Search

Given the proven benefits of screening to reduce diabetic ketoacidosis (DKA) likelihood at the time of stage 3 type 1 diabetes diagnosis, and emerging availability of therapy to delay disease progression, type 1 diabetes screening programs are being increasingly emphasized. Once broadly implemented, screening initiatives will identify significant numbers of islet autoantibody-positive (IAb+) children and adults who are at risk for (confirmed single IAb+) or living with (multiple IAb+) early-stage (stage 1 and stage 2) type 1 diabetes. These individuals will need monitoring for disease progression; much of this care will happen in nonspecialized settings. To inform this monitoring, JDRF, in conjunction with international experts and societies, developed consensus guidance. Broad advice from this guidance includes the following: 1) partnerships should be fostered between endocrinologists and primary care providers to care for people who are IAb+; 2) when people who are IAb+ are initially identified, there is a need for confirmation using a second sample; 3) single IAb+ individuals are at lower risk of progression than multiple IAb+ individuals; 4) individuals with early-stage type 1 diabetes should have periodic medical monitoring, including regular assessments of glucose levels, regular education about symptoms of diabetes and DKA, and psychosocial support; 5) interested people with stage 2 type 1 diabetes should be offered trial participation or approved therapies; and 6) all health professionals involved in monitoring and care of individuals with type 1 diabetes have a responsibility to provide education. The guidance also emphasizes significant unmet needs for further research on early-stage type 1 diabetes to increase the rigor of future recommendations and inform clinical care., (© 2024 by the American Diabetes Association and the European Association for the Study of Diabetes.)

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%., Competing Interests: O.E. is a compensated Health Equity Advisory Board member for Medtronic Diabetes and serves as principal investigator for investigator-led projects sponsored by Abbott, Eli Lilly, Insulet, and Medtronic. He is compensated through his organization, the T1D Exchange. No other potential conflicts of interest relevant to this article were reported., (© 2024 by the American Diabetes Association.)

This large type 1 diabetes cohort study showed that insulin pump utilization has increased over time and that use differs by sex, insurance type, and race/ethnicity. Insulin pump use was associated with more optimal A1C, increased use of continuous glucose monitoring (CGM), and lower rates of diabetic ketoacidosis and severe hypoglycemia. People who used an insulin pump with CGM had lower rates of acute events than their counterparts who used an insulin pump without CGM. These findings highlight the need to improve access of diabetes technology through provider engagement, multidisciplinary approaches, and efforts to address health inequities., Competing Interests: O.E. is on the Medtronic Health Equity Advisor Board. H.K.A. has received research grants through the University of Colorado from Dexcom, Eli Lilly, IM Therapeutics, MannKind, REMD, and Senseonics. No other potential conflicts of interest relevant to this article were reported., (© 2024 by the American Diabetes Association.)

The American Diabetes Association's Standards of Care in Diabetes recommends the use of diabetes technology such as continuous glucose monitoring systems and insulin pumps for people living with type 1 diabetes. Unfortunately, there are multiple barriers to uptake of these devices, including local diabetes center practices. This study aimed to examine overall change and center-to-center variation in uptake of diabetes technology across 21 pediatric centers in the T1D Exchange Quality Improvement Collaborative. It found an overall increase in diabetes technology use for most centers from 2021 to 2022 with significant variation., Competing Interests: M.A.C. is the chief medical officer of Glooko and receives research support from Abbott Diabetes Care and Dexcom. O.E. is a Diabetes Health Equity Advisory Board member for Medtronic; his organization, T1D Exchange, has received research support on his behalf from Abbott, Dexcom, Eli Lilly, Medtronic Diabetes, and Vertex; and he has received honoraria from Medtronic Diabetes and Vertex. No other potential conflicts of interest relevant to this article were reported., (© 2024 by the American Diabetes Association.)

Screening for autoantibodies associated with type 1 diabetes can identify people most at risk for progressing to clinical type 1 diabetes and provide an opportunity for early intervention. Drawbacks and barriers to screening exist, and concerns arise, as methods for disease prevention are limited and no cure exists today. The availability of novel treatment options such as teplizumab to delay progression to clinical type 1 diabetes in high-risk individuals has led to the reassessment of screening programs. This study explored awareness, readiness, and attitudes of endocrinology providers toward type 1 diabetes autoantibody screening., Competing Interests: R.S.W. participates in clinical trials that are sponsored, through her institution, by Boehringer Ingelheim, Eli Lilly, Insulet, Medtronic, Novo Nordisk, and Tandem, and uses Dexcom continuing glucose monitoring systems in clinical research studies. O.E. is a Health Equity Advisory Board member for Medtronic Diabetes. No other potential conflicts of interest relevant to this article were reported., (© 2024 by the American Diabetes Association.)

The aim of this study was to describe rates of telemedicine use 18 months after the start of the coronavirus disease 2019 pandemic and to assess the institutional barriers to its implementation for type 1 diabetes care across centers of the T1D Exchange Quality Improvement Collaborative. Observational electronic health record data capturing telemedicine rates from 15 U.S. centers between September 2020 and September 2021 and a survey of 33 centers capturing telemedicine rates and key components of telemedicine were analyzed. A capacity score was developed and summed to a total capacity score and compared with overall telemedicine rates across centers. Telemedicine visits decreased by 17.4% from September 2020 to September 2021. Generally, it was observed that the lower the average telemedicine capacity score, the lower the rate of telemedicine visits. Despite a decline in the utilization of telemedicine 18 months after the start of the pandemic, visit rates were still 20% higher than in the pre-pandemic period. However, there is a need to improve structural components to ensure telemedicine capacity and robust telemedicine utilization., Competing Interests: J.M.L. is on the GoodRx medical advisory board and is a consultant for Tandem. O.E. is a Health Equity Advisory Board member for Medtronic Diabetes. F.V. is a consultant for Eli Lilly. No other potential conflicts of interest relevant to this article were reported., (© 2024 by the American Diabetes Association.)

Social determinants of health (SDOH) are strongly associated with outcomes for people with type 1 diabetes. Six centers in the T1D Exchange Quality Improvement Collaborative applied quality improvement principles to design iterative Plan-Do-Study-Act cycles to develop and expand interventions to improve SDOH screening rates. The interventions tested include staff training, a social risk index, an electronic health record patient-facing portal, partnerships with community organizations, and referrals to community resources. All centers were successful in improving SDOH screening rates, with individual site improvements ranging from 41 to 70% and overall screening across the six centers increasing from a baseline of 1% to 70% in 27 months., Competing Interests: O.E. is a compensated Health Equity Advisory Board member for Medtronic Diabetes and serves as principal investigator for investigator-led projects sponsored by Abbott, Eli Lilly, Insulet, and Medtronic. He is compensated through his organization, the T1D Exchange. No other potential conflicts of interest relevant to this article were reported., (© 2024 by the American Diabetes Association.)

Competing Interests: S.A. works as a health care disparities advisor for Beta Bionics and Medtronic, Inc. O.E. is an advisory board member for the Medtronic Diabetes Health Equity Council. No other potential conflicts of interest relevant to this article were reported.

Objective: To compare demographic, clinical, and therapeutic characteristics of children with type 1 diabetes age <6 years across three international registries: Diabetes Prospective Follow-Up Registry (DPV; Europe), T1D Exchange Quality Improvement Network (T1DX-QI; U.S.), and Australasian Diabetes Data Network (ADDN; Australasia)., Research Design and Methods: An analysis was conducted comparing 2019-2021 prospective registry data from 8,004 children., Results: Mean ± SD ages at diabetes diagnosis were 3.2 ± 1.4 (DPV and ADDN) and 3.7 ± 1.8 years (T1DX-QI). Mean ± SD diabetes durations were 1.4 ± 1.3 (DPV), 1.4 ± 1.6 (T1DX-QI), and 1.5 ± 1.3 years (ADDN). BMI z scores were in the overweight range in 36.2% (DPV), 41.8% (T1DX-QI), and 50.0% (ADDN) of participants. Mean ± SD HbA1c varied among registries: DPV 7.3 ± 0.9% (56 ± 10 mmol/mol), T1DX-QI 8.0 ± 1.4% (64 ± 16 mmol/mol), and ADDN 7.7 ± 1.2% (61 ± 13 mmol/mol). Overall, 37.5% of children achieved the target HbA1c of <7.0% (53 mmol/mol): 43.6% in DPV, 25.5% in T1DX-QI, and 27.5% in ADDN. Use of diabetes technologies such as insulin pump (DPV 86.6%, T1DX 46.6%, and ADDN 39.2%) and continuous glucose monitoring (CGM; DPV 85.1%, T1DX-QI 57.6%, and ADDN 70.5%) varied among registries. Use of hybrid closed-loop (HCL) systems was uncommon (from 0.5% [ADDN] to 6.9% [DPV])., Conclusions: Across three major registries, more than half of children age <6 years did not achieve the target HbA1c of <7.0% (53 mmol/mol). CGM was used by most participants, whereas insulin pump use varied across registries, and HCL system use was rare. The differences seen in glycemia and use of diabetes technologies among registries require further investigation to determine potential contributing factors and areas to target to improve the care of this vulnerable group., (© 2024 by the American Diabetes Association.)

Background: Health insurance coverage type differs significantly by socioeconomic status and racial group in the United States. The aim of this study was to determine whether publicly insured children and young adults with type 1 diabetes were more likely to experience adverse outcomes compared with privately insured patients with acute coronavirus disease 2019 (COVID-19) infections., Methods: Data from 619 patients with previously established type 1 diabetes who were <24 years of age with acute COVID-19 infections were analyzed from the T1D Exchange COVID-19 surveillance registry. Data for the registry was collected from 52 endocrinology clinics across the United States using an online survey tool. Each site completed the survey using electronic health record data between April 2020 and December 2021., Results: Of the 619 patients included in this study, 257 had public insurance and 362 had private insurance. Of the 257 publicly insured patients with COVID-19, 57 reported severe adverse outcomes (22%), defined as diabetic ketoacidosis (DKA) or severe hypoglycemia. In comparison, there were 25 reported adverse outcomes (7%) among the 362 privately insured patients., Conclusion: Our data reveal high rates of hospitalization and DKA among publicly insured racial/ethnic minority children and young adults with type 1 diabetes and COVID-19., Competing Interests: O.E. is the principal investigator for research projects funded through his institution by Dexcom, Eli Lilly, and Medtronic; he is also a member of the Medtronic Diabetes Health Inequity Advisory Board. No other potential conflicts of interest relevant to this article were reported., (© 2023 by the American Diabetes Association.)

This article describes successful interventions from the T1D Exchange Quality Improvement Collaborative (T1DX-QI) to reduce inequities in access to and use of continuous glucose monitoring (CGM). The author proposes a roadmap with recommendations for different stakeholders to achieve CGM equity using insights from the T1DX-QI experience., Competing Interests: O.E. is a member of the Medtronic Diabetes Health Equity Advisory Board and Sanofi Diabetes T1D Screening Advisory Board. His organization, the T1D Exchange, has received research support on his behalf from Abbott, Dexcom, Eli Lilly, Medtronic Diabetes, and Vertex. He has received honoraria from Medtronic Diabetes and Vertex. No other potential conflicts of interest relevant to this article were reported., (© 2023 by the American Diabetes Association.)

Quality Improvement Success Stories are published by the American Diabetes Association in collaboration with the American College of Physicians and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes . The following article describes an effort to improve the remote collection of insulin pump data in an academic center in South Florida., Competing Interests: No potential conflicts of interest relevant to this article were reported., (© 2023 by the American Diabetes Association.)

The optimal care of type 1 diabetes involves consistent glycemic management to avoid short- and long-term complications. However, despite advancements in diabetes technology and standards, achieving adequate glycemic levels in children and adolescents remains a challenge. This study aimed to identify factors associated with achieving the recommended A1C target of <7% from the United States-based multicenter T1D Exchange Quality Improvement Collaborative cohort, including 25,383 children and adolescents living with type 1 diabetes., (© 2022 by the American Diabetes Association.)

This article describes how the T1D Exchange Quality Improvement Collaborative leverages an innovative web platform, the QI Portal, to gather and store electronic medical record (EMR) data to promote benchmarking and population health improvement in a type 1 diabetes learning health system. The authors explain the value of the QI Portal, the process for mapping center-level data from EMRs using standardized data specifications, and the QI Portal's unique features for advancing population health., (© 2022 by the American Diabetes Association.)

This study sought to identify barriers and facilitators to successful smart insulin pen (SIP) use and gauge prescribing practices and integration into clinical practice by assessing provider and care team perspectives at participating endocrinology clinics within the T1D Exchange Quality Improvement Collaborative. The identified provider-related, patient-related, and clinic- and operational-level barriers and facilitators varied based on clinic knowledge, capacity, and resources. High-impact barriers included insurance coverage and prescribing processes; high-impact facilitators included improved diabetes clinic visit quality and use of SIPs as an alternative to insulin pump therapy. Findings indicated the need for provider and care team education and training on proper SIP features, use, and prescribing., (© 2022 by the American Diabetes Association.)

This article describes the evolution of the Type 1 Diabetes Exchange Quality Improvement Collaborative (T1DX-QI) and provides insight into the development and growth of a successful type 1 diabetes quality improvement (QI) program. Since its inception 8 years ago, the collaborative has expanded to include centers across the United States with varying levels of QI experience, while simultaneously achieving many tangible improvements in type 1 diabetes care. These successes underscore the importance of learning health systems, data-sharing, benchmarking, and peer collaboration as drivers for continuous QI. Future efforts will include recruiting additional small- to medium-sized centers focused on adult care and underserved communities to further the goal of improving care and outcomes for all people living with type 1 diabetes., (© 2022 by the American Diabetes Association.)

Many adults with diabetes do not reach optimal glycemic targets, and, despite advances in diabetes management, diabetes technology use remains significantly lower in racial/ethnic minority groups. This study aimed to identify factors associated with achieving the recommended A1C target of <7% using data on 12,035 adults with type 1 diabetes from 15 centers participating in the T1D Exchange Quality Improvement Collaborative. Individuals attaining the target A1C were more likely to be older, White, have private health insurance, and use diabetes technology and less likely to report depressive symptoms or episodes of severe hypoglycemia or diabetic ketoacidosis than those with higher A1C levels. These findings highlight the importance of overcoming inequities in diabetes care., (© 2022 by the American Diabetes Association.)

There are limited tools to address equity in diabetes research and clinical trials. The T1D Exchange has established a 10-step equity framework to advance equity in diabetes research. Herein, the authors outline this approach and expand on its practical application., (© 2022 by the American Diabetes Association.)

Insulin pump therapy in pediatric type 1 diabetes has been associated with better glycemic control than multiple daily injections. However, insulin pump use remains limited. This article describes an initiative from the T1D Exchange Quality Improvement Collaborative aimed at increasing insulin pump use in patients aged 12-26 years with type 1 diabetes from a baseline of 45% in May 2018 to >50% by February 2020. Interventions developed by participating centers included increasing in-person and telehealth education about insulin pump technology, creating and distributing tools to assist in informed decision-making, facilitating insulin pump insurance approval and onboarding processes, and improving clinic staff knowledge about insulin pumps. These efforts yielded a 13% improvement in pump use among the five participating centers, from 45 to 58% over 22 months., Competing Interests: O.E. is a compensated Health Equity Advisory Board member for Medtronic Diabetes and serves as the principal investigator for investigator-led projects sponsored by Abbott, Dexcom, Eli Lilly, Insulet, and Medtronic. J.M.L. is on the medical advisory board for GoodRx. No other potential conflicts of interest relevant to this article were reported., (© 2021 by the American Diabetes Association.)

Despite immense strides in therapeutic advances, clinical outcomes continue to be less than ideal for people with type 1 diabetes. This discrepancy has prompted an outpouring of quality improvement (QI) initiatives to address the medical, psychosocial, and health equity challenges that complicate ideal type 1 diabetes care and outcomes. This article reviews a framework for QI in diabetes care that guided the development of the T1D Exchange Quality Improvement Collaborative to improve care delivery and health outcomes in type 1 diabetes. Evaluation of the methodology, outcomes, and knowledge gained from these initiatives will highlight the importance of continued QI initiatives in diabetes care., Competing Interests: O.E. is a compensated Health Equity Advisory Board member for Medtronic Diabetes and serves as the principal investigator for investigator-led projects sponsored by Abbott, Dexcom, Eli Lilly, Insulet, and Medtronic. J.M.L. is on the medical advisory board for GoodRx. D.J.D. is a consultant to Dexcom and Insulet. No other potential conflicts of interest relevant to this article were reported., (© 2021 by the American Diabetes Association.)

Health care inequities among racial and ethnic groups remain prevalent. For people with type 1 diabetes who require increased medical access and care, disparities are seen in access to care and health outcomes. This article reports on a study by the T1D Exchange Quality Improvement Collaborative evaluating differences in A1C, diabetic ketoacidosis (DKA), severe hypoglycemia, and technology use among racial and ethnic groups. In a diverse cohort of nearly 20,000 children and adults with type 1 diabetes, A1C was found to differ significantly among racial and ethnic groups. Non-Hispanic Blacks had higher rates of DKA and severe hypoglycemia and the lowest rate of technology use. These results underscore the crucial need to study and overcome the barriers that lead to inequities in the care and outcomes of people with type 1 diabetes., Competing Interests: O.E. is a compensated Health Equity Advisory Board member for Medtronic Diabetes and serves as the principal investigator for investigator-led projects sponsored by Abbott, Dexcom, Eli Lilly, Insulet, and Medtronic. No other potential conflicts of interest relevant to this article were reported., (© 2021 by the American Diabetes Association.)

Continuous glucose monitoring (CGM) use is associated with improved A1C outcomes and quality of life in adolescents and young adults with diabetes; however, CGM uptake is low. This article reports on a quality improvement (QI) initiative of the T1D Exchange Quality Improvement Collaborative to increase CGM use among patients in this age-group. Ten centers participated in developing a key driver diagram and center-specific interventions that resulted in an increase in CGM use from 34 to 55% in adolescents and young adults over 19-22 months. Sites that performed QI tests of change and documented their interventions had the highest increases in CGM uptake, demonstrating that QI methodology and sharing of learnings can increase CGM uptake., Competing Interests: O.E. is a compensated Health Equity Advisory Board member for Medtronic Diabetes and serves as principal investigator for investigator-led projects sponsored by Abbott, Eli Lilly, Insulet, and Medtronic. M.C. has consulting arrangements with Eli Lilly and Medtronic, is an employee (chief medical officer) of Glooko, and has received research support from Abbott Diabetes Care and Dexcom and travel support from Intrexon and Provention Bio. J.M.L. is on a medical advisory board for GoodRx. D.M.M. has received research support from the Helmsley Charitable Trust, JDRF, the National Institutes of Health, and the National Science Foundation; his institution has received research support from Bigfoot Biomedical, Dexcom, Insulet, Medtronic, Roche, and Tandem; and he has been a consultant for Abbott, Aditxt, Dompe, Eli Lilly, the Helmsley Charitable Trust, Insulet, Medtronic, Novo Nordisk, and Sanofi. No other potential conflicts of interest relevant to this article were reported., (© 2021 by the American Diabetes Association.)