Day 1: Improving T1D Patient Care — Highlights from T1DX-QI Learning Session 2022

The T1D Exchange Quality Improvement Collaborative (T1DX-QI) Learning Session event 2022 takes place in Miami, FL, on November 7 and 8 — “T1DX-QI 52 Centers Strong: Implementation and Advocacy for Change.”

Osagie Ebekozien, MD, MPH Executive Vice President, Chief Medical Officer T1D Exchange

The T1DX-QI has grown from just over a dozen participating clinics in 2019 to 52 participating clinics in 2022, serving over 80,000 patients across the U.S. The newest centers to join the T1DX-QI include Billings Clinic, UPMC, Oregon Health and Science University, Cleveland Clinic and UC Davis.

Members from participating endocrinology clinics across the country come together to share insights on improving the care provided to people with diabetes — with the goal of improving quality of life and overall health.

Goals and Accomplishments in 2022

What is the T1DX-QI trying to accomplish? Osagie Ebekozien, MD, MPH points to the following questions that should influence every part of this work:

  • Do we have the right kind of data to drive real-world improvements?
  • Are we making the best decisions based on available data?
  • How can we improve clinical and population health outcomes?
  • Are outcomes equitable?
Dave Walton, CEO
T1D Exchange

Since its creation, the T1DX-QI has accomplished a variety of impactful work, including:

  • 90+ active research projects striving to improve patient care
  • Launched a pilot program to serve the type 2 diabetes population
  • Published research in over 40 top medical journals since 2019
  • Shared 70+ presentations at international conferences
  • Influencing active international collaborations
  • Expanding the Health Equity Advancement Lab (HEAL) Program
  • Mapping data at 16 participating centers
  • Improving overall HbA1c trends across all participating clinics
  • 18 manuscripts accepted and published so far in 2022
  • 25 abstracts accepted/presented at 5 International conferences in 2022

In just a few years, this program has grown immensely and is proving its ability to impact patient care and health outcomes for people with T1D.

“We are very thankful for the continued support of the Helmsley Charitable Trust, our other partners, and the practitioners putting their hearts into improving diabetes care,” explained David Walton, CEO, MBA.

Learn more about our work in the T1DX-QI, our self-reporting patient Registry, custom research, the Online Community, and extensive study recruitment.

DAY 1 Session Highlights

Here are highlights from presentations throughout Day 1 — review the full agenda here.

Interventions to Improve Technology Equity in Young Adults (YA) with Type 1 Diabetes

Presenter: Priyanka Mathias, MD
Albert Einstein College of Medicine and Montefiore Medical Center

Young adults are the fastest growing population with T1D, explains this research. This population also has the lowest rate of using diabetes technology despite the benefits. Compared to other age groups with T1D, young adults have:

  • Higher HbA1c levels
  • Higher hospitalization rates
  • Higher psychiatric comorbidity
  • Higher risk of mortality

Despite adjusting for social and economic factors, the disparities in technology use in the young adult population are significant. This research established a goal of examining technology use in patients aged 18 to 35 years old from January 2019 to December 2021.

Participant ethnicities were:

  • 55% Hispanic
  • 22% Non-Hispanic Black
  • 10% White
  • 13% Other/unknown

This research focused on addressing those disparities using the SEAD model of care:

  • Talk directly to patients
  • Equity focus
  • Manage expectations
  • Build people up, emphasize positives
  • Manage negatives
  • Avoid doomsday talk

Overall, using the SEAD model of care significantly increased CGM usage rates in young adults with T1D:

  • Overall increase: 31% to 69%
  • Hispanic increase: 12.5% to 71%
  • Non-Hispanic Black increase: 33% to 55%
  • White increase: 33% to 75%

This research concluded that it’s very possible to increase CGM usage in the young adult population but requires a more intentional effort.

Increasing Accessibility to CGM in an Equitable Fashion

Presenter: Blake Adams, BSN, RN
LeBonheur Children’s Hospital and University of Tennessee Health Science Center

This research set forth the goal of reducing inequities in CGM use between white and non-Hispanic black patients from 35% to at least 45% by June 2022 and reducing the use difference by at least 10%.

  • Broad-level tactics (with further detail in each) to address these disparities include:
  • Identify a “CGM champion” within the clinic to streamline the process for prescribing/starting
  • Form relationships DME companies
  • Manage patient education folders with up-to-date information
  • Work with staff to increase CGM knowledge and process awareness
  • Require staff to attend bias training
  • Develop new onset education
  • Work to change insurance coverage requirements

Results were significant, with an increase in the clinic’s overall CGM usage from 35% to 70%.

Developing a Population Health Dashboard Based on Performing Diabetes Self-Management Habits

Presenter: Craig Vandervelden, PhD
Children’s Mercy Hospital

With the goal of improving a patient’s immediate and long-term health, this research proposes the development of a population-health management dashboard focused on critical daily self-management habits. Using the six key habits identified in published work by Joyce Lee, MD, MPH, this research aimed to improve outcomes, increase time-in-range (TIR), and reduce the amount of time a provider must spend with each patient.

Six Habits that improve health outcomes in diabetes

  1. Using a CGM or checking blood sugar at least 4x per day with glucometer
  2. Giving at least 3 rapid-acting boluses per day
  3. Using an insulin pump
  4. Delivering mealtime insulin before meals
  5. Reviewing glucose data at least once between clinic visits
  6. Self-adjusting insulin doses at least once between clinic visits
  7. (Future habit to propose when ready: Improving overall diet)
  8. (Future habit to propose when ready: Increase daily physical activity)

This population health management tool will use these six key habits to help providers assess and incorporate new self-management behaviors. These habits also aim to reduce a patient’s risk of DKA and decrease HbA1c levels.

Based on a patient’s current habits in diabetes self-management, providers can propose new habits with the addition of habits 7 and 8 when ready.

Habits are based on the known 7 pillars of diabetes self-care:

  • Healthy eating
  • Being active
  • Monitoring
  • Taking medication
  • Problem-solving
  • Reducing risk
  • Healthy coping

Further development of this dashboard will consider features that incorporate device data and electronic health data, and ensure every process is easily reusable from one patient to the next.

Nuances of Socioeconomic Status and Health Insurance Associations with HbA1c in Adults with Type 1 Diabetes

Presenter: Caitlin S. Kelly, PhD
T1D Exchange Quality Improvement Collaborative

This research focused on the impact of a patient’s socioeconomic status (SES) on their overall diabetes health. Lower SES is associated with a higher HbA1c in adults with T1D. Markers of SES include personal income, educational attainment, and insurance type.

Research focused on various measured factors in a group of 9,027 participants from the T1D Exchange Registry. Measured factors included:

  • Demographics (race, ethnicity, age, gender)
  • Diabetes technology use (pump use, CGM use)
  • SES (income, education)
  • Residential area (zip code, median county income, metro vs. non-metro)
  • Health insurance type

Findings from the collected data revealed:

  • Participants with higher HbA1c levels were more likely non-white, on Medicaid, or had no health insurance at all.
  • Diabetes technology had the largest impact on HbA1c levels
  • Lower income associated with higher HbA1c levels

The data also suggested that resources available within any given county may play a significant role in the overall health outcomes for adults with T1D. This highlights a need for further investigation into which community resources (or lack thereof) contribute most to HbA1c levels.

Increasing Access to Continuous Glucose Monitor: Addressing Disparities in Type 1 Diabetes

Presenter: Christy Byer-Mendoza, MSN, RN, CPN, CNS
Rady Children’s Hospital and University of California, San Diego School of Medicine

This research emphasized the significant disparities in which populations have access to continuous glucose monitor technology despite the measurable impact it has on health outcomes in type 1 diabetes.

The clinic’s goal was to increase the percentage of children and adolescents with T1D wearing a CGM from 64% to 80% between February 2021 and February 2022.

Children with public insurance have the lowest rates of CGM use. Within the patient cohort of 116 pediatric patients on Medicaid, 83% were prescribed a CGM but only 46% were able to obtain and wear the device.

Equity in Diabetes Care & Transformation: Implementation of Social Determinants of Health Screening in Diabetes Clinic

Presenter: Nana-Hawa Yayah Jones, MD
Cincinnati Children’s Hospital

This research identified significant health inequities related largely to SDOH. Compared to the white population, significant findings about the Black T1D youth population include:

  • Higher HbA1c levels
  • Lower rates of diabetes technology use
  • Higher rates of hospitalizations

By implementing an SDOH screening tool, clinicians can target high-risk patients to ensure their care doesn’t suffer.

Screening questions address issues concerning:

  • Running out of food, worrying about food
  • Feeling depressed, down, or hopeless
  • Struggling with WIC, SNAP, etc.
  • Housing instability
  • Threatened eviction and other housing concerns
  • Difficulty paying for medications
  • Difficulty getting to the doctor or pharmacy

By gathering this data, clinicians can address and support these significant concerns that inevitably impact diabetes care and overall wellness.

As of September 2022, over 5,400 screenings have been completed. SDOH screening in T1D population can be readily adapted to screen other pediatric chronic disease populations in large tertiary care centers, magnifying its impact on healthcare outcomes.

Improving Mental Health Screening in an Adult Endocrinology Clinic

Presenter: Denne Mohandas, BA
Standford Medicine

This research focused on improving the screening process for adults with T1D within clinics consisting of 1,600 to 1,700 patients and 35 to 45 newly diagnosed patients per year. T1D is known to increase rates of depression and other psychosocial challenges.

Prior to this research, the Stanford Adult Endocrine Clinic had no established system for routine mental health screening in patients with T1D. The goal of this research was to increase screening to at least 50% of patients.

Key issues contributing to lack of screening:

  • Depression and anxiety screening may fall under primary care with no official policy
  • No existing procedure for mental health screening in diabetes care
  • No existing procedure for follow-up care in diabetes care

Proposed tactics to increase depression screening:

  • 1 week prior to visit: patient receives PHQ-2 to 8 and GAD-7 surveys
  • 2-3 days prior to visit: patient is reminded to fill out surveys
  • If the patient fails to complete surveys prior to appointment, reassign for next visit
  • Based on survey scores, consider a direct referral for evaluations with psychologist or psychiatrist.
  • Send a follow-up message to the patient confirming the ability to make appointments and establish further support.

For successful implementation, the findings conclude the following is necessary:

  • Further develop an effective workflow to manage referrals based on survey scores
  • Investigate automated invitations/reminders/methods to more efficiently manage survey scores that indicate a need for referrals.
  • Develop a reusable method to reach out directly to patients who are not completing surveys and identify obstacles and barriers.

Improving Screening for Depression in Adolescents with Diabetes

Presenter: Angel Nip, MD (virtual)
Benioff Children’s Hospital and University of San Francisco

This research focused on improving the screening process for adolescents with T1D. Depression is common among adolescents, but rates of depression in those with diabetes are significantly higher. Depression is also associated with higher HbA1c levels and increased rates of diabetes-related hospitalizations.

Initial findings revealed that mental health screenings were not routinely completed for all patients within a clinic and some clinics had no formal screening tool in place at all.

With the goal of achieving depression screening in more than 50% of adolescents with diabetes, a multidisciplinary task force is recommended. This task force should include providers, social workers, transition coordinators, office assistants, diabetes educators, and practice administrators.

Proposed tactics to increase depression screening:

  • Increase screening for depression and referral to social workers for eligible patients
  • Use a consistent screening method with electronic documentation
  • Integrate screening method into routine clinic workflow involving clinic staff and visit planning
  • Increase adequate social work referrals based on screening results
  • Use increased referrals to justify increased staffing of social workers
  • When implemented, these proposed tactics ensured more than 50% of patients were screened for depression.

Click here to request more information about how your clinic can join the T1D Exchange Quality Improvement Collaborative.

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