of AID systems to ultimately support sustained AID use. Setting realistic expectations, providing comprehensive training, developing willingness to adopt new treatments and workflows, upskilling of diabetes team members, and increasing flexibility of care to tailor care to individual needs, preferences, lifestyle, and personal goals will be most effective in facilitating effective, widespread, person-centered implementation of AID systems.
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Affiliation(s)
- Molly L Tanenbaum
- Division of Endocrinology, Gerontology, and Metabolism, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Persis V Commissariat
- Section on Clinical, Behavioral, and Outcomes Research, Joslin Diabetes Center, Boston, MA, USA
| | - Emma G Wilmot
- Academic Unit of Translational Medical Sciences, School of Medicine, University of Nottingham, University of Nottingham, Nottingham, UK
| | - Karin Lange
- Department of Medical Psychology, Hannover Medical School, Hannover, Germany
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2
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Nally LM, Blanchette JE. Integrated Strategies to Support Diabetes Technology in Pregnancy. Obstet Gynecol 2024:00006250-990000000-01139. [PMID: 39208437 DOI: 10.1097/aog.0000000000005710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2024] [Accepted: 07/25/2024] [Indexed: 09/04/2024]
Abstract
Managing diabetes in pregnancy can be overwhelming, with numerous dramatic physiologic changes taking place that require constant diligence and attention. Advances in diabetes technology have improved glycemic outcomes, well-being, and quality of life for people with type 1 diabetes of all ages. However, regulatory approval and access to diabetes technology in pregnancy has lagged behind these advancements, leaving many pregnant individuals without tools that could dramatically improve diabetes care before, during, and after gestation. Here, we review the benefits of continuous glucose monitors and automated insulin-delivery systems in pregnancy and highlight specific scientific and structural supports to help implement diabetes technology safely, effectively, and equitably in pregnancy.
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Affiliation(s)
- Laura M Nally
- Yale University School of Medicine, New Haven, Connecticut; and the School of Medicine, Case Western Reserve University, Cleveland, Ohio
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3
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Romeo GR, Caputo T, Stanescu IW, Alkhaddo JB. The Arduous Path Toward Equitable Access to Endocrinology Care. J Endocr Soc 2024; 8:bvae134. [PMID: 39071475 PMCID: PMC11273240 DOI: 10.1210/jendso/bvae134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Indexed: 07/30/2024] Open
Abstract
Multiple factors contribute to the widening gap between supply and demand of endocrinology services. In addition to the inadequate growth of the workforce, the inefficient utilization of endocrinologists' expertise coupled with the rising prevalence of endocrine conditions has generated a crisis in access to specialty care. This mismatch is magnified in underserved communities and among certain racial/ethnic groups that carry a disproportionate burden of chronic diseases, like diabetes and osteoporosis, thus perpetuating the cycle of health disparities in vulnerable populations. Reorienting the framework of endocrine care toward more effective and equitable access will require comprehensive changes in operational processes, system-based policies, and in the diversity of our workforce. Specifically, the progressive transition to outcome-driven, team-based models of care can extend endocrinology services beyond the traditional boundaries of in-office referrals and promote job satisfaction. Further, the implementation of policies that directly tackle structural determinants of health is a prerequisite to a more precise and equitable deployment of specialty care. In this view, the recruitment and professional growth of clinicians underrepresented in medicine along the career ladder, including leadership roles, is a key conduit to revitalize our field and to innovate the delivery of endocrine care across all communities.
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Affiliation(s)
- Giulio R Romeo
- Joslin Diabetes Center, Harvard Medical School, Boston, MA 02215, USA
- Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, Boston, MA 02215, USA
| | - Tiziana Caputo
- Joslin Diabetes Center, Harvard Medical School, Boston, MA 02215, USA
| | - Izabela W Stanescu
- Ambulatory Operation Services, Mass General Brigham, Harvard Medical School, Boston, MA 02215, USA
| | - Jamil B Alkhaddo
- Division of Endocrinology, Department of Medicine, Allegheny Health Network, Pittsburgh, PA 15212, USA
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Hall TL, Dickinson LM, Warman MK, Oser TK, Oser SM. Continuous glucose monitoring among nurse practitioners in primary care: Characteristics associated with prescribing and resources needed to support use. J Am Assoc Nurse Pract 2024:01741002-990000000-00237. [PMID: 39046421 DOI: 10.1097/jxx.0000000000001060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Accepted: 07/03/2024] [Indexed: 07/25/2024]
Abstract
BACKGROUND Continuous glucose monitoring (CGM) can improve health for people with diabetes but is limited in primary care (PC). Nurse Practitioners (NPs) in PC can improve diabetes management through CGM, but NPs' interest in CGM and support needed are unclear. PURPOSE We describe behaviors and attitudes related to CGM for diabetes management among NPs in PC. METHODOLOGY This cross-sectional web-based survey of NPs practicing in PC settings used descriptive statistics to describe CGM experience and identify resources to support prescribing. We used multivariable regression to explore characteristics predicting prescribing and confidence using CGM for diabetes. RESULTS Nurse practitioners in hospital-owned settings were twice as likely to have prescribed CGM (odds ratio [OR] = 2.320, 95% CI [1.097, 4.903]; p = .002) than private practice; those in academic medical centers were less likely (OR = 0.098, 95% CI [0.012, 0.799]; p = .002). Past prescribing was associated with favorability toward future prescribing (coef. = 0.7284, SE = 0.1255, p < .001) and confidence using CGM to manage diabetes (type 1: coef. = 3.57, SE = 0.51, p < .001; type 2: coef. = 3.49, SE = 0.51, p < .001). Resources to prescribe CGM included consultation with an endocrinologist (62%), educational website (61%), and endocrinological e-consultations (59%). CONCLUSIONS Nurse practitioners are open to prescribing CGM and can improve diabetes management and health outcomes for PC patients. IMPLICATIONS Research should explore mechanisms behind associations with CGM experience and attitudes. Efforts to advance CGM should include educational websites and endocrinology consultations for NPs in PC.
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Affiliation(s)
- Tristen L Hall
- Department of Family Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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5
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Blanchette JE, Lewis CB, Shannon CS, Kanchibhatla A, Rieke J, Roche MJ, Johnson DA, Williams D, Webb S, Diaz CN, Lundgrin EL, Allen NA, Litchman ML, Hatipoglu B. Empowering emerging adults with type 1 diabetes: crafting a financial and health insurance toolkit through community-based participatory action research. RESEARCH INVOLVEMENT AND ENGAGEMENT 2024; 10:75. [PMID: 39044303 PMCID: PMC11265338 DOI: 10.1186/s40900-024-00602-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 06/28/2024] [Indexed: 07/25/2024]
Abstract
BACKGROUND Emerging adults aged 18-30 years face challenges during life transitions, with an added burden of navigating the health care system and additional costs associated with diabetes. This stress is compounded by overall low levels of health insurance literacy in this population, as people may not know about available financial and health care resources to minimize suboptimal diabetes outcomes. This study aimed to tailor a financial and health insurance toolkit to emerging adults with type 1 diabetes, including racially, ethnically diverse, and Medicaid-insured individuals, through community-based participatory action research. METHODS An academic research team and community members from a national organization held six online community advisory board (CAB) content-creation meetings to understand how to tailor a financial and health insurance Toolkit. The CAB was comprised of six racially and insurance-diverse emerging adults with type 1 diabetes and four content experts (clinical, financial, and insurance). Six 60-minute online CAB meetings were held via University Hospitals (UH)-encrypted Zoom over five months. Pre-reading materials were emailed to CAB members before the meetings. A moderator established the purpose of each meeting and briefly discussed meeting rules before each meeting commenced. During the meetings, the moderator guided the discussions and provided the CAB members opportunities to respond and build on one another's feedback. A deductive thematic qualitative analysis was utilized. Three researchers independently coded the cross-referenced and de-identified CAB meeting transcripts and then convened to reach a group consensus. Two CAB members performed member-checking. RESULTS The following key themes emerged to tailor the Toolkit: ensuring that content covers empowerment and self-advocacy, including genuine stories and multimedia visuals for aesthetics, addressing clinician bias, acknowledging racial and ethnic disparities in care, incorporating cultural representation, and demystifying Medicaid stigma. CONCLUSIONS By successfully partnering with the CAB and a community organization through a community-based participatory action research approach, we will develop a financial and health insurance Toolkit tailored to the needs of racially and ethnically diverse and Medicaid-insured emerging adults with type 1 diabetes.
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Affiliation(s)
- Julia E Blanchette
- Department of Medicine, Diabetes and Metabolic Care Center, Division of Endocrinology, University Hospitals, Cleveland, OH, USA.
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA.
| | - Claudia B Lewis
- Department of Medicine, Diabetes and Metabolic Care Center, Division of Endocrinology, University Hospitals, Cleveland, OH, USA
| | - Chantel S Shannon
- Department of Medicine, Diabetes and Metabolic Care Center, Division of Endocrinology, University Hospitals, Cleveland, OH, USA
- College of Public Health, Kent State University, Kent, OH, USA
| | - Anuhya Kanchibhatla
- Department of Medicine, Diabetes and Metabolic Care Center, Division of Endocrinology, University Hospitals, Cleveland, OH, USA
- Department of Nutrition, Undergraduate Studies, Case Western Reserve University, Cleveland, OH, USA
| | - Jorden Rieke
- Department of Medicine, Diabetes and Metabolic Care Center, Division of Endocrinology, University Hospitals, Cleveland, OH, USA
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, USA
| | - Mary Jane Roche
- The Diabetes Link, Boston, MA, USA
- Young Adult Living with Type 1 Diabetes/Lay Person Community Member, New Hampshire, North Carolina, California, USA
| | - Dove-Anna Johnson
- Department of Medicine, Diabetes and Metabolic Care Center, Division of Endocrinology, University Hospitals, Cleveland, OH, USA
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Dionne Williams
- Department of Medicine, Diabetes and Metabolic Care Center, Division of Endocrinology, University Hospitals, Cleveland, OH, USA
| | - Shay Webb
- College of Pharmacy and Health Sciences, Campbell University, Buies Creek, NC, USA
- Young Adult Living with Type 1 Diabetes/Lay Person Community Member, New Hampshire, North Carolina, California, USA
| | - Crystal N Diaz
- Global Disease Biology, University of California, Davis, CA, USA
- Young Adult Living with Type 1 Diabetes/Lay Person Community Member, New Hampshire, North Carolina, California, USA
| | - Erika L Lundgrin
- Department of Medicine, Diabetes and Metabolic Care Center, Division of Endocrinology, University Hospitals, Cleveland, OH, USA
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
- Divison of Pediatric Endocrinology, Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - Nancy A Allen
- College of Nursing, University of Utah, Salt Lake City, UT, USA
| | | | - Betul Hatipoglu
- Department of Medicine, Diabetes and Metabolic Care Center, Division of Endocrinology, University Hospitals, Cleveland, OH, USA
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
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6
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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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Ni K, Tampe CA, Sol K, Cervantes L, Pereira RI. Continuous Glucose Monitor: Reclaiming Type 2 Diabetes Self-efficacy and Mitigating Disparities. J Endocr Soc 2024; 8:bvae125. [PMID: 38974988 PMCID: PMC11223994 DOI: 10.1210/jendso/bvae125] [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] [Received: 12/29/2023] [Indexed: 07/09/2024] Open
Abstract
Context The rise in continuous glucose monitor (CGM) use has been characterized by widening disparities between the least and most socially marginalized. Given access barriers, there is limited CGM patient experience information that is inclusive of those with type 2 diabetes mellitus from socially marginalized backgrounds. Objective To understand the CGM usage experience in the primary care setting across a US Medicaid population with type 2 diabetes at federally qualified health centers. Methods This qualitative study used semi-structured phone interviews with 28 English- or Spanish-speaking participants prescribed the CGM who were enrolled in a US Medicaid program that subsidized CGMs. Audio recordings of interviews were transcribed and analyzed by reflective thematic analysis. Results Twenty-eight participants (75% female, median age 56 years with interquartile-range 48-60 years) were interviewed. Participants were from different racial/ethnic backgrounds: 21% non-Hispanic White, 57% Hispanic, and 18% non-Hispanic Black. Participants primarily spoke English (68%) or Spanish (32%), and 53% reported 9 or fewer years of formal education. We identified 6 major themes: initial expectations and overcoming initiation barriers, convenience and ease promote daily use, increased knowledge leads to improved self-management, collaboration with provider and clinical team, improved self-reported outcomes, and barriers and burdens are generally tolerated. Conclusion CGM use was experienced as easy to understand and viewed as a tool for diabetes self-efficacy. Expanded CGM access for socially marginalized patients with type 2 diabetes can enhance diabetes self-management to help mitigate diabetes outcome disparities.
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Affiliation(s)
- Kevin Ni
- Medicine Service-Endocrinology, Denver Health, Denver, CO 80204, USA
- Department of Medicine, University of Colorado, Aurora, CO 80045, USA
| | - Carolyn A Tampe
- Medicine Service-Endocrinology, Denver Health, Denver, CO 80204, USA
| | - Kayce Sol
- Medicine Service-Endocrinology, Denver Health, Denver, CO 80204, USA
| | - Lilia Cervantes
- Department of Medicine, University of Colorado, Aurora, CO 80045, USA
| | - Rocio I Pereira
- Medicine Service-Endocrinology, Denver Health, Denver, CO 80204, USA
- Department of Medicine, University of Colorado, Aurora, CO 80045, USA
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Maizel JL, Haller MJ, Maahs DM, Addala A, Lal RA, Filipp SL, Gurka MJ, Westen S, Dixon BN, Figg L, Hechavarria M, Malden KG, Walker AF. COVID-19 impacts and inequities among underserved communities with diabetes. J Clin Transl Endocrinol 2024; 36:100337. [PMID: 38559803 PMCID: PMC10973684 DOI: 10.1016/j.jcte.2024.100337] [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] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 02/22/2024] [Accepted: 03/15/2024] [Indexed: 04/04/2024] Open
Abstract
Background People with diabetes have higher COVID-19 morbidity and mortality. These risks are amplified for underserved communities including racial/ethnic minorities and people with lower socioeconomic status. However, limited research has examined COVID-19 outcomes specifically affecting underserved communities with diabetes. Methods From November 2021 to July 2022, adults with insulin-requiring diabetes at federally qualified health centers in Florida and California (n = 450) completed surveys examining COVID-19 outcomes and demographics. Surveys assessed COVID-19 severity, vaccination uptake, mask-wearing habits, income changes, and healthcare access changes. Surveys also included the full Coronavirus Anxiety Scale (CAS-19). Descriptive statistics were computed for all outcomes. Between-group comparisons for state and race/ethnicity were evaluated via Chi-Squared, Fisher's Exact, Cochran-Mantel-Haenszel, One-Way ANOVA, and t-tests. Logistic regression determined factors associated with COVID-19 vaccination uptake. Data were self-reported and analyzed cross-sectionally. Results Overall, 29.7 % reported contracting COVID-19; of those, 45.3 % sought care or were hospitalized. Most (81.3 %) received ≥ 1 vaccine. Hispanics had the highest vaccination rate (91.1 %); Non-Hispanic Blacks (NHBs) had the lowest (73.9 %; p =.0281). Hispanics had 4.63x greater vaccination odds than Non-Hispanic Whites ([NHWs]; 95 % CI = [1.81, 11.89]). NHWs least often wore masks (18.8 %; p <.001). Participants reported pandemic-related healthcare changes (62 %) and higher costs of diabetes medications (41 %). Income loss was more frequent in Florida (76 %; p <.001). NHBs most frequently reported "severe" income loss (26.4 %; p =.0124). Loss of health insurance was more common among NHBs (13.3 %; p =.0416) and in Florida (9.7 %; p =.039). COVID-19 anxiety was highest among NHBs and Hispanics (IQR = [0.0, 3.0]; p =.0232) and in Florida (IQR = [0.0, 2.0]; p =.0435). Conclusions Underserved communities with diabetes had high COVID-19 vaccine uptake but experienced significant COVID-19-related physical, psychosocial, and financial impacts. NHBs and those in Florida had worse outcomes than other racial/ethnic groups and those in California. Further research, interventions, and policy changes are needed to promote health equity for this population.
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Affiliation(s)
- Jennifer L. Maizel
- Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Department of Public Health, 3300 South University Drive, Fort Lauderdale, FL 33328, USA
- University of Florida College of Public Health and Health Professions, Department of Health Services Research, Management, and Policy, 1225 Center Drive, Gainesville, FL 32611, USA
| | - Michael J. Haller
- University of Florida College of Medicine, Department of Pediatrics, 1600 Southwest Archer Road, Gainesville, FL 32610, USA
| | - David M. Maahs
- Stanford University School of Medicine, Department of Pediatrics and Division of Diabetes and Endocrinology, 291 Campus Drive, Stanford, CA 94305, USA
| | - Ananta Addala
- Stanford University School of Medicine, Department of Pediatrics and Division of Diabetes and Endocrinology, 291 Campus Drive, Stanford, CA 94305, USA
| | - Rayhan A. Lal
- Stanford University School of Medicine, Department of Pediatrics and Division of Diabetes and Endocrinology, 291 Campus Drive, Stanford, CA 94305, USA
- Stanford University School of Medicine, Division of Endocrinology, Gerontology, and Metabolism, 291 Campus Drive, Stanford, CA 94305, USA
| | - Stephanie L. Filipp
- University of Florida College of Medicine, Department of Pediatrics, 1600 Southwest Archer Road, Gainesville, FL 32610, USA
| | - Matthew J. Gurka
- University of Florida College of Medicine, Department of Pediatrics, 1600 Southwest Archer Road, Gainesville, FL 32610, USA
| | - Sarah Westen
- University of Florida College of Public Health and Health Professions, Department of Clinical and Health Psychology, 1225 Center Drive, Gainesville, FL 32611, USA
| | - Brittney N. Dixon
- University of Florida College of Public Health and Health Professions, Department of Health Services Research, Management, and Policy, 1225 Center Drive, Gainesville, FL 32611, USA
| | - Lauren Figg
- Stanford University School of Medicine, Department of Pediatrics and Division of Diabetes and Endocrinology, 291 Campus Drive, Stanford, CA 94305, USA
| | - Melanie Hechavarria
- University of Florida College of Medicine, Department of Pediatrics, 1600 Southwest Archer Road, Gainesville, FL 32610, USA
| | - Keilecia G. Malden
- University of Florida College of Medicine, Department of Pediatrics, 1600 Southwest Archer Road, Gainesville, FL 32610, USA
| | - Ashby F. Walker
- University of Florida College of Public Health and Health Professions, Department of Health Services Research, Management, and Policy, 1225 Center Drive, Gainesville, FL 32611, USA
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Hadid S, Zhang E, Frishman WH, Brutsaert E. Insulin's Legacy: A Century of Breakthroughs and Innovation. Cardiol Rev 2024:00045415-990000000-00229. [PMID: 38477588 DOI: 10.1097/crd.0000000000000680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
The clinical use of insulin to treat diabetes started just over 100 years ago. The past century has witnessed remarkable innovations in insulin therapy, evolving from animal organ extracts to bioengineered human insulins with ultra-rapid onset or prolonged action. Insulin delivery systems have also progressed to current automated insulin delivery systems. In this review, we discuss the history of insulin and the pharmacology and therapeutic indications for a variety of available insulins, especially newer analog insulins. We highlight recent advances in insulin pump therapy and review evidence on the therapeutic benefits of automated insulin delivery. As with any form of progress, there have been setbacks, and insulin has recently faced an affordability crisis. We address the challenges of insulin accessibility, along with recent progress to improve insulin affordability. Finally, we mention research on glucose-responsive insulins and hepato-preferential insulins that are likely to shape the future of insulin therapy.
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Affiliation(s)
- Somar Hadid
- From the School of Medicine, New York Medical College, Valhalla NY
| | - Emily Zhang
- From the School of Medicine, New York Medical College, Valhalla NY
| | - William H Frishman
- From the School of Medicine, New York Medical College, Valhalla NY
- Department of Cardiology, Westchester Medical Center, Valhalla NY
| | - Erika Brutsaert
- From the School of Medicine, New York Medical College, Valhalla NY
- Department of Endocrinology, Westchester Medical Center, Hawthorne NY
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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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11
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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: 0] [Impact Index Per Article: 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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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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13
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Steenkamp DW, Fantasia KL, Wolpert HA. Optimizing Glycemic Outcomes for Minoritized and Medically Underserved Adults Living with Type 1 Diabetes. Endocrinol Metab Clin North Am 2024; 53:67-80. [PMID: 38272599 DOI: 10.1016/j.ecl.2023.07.001] [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
Individuals living with type 1 diabetes (T1D) from medically underserved communities have poorer health outcomes. Efforts to improve outcomes include a focus on team-based care, activation of behavior change, and enhancing self-management skills and practices. Advanced diabetes technologies are part of the standard of care for adults with T1D. However, health care providers often carry implicit biases and may be uncomfortable with recommending technologies to patients who have traditionally been excluded from efficacy trials or have limited real-world exposure to devices. We review the literature on this topic and provide an approach to address these issues in clinical practice.
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Affiliation(s)
- Devin W Steenkamp
- Section of Endocrinology, Diabetes and Nutrition, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, 72 East Concord Street, C3, Boston, MA 02118, USA.
| | - Kathryn L Fantasia
- Section of Endocrinology, Diabetes and Nutrition, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, 72 East Concord Street, C3, Boston, MA 02118, USA; Department of Medicine, Evans Center for Implementation and Improvement Sciences (CIIS), Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Howard A Wolpert
- Section of Endocrinology, Diabetes and Nutrition, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, 72 East Concord Street, C3, Boston, MA 02118, USA
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14
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Lingen K, Maahs D, Bellini N, Isaacs D. Removing Barriers, Bridging the Gap, and the Changing Role of the Health Care Professional with Automated Insulin Delivery Systems. Diabetes Technol Ther 2024; 26:45-52. [PMID: 38377318 DOI: 10.1089/dia.2023.0440] [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: 02/22/2024]
Abstract
As all people with type 1 diabetes (T1D) and some with type 2 diabetes (T2D) require insulin, there is a need to develop management methods that not only achieve glycemic targets but also reduce the burden of living with diabetes. After insulin pumps and continuous glucose monitors, the next step in the evolution of diabetes technology is automated insulin delivery (AID) systems, which have transformed intensive insulin management over the past decade, as these systems address the shortcomings of previous management options. However, AID use remains fairly limited, and access represents a major barrier to use for many people with diabetes, despite these systems being standard of care. Therefore, the future of AID will necessitate addressing barriers related to social determinants of health, finances, and an expansion of the number and type of health care professionals (HCPs) prescribing AID systems. These crucial steps will be essential to ensure that everyone with intensively managed diabetes can use AID systems. The impact of implementing these changes will create a shift in the future of diabetes care that will result in achievement of more targeted glycemia and psychosocial outcomes for all people with diabetes and an expansion of the role of all HCPs in AID-related diabetes care. Even more importantly, by addressing social determinants of health and clinical inertia related to AID, the field can address disparities in outcomes across countries, race, gender, socioeconomic status, and insurance status. Furthermore, the increased use of AID system will provide more time during appointments for a shift in the discussion away from fine tuning insulin dosing and toward a focus on more topics related to behavior and conversations about general health. This will include psychosocial outcomes, and quality of life. In addition, these changes can hopefully allow for time to discuss more general issues, such as cardiovascular health, obesity prevention, diabetes-related complications, and other health-related concerns.
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Affiliation(s)
| | - David Maahs
- Division of Pediatric Endocrinology, Lucille Packard Children's Hospital, Stanford University School of Medicine, Stanford, California, USA
| | - Natalie Bellini
- Department of Endocrinology, University Hospitals Cleveland, Cleveland, Ohio, USA
| | - Diana Isaacs
- Endocrinology and Metabolism Institute, Cleveland Clinic, Ohio, USA
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15
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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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16
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Wang CJ, Lewit EM, Clark CL, Lee FSW, Maahs DM, Haller MJ, Addala A, Lal RA, Cuttriss N, Baer LG, Figg LE, Añez-Zabala C, Sheehan EP, Westen SC, Bernier AV, Donahoo WT, Walker AF. Multisite Quality Improvement Program Within the Project ECHO Diabetes Remote Network. Jt Comm J Qual Patient Saf 2024; 50:66-74. [PMID: 37718146 DOI: 10.1016/j.jcjq.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 08/05/2023] [Accepted: 08/09/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND The telementoring Project ECHO (Extension for Community Healthcare Outcomes) model has been shown to improve disease management in diabetes in many underserved communities. The authors aim to evaluate if ECHO could also be an effective tool for quality improvement (QI) of diabetes care in these communities. METHODS Thirteen clinics in underserved communities in California and Florida participating in Project ECHO Diabetes were recruited for a 12-month QI program. The program provided weekly tele-education sessions, including a didactic presentation and case-based discussion. In addition, clinics chose their own set of quality measures to improve and met remotely to discuss their efforts, successes, and setbacks every quarter with mentorship from QI experts. RESULTS Of the 31 QI initiatives attempted by different clinics, all had either made improvements (25 initiatives, 80.6%) or were in the process of making improvements (6 initiatives, 19.4%) in structural, process, and outcome measures. Examples of these measures include whether clinics have protocols to identify high-risk patients (structure), numbers of continuous glucose monitor prescriptions submitted by the clinics (process), and percentage of patients with diabetes whose most recent HbA1c are > 9% (outcome). For one measure, 40.0% of the clinics had achieved a higher percentage of cumulative HbA1c measurement in the third quarter of the year, compared to the fourth quarter in the previous year. The cost of QI implementation varied widely due to different number of personnel involved across sites. CONCLUSION A QI program delivered via Project ECHO Diabetes can facilitate quality improvements in underserved communities.
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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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18
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Zupa MF, Vimalananda VG, Rothenberger SD, Lin JY, Ng JM, McCoy RG, Rosland AM. Patterns of Telemedicine Use and Glycemic Outcomes of Endocrinology Care for Patients With Type 2 Diabetes. JAMA Netw Open 2023; 6:e2346305. [PMID: 38055278 PMCID: PMC10701613 DOI: 10.1001/jamanetworkopen.2023.46305] [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] [Received: 07/25/2023] [Accepted: 10/23/2023] [Indexed: 12/07/2023] Open
Abstract
Importance Telemedicine can increase access to endocrinology care for people with type 2 diabetes (T2D), but patterns of use and outcomes of telemedicine specialty care for adults with T2D beyond initial uptake in 2020 are not known. Objective To evaluate patterns of telemedicine use and their association with glycemic control among adults with varying clinical complexity receiving endocrinology care for T2D. Design, Setting, and Participants Retrospective cohort study in a single large integrated US health system. Participants were adults who had a telemedicine endocrinology visit for T2D from May to October 2020. Data were analyzed from June 2022 to October 2023. Exposure Patients were followed up through May 2022 and assigned to telemedicine-only, in-person, or mixed care (both telemedicine and in-person) cohorts according to visit modality. Main Outcomes and Measures Multivariable regression models were used to estimate hemoglobin A1c (HbA1c) change at 12 months within each cohort and the association of factors indicating clinical complexity (insulin regimen and cardiovascular and psychological comorbidities) with HbA1c change across cohorts. Subgroup analysis was performed for patients with baseline HbA1c of 8% or higher. Results Of 11 498 potentially eligible patients, 3778 were included in the final cohort (81 Asian participants [2%], 300 Black participants [8%], and 3332 White participants [88%]); 1182 used telemedicine only (mean [SD] age 57.4 [12.9] years; 743 female participants [63%]), 1049 used in-person care (mean [SD] age 63.0 [12.2] years; 577 female participants [55%]), and 1547 used mixed care (mean [SD] age 60.7 [12.5] years; 881 female participants [57%]). Among telemedicine-only patients, there was no significant change in adjusted HbA1c at 12 months (-0.06%; 95% CI, -0.26% to 0.14%; P = .55) while in-person and mixed cohorts had improvements of 0.37% (95% CI, 0.15% to 0.59%; P < .001) and 0.22% (95% CI, 0.07% to 0.38%; P = .004), respectively. Patients with a baseline HbA1c of 8% or higher had a similar pattern of glycemic outcomes. For patients prescribed multiple daily injections vs no insulin, the 12-month estimated change in HbA1c was 0.25% higher (95% CI, 0.02% to 0.47%; P = .03) for telemedicine vs in-person care. Comorbidities were not associated with HbA1c change in any cohort. Conclusions and Relevance In this cohort study of adults with T2D receiving endocrinology care, patients using telemedicine alone had inferior glycemic outcomes compared with patients who used in-person or mixed care. Additional strategies may be needed to support adults with T2D who rely on telemedicine alone to access endocrinology care, especially for those with complex treatment or elevated HbA1c.
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Affiliation(s)
- Margaret F. Zupa
- Division of Endocrinology and Metabolism, University of Pittsburgh School of Medicine, Pennsylvania
| | - Varsha G. Vimalananda
- Center for Health Outcomes Research, Veterans Affairs Bedford Healthcare System, Bedford, Massachusetts
- Department of Medicine, Boston University School of Medicine, Massachusetts
| | - Scott D. Rothenberger
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pennsylvania
| | - Jonathan Y. Lin
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pennsylvania
| | - Jason M. Ng
- Division of Endocrinology and Metabolism, University of Pittsburgh School of Medicine, Pennsylvania
| | - Rozalina G. McCoy
- Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, Baltimore
- University of Maryland Institute for Health Computing, Bethesda
| | - Ann-Marie Rosland
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pennsylvania
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pennsylvania
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Penfornis A, Down S, Seignez A, Vives A, Bonnemaire M, Kulzer B. European Survey on Adult People With Type 1 Diabetes and Their Caregivers: Insights Into Perceptions of Technology. J Diabetes Sci Technol 2023:19322968231208690. [PMID: 37937589 DOI: 10.1177/19322968231208690] [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] [Indexed: 11/09/2023]
Abstract
BACKGROUND Type 1 diabetes (T1D) is a complex condition requiring constant monitoring and self-management. The landscape of diabetes management is evolving with the development of new technologies. This survey aimed to gain insight into the perceptions and experiences of people with T1D (PWD) and their caregivers on the use of technology in diabetes care, and identify future needs for T1D management. METHODS PWD and caregivers (≥18 years) living in five European countries (France, Germany, Italy, Spain, and the United Kingdom) completed an online survey. Data were collected during July and August 2021. RESULTS Responders included 458 PWD and 54 caregivers. More than 60% of PWD perceived devices/digital tools for diabetes management as useful and 63% reported that access to monitoring device data made their life easier. Nearly half of participants hoped for new devices and/or digital tools. While approximately one-third of all PWD had used teleconsultation, perceptions and usage varied significantly between countries and by age (both P < .0001), with the lowest use in Germany (20%) and the highest in Spain (48%). The proportions of PWD contributing to diabetes care costs varied by device and were highest for smart insulin pen users at 83% compared with 44% for insulin pen users and 37% for insulin pump users. One-quarter (24%) of PWD and 15% of caregivers felt they lacked knowledge about devices/digital tools for T1D. CONCLUSIONS Most PWD and caregivers had positive perceptions and experiences of new technologies/digital solutions for diabetes management, although improved support and structured education for devices/digital tools are still required.
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Affiliation(s)
- Alfred Penfornis
- Diabetology Department, Centre Hospitalier Sud Francilien, Corbeil-Essonnes, France and Université Paris-Saclay, Saclay, France
| | - Su Down
- Somerset NHS Foundation Trust, Somerset, UK
| | | | | | | | - Bernhard Kulzer
- Diabetes Zentrum Mergentheim, Forschungsinstitut der Diabetes-Akademie Bad Mergentheim, Universität Bamberg, Bamberg, Germany
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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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21
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Odugbesan O, Mungmode A, Rioles N, Buckingham D, Nelson G, Agarwal S, Grant A, Wright T, Hess E, Ebekozien O. Increasing Continuous Glucose Monitoring Use for Non-Hispanic Black and Hispanic People With Type 1 Diabetes: Results From the T1D Exchange Quality Improvement Collaborative Equity Study. Clin Diabetes 2023; 42:40-48. [PMID: 38230339 PMCID: PMC10788664 DOI: 10.2337/cd23-0050] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
Despite the benefits of continuous glucose monitoring (CGM), there is lower use of this technology among non-Hispanic Black and Hispanic people with type 1 diabetes compared with their non-Hispanic White counterparts. The T1D Exchange Quality Improvement Collaborative recruited five endocrinology centers to pilot an equity-focused quality improvement (QI) study to reduce racial inequities in CGM use. The centers used rapid QI cycles to test and expand interventions such as provider bias training, translation of CGM materials, provision of CGM education in multiple languages, screening for social determinants of health, and shared decision-making. After implementation of these interventions, median CGM use increased by 7% in non-Hispanic White, 12% in non-Hispanic Black, and 15% in Hispanic people with type 1 diabetes. The gap between non-Hispanic White and non-Hispanic Black patients decreased by 5%, and the gap between non-Hispanic White and Hispanic patients decreased by 8%.
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Affiliation(s)
| | | | | | | | - Grace Nelson
- Le Bonheur Children’s Hospital, University of Tennessee, Memphis, TN
| | - Shivani Agarwal
- Albert Einstein College of Medicine–Montefiore Medical Center, Bronx, NY
| | - Amy Grant
- Cincinnati Children Hospital Medical Center, Columbus, OH
| | | | - Emilie Hess
- SUNY Upstate Medical University, Syracuse, NY
| | - Osagie Ebekozien
- T1D Exchange, Boston, MA
- University of Mississippi Medical Center School of Population Health, Jackson, MS
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22
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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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23
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Addala A, Hechavarria M, Figg L, Roque X, Filipp SL, Anez-Zabala C, Lal R, Gurka MJ, Haller MJ, Maahs DM, Walker AF. Recruiting historically under-represented individuals into Project ECHO Diabetes: using barrier analysis to understand disparities in clinical research in the USA. BMJ Open 2023; 13:e072546. [PMID: 37648378 PMCID: PMC10471869 DOI: 10.1136/bmjopen-2023-072546] [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: 02/08/2023] [Accepted: 08/14/2023] [Indexed: 09/01/2023] Open
Abstract
OBJECTIVES Individuals under-recruited in diabetes research studies include those not seen at endocrinology centres and those from rural, low socioeconomic and/or under-represented racial/ethnic groups. The purpose of this descriptive analysis is to detail recruitment and retention efforts of Project ECHO Diabetes clinical sites affiliated with Stanford University and University of Florida. DESIGN Prospective collection of participant engagement and qualitative analysis of barriers and facilitators of research engagement within Project ECHO Diabetes, a virtual tele-education programme for healthcare providers in the management of individuals with insulin-requiring diabetes. SETTING Data were collected at the patient level, provider level and clinic level between 1 May 2021 and 31 July 2022. PARTICIPANTS Participants and study personnel were recruited from 33 Project ECHO Diabetes sites in California and Florida. OUTCOMES We report study completion rates for participants recruited into 33 Project ECHO Diabetes sites. Using barrier analysis, a methodology designed for the real-time assessment of interventions and system processes to identify barriers and facilitators, study personnel identified significant barriers to recruitment and retention and mapped them to actionable solutions. RESULTS In total, 872 participants (California n=495, Florida n=377) were recruited with differing recruitment rates by site (California=52.7%, Florida=21.5%). Barrier analysis identified lack of trust, unreliable contact information, communication issues and institutional review board (IRB) requirements as key recruitment barriers. Culturally congruent staff, community health centre (CHC) support, adequate funding and consent process flexibility were solutions to address recruitment challenges. Barriers to retention were inconsistent postal access, haemoglobin A1c kit collection challenges, COVID-19 pandemic and broadband/connectivity issues. Additional funding supporting research staff and analogue communication methods were identified as solutions address barriers to retention. CONCLUSIONS Funded partnerships with CHCs, trusted by their local communities, were key in our recruitment and retention strategies. IRB consent process flexibility reduced barriers to recruitment. Recruiting historically under-represented populations is feasible with funding aimed to address structural barriers to research participation.
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Affiliation(s)
- Ananta Addala
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, California, USA
- Department of Pediatrics, Stanford Diabetes Research Center, Stanford, California, USA
| | | | - Lauren Figg
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, California, USA
| | - Xanadu Roque
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA
| | - Stephanie L Filipp
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA
| | | | - Rayhan Lal
- Department of Pediatrics, Stanford Diabetes Research Center, Stanford, California, USA
- Department of Medicine, Division of Endocrinology, Stanford University School of Medicine, Stanford, California, USA
| | - Matthew J Gurka
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA
| | - Michael J Haller
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA
| | - David M Maahs
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, California, USA
- Department of Pediatrics, Stanford Diabetes Research Center, Stanford, California, USA
| | - Ashby F Walker
- Health Services Research Management and Policy, University of Florida, Gainesville, Florida, USA
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Figg L, Addala A, Jain I, Anez C, Midney P, DeChirico C, Symanski C, Fitzgerald BC, Colbert K, Raymer T, Stockton-Joreteg C, Murphy E, Collins L, Bernstein C, Hechavarria M, Sheehan EP, Bernier A, Westen SC, Hood KK, Zaharieva DP, Basina M, Cuttriss N, Filipp SL, Gurka MJ, Walker AF, Maahs DM, Haller MJ, Lal RA. The Promising Success of Project Extension for Community Healthcare Outcomes (ECHO) Diabetes: Case Series. JMIR Diabetes 2023; 8:e46050. [PMID: 37535407 PMCID: PMC10436109 DOI: 10.2196/46050] [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: 01/30/2023] [Revised: 05/04/2023] [Accepted: 05/24/2023] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND In the United States, there are over 37 million people with diabetes but only 8000 endocrinologists. Therefore, many people with diabetes receive care exclusively from primary care providers (PCPs). To democratize knowledge regarding insulin-requiring diabetes through tele-education, Stanford University and the University of Florida developed Project Extension for Community Healthcare Outcomes (ECHO) Diabetes. OBJECTIVE ECHO Diabetes uses a Hub and Spoke model connecting specialists (the "Hub") with PCPs (the "Spokes"). One-hour, weekly sessions include Hub diabetes didactic presentations and Spoke deidentified case presentations. Lessons learned during these sessions target provider knowledge and confidence surrounding diabetes management and patient care. METHODS Spokes were asked to provide short descriptions of people with diabetes whose diabetes management improved directly or indirectly from their providers' participation or their involvement with a Diabetes Support Coach (DSC). We provide a case series to describe individuals and outcomes. Because this study was not a randomized controlled trial and was a prospective observation of patients with the intervention delivered to providers, the trial is not registered in a public trials registry. RESULTS A case series of 11 people with diabetes was compiled from 10 PCPs and 1 DSC from California and Florida between 2021 and 2022. The principal impact of ECHO Diabetes is the education amplified from PCPs and DSCs to people with diabetes. In all cases, people with diabetes reported increased engagement and improved diabetes management. Several cases reflected increased access to diabetes technology, improvement in glycemic outcomes, and positive trends in mental health measures. CONCLUSIONS This case series elucidates the potential value of the ECHO Diabetes program to people with diabetes who receive their diabetes care from PCPs. Those matched with a DSC saw clinically significant improvements in hemoglobin A1c and mental health outcomes.
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Affiliation(s)
- Lauren Figg
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States
| | - Ananta Addala
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States
- Stanford Diabetes Research Center, Stanford University School of Medicine, Stanford, CA, United States
| | - Ishaan Jain
- Stanford University, Stanford, CA, United States
| | - Claudia Anez
- Division of Endocrinology, Department of Pediatrics, University of Florida College of Medicine, Gainesville, FL, United States
- University of Florida Diabetes Institute, Gainesville, FL, United States
| | - Paul Midney
- Healthcare Network of Southwest Florida, Naples, FL, United States
| | - Corin DeChirico
- Healthcare Network of Southwest Florida, Naples, FL, United States
| | - Colleen Symanski
- Treasure Coast Community Health Center, Vero Beach, FL, United States
| | - Brian C Fitzgerald
- University of Florida Health Family Medicine, Old Town, FL, United States
| | - Kristi Colbert
- United Indian Health Services Potawot Health Village, Arcata, CA, United States
| | - Terry Raymer
- United Indian Health Services Potawot Health Village, Arcata, CA, United States
| | | | | | - Leah Collins
- Anderson Valley Health Center, Boonville, CA, United States
| | - Cyd Bernstein
- Anderson Valley Health Center, Boonville, CA, United States
| | - Melanie Hechavarria
- Division of Endocrinology, Department of Pediatrics, University of Florida College of Medicine, Gainesville, FL, United States
- University of Florida Diabetes Institute, Gainesville, FL, United States
| | - Eleni P Sheehan
- Division of Endocrinology, Department of Pediatrics, University of Florida College of Medicine, Gainesville, FL, United States
- University of Florida Diabetes Institute, Gainesville, FL, United States
| | - Angelina Bernier
- Division of Endocrinology, Department of Pediatrics, University of Florida College of Medicine, Gainesville, FL, United States
- University of Florida Diabetes Institute, Gainesville, FL, United States
| | - Sarah C Westen
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, United States
| | - Korey K Hood
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States
- Stanford Diabetes Research Center, Stanford University School of Medicine, Stanford, CA, United States
| | - Dessi P Zaharieva
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States
| | - Marina Basina
- Stanford Diabetes Research Center, Stanford University School of Medicine, Stanford, CA, United States
- Division of Endocrinology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Nicolas Cuttriss
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States
- Stanford Diabetes Research Center, Stanford University School of Medicine, Stanford, CA, United States
- Extension for Community Healthcare Outcomes Diabetes Action Network, Chevy Chase, MD, United States
| | - Stephanie L Filipp
- Department of Pediatrics, University of Florida College of Medicine, Gainesville, FL, United States
| | - Matthew J Gurka
- Department of Pediatrics, University of Florida College of Medicine, Gainesville, FL, United States
| | - Ashby F Walker
- University of Florida Diabetes Institute, Gainesville, FL, United States
- Department of Health Services Research, Management and Policy, University of Florida, Gainesville, FL, United States
| | - David M Maahs
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States
- Stanford Diabetes Research Center, Stanford University School of Medicine, Stanford, CA, United States
| | - Michael J Haller
- Division of Endocrinology, Department of Pediatrics, University of Florida College of Medicine, Gainesville, FL, United States
- University of Florida Diabetes Institute, Gainesville, FL, United States
| | - Rayhan A Lal
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States
- Stanford Diabetes Research Center, Stanford University School of Medicine, Stanford, CA, United States
- Division of Endocrinology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States
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25
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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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Bruggeman BS, Walker AF, Peters AL, D’Avolio LW, Haller MJ. Blue Circle Health: A Novel Patient-Centered Model of Health Care Delivery for Low-Income Patients With Type 1 Diabetes. J Diabetes Sci Technol 2023; 17:925-934. [PMID: 36710449 PMCID: PMC10348005 DOI: 10.1177/19322968221149008] [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: 01/31/2023]
Abstract
Analog insulins, insulin pumps, and continuous glucose monitors (CGM) have revolutionized type 1 diabetes (T1D) treatment over the last 50 years. Nevertheless, less than 20% of patients in the United States reach guideline-based HbA1c targets. The dysfunctional delivery of U.S. health care has further worsened glycemic outcomes among structurally disadvantaged groups such as non-Hispanic Black and low-income populations. Administrative complexities resulting from mixed insurance coverage and delivery systems, incongruity between effective policies and reimbursement, structural racism, and implicit biases have led to high diabetes care-related costs, provider scarcity and burnout, and patient diabetes distress. The Extension for Community Healthcare Outcomes (ECHO) Diabetes tele-education outreach model was created to increase self-efficacy among primary care providers through a combination of weekly didactic sessions led by a team of diabetes experts and access to community-based peer coaches. As an evolution of ECHO Diabetes, Blue Circle Health has been established as a philanthropically funded health care delivery system, using a whole-person, individualized approach to T1D care for adults living in underserved communities. The program will provide direct-to-patient telehealth services, including diabetes education, management, and related psychological care regardless of ability to pay. Community-based diabetes support coaches will serve as the primary point of contact, or guide on the "Blue Circle Health Member Journey." Access to needed insulins, supplies, and CGMs will be provided at no cost to the individual. Through a continuous learning and improvement model, a person-centered, equitable, accessible, and effective health care delivery model will be built for people living with T1D.
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Affiliation(s)
| | - Ashby F. Walker
- College of Public Health & Health Professions, University of Florida, Gainesville, FL, USA
| | - Anne L. Peters
- Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
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Garcia JF, Faye E, Reid MW, Pyatak EA, Fox DS, Bisno DI, Salcedo-Rodriguez E, Sanchez AT, Hiyari S, Fogel JL, Raymond JK. Greater Telehealth Use Results in Increased Visit Frequency and Lower Physician Related-Distress in Adolescents and Young Adults With Type 1 Diabetes. J Diabetes Sci Technol 2023; 17:878-886. [PMID: 36546602 PMCID: PMC10347987 DOI: 10.1177/19322968221146806] [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: 12/24/2022]
Abstract
BACKGROUND Type one diabetes (T1D) management is challenging for adolescents and young adults (AYAs) due to physiological changes, psychosocial challenges, and increasing independence, resulting in increased diabetes distress and hemoglobin A1c (HbA1c). Alternative care models that engage AYAs and improve diabetes-related health outcomes are needed. METHODS A 15-month study evaluated an adaptation of the Colorado Young Adults with T1D (CoYoT1) Care model. CoYoT1 Care includes person-centered care, virtual peer groups, and physician training delivered via telehealth. AYAs (aged 16-25 years) were partially randomized to CoYoT1 or standard care, delivered via telehealth or in-person. As the study was ending, the COVID-19 pandemic forced all AYAs to transition to primarily telehealth appointments. This secondary analysis compares changes in clinic attendance, T1D-related distress, HbA1c, and device use between those who attended more than 50% of diabetes clinic visits via telehealth and those who attended more sessions in-person throughout the course of the study. RESULTS Out of 68 AYA participants, individuals (n = 39, 57%) who attended most (>50%) study visits by telehealth completed more diabetes care visits (3.3 visits) than those (n = 29, 43%) who primarily attended visits in-person (2.5 visits; P = .007). AYAs who primarily attended visits via telehealth maintained stable physician-related distress, while those who attended more in-person visits reported increases in physician-related distress (P = .03). CONCLUSIONS Greater usage of telehealth improved AYA engagement with their care, resulting in increased clinic attendance and reduced physician-related diabetes distress. A person-centered care model delivered via telehealth effectively meets the needs of AYAs with T1D.
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Affiliation(s)
| | - Ethan Faye
- University of Southern California, Los Angeles, CA, USA
| | - Mark W. Reid
- Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | | | - D. Steven Fox
- University of Southern California, Los Angeles, CA, USA
| | - Daniel I. Bisno
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | | | | | - Sarah Hiyari
- Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | | | - Jennifer K. Raymond
- Children’s Hospital Los Angeles, Los Angeles, CA, USA
- University of Southern California, Los Angeles, CA, USA
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28
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Ehrhardt N, Bouchonville M, Peek ME, Thomas CC, Zou T, Cuttriss N, Desimone M, Weinstock RS, Baer LG, Gabbay RA. Telementoring With Project ECHO: A New Era in Diabetes-Related Continuing Education for Primary Care to Address Health Disparities. J Diabetes Sci Technol 2023; 17:916-924. [PMID: 36879471 PMCID: PMC10348009 DOI: 10.1177/19322968231155150] [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: 03/08/2023]
Abstract
Project ECHO® is a telementoring workforce development model that targets under-resourced communities lacking access to specialty care. The model builds virtual communities of practice, including specialists and community primary care professionals (PCPs) to combat clinical inertia and health disparities. While the ECHO model has gained global recognition, implementation of the model related to diabetes is lagging compared to other specialty conditions. This review highlights diabetes-endocrine (ENDO)-focused ECHOs using data reported in the ECHO Institute's centralized data repository (iECHO) and the learning collaborative for diabetes ECHOs. It also describes the implementation of diabetes ECHOs and their evaluation. Learner and patient-centered outcomes related to diabetes ECHOs are reviewed. Program implementation and evaluations have demonstrated utility of the ECHO model for diabetes programs to (1) address unmet needs of diabetes care in the primary care setting, (2) improve knowledge and confidence in managing complex diabetes and change provider prescribing habits, (3) improve patient outcomes, and (4) address diabetes quality improvement practices in primary care. More studies with broader collaboration among sites are needed to evaluate the model related to diabetes, especially applied to addressing therapeutic inertia, adoption of diabetes technology, and reducing health disparities.
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Affiliation(s)
- Nicole Ehrhardt
- Division of Endocrinology, Diabetes and Metabolism, University of Washington Diabetes Institute, Seattle, WA, USA
| | - Matt Bouchonville
- Division of Endocrinology, Diabetes, and Metabolism, School of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Monica E. Peek
- Section of General Internal Medicine, Chicago Center for Diabetes Translation Research, The MacLean Center for Clinical Medical Ethics, and The University of Chicago, Chicago, IL, USA
| | - Celeste C. Thomas
- Section of Adult and Pediatric Endocrinology, Diabetes and Metabolism, The University of Chicago, Chicago, IL, USA
| | - Tracy Zou
- Division of Endocrinology, Diabetes and Metabolism, University of Washington Diabetes Institute, Seattle, WA, USA
| | - Nicolas Cuttriss
- ECHO Diabetes Action Network, ENDO Diabetes & Wellness, Washington, DC, USA
| | - Marisa Desimone
- Endocrinology, Diabetes and Metabolism, Joslin Diabetes Center, and SUNY Upstate Medical University, Syracuse, NY, USA
| | - Ruth S. Weinstock
- Endocrinology, Diabetes and Metabolism, Clinical Research Unit and Joslin Diabetes Center, and SUNY Upstate Medical University, Syracuse, NY, USA
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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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Grundman JB, Perkins A, Monaghan M, Meighan S, Streisand R, Marks BE. Differences in positive expectancy of hybrid closed loop (HCL) insulin delivery systems do not explain racial differences in HCL use. J Clin Transl Endocrinol 2023; 32:100319. [PMID: 37273975 PMCID: PMC10238440 DOI: 10.1016/j.jcte.2023.100319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 05/12/2023] [Accepted: 05/18/2023] [Indexed: 06/06/2023] Open
Abstract
Aims Hybrid closed loop (HCL) insulin delivery systems improve glycemia and quality of life among youth with type 1 diabetes (T1D), however there are inequities in use. We aimed to evaluate whether differences in positive expectancy of HCL systems may explain differences in use. Methods Fifteen publicly-insured, non-Hispanic Black (NHB) youth with hemoglobin A1C (HbA1c) ≥ 10% enrolled in a study exploring changes in glycemia and person reported outcomes (PRO) during 6 months of Tandem t:slim X2 insulin pump with Control-IQ technology. At baseline youth and parents completed PROs, including Insulin Delivery Systems: Perceptions, Ideas, Reflections and Expectations (INSPIRE) survey assessing positive expectancy of HCL use, and Problem Areas in Diabetes (PAID) survey assessing diabetes-related distress. Differences between this cohort and the Tandem Control-IQ pediatric pivotal trial (DCLP5) cohort were assessed. Results As compared to the DCLP5 cohort (0% NHB, 10% publicly-insured), baseline glycemic indicators were suboptimal (MHbA1c 11.9 ± 1.4% vs 7.6 ± 0.9%, p < 0.0001; continuous glucose monitor (CGM) time-above-range > 180 mg/dL 82 ± 15% vs 45 ± 18%, p < 0.0001). INSPIRE scores in both cohorts were equally high among youth (80 ± 10 vs 77 ± 13, p = 0.41) and parents (88 ± 14 vs 85 ± 11, p = 0.37). PAID scores were higher among parents (68 ± 19 vs 43 ± 16, p < 0.0001), but not youth (43 ± 16 vs 35 ± 16, p = 0.09) in the historically marginalized cohort as compared to the DCLP5 cohort. Conclusions Despite differences in glycemic control and diabetes related burden, positive expectancy of HCL systems is comparable among historically marginalized youth with T1D and the predominantly non-Hispanic White, privately insured DCLP5 cohort. These findings suggest that differences in perceptions of HCL technology may not explain inequities in use.
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Affiliation(s)
- Jody B. Grundman
- Children’s National Hospital, 111 Michigan Ave NW, Washington DC 20010, USA
| | - Amanda Perkins
- Children’s National Hospital, 111 Michigan Ave NW, Washington DC 20010, USA
| | - Maureen Monaghan
- Children’s National Hospital, 111 Michigan Ave NW, Washington DC 20010, USA
- George Washington University School of Medicine, 3200 I St NW, Washington DC 20052, USA
| | - Seema Meighan
- Children’s Hospital of Philadelphia, 3501 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Randi Streisand
- Children’s National Hospital, 111 Michigan Ave NW, Washington DC 20010, USA
- George Washington University School of Medicine, 3200 I St NW, Washington DC 20052, USA
| | - Brynn E. Marks
- Children’s Hospital of Philadelphia, 3501 Civic Center Boulevard, Philadelphia, PA 19104, USA
- Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
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31
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Addala A, Ding V, Zaharieva DP, Bishop FK, Adams AS, King AC, Johari R, Scheinker D, Hood KK, Desai M, Maahs DM, Prahalad P. Disparities in Hemoglobin A1c Levels in the First Year After Diagnosis Among Youths With Type 1 Diabetes Offered Continuous Glucose Monitoring. JAMA Netw Open 2023; 6:e238881. [PMID: 37074715 PMCID: PMC10116368 DOI: 10.1001/jamanetworkopen.2023.8881] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 03/05/2023] [Indexed: 04/20/2023] Open
Abstract
Importance Continuous glucose monitoring (CGM) is associated with improvements in hemoglobin A1c (HbA1c) in youths with type 1 diabetes (T1D); however, youths from minoritized racial and ethnic groups and those with public insurance face greater barriers to CGM access. Early initiation of and access to CGM may reduce disparities in CGM uptake and improve diabetes outcomes. Objective To determine whether HbA1c decreases differed by ethnicity and insurance status among a cohort of youths newly diagnosed with T1D and provided CGM. Design, Setting, and Participants This cohort study used data from the Teamwork, Targets, Technology, and Tight Control (4T) study, a clinical research program that aims to initiate CGM within 1 month of T1D diagnosis. All youths with new-onset T1D diagnosed between July 25, 2018, and June 15, 2020, at Stanford Children's Hospital, a single-site, freestanding children's hospital in California, were approached to enroll in the Pilot-4T study and were followed for 12 months. Data analysis was performed and completed on June 3, 2022. Exposures All eligible participants were offered CGM within 1 month of diabetes diagnosis. Main Outcomes and Measures To assess HbA1c change over the study period, analyses were stratified by ethnicity (Hispanic vs non-Hispanic) or insurance status (public vs private) to compare the Pilot-4T cohort with a historical cohort of 272 youths diagnosed with T1D between June 1, 2014, and December 28, 2016. Results The Pilot-4T cohort comprised 135 youths, with a median age of 9.7 years (IQR, 6.8-12.7 years) at diagnosis. There were 71 boys (52.6%) and 64 girls (47.4%). Based on self-report, participants' race was categorized as Asian or Pacific Islander (19 [14.1%]), White (62 [45.9%]), or other race (39 [28.9%]); race was missing or not reported for 15 participants (11.1%). Participants also self-reported their ethnicity as Hispanic (29 [21.5%]) or non-Hispanic (92 [68.1%]). A total of 104 participants (77.0%) had private insurance and 31 (23.0%) had public insurance. Compared with the historical cohort, similar reductions in HbA1c at 6, 9, and 12 months postdiagnosis were observed for Hispanic individuals (estimated difference, -0.26% [95% CI, -1.05% to 0.43%], -0.60% [-1.46% to 0.21%], and -0.15% [-1.48% to 0.80%]) and non-Hispanic individuals (estimated difference, -0.27% [95% CI, -0.62% to 0.10%], -0.50% [-0.81% to -0.11%], and -0.47% [-0.91% to 0.06%]) in the Pilot-4T cohort. Similar reductions in HbA1c at 6, 9, and 12 months postdiagnosis were also observed for publicly insured individuals (estimated difference, -0.52% [95% CI, -1.22% to 0.15%], -0.38% [-1.26% to 0.33%], and -0.57% [-2.08% to 0.74%]) and privately insured individuals (estimated difference, -0.34% [95% CI, -0.67% to 0.03%], -0.57% [-0.85% to -0.26%], and -0.43% [-0.85% to 0.01%]) in the Pilot-4T cohort. Hispanic youths in the Pilot-4T cohort had higher HbA1c at 6, 9, and 12 months postdiagnosis than non-Hispanic youths (estimated difference, 0.28% [95% CI, -0.46% to 0.86%], 0.63% [0.02% to 1.20%], and 1.39% [0.37% to 1.96%]), as did publicly insured youths compared with privately insured youths (estimated difference, 0.39% [95% CI, -0.23% to 0.99%], 0.95% [0.28% to 1.45%], and 1.16% [-0.09% to 2.13%]). Conclusions and Relevance The findings of this cohort study suggest that CGM initiation soon after diagnosis is associated with similar improvements in HbA1c for Hispanic and non-Hispanic youths as well as for publicly and privately insured youths. These results further suggest that equitable access to CGM soon after T1D diagnosis may be a first step to improve HbA1c for all youths but is unlikely to eliminate disparities entirely. Trial Registration ClinicalTrials.gov Identifier: NCT04336969.
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Affiliation(s)
- Ananta Addala
- Division of Pediatric Endocrinology, Department of Pediatrics, Stanford University, Stanford, California
| | - Victoria Ding
- Division of Biomedical Informatics Research, Department of Medicine, Stanford University, Stanford, California
| | - Dessi P. Zaharieva
- Division of Pediatric Endocrinology, Department of Pediatrics, Stanford University, Stanford, California
| | - Franziska K. Bishop
- Division of Pediatric Endocrinology, Department of Pediatrics, Stanford University, Stanford, California
| | - Alyce S. Adams
- Division of Pediatric Endocrinology, Department of Pediatrics, Stanford University, Stanford, California
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California
- Department of Health Policy, Stanford University School of Medicine, Stanford, California
- Stanford Diabetes Research Center, Stanford University, Stanford, California
| | - Abby C. King
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California
- Stanford Prevention Research Center Division, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Ramesh Johari
- Clinical Excellence Research Center, Stanford University, Stanford, California
| | - David Scheinker
- Division of Pediatric Endocrinology, Department of Pediatrics, Stanford University, Stanford, California
- Stanford Diabetes Research Center, Stanford University, Stanford, California
- Clinical Excellence Research Center, Stanford University, Stanford, California
- Department of Management Science and Engineering, Stanford University, Stanford, California
| | - Korey K. Hood
- Division of Pediatric Endocrinology, Department of Pediatrics, Stanford University, Stanford, California
- Stanford Diabetes Research Center, Stanford University, Stanford, California
| | - Manisha Desai
- Division of Biomedical Informatics Research, Department of Medicine, Stanford University, Stanford, California
| | - David M. Maahs
- Division of Pediatric Endocrinology, Department of Pediatrics, Stanford University, Stanford, California
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California
- Stanford Diabetes Research Center, Stanford University, Stanford, California
| | - Priya Prahalad
- Division of Pediatric Endocrinology, Department of Pediatrics, Stanford University, Stanford, California
- Stanford Diabetes Research Center, Stanford University, Stanford, California
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Diez Alvarez S, Fellas A, Santos D, Sculley D, Wynne K, Acharya S, Navathe P, Girones X, Coda A. The Clinical Impact of Flash Glucose Monitoring-a Digital Health App and Smartwatch Technology in Patients With Type 2 Diabetes: Scoping Review. JMIR Diabetes 2023; 8:e42389. [PMID: 36920464 PMCID: PMC10131890 DOI: 10.2196/42389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 12/29/2022] [Accepted: 01/19/2023] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Type 2 diabetes has a growing prevalence and confers significant cost burden to the health care system, raising the urgent need for cost-effective and easily accessible solutions. The management of type 2 diabetes requires significant commitment from the patient, caregivers, and the treating team to optimize clinical outcomes and prevent complications. Technology and its implications for the management of type 2 diabetes is a nascent area of research. The impact of some of the more recent technological innovations in this space, such as continuous glucose monitoring, flash glucose monitoring, web-based applications, as well as smartphone- and smart watch-based interactive apps has received limited attention in the research literature. OBJECTIVE This scoping review aims to explore the literature available on type 2 diabetes, flash glucose monitoring, and digital health technology to improve diabetic clinical outcomes and inform future research in this area. METHODS A scoping review was undertaken by searching Ovid MEDLINE and CINAHL databases. A second search using all identified keywords and index terms was performed on Ovid MEDLINE (January 1966 to July 2021), EMBASE (January 1980 to July 2021), Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library, latest issue), CINAHL (from 1982), IEEE Xplore, ACM Digital Libraries, and Web of Science databases. RESULTS There were very few studies that have explored the use of mobile health and flash glucose monitoring in type 2 diabetes. These studies have explored somewhat disparate and limited areas of research, and there is a distinct lack of methodological rigor in this area of research. The 3 studies that met the inclusion criteria have addressed aspects of the proposed research question. CONCLUSIONS This scoping review has highlighted the lack of research in this area, raising the opportunity for further research in this area, focusing on the clinical impact and feasibility of the use of multiple technologies, including flash glucose monitoring in the management of patients with type 2 diabetes.
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Affiliation(s)
- Sergio Diez Alvarez
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Newcastle, Australia
| | - Antoni Fellas
- School of Health Sciences, College of Health, Medicine and Wellbeing, University of Newcastle, Ourimbah, Australia
| | - Derek Santos
- School of Health Sciences, Queen Margaret University, Edinburgh, United Kingdom
| | - Dean Sculley
- School of Biomedical Sciences and Pharmacy, College of Health, Medicine and Wellbeing, University of Newcastle, Newcastle, Australia
| | - Katie Wynne
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Newcastle, Australia
- Equity in Health and Wellbeing Research Program, Hunter Medical Research Institute, Newcastle, Australia
- Department of Diabetes and Endocrinology, Hunter New England Health, John Hunter Hospital, Newcastle, Australia
| | - Shamasunder Acharya
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Newcastle, Australia
- Department of Diabetes and Endocrinology, Hunter New England Health, John Hunter Hospital, Newcastle, Australia
| | - Pooshan Navathe
- Central Queensland Hospital and Health Service, Brisbane, Australia
| | - Xavier Girones
- Department of Research, Universities de Catalunya, Generalitat de Catalunya, Barcelona, Cataluna, Spain
| | - Andrea Coda
- School of Health Sciences, College of Health, Medicine and Wellbeing, University of Newcastle, Ourimbah, Australia
- Equity in Health and Wellbeing Research Program, Hunter Medical Research Institute, Newcastle, Australia
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Phillip M, Nimri R, Bergenstal RM, Barnard-Kelly K, Danne T, Hovorka R, Kovatchev BP, Messer LH, Parkin CG, Ambler-Osborn L, Amiel SA, Bally L, Beck RW, Biester S, Biester T, Blanchette JE, Bosi E, Boughton CK, Breton MD, Brown SA, Buckingham BA, Cai A, Carlson AL, Castle JR, Choudhary P, Close KL, Cobelli C, Criego AB, Davis E, de Beaufort C, de Bock MI, DeSalvo DJ, DeVries JH, Dovc K, Doyle FJ, Ekhlaspour L, Shvalb NF, Forlenza GP, Gallen G, Garg SK, Gershenoff DC, Gonder-Frederick LA, Haidar A, Hartnell S, Heinemann L, Heller S, Hirsch IB, Hood KK, Isaacs D, Klonoff DC, Kordonouri O, Kowalski A, Laffel L, Lawton J, Lal RA, Leelarathna L, Maahs DM, Murphy HR, Nørgaard K, O’Neal D, Oser S, Oser T, Renard E, Riddell MC, Rodbard D, Russell SJ, Schatz DA, Shah VN, Sherr JL, Simonson GD, Wadwa RP, Ward C, Weinzimer SA, Wilmot EG, Battelino T. Consensus Recommendations for the Use of Automated Insulin Delivery Technologies in Clinical Practice. Endocr Rev 2023; 44:254-280. [PMID: 36066457 PMCID: PMC9985411 DOI: 10.1210/endrev/bnac022] [Citation(s) in RCA: 111] [Impact Index Per Article: 111.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 07/22/2022] [Indexed: 02/06/2023]
Abstract
The significant and growing global prevalence of diabetes continues to challenge people with diabetes (PwD), healthcare providers, and payers. While maintaining near-normal glucose levels has been shown to prevent or delay the progression of the long-term complications of diabetes, a significant proportion of PwD are not attaining their glycemic goals. During the past 6 years, we have seen tremendous advances in automated insulin delivery (AID) technologies. Numerous randomized controlled trials and real-world studies have shown that the use of AID systems is safe and effective in helping PwD achieve their long-term glycemic goals while reducing hypoglycemia risk. Thus, AID systems have recently become an integral part of diabetes management. However, recommendations for using AID systems in clinical settings have been lacking. Such guided recommendations are critical for AID success and acceptance. All clinicians working with PwD need to become familiar with the available systems in order to eliminate disparities in diabetes quality of care. This report provides much-needed guidance for clinicians who are interested in utilizing AIDs and presents a comprehensive listing of the evidence payers should consider when determining eligibility criteria for AID insurance coverage.
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Affiliation(s)
- Moshe Phillip
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children’s Medical Center of Israel, 49202 Petah Tikva, Israel
- Sacker Faculty of Medicine, Tel-Aviv University, 39040 Tel-Aviv, Israel
| | - Revital Nimri
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children’s Medical Center of Israel, 49202 Petah Tikva, Israel
- Sacker Faculty of Medicine, Tel-Aviv University, 39040 Tel-Aviv, Israel
| | - Richard M Bergenstal
- International Diabetes Center, HealthPartners Institute, Minneapolis, MN 55416, USA
| | | | - Thomas Danne
- AUF DER BULT, Diabetes-Center for Children and Adolescents, Endocrinology and General Paediatrics, Hannover, Germany
| | - Roman Hovorka
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Boris P Kovatchev
- Center for Diabetes Technology, School of Medicine, University of Virginia, Charlottesville, VA 22903, USA
| | - Laurel H Messer
- Barbara Davis Center for Diabetes, University of Colorado Denver—Anschutz Medical Campus, Aurora, CO 80045, USA
| | | | | | | | - Lia Bally
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Roy W Beck
- Jaeb Center for Health Research Foundation, Inc., Tampa, FL 33647, USA
| | - Sarah Biester
- AUF DER BULT, Diabetes-Center for Children and Adolescents, Endocrinology and General Paediatrics, Hannover, Germany
| | - Torben Biester
- AUF DER BULT, Diabetes-Center for Children and Adolescents, Endocrinology and General Paediatrics, Hannover, Germany
| | - Julia E Blanchette
- College of Nursing, University of Utah, Salt Lake City, UT 84112, USA
- Center for Diabetes and Obesity, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| | - Emanuele Bosi
- Diabetes Research Institute, IRCCS San Raffaele Hospital and San Raffaele Vita Salute University, Milan, Italy
| | - Charlotte K Boughton
- Wellcome Trust-MRC Institute of Metabolic Science, Addenbrooke’s Hospital, University of Cambridge Metabolic Research Laboratories, Cambridge, UK
| | - Marc D Breton
- Center for Diabetes Technology, School of Medicine, University of Virginia, Charlottesville, VA 22903, USA
| | - Sue A Brown
- Center for Diabetes Technology, School of Medicine, University of Virginia, Charlottesville, VA 22903, USA
- Division of Endocrinology, University of Virginia, Charlottesville, VA 22903, USA
| | - Bruce A Buckingham
- Division of Endocrinology, Department of Pediatrics, Stanford University, School of Medicine, Stanford, CA 94304, USA
| | - Albert Cai
- The diaTribe Foundation/Close Concerns, San Diego, CA 94117, USA
| | - Anders L Carlson
- International Diabetes Center, HealthPartners Institute, Minneapolis, MN 55416, USA
| | - Jessica R Castle
- Harold Schnitzer Diabetes Health Center, Oregon Health & Science University, Portland, OR 97239, USA
| | - Pratik Choudhary
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Kelly L Close
- The diaTribe Foundation/Close Concerns, San Diego, CA 94117, USA
| | - Claudio Cobelli
- Department of Woman and Child’s Health, University of Padova, Padova, Italy
| | - Amy B Criego
- International Diabetes Center, HealthPartners Institute, Minneapolis, MN 55416, USA
| | - Elizabeth Davis
- Telethon Kids Institute, University of Western Australia, Perth Children’s Hospital, Perth, Australia
| | - Carine de Beaufort
- Diabetes & Endocrine Care Clinique Pédiatrique DECCP/Centre Hospitalier Luxembourg, and Faculty of Sciences, Technology and Medicine, University of Luxembourg, Esch sur Alzette, GD Luxembourg/Department of Paediatrics, UZ-VUB, Brussels, Belgium
| | - Martin I de Bock
- Department of Paediatrics, University of Otago, Christchurch, New Zealand
| | - Daniel J DeSalvo
- Division of Pediatric Diabetes and Endocrinology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX 77598, USA
| | - J Hans DeVries
- Amsterdam UMC, University of Amsterdam, Internal Medicine, Amsterdam, The Netherlands
| | - Klemen Dovc
- Department of Pediatric Endocrinology, Diabetes and Metabolic Diseases, UMC - University Children’s Hospital, Ljubljana, Slovenia, and Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Francis J Doyle
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA 02138, USA
| | - Laya Ekhlaspour
- Lucile Packard Children’s Hospital—Pediatric Endocrinology, Stanford University School of Medicine, Palo Alto, CA 94304, USA
| | - Naama Fisch Shvalb
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children’s Medical Center of Israel, 49202 Petah Tikva, Israel
| | - Gregory P Forlenza
- Barbara Davis Center for Diabetes, University of Colorado Denver—Anschutz Medical Campus, Aurora, CO 80045, USA
| | | | - Satish K Garg
- Barbara Davis Center for Diabetes, University of Colorado Denver—Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Dana C Gershenoff
- International Diabetes Center, HealthPartners Institute, Minneapolis, MN 55416, USA
| | - Linda A Gonder-Frederick
- Center for Diabetes Technology, School of Medicine, University of Virginia, Charlottesville, VA 22903, USA
| | - Ahmad Haidar
- Department of Biomedical Engineering, McGill University, Montreal, Canada
| | - Sara Hartnell
- Wolfson Diabetes and Endocrine Clinic, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Simon Heller
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Irl B Hirsch
- Department of Medicine, University of Washington Diabetes Institute, University of Washington, Seattle, WA, USA
| | - Korey K Hood
- Stanford Diabetes Research Center, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Diana Isaacs
- Cleveland Clinic, Endocrinology and Metabolism Institute, Cleveland, OH 44106, USA
| | - David C Klonoff
- Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, CA 94010, USA
| | - Olga Kordonouri
- AUF DER BULT, Diabetes-Center for Children and Adolescents, Endocrinology and General Paediatrics, Hannover, Germany
| | | | - Lori Laffel
- Joslin Diabetes Center, Harvard Medical School, Boston, MA 02215, USA
| | - Julia Lawton
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Rayhan A Lal
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Lalantha Leelarathna
- Manchester University Hospitals NHS Foundation Trust/University of Manchester, Manchester, UK
| | - David M Maahs
- Division of Endocrinology, Department of Pediatrics, Stanford University, School of Medicine, Stanford, CA 94304, USA
| | - Helen R Murphy
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Kirsten Nørgaard
- Steno Diabetes Center Copenhagen and Department of Clinical Medicine, University of Copenhagen, Gentofte, Denmark
| | - David O’Neal
- Department of Medicine and Department of Endocrinology, St Vincent’s Hospital Melbourne, University of Melbourne, Melbourne, Australia
| | - Sean Oser
- Department of Family Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Tamara Oser
- Department of Family Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Eric Renard
- Department of Endocrinology, Diabetes, Nutrition, Montpellier University Hospital, and Institute of Functional Genomics, University of Montpellier, CNRS, INSERM, Montpellier, France
| | - Michael C Riddell
- School of Kinesiology & Health Science, Muscle Health Research Centre, York University, Toronto, Canada
| | - David Rodbard
- Biomedical Informatics Consultants LLC, Potomac, MD, USA
| | - Steven J Russell
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Desmond A Schatz
- Department of Pediatrics, College of Medicine, Diabetes Institute, University of Florida, Gainesville, FL 02114, USA
| | - Viral N Shah
- Barbara Davis Center for Diabetes, University of Colorado Denver—Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Jennifer L Sherr
- Department of Pediatrics, Yale University School of Medicine, Pediatric Endocrinology, New Haven, CT 06511, USA
| | - Gregg D Simonson
- International Diabetes Center, HealthPartners Institute, Minneapolis, MN 55416, USA
| | - R Paul Wadwa
- Barbara Davis Center for Diabetes, University of Colorado Denver—Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Candice Ward
- Institute of Metabolic Science, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Stuart A Weinzimer
- Department of Pediatrics, Yale University School of Medicine, Pediatric Endocrinology, New Haven, CT 06511, USA
| | - Emma G Wilmot
- Department of Diabetes & Endocrinology, University Hospitals of Derby and Burton NHS Trust, Derby, UK
- Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, England, UK
| | - Tadej Battelino
- Department of Pediatric Endocrinology, Diabetes and Metabolic Diseases, UMC - University Children’s Hospital, Ljubljana, Slovenia, and Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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Lewis DM, Oser TK, Wheeler BJ. Continuous glucose monitoring. BMJ 2023; 380:e072420. [PMID: 36868576 DOI: 10.1136/bmj-2022-072420] [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: 03/05/2023]
Affiliation(s)
| | - Tamara K Oser
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Benjamin J Wheeler
- Department of Women's and Children's Health, Dunedin School of Medicine, University of Otago, New Zealand
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Lewit EM, Figg LE, Addala A, Filipp SL, Lal R, Gurka MJ, Herndon JB, Haller MJ, Maahs DM, Walker AF. Project ECHO Diabetes Cost Modeling to Support the Replication and Expansion of Tele-mentoring Programs in Non-research Settings. Diabetes Ther 2023; 14:509-518. [PMID: 36680682 PMCID: PMC9981830 DOI: 10.1007/s13300-022-01364-3] [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: 11/18/2022] [Accepted: 12/23/2022] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION Project ECHO Diabetes is a tele-education learning model for primary care providers (PCPs) seeking to improve care for patients with diabetes from marginalized communities. Project ECHO Diabetes utilized expert "hub" teams comprising endocrinologists, dieticians, nurses, psychologists, and social workers and "spokes" consisting of PCPs and their patients with diabetes. This Project ECHO Diabetes model provided diabetes support coaches to provide additional support to patients. We sought to estimate the costs of operating a Project ECHO Diabetes hub, inclusive of diabetes support coach costs. METHODS Data from Project ECHO Diabetes from June 2021 to June 2022 and wages from national databases were used to estimate hub and diabetes support coach costs to operate a 6-month, 24-session Project ECHO Diabetes program at hubs (University of Florida and Stanford University) and spokes (PCP clinic sites in Florida and California). RESULTS Hub costs for delivering a 6-month Project ECHO Diabetes program to five spoke clinics were $96,873. Personnel costs were the principal driver. Mean cost was $19,673 per spoke clinic and $11.37 per spoke clinic patient. Diabetes support coach costs were estimated per spoke clinic and considered scalable in that they would increase proportionately with the number of spoke clinics in a Project ECHO Diabetes cohort. Mean diabetes support coach costs were $6,506 per spoke clinic and $3.72 per patient. Total program costs per hub were $129,404. Mean cost per clinic was $25,881. Mean cost per patient was $15.03. CONCLUSION Herein, we document real-world costs to operate a Project ECHO Diabetes hub and diabetes support coaches. Future analysis of Project ECHO Diabetes will include estimates of spoke participation costs and changes in health care costs and savings. As state agencies, insurers, and philanthropies consider the replication of Project ECHO Diabetes, this analysis provides important initial information regarding primary operating costs.
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Affiliation(s)
- Eugene M Lewit
- Department of Health Policy, Stanford University, Stanford, CA, USA.
- , 2448 Emerson Street, Palo Alto, CA, 94301, USA.
| | - Lauren E Figg
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, CA, USA
| | - Ananta Addala
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, CA, USA
| | - Stephanie L Filipp
- Department of Pediatrics, Pediatric Endocrinology, University of Florida, PO Box 100296, Gainesville, FL, 32610, USA
| | - Rayhan Lal
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, CA, USA
- Department of Medicine, Division of Endocrinology, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Diabetes Research Center, Stanford University, Stanford, CA, USA
| | - Matthew J Gurka
- Department of Pediatrics, Pediatric Endocrinology, University of Florida, PO Box 100296, Gainesville, FL, 32610, USA
| | | | - Michael J Haller
- Department of Pediatrics, Pediatric Endocrinology, University of Florida, PO Box 100296, Gainesville, FL, 32610, USA.
| | - David M Maahs
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, CA, USA
- Stanford Diabetes Research Center, Stanford University, Stanford, CA, USA
| | - Ashby F Walker
- Department of Health Services Research, Management and Policy, University of Florida, Gainesville, FL, USA
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O'Donnell S, Cooper D, Chen Y, Ballhausen H, Lewis DM, Froment T, Anna Gajewska K, Tappe A, Skinner T, Cleal B, Braune K. Barriers to uptake of Open-Source automated insulin delivery Systems: Analysis of socioeconomic factors and perceived challenges of adults with type 1 diabetes from the OPEN survey. Diabetes Res Clin Pract 2023; 197:110235. [PMID: 36581143 DOI: 10.1016/j.diabres.2022.110235] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 12/13/2022] [Accepted: 12/21/2022] [Indexed: 12/27/2022]
Abstract
AIMS Social and technical trends are empowering people with diabetes to co-create or self-develop medical devices and treatments to address their unmet healthcare needs, for example, open-source automated insulin delivery (AID) systems. This study aims to investigate the perceived barriers towards adoption and maintaining of open-source AID systems. METHODS This is a multinational study based on a cross-sectional, retrospective web-based survey of non-users of open-source AID. Participants (n = 129) with type 1 diabetes from 31 countries were recruited online to elicit their perceived barriers towards building and maintaining of an open-source AID system. RESULTS Sourcing the necessary components, lack of confidence in one's own technology knowledge and skills, perceived time and energy required to build a system, and fear of losing healthcare provider support appear to be major barriers towards the uptake of open-source AID. CONCLUSIONS This study identified a range of structural and individual-level barriers to uptake of open-source AID. Some of these individual-level barriers may be overcome over time through the peer support of the DIY online community as well as greater acceptance of open-source innovation among healthcare professionals. The findings have important implications for understanding the possible wider diffusion of open-source diabetes technology solutions in the future.
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Affiliation(s)
- Shane O'Donnell
- University College Dublin, School of Sociology, Belfield, Ireland; University of Copenhagen, Department of Psychology, Copenhagen, Denmark.
| | - Drew Cooper
- Charité - Universitätsmedizin Berlin, Institute of Medical Informatics, Berlin, Germany; Charité - Universitätsmedizin Berlin, Department of Paediatric Endocrinology and Diabetes, Berlin, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany.
| | - Yanbing Chen
- University College Dublin, Michael Smurfit Graduate Business School, Dublin, Ireland.
| | - Hanne Ballhausen
- Charité - Universitätsmedizin Berlin, Department of Paediatric Endocrinology and Diabetes, Berlin, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany; #dedoc° Diabetes Online Community, Dedoc Labs GmbH, Berlin, Germany.
| | | | - Timothée Froment
- University College Dublin, School of Sociology, Belfield, Ireland.
| | | | | | - Timothy Skinner
- Australian Centre for Behavioural Research in Diabetes, Melbourne, Australia; Department of Psychology, University of Copenhagen, Copenhagen Denmark; La Trobe University, Bendigo, Australia.
| | - Bryan Cleal
- Steno Diabetes Center Copenhagen, Herlev, Denmark.
| | - Katarina Braune
- Charité - Universitätsmedizin Berlin, Institute of Medical Informatics, Berlin, Germany; Charité - Universitätsmedizin Berlin, Department of Paediatric Endocrinology and Diabetes, Berlin, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany.
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Dovc K, Lanzinger S, Cardona-Hernandez R, Tauschmann M, Marigliano M, Cherubini V, Preikša R, Schierloh U, Clapin H, AlJaser F, Pelicand J, Shukla R, Biester T. Association of Achieving Time in Range Clinical Targets With Treatment Modality Among Youths With Type 1 Diabetes. JAMA Netw Open 2023; 6:e230077. [PMID: 36808243 PMCID: PMC9941889 DOI: 10.1001/jamanetworkopen.2023.0077] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
IMPORTANCE Continuous glucose monitoring (CGM) devices have demonstrated efficacy in adults and more recently in youths and older adults with type 1 diabetes. In adults with type 1 diabetes, the use of real-time CGM compared with intermittently scanned CGM was associated with improved glycemic control, but there are limited data available for youths. OBJECTIVE To assess real-world data on achievement of time in range clinical targets associated with different treatment modalities in youths with type 1 diabetes. DESIGN, SETTING, AND PARTICIPANTS This multinational cohort study included children, adolescents, and young adults younger than 21 years (hereinafter referred to collectively as youths) with type 1 diabetes for a duration of at least 6 months who provided CGM data between January 1, 2016, and December 31, 2021. Participants were enrolled from the international Better Control in Pediatric and Adolescent Diabetes: Working to Create Centers of Reference (SWEET) registry. Data from 21 countries were included. Participants were divided into 4 treatment modalities: intermittently scanned CGM with or without insulin pump use and real-time CGM with or without insulin pump use. EXPOSURES Type 1 diabetes and the use of CGM with or without an insulin pump. MAIN OUTCOMES AND MEASURES Proportion of individuals in each treatment modality group achieving recommended CGM clinical targets. RESULTS Among the 5219 participants (2714 [52.0%] male; median age, 14.4 [IQR, 11.2-17.1] years), median duration of diabetes was 5.2 (IQR, 2.7-8.7) years and median hemoglobin A1c level was 7.4% (IQR, 6.8%-8.0%). Treatment modality was associated with the proportion of individuals achieving recommended clinical targets. Adjusted for sex, age, diabetes duration, and body mass index standard deviation score, the proportion achieving the recommended greater than 70% time in range target was highest with real-time CGM plus insulin pump use (36.2% [95% CI, 33.9%-38.4%]), followed by real-time CGM plus injection use (20.9% [95% CI, 18.0%-24.1%]), intermittently scanned CGM plus injection use (12.5% [95% CI, 10.7%-14.4%]), and intermittently scanned CGM plus insulin pump use (11.3% [95% CI, 9.2%-13.8%]) (P < .001). Similar trends were observed for less than 25% time above (real-time CGM plus insulin pump, 32.5% [95% CI, 30.4%-34.7%]; intermittently scanned CGM plus insulin pump, 12.8% [95% CI, 10.6%-15.4%]; P < .001) and less than 4% time below range target (real-time CGM plus insulin pump, 73.1% [95% CI, 71.1%-75.0%]; intermittently scanned CGM plus insulin pump, 47.6% [95% CI, 44.1%-51.1%]; P < .001). Adjusted time in range was highest among real-time CGM plus insulin pump users (64.7% [95% CI, 62.6%-66.7%]). Treatment modality was associated with the proportion of participants experiencing severe hypoglycemia and diabetic ketoacidosis events. CONCLUSIONS AND RELEVANCE In this multinational cohort study of youths with type 1 diabetes, concurrent use of real-time CGM and an insulin pump was associated with increased probability of achieving recommended clinical targets and time in range target as well as lower probability of severe adverse events compared with other treatment modalities.
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Affiliation(s)
- Klemen Dovc
- Department of Pediatric Endocrinology, Diabetes and Metabolic Diseases, University Children’s Hospital, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Stefanie Lanzinger
- Institute of Epidemiology and Medical Biometry, ZIBMT, Ulm University, Ulm, Germany
- German Center for Diabetes Research (DZD), Munich–Neuherberg, Germany
| | | | - Martin Tauschmann
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Marco Marigliano
- Pediatric Diabetes and Metabolic Disorders Unit, Regional Center for Pediatric Diabetes, University City Hospital of Verona, Verona, Italy
- Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Verona, Italy
| | - Valentino Cherubini
- Division of Pediatric Diabetology, Department of Women’s and Children’s Health, Salesi Hospital, Ancona, Italy
| | - Romualdas Preikša
- Institute and Clinic of Endocrinology, Lithuanian University of Health Sciences, Kaunas
| | - Ulrike Schierloh
- Department of Pediatric Diabetes and Endocrinology, Centre Hospitalier Luxembourg, Luxembourg, Luxembourg
| | - Helen Clapin
- Department of Diabetes and Endocrinology, Perth Children’s Hospital, Perth, Australia
| | - Fahed AlJaser
- Department of Pediatrics, Amiri Hospital, Ministry of Health, Dasman, Kuwait
| | - Julie Pelicand
- Pediatric and Adolescent Diabetes Program, Department of Pediatrics, San Camilo Hospital, San Felipe, Chile
- Medicine School, Universidad de Valparaiso, San Felipe, Chile
| | - Rishi Shukla
- Department of Diabetes and Endocrinology, Center for Diabetes & Endocrine Diseases, Kanpur, India
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Inequity in access to continuous glucose monitoring and health outcomes in paediatric diabetes, a case for national continuous glucose monitoring funding: A cross-sectional population study of children with type 1 diabetes in New Zealand. THE LANCET REGIONAL HEALTH - WESTERN PACIFIC 2023; 31:100644. [DOI: 10.1016/j.lanwpc.2022.100644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 10/17/2022] [Accepted: 10/30/2022] [Indexed: 11/18/2022]
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Ni K, Tampe CA, Sol K, Richardson DB, Pereira RI. Effect of CGM Access Expansion on Uptake Among Patients on Medicaid With Diabetes. Diabetes Care 2023; 46:391-398. [PMID: 36480729 PMCID: PMC9887615 DOI: 10.2337/dc22-1287] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 11/07/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Current studies on continuous glucose monitor (CGM) uptake are revealing for significant barriers and inequities for CGM use among patients from socially underprivileged communities. This study explores the effect of full subsidies regardless of diabetes type on CGM uptake and HbA1c outcomes in a U.S. adult patient population on Medicaid. RESEARCH DESIGN AND METHODS This retrospective cohort study examined 3,036 adults with diabetes enrolled in a U.S. Medicaid program that fully subsidized CGM. CGM uptake and adherence were assessed by CGM prescription and dispense data, including more than one fill and adherence by medication possession ratio (MPR). Multivariate logistic regression evaluated predictors of CGM uptake. Pre- and post-CGM use HbA1c were compared. RESULTS CGM were very well received by both individuals with type 1 diabetes and individuals with type 2 diabetes with similar high fill adherence levels (mean MPR 0.78 vs. 0.72; P = 0.06). No significant difference in CGM uptake outcomes were noted among major racial/ethnic groups. CGM use was associated with improved HbA1c among those with type 2 diabetes (-1.2% [13.1 mmol/mol]; P < 0.001) that was comparable between major racial/ethnic groups and those with higher fill adherence achieved greater HbA1c reduction (-1.4% [15.3 mmol/mol]; P < 0.001) compared with those with lower adherence (-1.0% [10.9 mmol/mol]; P < 0.001). CONCLUSIONS CGM uptake disparities can largely be overcome by eliminating CGM cost barriers. CGM use was associated with improved HbA1c across all major racial/ethnic groups, highlighting broad CGM appeal, utilization, and effectiveness across an underprivileged patient population.
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Affiliation(s)
- Kevin Ni
- Medicine Service–Endocrinology, Denver Health, Denver, CO
- Department of Medicine, University of Colorado, Aurora, CO
| | | | - Kayce Sol
- Medicine Service–Endocrinology, Denver Health, Denver, CO
| | | | - Rocio I. Pereira
- Medicine Service–Endocrinology, Denver Health, Denver, CO
- Department of Medicine, University of Colorado, Aurora, CO
- Corresponding author: Rocio I. Pereira,
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Lin T, Manfredo JA, Illesca N, Abiola K, Hwang N, Salsberg S, Akhtar Y, Mathioudakis N, Brown EA, Wolf RM. Improving Continuous Glucose Monitoring Uptake in Underserved Youth with Type 1 Diabetes: The IMPACT Study. Diabetes Technol Ther 2023; 25:13-19. [PMID: 36223197 DOI: 10.1089/dia.2022.0347] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background: Continuous glucose monitoring (CGM) improves glycemic control. Less than half of youth with type 1 diabetes (T1D) use CGM, with disparities among minority and low-income youth. The aim of this study was to determine if trial CGM use increases uptake of personal CGM. Methods: T1D youth were provided sample CGM placement at the point of care, with CGM education and app setup. Follow-up calls at 5 and 10 days assessed CGM data, and desire to continue using CGM. Follow-up at 3-6 months recorded CGM use, CGM data, and A1c. Participants completed surveys at enrollment, 10 days, and 3 months. Differences were assessed between baseline and follow-up. Results: Of the 26 enrolled participants with T1D, 15 were CGM naive, and 11 were prior CGM users. The mean age was 14.1 ± 2.9 years, 65% male, 42% were Black, 12% were Hispanic, 65% were on public insurance, and 43% had household income of <$50,000. The median duration of diabetes was 4.6 years (interquartile range 2.4-7.7), mean baseline A1c was 10.7% ± 2.4%. After trial CGM use, 85% of participants reported wanting personal CGM, and at 3-6 months follow-up 76% had obtained one and 43% were using a personal CGM. There were no improvements in A1C or time in range, but participants reported an increase in the perceived benefits of CGM usage (4.0 vs. 4.3, p = 0.03). Conclusions: Placing a sample CGM at the point of care can improve uptake of personal CGM and may help mitigate disparities in CGM use in minority and underserved youth. Long-term studies are needed to determine how similar interventions impact glycemic control and patient outcomes. ClinicalTrials.gov: NCT04721145.
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Affiliation(s)
- Tyger Lin
- Department of Pediatrics and Division of Endocrinology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jacquelyn A Manfredo
- Department of Pediatrics and Division of Endocrinology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nicole Illesca
- Department of Pediatrics and Division of Endocrinology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kai Abiola
- Department of Pediatrics and Division of Endocrinology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nearry Hwang
- Department of Pediatrics and Division of Endocrinology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sandra Salsberg
- Department of Pediatrics and Division of Endocrinology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yasmin Akhtar
- Department of Pediatrics and Division of Endocrinology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nestoras Mathioudakis
- Department of Medicine, Division of Endocrinology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth A Brown
- Department of Pediatrics and Division of Endocrinology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Risa M Wolf
- Department of Pediatrics and Division of Endocrinology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Addala A, Filipp SL, Figg LE, Anez-Zabala C, Lal RA, Gurka MJ, Haller MJ, Maahs DM, Walker AF. Tele-education model for primary care providers to advance diabetes equity: Findings from Project ECHO Diabetes. Front Endocrinol (Lausanne) 2022; 13:1066521. [PMID: 36589850 PMCID: PMC9800890 DOI: 10.3389/fendo.2022.1066521] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 11/29/2022] [Indexed: 12/24/2022] Open
Abstract
Introduction In the US, many individuals with diabetes do not have consistent access to endocrinologists and therefore rely on primary care providers (PCPs) for their diabetes management. Project ECHO (Extension for Community Healthcare Outcomes) Diabetes, a tele-education model, was developed to empower PCPs to independently manage diabetes, including education on diabetes technology initiation and use, to bridge disparities in diabetes. Methods PCPs (n=116) who participated in Project ECHO Diabetes and completed pre- and post-intervention surveys were included in this analysis. The survey was administered in California and Florida to participating PCPs via REDCap and paper surveys. This survey aimed to evaluate practice demographics, protocols with adult and pediatric T1D management, challenges, resources, and provider knowledge and confidence in diabetes management. Differences and statistical significance in pre- and post-intervention responses were evaluated via McNemar's tests. Results PCPs reported improvement in all domains of diabetes education and management. From baseline, PCPs reported improvement in their confidence to serve as the T1D provider for their community (pre vs post: 43.8% vs 68.8%, p=0.005), manage insulin therapy (pre vs post: 62.8% vs 84.3%, p=0.002), and identify symptoms of diabetes distress (pre vs post: 62.8% vs 84.3%, p=0.002) post-intervention. Compared to pre-intervention, providers reported significant improvement in their confidence in all aspects of diabetes technology including prescribing technology (41.2% vs 68.6%, p=0.001), managing insulin pumps (41.2% vs 68.6%, p=0.001) and hybrid closed loop (10.2% vs 26.5%, p=0.033), and interpreting sensor data (41.2% vs 68.6%, p=0.001) post-intervention. Discussion PCPs who participated in Project ECHO Diabetes reported increased confidence in diabetes management, with notable improvement in their ability to prescribe, manage, and troubleshoot diabetes technology. These data support the use of tele-education of PCPs to increase confidence in diabetes technology management as a feasible strategy to advance equity in diabetes management and outcomes.
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Affiliation(s)
- Ananta Addala
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, CA, United States
| | - Stephanie L Filipp
- Department of Pediatrics, University of Florida, Gainesville, FL, United States
| | - Lauren E Figg
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, CA, United States
| | - Claudia Anez-Zabala
- Department of Pediatrics, University of Florida, Gainesville, FL, United States
| | - Rayhan A Lal
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, CA, United States
- Department of Medicine, Division of Endocrinology, Stanford University School of Medicine, Stanford, CA, United States
| | - Matthew J Gurka
- Department of Pediatrics, University of Florida, Gainesville, FL, United States
| | - Michael J Haller
- Department of Pediatrics, University of Florida, Gainesville, FL, United States
| | - David M Maahs
- Department of Pediatrics, Division of Pediatric Endocrinology, Stanford University, Stanford, CA, United States
- Stanford Diabetes Research Center, Stanford University, Stanford, CA, United States
| | - Ashby F Walker
- Department of Health Services Research, Management and Policy, University of Florida, Gainesville, FL, United States
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Odugbesan O, Addala A, Nelson G, Hopkins R, Cossen K, Schmitt J, Indyk J, Jones NHY, Agarwal S, Rompicherla S, Ebekozien O. Implicit Racial-Ethnic and Insurance-Mediated Bias to Recommending Diabetes Technology: Insights from T1D Exchange Multicenter Pediatric and Adult Diabetes Provider Cohort. Diabetes Technol Ther 2022; 24:619-627. [PMID: 35604789 PMCID: PMC9422789 DOI: 10.1089/dia.2022.0042] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Background: Despite documented benefits of diabetes technology in managing type 1 diabetes, inequities persist in the use of these devices. Provider bias may be a driver of inequities, but the evidence is limited. Therefore, we aimed to examine the role of race/ethnicity and insurance-mediated provider implicit bias in recommending diabetes technology. Method: We recruited 109 adult and pediatric diabetes providers across 7 U.S. endocrinology centers to complete an implicit bias assessment composed of a clinical vignette and ranking exercise. Providers were randomized to receive clinical vignettes with differing insurance and patient names as proxy for Racial-Ethnic identity. Bias was identified if providers: (1) recommended more technology for patients with an English name (Racial-Ethnic bias) or private insurance (insurance bias), or (2) Race/Ethnicity or insurance was ranked high (Racial-Ethnic and insurance bias, respectively) in recommending diabetes technology. Provider characteristics were analyzed using descriptive statistics and multivariate logistic regression. Result: Insurance-mediated implicit bias was common in our cohort (n = 66, 61%). Providers who were identified to have insurance-mediated bias had greater years in practice (5.3 ± 5.3 years vs. 9.3 ± 9 years, P = 0.006). Racial-Ethnic-mediated implicit bias was also observed in our study (n = 37, 34%). Compared with those without Racial-Ethnic bias, providers with Racial-Ethnic bias were more likely to state that they could recognize their own implicit bias (89% vs. 61%, P = 0.001). Conclusion: Provider implicit bias to recommend diabetes technology was observed based on insurance and Race/Ethnicity in our pediatric and adult diabetes provider cohort. These data raise the need to address provider implicit bias in diabetes care.
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Affiliation(s)
- Ori Odugbesan
- T1D Exchange, QI & Population Health Department, Boston, Massachusetts, USA
| | - Ananta Addala
- Stanford University, Division of Pediatric Endocrinology & Diabetes, Lucile Packard Children's Hospital, Stanford, California, USA
| | - Grace Nelson
- Le Bonheur Children's Hospital, Pediatric Endocrinology, Memphis, Tennessee, USA
| | - Rachel Hopkins
- SUNY Upstate Medical Center, Division of Endocrinology and Metabolism, Syracuse, New York, USA
| | - Kristina Cossen
- Children's Healthcare of Atlanta, Division of Pediatric Endocrinology, Atlanta, Georgia, USA
| | - Jessica Schmitt
- The University of Alabama Pediatric Endocrinology and Diabetes at Birmingham Hospital, Birmingham, Alabama, USA
| | - Justin Indyk
- Nationwide Children Hospital, Division of Endocrinology, Columbus, Ohio, USA
| | | | - Shivani Agarwal
- Yeshiva University Albert Einstein College of Medicine, Division of Endocrinology, Bronx, New York, USA
| | - Saketh Rompicherla
- T1D Exchange, QI & Population Health Department, Boston, Massachusetts, USA
| | - Osagie Ebekozien
- T1D Exchange, QI & Population Health Department, Boston, Massachusetts, USA
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Walker AF, Addala A, Sheehan E, Lal R, Haller M, Cuttriss N, Filipp S, Baer L, Gurka M, Bernier A, Figg L, Westen S, Hood K, Anez-Zabala C, Frank E, Roque X, Maizel J, Maahs D. Using Peer Power to Reduce Health Disparities: Implementation of a Diabetes Support Coach Program in Federally Qualified Health Centers. Diabetes Spectr 2022; 35:295-303. [PMID: 36082018 PMCID: PMC9396730 DOI: 10.2337/dsi22-0004] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Community health workers (CHWs) provide vital support to underserved communities in the promotion of health equity by addressing barriers related to the social determinants of health that often prevent people living with diabetes from achieving optimal health outcomes. Peer support programs in diabetes can also offer people living with diabetes invaluable support through a shared understanding of the disease and by offsetting diabetes-related stigma. As part of a Project Extension for Community Healthcare Outcomes (ECHO) Diabetes program, participating federally qualified healthcare centers were provided diabetes support coaches (DSCs) to facilitate patient engagement. DSCs hold invaluable expert knowledge, as they live with diabetes themselves and reside in areas they serve, thus combining the CHW role with peer support models. The use of DSCs and CHWs during the coronavirus disease 2019 pandemic and beyond is highly effective at reaching underserved communities with diabetes and promoting health equity.
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Affiliation(s)
- Ashby F Walker
- University of Florida Diabetes Institute, Gainesville, FL
- University of Florida, Department of Health Services Research, Management, and Policy, Gainesville, FL
| | - Ananta Addala
- Stanford University, Department of Pediatrics and Division of Endocrinology & Diabetes, Palo Alto, CA
| | - Eleni Sheehan
- University of Florida, Department of Pediatrics, Gainesville, FL
| | - Rayhan Lal
- Stanford University, Department of Pediatrics and Division of Endocrinology & Diabetes, Palo Alto, CA
- Stanford University, Department of Medicine, Division of Endocrinology, Gerontology & Metabolism, Palo Alto, CA
| | - Michael Haller
- University of Florida Diabetes Institute, Gainesville, FL
- University of Florida, Department of Pediatrics, Gainesville, FL
| | - Nicholas Cuttriss
- ECHO Diabetes Action Network, Chevy Chase, MD
- ENDO Diabetes & Wellness, Chevy Chase, MD
| | - Stephanie Filipp
- University of Florida, Department of Health Outcomes and Biomedical Informatics, Gainesville, FL
| | - Linda Baer
- Stanford University, Department of Pediatrics and Division of Endocrinology & Diabetes, Palo Alto, CA
| | - Matthew Gurka
- University of Florida, Department of Health Outcomes and Biomedical Informatics, Gainesville, FL
| | - Angelina Bernier
- University of Florida, Department of Pediatrics, Gainesville, FL
| | - Lauren Figg
- Stanford University, Department of Pediatrics and Division of Endocrinology & Diabetes, Palo Alto, CA
| | - Sarah Westen
- University of Florida, Department of Clinical and Health Psychology, Gainesville, FL
| | - Korey Hood
- Stanford University, Department of Pediatrics and Division of Endocrinology & Diabetes, Palo Alto, CA
| | | | - Eliana Frank
- Stanford University, Department of Pediatrics and Division of Endocrinology & Diabetes, Palo Alto, CA
| | - Xanadu Roque
- University of Florida, Department of Pediatrics, Gainesville, FL
| | - Jennifer Maizel
- University of Florida, College of Public Health and Health Professions, Gainesville, FL
| | - David Maahs
- Stanford University, Department of Pediatrics and Division of Endocrinology & Diabetes, Palo Alto, CA
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Zaharieva DP, Bishop FK, Maahs DM. Advancements and future directions in the teamwork, targets, technology, and tight control-the 4T study: improving clinical outcomes in newly diagnosed pediatric type 1 diabetes. Curr Opin Pediatr 2022; 34:423-429. [PMID: 35836400 PMCID: PMC9298953 DOI: 10.1097/mop.0000000000001140] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
PURPOSE OF REVIEW The benefits of intensive diabetes management have been established by the Diabetes Control and Complications Trial. However, challenges with optimizing glycemic management in youth with type 1 diabetes (T1D) remain across pediatric clinics in the United States. This article will review our Teamwork, Targets, Technology, and Tight Control (4T) study that implements emerging diabetes technology into clinical practice with a team approach to sustain tight glycemic control from the onset of T1D and beyond to optimize clinical outcomes. RECENT FINDINGS During the 4T Pilot study and study 1, our team-based approach to intensive target setting, education, and remote data review has led to significant improvements in hemoglobin A1c throughout the first year of T1D diagnosis in youth, as well as family and provider satisfaction. SUMMARY The next steps include refinement of the current 4T study 1, developing a business case, and broader implementation of the 4T study. In study 2, we are including a more pragmatic cadence of remote data review and disseminating exercise education and activity tracking to both English- and Spanish-speaking families. The overall goal is to create and implement a translatable program that can facilitate better outcomes for pediatric clinics across the USA.
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Affiliation(s)
- Dessi P. Zaharieva
- Division of Endocrinology, Department of Pediatrics, Stanford University, School of Medicine, Stanford, CA
| | - Franziska K. Bishop
- Division of Endocrinology, Department of Pediatrics, Stanford University, School of Medicine, Stanford, CA
| | - David M. Maahs
- Division of Endocrinology, Department of Pediatrics, Stanford University, School of Medicine, Stanford, CA
- Stanford Diabetes Research Center, Stanford, CA
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Tanenbaum ML, Commissariat PV. Barriers and Facilitators to Diabetes Device Adoption for People with Type 1 Diabetes. Curr Diab Rep 2022; 22:291-299. [PMID: 35522355 PMCID: PMC9189072 DOI: 10.1007/s11892-022-01469-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/14/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE OF REVIEW Diabetes technology (insulin pumps, continuous glucose monitoring, automated insulin delivery systems) has advanced significantly and provides benefits to the user. This article reviews the current barriers to diabetes device adoption and sustained use, and outlines the known and potential facilitators for increasing and sustaining device adoption. RECENT FINDINGS Barriers to diabetes device adoption continue to exist at the system-, provider-, and individual-level. Known facilitators to promote sustained adoption include consistent insurance coverage, support for providers and clinics, structured education and support for technology users, and device user access to support as needed (e.g., through online resources). Systemic barriers to diabetes device adoption persist while growing evidence demonstrates the increasing benefits of newest devices and systems. There are ongoing efforts to develop evidence-based structured education programs to support device adoption and sustained use.
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Affiliation(s)
- Molly L Tanenbaum
- Department of Pediatrics, Division of Endocrinology and Diabetes, Stanford University School of Medicine, Stanford, CA, USA.
| | - Persis V Commissariat
- Pediatric, Adolescent and Young Adult Section, Joslin Diabetes Center, Boston, MA, USA
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Agarwal S, Simmonds I, Myers AK. The Use of Diabetes Technology to Address Inequity in Health Outcomes: Limitations and Opportunities. Curr Diab Rep 2022; 22:275-281. [PMID: 35648277 PMCID: PMC9157044 DOI: 10.1007/s11892-022-01470-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/21/2022] [Indexed: 01/05/2023]
Abstract
PURPOSE OF REVIEW The management of diabetes has been revolutionized by the introduction of novel technological treatments and modalities of care, such as continuous glucose monitoring, insulin pump therapy, and telehealth. While these technologies have demonstrated improvement in health outcomes, it remains unclear whether they have reduced inequities from racial/ethnic minority or socioeconomic status. We review the current literature to discuss evidence of benefit, current limitations, and future opportunities of diabetes technologies. FINDINGS While there is ample evidence of the health and psychological benefit of diabetes technologies in large populations of people with type 1 and type 2 diabetes, there remain wide disparities in the use of diabetes technologies, which may be perpetuating or widening inequities. Multilevel barriers include inequitable prescribing practices, lack of support for social determinants of health, mismatch of patient preferences and care models, and cost. We provide a review of disparities in diabetes technology use, possible root causes of continued inequity in outcomes, and insight into ways to overcome remaining gaps.
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Affiliation(s)
- Shivani Agarwal
- Fleischer Institute for Diabetes and Metabolism, Albert Einstein College of Medicine-Montefiore Medical Center, Bronx, NY USA
- NY Regional Center for Diabetes Translational Research, Albert Einstein College of Medicine, Bronx, NY USA
| | - Iman Simmonds
- Department of Cardiology, CORE Yale, New Haven, CT 06510 USA
| | - Alyson K. Myers
- Department of Medicine, Division of Endocrinology, North Shore University Hospital, Manhasset, NY USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY USA
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Abstract
INTRODUCTION Despite advances in and increased adoption of technology, glycemic outcomes for individuals with type 1 diabetes (T1D) have not improved. Access to care is limited for many, in part due to a shortage of endocrinologists and their concentration in urban areas. Managing T1D via telehealth has potential to improve glycemic outcomes, as the barriers of travel-related time and cost are mitigated. METHODS Our endocrine telehealth program started in 2013 and currently provides care to nine rural community hospitals in Nebraska and Iowa. A retrospective cohort study was performed to evaluate glycemic outcomes in people with T1D who received care at these telehealth clinics from 2013-2019. Data were collected on age, race, gender, prior diabetes provider, use of diabetes technology, and A1c values over time. RESULTS One hundred thirty-nine individuals were followed for an average duration of 32 months (range 4-69 months). Sixty-six percent of people were previously under the care of an endocrinologist. The most common therapeutic action, in addition to insulin adjustment, was addition of a CGM (52%). Each year in telemedicine care was associated with a decline of 0.13% in A1c (95% CI: -0.20, -0.06). There was no association between A1c and age or gender. When stratifying by previous diabetes provider, all groups had a statistically significant decline in A1c, even those with a previous endocrine provider. There was no statistically significant decline in A1c based on addition of technology. CONCLUSION We have shown that traditional telehealth visits are an effective way to provide care for people with T1D long-term and may provide distinct advantages to home telehealth visits.
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Affiliation(s)
- Leslie A Eiland
- Division of Diabetes, Endocrinology
& Metabolism, University of Nebraska Medical Center, Omaha, NE, USA
- Leslie A Eiland, MD, Division of Diabetes,
Endocrinology & Metabolism, University of Nebraska Medical Center, 984130
Nebraska Medical Center, Omaha, NE 68198-4130, USA.
| | - Andjela Drincic
- Division of Diabetes, Endocrinology
& Metabolism, University of Nebraska Medical Center, Omaha, NE, USA
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Agarwal S, Crespo-Ramos G, Leung SL, Finnan M, Park T, McCurdy K, Gonzalez JS, Long JA. Solutions to Address Inequity in Diabetes Technology Use in Type 1 Diabetes: Results from Multidisciplinary Stakeholder Co-creation Workshops. Diabetes Technol Ther 2022; 24:381-389. [PMID: 35138944 PMCID: PMC9208861 DOI: 10.1089/dia.2021.0496] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Background: Racial-ethnic inequity in type 1 diabetes technology use is well documented and contributes to disparities in glycemic and long-term outcomes. However, solutions to address technology inequity remain sparse and lack stakeholder input. Methods: We employed user-centered design principles to conduct workshop sessions with multidisciplinary panels of stakeholders, building off of our prior study highlighting patient-identified barriers and proposed solutions. Stakeholders were convened to review our prior findings and co-create interventions to increase technology use among underserved populations with type 1 diabetes. Stakeholders included type 1 diabetes patients who had recently onboarded to technology; endocrinology and primary care physicians; nurses; diabetes educators; psychologists; and community health workers. Sessions were recorded and analyzed iteratively by multiple coders for common themes. Results: We convened 7 virtual 2-h workshops for 32 stakeholders from 11 states in the United States. Patients and providers confirmed prior published studies highlighting patient barriers and generated new ideas by co-creating solutions. Common themes of proposed interventions included (1) prioritizing more equitable systems of offering technology, (2) using visual and hands-on approaches to increase accessibility of technology and education, (3) including peer and family support systems more, and (4) assisting with insurance navigation and social needs. Discussion: Our study furthers the field by providing stakeholder-endorsed intervention ideas that propose feasible changes at the patient, provider, and system levels to reduce inequity in diabetes technology use in type 1 diabetes. Multidisciplinary stakeholder engagement in disparities research offers unique insight that is impactful and acceptable to the target population.
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Affiliation(s)
- Shivani Agarwal
- Division of Endocrinology, Diabetes, and Metabolism, Fleischer Institute for Diabetes and Metabolism, Albert Einstein College of Medicine-Montefiore Medical Center, Bronx, New York, USA
- NY-Regional Center for Diabetes Translation Research, Albert Einstein College of Medicine, Bronx, New York, USA
- Address correspondence to: Shivani Agarwal, MD, MPH, Department of Endocrinology, Diabetes, and Metabolism, Fleischer Institute for Diabetes and Metabolism, Albert Einstein College of Medicine-Montefiore Medical Center, 1180 Morris Park Avenue, Bronx, NY 10461, USA
| | - Gladys Crespo-Ramos
- Division of Endocrinology, Diabetes, and Metabolism, Fleischer Institute for Diabetes and Metabolism, Albert Einstein College of Medicine-Montefiore Medical Center, Bronx, New York, USA
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, New York, USA
| | - Stephanie L. Leung
- Division of Endocrinology, Diabetes, and Metabolism, Fleischer Institute for Diabetes and Metabolism, Albert Einstein College of Medicine-Montefiore Medical Center, Bronx, New York, USA
| | - Molly Finnan
- Division of Endocrinology, Diabetes, and Metabolism, Fleischer Institute for Diabetes and Metabolism, Albert Einstein College of Medicine-Montefiore Medical Center, Bronx, New York, USA
| | - Tina Park
- Diagram LLC, New York, New York, USA
| | | | - Jeffrey S. Gonzalez
- Division of Endocrinology, Diabetes, and Metabolism, Fleischer Institute for Diabetes and Metabolism, Albert Einstein College of Medicine-Montefiore Medical Center, Bronx, New York, USA
- NY-Regional Center for Diabetes Translation Research, Albert Einstein College of Medicine, Bronx, New York, USA
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, New York, USA
| | - Judith A. Long
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
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Lewis DM, Milo J, Espares J, Lin J, Li J, Tang D, Rataj H, Aronoff-Spencer E. Understanding the needs of people aging with type 1 diabetes: a user-focused research study with prototype diabetes advance directive and setting the stage for future research. J Diabetes Metab Disord 2022; 21:791-804. [PMID: 35607592 PMCID: PMC9117598 DOI: 10.1007/s40200-022-01056-6] [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: 11/19/2021] [Accepted: 05/10/2022] [Indexed: 10/28/2022]
Abstract
Purpose People living with Type 1 diabetes (T1D) are living longer than ever and facing the new "luxury" of the challenges of aging. While research is slowly expanding and addressing T1D physiology with regards to aging, there is little research addressing specific challenges and barriers to optimal care by those aging with T1D. To address this gap, this study employed human-centered design research to explore the gaps and barriers to care faced by people aging with T1D. Methods Researchers employed human-centered design methods of needfinding and user interviews and facilitated participatory workshops. In total, 27 people with T1D (PWT1D), 5 loved ones (partners of PWT1D), and 7 healthcare providers (HCPs) were engaged. Results Design artifacts were developed, including user personas that help visually articulate the different experiences of PWT1D and their unique needs as they age, as well as a prototype diabetes-specific advance directive that could be further refined to specifically aid those with Type 1 diabetes who are aging and requiring more interactions with the healthcare system. Initial user testing with people with T1D as well as healthcare providers demonstrated the need for such a diabetes advance directive tool or document. Conclusion This work supports the conclusion that additional focus and scientific enquiry should be given to the needs of people aging with Type 1 diabetes, with a goal of improving the experience of all people with T1D when interacting with their care providers or with the healthcare system as a whole.
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Affiliation(s)
| | | | - Jhea Espares
- University of California San Diego, San Diego, CA USA
| | - Jessie Lin
- University of California San Diego, San Diego, CA USA
| | - Jodie Li
- University of California San Diego, San Diego, CA USA
| | - Denise Tang
- Carnegie Mellon University, Pittsburgh, PA USA
| | - Heidi Rataj
- University of California San Diego, San Diego, CA USA
| | - Eliah Aronoff-Spencer
- Division of Infectious Disease and Global Public Health, UC San Diego, San Diego, CA USA
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Overcoming Barriers to Diabetes Technology in Youth with Type 1 Diabetes and Public Insurance: Cases and Call to Action. Case Rep Endocrinol 2022; 2022:9911736. [PMID: 35273814 PMCID: PMC8904094 DOI: 10.1155/2022/9911736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 02/03/2022] [Indexed: 11/21/2022] Open
Abstract
Advancements in diabetes technology such as continuous glucose monitoring (CGM), insulin pumps, and automated insulin delivery provide opportunities to improve glycemic control for youth with type 1 diabetes (T1D). However, diabetes technology use is lower in youth on public insurance, and this technology use gap is widening in the US. There is a significant need to develop effective interventions and policies to promote equitable care. The dual purpose of this case series is as follows: (1) describe success stories of the CGM Time in Range Program (CGM TIPs), which removed barriers for initiating CGM and provided asynchronous remote glucose monitoring for youth on public insurance, and (2) advocate for improving CGM coverage by public insurance. We describe a series of six youths with T1D and public insurance who obtained and sustained use of CGM with assistance from the program. Three youths had improved engagement with the care team while on CGM and the remote monitoring protocol, and three youths were able to leverage sustained CGM wear to obtain insurance coverage for automated insulin delivery systems. CGM TIPs helped these youths achieve lower hemoglobin A1c and improved time in range (TIR). Despite the successes, expansion of CGM TIPs is limited by stringent barriers for CGM approval and difficult postapproval patient workflows to receive shipments. These cases highlight the potential for combining diabetes technology and asynchronous remote monitoring to support continued use and provide education to improve glycemic control for youth with T1D on public insurance and the need to reduce barriers for obtaining CGM coverage by public insurance.
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