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Background: Glycemic control in the hospital setting is imperative for improving outcomes among patients with diabetes. Bedside point-of-care (POC) glucose monitoring has remained the gold standard for decades, while only providing momentary glimpses into a patient’s glycemic control. Continuous glucose monitoring (CGM) has been shown to improve glycemic control in the ambulatory setting. However, a paucity of inpatient experience and data remains a barrier to US Food and Drug Administration (FDA) approval and expanded/non-research use in the hospital setting. Method: Amid the COVID-19 pandemic, the FDA exercised its enforcement discretion to not object to the use of CGM systems for the treatment of patients in hospital settings to support COVID-19 health care–related efforts to reduce viral exposure of health care workers. Following this announcement, Scripps Health, a large not-for-profit health care system in San Diego, California, implemented CGM as the new “standard of care” (CGM as SOC) for glucose monitoring and management in the hospital. Results: The present report serves to (1) detail the implementation procedures for employing this new SOC; (2) describe the patients receiving CGM as SOC, their glycemic control, and hospital outcomes; and (3) share lessons learned over two years and nearly 900 hospital encounters involving CGM. Conclusions: Here, we conclude that CGM is feasible in the hospital setting by using a dedicated diabetes care team and the CGM technology with remote monitoring.

The majority of individuals referred to diabetes self-management education and support (DSMES) programs do not access this resource. Of those who do, attrition is high, with anecdotal reports pointing to the didactic and impersonal nature of these programs contributing to low utilization and completion rates. In an effort to develop a more engaging form of DSMES for adults with type 2 diabetes (T2D), we constructed a non-didactic, "discovery learning"-based DSMES program centered on real-time flash glucose monitoring (FGM).In this single-arm pilot study, 35 adults with T2D duration 1 - 5 years, ages 21 - 75 years, not using insulin and HbA1c8.0% were introduced to FGM and participated in five weekly group sessions. DSMES content was personalized, emerging from the concerns and questions arising from participants' FGM discoveries. The primary outcome was glycemic change as assessed by blinded FGM at baseline and month 3. Secondary outcomes included psychosocial and behavioral measures.There was a significant gain in % TIR 70 -180 mg/dL from baseline (55%) to month 3 (74%), and a parallel drop in TAR180 mg/dL from 44% to 25% (ps = 0.01). Overall well-being rose significantly (p = 0.04), while diabetes distress showed a non-significant drop. Participants reported improvements in healthy eating (p0.001) and physical activity, though the latter did not reach statistical significance.These findings support a new approach to DSMES, a method that integrates FGM with a highly interactive and engaging, patient-driven, "discovery learning" approach to education.

Type 2 diabetes disproportionately impacts ethnic minorities and individuals from low socioeconomic status. Diabetes self-management education and support has been shown to improve clinical outcomes in these populations, and mobile health (mHealth) interventions can reduce barriers to access. Dulce Digital-Me (DD-Me) was developed to integrate adaptive mHealth technologies to enhance self-management and reduce disparities in the high-risk, underserved Hispanic population. The objective of the present study was to evaluate reach, adoption, and implementation of an mHealth diabetes self-management education and support intervention in this underrepresented population. The present analysis is a multimethod process evaluation using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. The study was effective in reaching a sample that was representative of the intended population; only modest but significant differences were observed in sex and age. The DD-Me health coach (HC) cited several important facilitators of intervention adoption, including outreach frequency and personalization, and the automated HC report. Implementation fidelity was high, with participants receiving >90% of intended interventions. Participants who received DD-Me with support from a HC were most engaged, suggesting utility and acceptability of integrating HCs with mHealth interventions. Perceptions of implementation among study participants were positive and consistent across study arms. This evaluation revealed the target population was successfully reached and engaged in the digital health interventions, which was implemented with high fidelity. Further studies should evaluate the efficacy and maintenance of the study following the RE-AIM model to determine whether this intervention warrants expansion to additional settings and populations.

Team-based models that use medical assistants (MAs) to provide self-management support for adults with type 2 diabetes (T2D) have not been pragmatically tested in diverse samples. This cluster-randomized controlled trial compares MA health coaching with usual care in adults with T2D and poor clinical control (“MAC Trial”). The purpose was to conduct a multi-method process evaluation of the MAC Trial using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. Reach was assessed by calculating the proportion of enrolled participants out of the eligible pool and examining representativeness of those enrolled. Key informant interviews documented adoption by MA Health Coaches. We examined implementation from the research and patient perspectives by evaluating protocol adherence and the Patient Perceptions of Chronic Illness Care (PACIC-SF) measure, respectively. Findings indicate that the MAC Trial was efficient and effective in reaching patients who were representative of the target population. The acceptance rate among those approached for health coaching was high (87%). Both MA Health Coaches reported high satisfaction with the program and high levels of confidence in their role. The intervention was well-implemented, as evidenced by the protocol adherence rate of 79%; however, statistically significant changes in PACIC-SF scores were not observed. Overall, if found to be effective in improving clinical and patient-reported outcomes, the MAC model holds potential for wider-scale implementation given its successful adoption and implementation and demonstrated ability to reach patients with poorly controlled T2D who are at-risk for diabetes complications in diverse primary care settings.

While good cardiometabolic control can reduce complications in type 2 diabetes (T2D) , many individuals do not achieve clinical targets. This real-world trial compared medical assistant health coaching (MAC) to usual care (UC) in improving outcomes among adults with T2D and ≥ 1 of the following in the past 90 days: HbA1c ≥ 8%, LDL ≥ 100 mg/dL, SBP ≥ 140 mm/Hg. This N=600 study was conducted from 2016-2021 at four cluster-randomized clinics within two diverse health systems in Southern CA: a large, private insurance-based system [n = 298, majority non-Hispanic White, English-speaking, mid/upper socioeconomic status (SES) ]; M age = 70.2 ± 12.6] and a Federally-Qualified Health Center (n = 302, majority Hispanic, Spanish-speaking, lower SES; M age = 56.9 ± 12.0) . MAC and UC received diabetes care as usual in primary care, with referral to diabetes education and/or specialists as indicated. MAC also received in-clinic and telephone-based health coaching for up to one year (1-14 sessions; M = 5.2 ± 2.8) . Baseline mean HbA1c = 8.8 ± 2.2%, LDL = 101.8 ± 44.8 mg/dL, and SBP = 137.9 ± 19.4 mm/Hg. From baseline to 12-months, the percentage of individuals meeting quality metrics increased in both groups: HbA1c < 8% (MAC: 74.8 to 79.9%; UC: 64.0 to 80.4%) , LDL < 100 mg/dL (MAC: 75.7 to 84.9%; UC: 72.6 to 82.4%) , SBP < 140 mm/Hg (MAC: 75.0 to 86.9%; UC: 80.2 to 86.4%) . When outcomes were analyzed continuously using multi-level modeling, both MAC and UC demonstrated statistically significant improvements on all clinical outcomes; however, the rate of improvement was largely equivalent across groups (time-by-group ps > .05) . Due to the pragmatic nature of this trial, there was marked variation (by design) in intervention duration and intensity across participants, and in clinical and sociodemographic characteristics of participants across health systems. Additional analyses examining under what conditions and/or for whom the MAC intervention may prove more/less effective will be presented. Disclosure A.L.Fortmann: Consultant; Ascensia Diabetes Care, Employee; Dexcom, Inc. A.Philis-tsimikas: Advisory Panel; Bayer AG, Novo Nordisk, Research Support; Lilly Diabetes, National Institute of Diabetes and Digestive and Kidney Diseases, Novo Nordisk, Viking Therapeutics. T.Clark: None. S.R.Spierling bagsic: None. H.Sandoval: None. K.L.Savin: None. S.Roesch: None. L.Gallo: None. Funding NIH/NIDDK 1R18DK104250

Mobile health delivery of diabetes self-management education and support (DSME/S) can reduce barriers among racial/ethnic minority populations (e.g., Hispanics) , but little is known about how participant characteristics shape adherence and engagement with mHealth interventions. The current study examined this using data from Dulce Digital-Me, a randomized trial that tested an adaptive mHealth DSME/S intervention among 3Hispanic adults with poorly managed type 2 diabetes from a Federally Qualified Health Center in San Diego, CA. In addition to core educational content, participants in three intervention arms received text messages with ecological momentary assessment (EMA) of health behaviors and prompts to check their blood glucose (BG) over 24 weeks. Linear regression models examined associations of age, sex, diabetes duration, health literacy (Single Item Literacy Scale) , and diabetes distress (Diabetes Distress Scale-17) at baseline with the percentage of EMA and BG checks completed, controlling for study arm. Average participant age was 52.6 years ± 11.5; 70% were female. Younger age (B=-.88) , longer diabetes duration (B=.51) , lower health literacy (B=-4.7) , and lower diabetes distress (B=-6.7) predicted significantly higher EMA completion, while only lower distress (B=-4.5) predicted higher BG check completion (all ps Disclosure T.Clark: None. A.L.Fortmann: Consultant; Ascensia Diabetes Care, Employee; Dexcom, Inc. A.Philis-tsimikas: Advisory Panel; Bayer AG, Novo Nordisk, Research Support; Lilly Diabetes, National Institute of Diabetes and Digestive and Kidney Diseases, Novo Nordisk, Viking Therapeutics. K.L.Savin: None. H.Sandoval: None. S.R.Spierling bagsic: None. L.Gallo: None. Funding National Institutes of Health (NCT03130699)

Diabetes, high blood pressure, and obesity are major risk factors for cardiovascular disease (CVD) . Access to and awareness of health education programming is often low in ethnic/racial minorities and individuals of low socioeconomic status experience a higher prevalence of T2D, hypertension, CVD and stroke. Additionally, underserved, at-risk patients face barriers to accessing traditional in-person diabetes self-management education and support (DSME/S) due to transportation, caregiving, and work conflicts. To address this gap, the ADA’s Know Diabetes by Heart (KDBH) initiative partnered with Project Dulce, an evidence-based culturally and linguistically modified DSME/S program to overlay an innovative digital approach to diabetes support programming and resources in the community. In response to COVID-restrictions, Project Dulce sessions integrating KDBH content were delivered via telehealth group sessions and text messaging to encourage heart healthy self-management behaviors. Pre/post surveys assessed knowledge and self-management, and clinical metrics were evaluated via electronic health records. The KDBH/Project Dulce DSME/S program was delivered to 5 health systems in California: 2 Federally Qualified Health Centers, 2 County health clinics and 1 large community-based health system near the US/Mexico border. Of the N=553 who received KDBH/Project Dulce education, 47% were White, 36% Hispanic, 14% African American, Asian, Native American, Pacific Islander, and 3% other. Of all enrollees, 58% were female, and 15% were /= 66 y/o. Participant feedback indicated acceptance of both the group virtual and texting programs. Findings demonstrate the feasibility of disseminating important heart healthy interventions to diverse ethnic/racial minority groups via a variety of digital and telehealth methods. Disclosure M.Ruiz: n/a. A.L.Fortmann: Consultant; Ascensia Diabetes Care, Employee; Dexcom, Inc. H.Sandoval: None. A.Philis-tsimikas: Advisory Panel; Bayer AG, Novo Nordisk, Research Support; Lilly Diabetes, National Institute of Diabetes and Digestive and Kidney Diseases, Novo Nordisk, Viking Therapeutics. M.Chichmarenko: None. S.R.Bagsic: None. J.Boyer: None. Funding American Diabetes Association/KDBH

Dulce Digital (DD) , a simple low-cost text message program designed to enhance clinical diabetes care with educational, motivational and glucose reminder messages when delivered 2-3 times/day over 6 months has been shown to be highly acceptable in diverse racial/ethnic minorities and low SES communities and results in a mean 1% reduction in HbA1c compared to usual care. During the COVID pandemic, barriers to in-person care, including quarantines, stay-at-home work schedules, childcare, and transportation, make digital messaging a practical means of improving patient health. To maximize reach in the T2DM population, a large Southern California health care provider integrated DD into their DSME/S offering. This study aims to learn the reach, acceptability, and effectiveness of Dulce Digital in a real-world patient care setting to motivate patients with daily self-care behaviors. An existing diabetes registry identified N=1423 patients with T2DM and HbA1c>7.5% in the last 6 months. There was enthusiastic adoption of the DD texting program byprimary care clinic sites with 78 providers across the County. Patient recruitment was conducted via a patient portal message (EPIC My Chart) sent from healthcare providers encouraging participation in the program. Within one week of portal outreach, 116 patients (8.2%) enrolled (mean age = 57.3 y/o +/- 14.4, range 24-92; 50% female; mean HbA1c= 9.9 % +/- 1.5, range 8.1-16.2) . Program workflows include using support staff to monitor blood glucose responses in the texting platform, assess possible reasons for hyper/hypoglycemia, and encourage follow up with a provider as needed. Adoption by patients and providers to date demonstrate a digital texting program is acceptable and desired equally by men and women across a wide range of ages in patients with T2D and elevated HbA1c. Outreach to enroll patients using a patient EMR portal can be successful and can serve as an enhanced approach to support DSME/S. Disclosure M.Ruiz: n/a. A.Philis-tsimikas: Advisory Panel; Bayer AG, Novo Nordisk, Research Support; Lilly Diabetes, National Institute of Diabetes and Digestive and Kidney Diseases, Novo Nordisk, Viking Therapeutics. H.Sandoval: None. A.L.Fortmann: Consultant; Ascensia Diabetes Care, Employee; Dexcom, Inc. M.A.Stechschulte: None. S.R.Bagsic: None. K.Patel: None. K.Mendez: None.

Background: To examine experiences with real-time continuous glucose monitoring (RT-CGM) data sharing and its impact on health-related outcomes. Methods: Adults with type 1 diabetes (T1D) (N = 302) using the Dexcom G5 Mobile or G6 RT-CGM system and sharing data with ≥1 family/friend follower completed a survey exploring their perceived value of data sharing, the impact of sharing on health and quality of life (QoL) outcomes, and how their chief follower (CF) used shared data to support their diabetes management. Regression analyses examined whether CF actions were linked to reported changes in health and QoL outcomes for the T1D adult. Results: The majority had lived with T1D >10 years, (76.5%), used RT-CGM >1 year (58.0%), and identified their spouse/partner as CF (51.9%). Data sharing reportedly contributed to improved hypoglycemic confidence (for 89.4% of respondents), improved overall well-being (54.3%), and reduced diabetes distress (36.1%). Benefits related to data sharing included fewer episodes of severe hypoglycemia (62.2%), better sleep (52.4%), and A1C improvement (47.3%). In particular, three positive CF actions were independent predictors of health and QoL benefits: celebrating success related to glycemic control, providing encouragement when glycemic control is challenging, and teamwork discussions about how CF should respond to out-of-range values. Conclusions: RT-CGM data sharing was associated with a range of health and QoL-related benefits. The occurrence of benefits was influenced by the collaborative management approaches taken by RT-CGM users and their data-sharing followers. Longitudinal trials are needed to determine the most effective patterns of collaborative data sharing, leading to their implementation into routine diabetes management.

OBJECTIVEThe current standard for hospital glucose management is point-of-care (POC) testing. We conducted a randomized controlled trial of real-time continuous glucose monitoring (RT-CGM) compared with POC in a non–intensive care unit (ICU) hospital setting.RESEARCH DESIGN AND METHODSA total of 110 adults with type 2 diabetes on a non-ICU floor received RT-CGM with Dexcom G6 versus usual care (UC). RT-CGM data were wirelessly transmitted from the bedside. Hospital telemetry monitored RT-CGM data and notified bedside nursing of glucose alerts and trends. Standardized protocols were used for interventions.RESULTSThe RT-CGM group demonstrated significantly lower mean glucose (M∆ = −18.5 mg/dL) and percentage of time in hyperglycemia >250 mg/dL (−11.41%) and higher time in range 70–250 mg/dL (+11.26%) compared with UC (P values CONCLUSIONSRT-CGM can be used successfully in community-based hospital non-ICU settings to improve glucose management. Continuously streaming glucose readings may truly be the fifth vital sign.

IN BRIEF Diabetes continues to represent a substantial individual and societal burden for those affected by the disease and its complications in the United States, and especially for racial/ethnic minorities, the socioeconomically disadvantaged, and the underinsured. Although tools and strategies are now available to manage the condition and its associated comorbidities at the patient level, we continue to struggle to gain control of this health burden at the population health level. Most patients are not achieving desired clinical goals and thus continue to be exposed to preventable risks and complications. As the U.S. health system moves toward a more value-based system of reimbursement, there are opportunities to rethink our approaches to patient and population health management and to harness the available tools and technologies to better understand the disease burden, stratify our patient populations by risk, redirect finite resources to high-impact initiatives, and facilitate better diabetes care management for patients and providers alike.

Objective: The objective of the study is to identify predictors of utilization of a type 2 diabetes (T2D) management App over time for insulin users (IUs) and noninsulin users (NIUs). Research Design and Methods: We followed over 16 weeks a national sample of unselected T2D adults who independently elected to download and pair a CONTOUR DIABETES App with their CONTOUR NEXT ONE glucose meter. App use and frequency of glucose testing were recorded. Baseline surveys recorded participant demographic, disease status, distress, medication taking, and views of technology to predict utilization. Results: Mean age was 51.6 years (108 IUs; 353 NIUs), 48% were female, time with diabetes was 6.9 years, and self-reported HbA1c was 8.1% (36.3 mmol/mol). Mean duration of App use was 85.4 days and 40% stopped using the App before 16 weeks. Continuous users were older and reported higher distress, better medication taking, and more positive attitudes toward technology (all P < .01). IUs tested more frequently than NIUs, but frequency and intensity of testing decreased markedly for both groups over time. More predictors of App use frequency and testing occurred for NIUs than IUs: older age, higher HbA1c, lower distress, more medication taking (all P < .05). Conclusions: App use and testing decreased markedly over time. Variations in the predictors of frequency of App use suggest that the utilization of mobile technologies requires a tailored approach that addresses the specific needs of individual users, compared with adopting a one-size-fits-all strategy, and that IUs and NIUs may require very different strategies of customization.

COVID-19 challenges organizations to modify approaches to optimize diabetes management while reducing Personal Protective Equipment (PPE) use and nurse time, and maintaining patient safety. In April 2020, Scripps Health, a five-hospital health system in southern California created a subcutaneous Diabetes Ketoacidosis (DKA) treatment option for use with adults, admitted with mild to moderate DKA. Primary aims were to achieve DKA resolution and glycemic targets similar to the intravenous (IV) insulin treatment option, and no hypoglycemia The new order set utilized weight-based dosing, with similar orders for labs, electrolyte and IV fluid replacement, and resolution criteria. Differences included automatic insulin dosing and basal/bolus insulin. Key changes were a reduced frequency of point of care testing (POCT) and ≤140 mg/dL hypoglycemia prevention orders. Post-implementation audits between April - July 2020 showed no hypoglycemia and resolution time similar to IV insulin. However, only 6% (N=17) of DKA cases were managed with subcutaneous, as compared to IV insulin. To help understand why there was such a limited uptake, a detailed retrospective chart review was undertaken on a subset of twenty-two DKA cases managed with IV insulin. Findings showed that 17 (77%) had type 2 diabetes, 5 (23%) had type 1 diabetes. 47% of cases had opportunities for subcutaneous management based on DKA classification and no contraindications for subcutaneous therapy. Findings indicate organizations should consider a DKA subcutaneous option. Lack of knowledge of DKA severity may be a factor in low utilization, therefore an EHR DKA Classification tool was implemented to support providers. Research is needed to determine if this increases utilization of the subcutaneous treatment option and what other barriers exist. Disclosure D. Meehan: None. L. Talavera: None. A. Philis-tsimikas: Advisory Panel; Self; Bayer Inc., Lilly Diabetes, Medtronic, Novo Nordisk, Consultant; Self; Sanofi-Aventis, Employee; Spouse/Partner; Ionis, Other Relationship; Self; Merck & Co., Inc., Research Support; Self; Dexcom, Inc., Lilly Diabetes, Medtronic, Novo Nordisk, Sanofi-Aventis. A. L. Fortmann: None.

PurposeThis systematic review examined whether diabetes self-management education (DSME) interventions for US Latino adults improve general emotional distress (eg, depression symptoms) and/or health-specific emotional distress (eg, diabetes distress). The topic is important given the high prevalence of type 2 diabetes (T2DM), concomitant distress, and worse health outcomes among Latinos and considering the barriers that distress poses for effective diabetes self-management.MethodsFollowing PRISMA guidelines, a search of the online databases PsycINFO, CINAHL, PubMed, and CENTRAL was conducted from database inception through April 2018. A comprehensive search strategy identified trials testing DSME interventions for US Latinos with T2DM that reported on changes in general or health-specific emotional distress. Risk of bias was assessed using the EPHPP Quality Assessment Tool. Raw mean differences ( D) and effect sizes ( d) were computed where possible.ResultsFifteen studies were included in the review. Six of 8 studies that examined depression symptoms reported significant symptom reduction. Of 10 studies that examined health-specific emotional distress, 6 reported significant symptom reduction. Effect sizes ranged from −0.20 to –3.85. Null findings were more readily found among studies with very small sample sizes (n < 30) and studies testing interventions without specific psychosocial content, with little cultural tailoring, with less frequent intervention sessions, and with support sessions lacking concurrent diabetes education. Most studies (11) received a weak rating of evidence quality.ConclusionsThere is an absence of strong evidence to support that DSME programs tailored for Latino adults with T2DM are beneficial for improving emotional distress. Methodologically robust studies are needed.

Background: To examine caregivers’ experiences with real-time continuous glucose monitoring (RT-CGM) data sharing and its impact on quality of life (QoL) and health outcomes. Methods: Parents of children with type 1 diabetes (T1D) ( N = 303) and spouses/partners of T1D adults ( N = 212) using the Dexcom G5 Mobile or G6 RT-CGM system and who were actively following their T1Ds’ RT-CGM data completed a survey examining their perceived value of data sharing, the impact of sharing on their own QoL and their child/partner’s health, and how they used RT-CGM data to support their T1Ds’ diabetes management. Regression analyses examined whether their actions were linked to reported changes in QoL and health outcomes. Results: Respondents were predominantly non-Hispanic White (91.1% parents; 88.7% partners), female (78.2% parents; 54.7% partners), and college-educated (65.3% parents; 61.8% partners). The majority reported that data sharing had enhanced hypoglycemic confidence (97.7% parents; 98.1% partners), overall well-being (60.4% parents; 63.2% partners), and sleep quality (78.0% parents; 61.3% partners). Of note, three positive caregiver actions were broadly consistent and significant predictors of QoL and health benefits for both parents and partners: celebrating success related to glycemic control, providing encouragement when glycemic control is challenging, and teamwork discussions about how the caregiver should respond to out-of-range values. Conclusions: RT-CGM data sharing was associated with a range of QoL and health benefits for caregivers. Degree of benefits was influenced by the collaborative actions taken by caregivers to support their child’s or partner’s diabetes management. To determine the most effective strategies for collaborative data sharing, longitudinal trials are needed.

OBJECTIVE: The current standard for hospital glucose management is point-of-care (POC) testing. We conducted a randomized controlled trial comparing real-time CGM (RT-CGM) to POC in a non-ICU hospital setting. RESEARCH DESIGN AND METHODS: N=110 adults with type 2 diabetes (T2D) on a non-ICU floor received RT-CGM with Dexcom G6 vs usual care (UC). RT-CGM data were wirelessly transmitted from the bedside. Hospital telemetry monitored RT-CGM data and notified bedside nursing of glucose alerts and trends. Standardized protocols were used for interventions. RESULTS: The RT-CGM group demonstrated significantly lower mean glucose (M∆= -18.5 mg/dL) and percentage of time in hyperglycemia >250 mg/dL (-11.41%), and higher median TIR 70-250 mg/dL (+11.26%) compared with UC (ps CONCLUSION: RT-CGM can be used successfully in community-based hospital non-ICU settings to improve glucose management; continuously streaming glucose readings may truly be the 5th vital sign.

Self-adjusting insulin is challenging for people with type 2 diabetes (PWT2D). Mobile health technologies (mHealth) can help PWT2D track blood glucose more easily, but it remains unclear whether an mHealth-enabled digital therapeutic tool can effectively support basal insulin (BI) titration in a large multispecialty health care setting. We randomized 242 PWT2D on BI (baseline HbA1c 7.5% - 12.5%) to use either an app-based self-titration tool [Mobile Insulin Dosing System (MIDS)] or an enhanced paper titration tool based on a stepped algorithm with diabetes educator support (control) for 16 weeks. Cohort characteristics for the intent to treat sample (MIDS n = 117; control n = 120) were: median age 61 years [IQR: 53 - 69], 41.7% female, 75.9% non-Hispanic White, 11.4% new to insulin, median duration of diabetes 11 years [IQR: 7 - 18], and median baseline HbA1c of 8.7% [IQR: 8.0 - 9.6]. Improvements in HbA1c (-1.3% [IQR: -2.2 - -.5] and -1.2% [IQR: -1.9 - -.5]; both Ps < .05) with increased median insulin dose (+8 IU [IQR: 2 - 22] and +10 IU [IQR: 2 - 25.5]; both Ps < .05) and no change in hypoglycemia were observed at 16 weeks in both the MIDS and control groups, respectively. No differences in HbA1c (P = .48) or insulin dose change (P = .34) were observed between the groups. Among SMBG readings recorded during the study, the mean proportion of readings between 70-180 mg/dL (76.8% ± 22.0; 70.0% ± 26.7; p250 mg/dL (4.9% ± 9.2; 9.2% ± 18.4; p Disclosure A. Philis-Tsimikas: Advisory Panel; Self; Lilly Diabetes, Medtronic, Novo Nordisk A/S, Sanofi. Employee; Spouse/Partner; Ionis Pharmaceuticals, Inc. Research Support; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Dexcom, Inc., Lilly Diabetes, Medtronic, Novo Nordisk A/S, Sanofi. A.L. Fortmann: None. A. Bastian: None. A. Kanchi: Employee; Self; Glooko, Inc. Stock/Shareholder; Self; Glooko, Inc. R. Abad: Employee; Self; Glooko, Inc. T. Sheng: Employee; Self; Glooko, Inc. L. Parks: Employee; Self; Glooko, Inc. M. Greenfield: Consultant; Self; Glooko, Inc. M.A. Clements: Consultant; Self; Glooko, Inc. Other Relationship; Self; Glooko, Inc.

Continuous glucose monitors (CGM) are an integral aspect in the glucose management of many individuals with type 1 diabetes, and a growing number of people with insulin-requiring type 2 diabetes (T2D). A 2019 meta-analysis of 7 randomized controlled trials that investigated CGMs for T2D reported that CGM users had significantly lower HbA1c and shorter time spent with hypoglycemia compared with self-monitoring blood glucose comparison groups. However, little is known about optimal, real world approaches for integrating CGM in the routine management of patients with T2D. A pragmatic, feasibility pilot (n=6) was conducted to document the preliminary effectiveness and acceptability of introducing CGM in the context of a 5-class diabetes self-management education (DSME) series at Scripps Health, a large, non-profit, private insurance-based health system in San Diego, CA. Prior to class 2, English- (n = 3) and Spanish-speaking (n = 3) adults with T2D self-inserted the CGM and received enough sensors to wear the CGM until 6 weeks post-DSME (10 weeks total). During classes 3-5, time was devoted to reviewing the past week’s CGM data report and participants were encouraged to make associations between glucose trends and eating and exercise patterns. CGM wear ranged from 5 to 10 weeks (M =7.8 ± 1.7 weeks). Time-in-range (70-180 mg/dL) and mean average glucose improved from 54% and 185.1 ± 67.9 mg/dL at baseline to 74% and 159.1 ± 50.5 mg/dL by the end of DSME, and to 84% and 142.7 ± 30.6 mg/dL at 4-weeks post-DSME. Self-report surveys indicated improvements in healthful eating and physical activity over this time, and participants reported very high satisfaction with the CGM; the majority expressed a desire to continue CGM use post-study. Findings highlight DSME as a promising environment for effectively integrating CGM in the management of T2D. Future research should pinpoint the duration and frequency of CGM use for optimal clinical benefit in the general T2D population. Disclosure A.L. Fortmann: None. A. Bastian: None. C.J. Lensing: Employee; Self; UnitedHealth Group. Employee; Spouse/Partner; UnitedHealth Group. S. Hoversten: Employee; Self; UnitedHealth Group. K. Luu: None. K. Barger: None. L. Talavera: None. A. Philis-Tsimikas: Advisory Panel; Self; Lilly Diabetes, Medtronic, Novo Nordisk A/S, Sanofi. Employee; Spouse/Partner; Ionis Pharmaceuticals, Inc. Research Support; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Dexcom, Inc., Lilly Diabetes, Medtronic, Novo Nordisk A/S, Sanofi. Funding UnitedHealth Group; Dexcom, Inc.

Continuous Glucose Monitors (CGM) automatically capture interstitial glucose levels every 5 minutes, 24 hours/day, allowing users to view their glucose levels in real-time and make informed decisions about how to manage diet, exercise, and medications. While CGMs are a central component in the glucose management of type 1 diabetes and insulin-dependent type 2 diabetes, less is known about the potential value of CGMs for diabetes prevention. The original Diabetes Prevention Program (DPP) demonstrated that 5-7% weight loss - an outcome reliant upon healthful eating and exercise - was more effective than medication in preventing or delaying the onset of T2D; however, subsequent DPP translations have not consistently achieved the same weight loss outcomes. CGM may represent a way to reinforce and incentivize hard-to-make health behavior changes in real-time that are crucial to the more distal (and often elusive) weight loss outcome. This small (n=7) feasibility pilot examined the preliminary effectiveness and acceptability of integrating CGM in a DPP at Scripps Health, a large, non-profit, private insurance-based health system in San Diego, CA. Following a brief introduction to the CGM and target glucose ranges, DPP participants self-inserted and wore the CGM for 2 weeks. Mean time-in-range (70-140 mg/dL) improved from 70.4% to 76.4%, and time > 140 mg/dL decreased from 29.4% to 23.1% during this period. Individual change in time-in-range ranged from -9.7% to + 38.8% (M ∆ = +6.0%). Participants reported high satisfaction with the CGM, but expressed a desire for more education on blood glucose management. Given these findings, a longer-term, randomized controlled trial is planned to investigate whether a CGM-enhanced DPP leads to greater weight loss than DPP alone. This research will also further our understanding of the potential benefit of improved glycemic control for diabetes prevention even among the subset of cases who do not ultimately achieve the targeted weight loss goal. Disclosure A.L. Fortmann: None. A. Bastian: None. S.R.S. Bagsic: None. I. Loupasi: None. K. Luu: None. A.R. Hottinger: None. K.A. Barry: None. M. Ruiz: None. C. Walker: None. A. Philis-Tsimikas: Advisory Panel; Self; Lilly Diabetes, Medtronic, Novo Nordisk A/S, Sanofi. Employee; Spouse/Partner; Ionis Pharmaceuticals, Inc. Research Support; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Dexcom, Inc., Lilly Diabetes, Medtronic, Novo Nordisk A/S, Sanofi. Funding Confidence Foundation; Dexcom, Inc.

Hispanics have a 66% higher risk of developing type 2 diabetes (T2D), and exhibit worse outcomes than non-Hispanic whites. Many Hispanics lack access to diabetes self-management education and support (DSME/S) due to practical, cultural, and other barriers. Mobile health (mHealth) technology has the potential to circumvent such barriers and expand the reach of DSME/S. A 3-group, randomized controlled trial is currently underway to evaluate the effectiveness of mHealth DSME/S approaches in improving diabetes outcomes among predominantly low income, Hispanic adults with T2D and HbA1c ≥ 8% at a Federally Qualified Health Center in Southern California. Dulce Digital-Me (DD-Me) is an adaptive mHealth intervention that integrates educational text messaging with personalized goal-setting and feedback. Over 6 months, participants receive 2-3 messages/day, and are provided with a glucometer and pillbox that wirelessly transmit real-time data to a cloud. Ecological momentary assessment (EMA) gauges progress in healthful eating, exercise, and emotional well-being. Participants’ progress in lifestyle changes, medication adherence, and BG monitoring frequency and control is compared to pre-defined targets. Real-time feedback is delivered via automated, algorithm-driven messaging or by medical assistant Health Coach (n = 104 in each group). The control group (n = 207) receives educational text messages alone. Preliminary analyses (N = 163) showed higher BG monitoring frequency in the DD-Me Health Coach group (M = 7.02 ± 0.45 checks/week) versus the DD-Me algorithm-driven (M = 4.80 ± 0.49) and control groups (M = 5.25 ± 0.65), p Disclosure A.L. Fortmann: None. A. Philis-Tsimikas: Advisory Panel; Self; Lilly Diabetes, Medtronic, Novo Nordisk A/S, Sanofi. Employee; Spouse/Partner; Ionis Pharmaceuticals, Inc. Research Support; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Dexcom, Inc., Lilly Diabetes, Medtronic, Novo Nordisk A/S, Sanofi. S.R.S. Bagsic: None. D.G. Vital: None. J.A. Jones: None. H. Sandoval: None. K.L. Savin: None. T. Clark: None. K. Luu: None. J.G. Godino: None. L. Gallo: None. Funding National Institutes of Health (1R01DK112322)

In the US, nearly 11% of adults were living with diagnosed diabetes in 2017, and significant type 2 diabetes (T2D) disparities are experienced by socioeconomically disadvantaged, racial/ethnic minority populations, including Hispanics. The standard 15-minute primary care visit does not allow for the ongoing self-management support that is needed to meet the complex needs of individuals with diabetes. “Team-based” chronic care delivery is an alternative approach that supplements physician care with contact from allied health personnel in the primary care setting (e.g., medical assistants; MAs) who are specially trained to provide ongoing self-management support or “health coaching.” While rigorous trials have shown MA health coaching to improve diabetes outcomes, less is known about if and how such a model can be integrated within real world, primary care clinic workflows. Medical Assistant Health Coaching for Type 2 Diabetes in Diverse Primary Care Settings – A Pragmatic, Cluster-Randomized Controlled Trial will address this gap. Specifically, this study compares MA health coaching versus usual care in improving diabetes clinical control among N=600 at-risk adults with T2D, and is being conducted at four primary care clinics that are part of two health systems that serve large, ethnically/racially, and socioeconomically diverse populations in Southern California. Electronic medical records are used to identify eligible patients at both health systems, and to examine change in clinical control over one year in the overall sample. Changes in behavioral and psychosocial outcomes are being evaluated by telephone assessment in a subset (n=300) of participants, and rigorous process and cost evaluations will assess potential for sustainability and scalability. ClinicalTrials.gov: NCT02643797 (registered November 30, 2015: https://clinicaltrials.gov/ct2/show/NCT02643797?term=philis-tsimikas&rank=10) Trial registration: NCT02643797

Purpose The purpose of this study was to examine whether baseline levels of diabetes distress (DD) impacted clinical benefit from a mobile health (mHealth) diabetes self-management education and support (DSME/S) intervention (“Dulce Digital”). Methods This secondary analysis included the full sample of 126 Hispanic adults (mean age = 48.43 years, SD = 9.80) with type 2 diabetes and glycosylated hemoglobin A1C >7.5% enrolled from a Federally Qualified Health Center in a randomized, nonblinded clinical trial that compared Dulce Digital to usual care. Dulce Digital participants received educational/motivational, medication reminders, and blood glucose monitoring prompt text messages over 6 months. Results Baseline levels of DD prospectively moderated the effect of Dulce Digital (vs usual care) on glycemic control over 6 months, such that Dulce Digital participants with higher DD experienced relatively greater benefit from the intervention. The effect of the intervention on A1C change was 178% larger among individuals experiencing moderate/high versus no/low DD. Conclusions Although research has found DD to be associated with poorer self-management and clinical outcomes, individuals already distressed about their diabetes may benefit from a lower-burden mHealth DSME/S approach.

Background Multimorbidity affects four of ten US adults and eight of ten adults ages 65 years and older, and frequently includes both cardiometabolic conditions and behavioral health concerns. Hispanics/Latinos (hereafter, Latinos) and other ethnic minorities are more vulnerable to these conditions, and face structural, social, and cultural barriers to obtaining quality physical and behavioral healthcare. We report the protocol for a randomized controlled trial that will compare Mi Puente (My Bridge), a cost-efficient care transitions intervention conducted by a specially trained Behavioral Health Nurse and Volunteer Community Mentor team, to usual care or best-practice discharge approaches, in reducing hospital utilization and improving patient reported outcomes in Latino adults with multiple cardiometabolic conditions and behavioral health concerns. The study will examine the degree to which Mi Puente produces superior reductions in hospital utilization at 30 and 180 days (primary aim) and better patient-reported outcomes (quality of life/physical health; barriers to healthcare; engagement with outpatient care; patient activation; resources for chronic disease management), and will examine the cost effectiveness of the Mi Puente intervention relative to usual care. Methods Participants are enrolled as inpatients at a South San Diego safety net hospital, using information from electronic medical records and in-person screenings. After providing written informed consent and completing self-report assessments, participants randomized to usual care receive best-practice discharge processes, which include educational materials, assistance with outpatient appointments, referrals to community-based providers, and other assistance (e.g., with billing, insurance) as required. Those randomized to Mi Puente receive usual-care materials and processes, along with inpatient visits and up to 4 weeks of follow-up phone calls from the intervention team to address their integrated physical-behavioral health needs and support the transition to outpatient care. Discussion The Mi Puente Behavioral Health Nurse and Volunteer Community Mentor team intervention is proposed as a cost-effective and culturally appropriate care transitions intervention for Latinos with multimorbidity and behavioral health concerns. If shown to be effective, close linkages with outpatient healthcare and community organizations will help maximize uptake, dissemination, and scaling of the Mi Puente intervention. Trial registration ClinicalTrials.gov: NCT02723019. Registered on 30 March 2016.

Despite significant treatment advances, diabetes outcomes remain suboptimal and health care costs continue to rise. There are limited data on the feasibility and financial implications of integrating a diabetes-specific care team in the primary care setting (ie, where the majority of diabetes is treated). This pragmatic quality improvement project investigated whether a cardiometabolic care team intervention (CMC-TI) could achieve greater improvements in clinical, behavioral, and cost outcomes compared to usual diabetes care in a large primary care group in Southern California. Over 12 months, n = 236 CMC-TI and n = 239 usual care patients with type 1 or 2 diabetes were identified using the electronic medical record. In the CMC-TI group, a registered nurse (RN)/certified diabetes educator care manager, medical assistant health coach, and RN depression care manager utilized electronic medical record-based risk stratification reports, standardized decision-support tools, live and remote tailored treatments, and coaching to manage care. Results indicated that the CMC-TI group achieved greater improvements in glycemic and lipid control, diabetes self-management behaviors, and emotional distress over 1 year compared with the usual care group (all P

IN BRIEF In the United States, Hispanics have a 66% greater risk of developing type 2 diabetes and, once diagnosed, exhibit worse outcomes than non-Hispanic whites. It is therefore imperative to ensure that interventions meet the specific needs of this at-risk group. This article provides a selective review of the evidence on innovative, real-world approaches (both live and technology-based) to improving behavioral, psychosocial, and clinical outcomes in underserved Hispanics with type 2 diabetes. Key aspects of successful live interventions have included multimodal delivery, greater dosage/attendance, and at least some in-person delivery; effective technology-based approaches involved frequent but intermittent communication, bi-directional messaging, tailored feedback, multimodal delivery, and some human interaction. Across modalities, cultural tailoring also improved outcomes. Additional research is needed to address methodological limitations of studies to date and pinpoint the most efficacious components and optimal duration of interventions. Future efforts should also attend to variability within the U.S. Hispanic population to ensure acceptability and sustainability of interventions in this diverse group.

To investigate the problem of adults with type 1 diabetes (T1D) who purposefully keep their glucose levels low, and to explore contributors to, and possible impact of, this potentially dangerous phenomenon.We developed three self-report items as a means to identify individuals who endorse a consistent preference for hypoglycemia over hyperglycemia ("Hyperglycemia Aversives"). In a large T1D survey (n = 219), validated measures of well-being, emotional distress and hypoglycemic awareness, and glycemic metrics derived from the past 14-day period, were used to examine whether Hyperglycemia Aversives could be characterized as a distinct group.Hyperglycemia Aversives comprised 16.4% of the sample. This unique group demonstrated significantly higher mean %TIR (71.6% vs. 63.6%) and %TBR (5.1% vs. 2.2%), lower mean %TAR 250 mg/dL (6.0% vs. 10.1%), and higher rates of impaired hypoglycemic awareness and recurrent severe hypoglycemia episodes than the remaining study sample ("Non-Aversives") (all ps 0.01). The two groups did not demonstrate significant differences on psychosocial outcomes.We identified a group of T1D adults reporting a consistent preference for hypoglycemia over hyperglycemia. These individuals achieve significantly greater %TIR and less %TAR, but at the cost of greater %TBR and more frequent severe hypoglycemia episodes.

OBJECTIVE Type 2 diabetes is growing in epidemic proportions and disproportionately affects lower-income, diverse communities. Text messaging may provide one of the most rapid methods to overcome the “digital divide” to improve care. RESEARCH DESIGN AND METHODS A randomized, nonblinded, parallel-groups clinical trial design allocated N = 126 low-income, Hispanic participants with poorly controlled type 2 diabetes to receive the Dulce Digital intervention or usual care (UC). Dulce Digital participants received up to three motivational, educational, and/or call-to-action text messages per day over 6 months. The primary outcome was HbA1c; lipids, blood pressure, and BMI were secondary outcomes. Satisfaction and acceptability were evaluated via focus groups and self-report survey items. RESULTS The majority of patients were middle-aged (mean age 48.43 years, SD 9.80), female (75%), born in Mexico (91%), and uninsured (75%) and reported less than a ninth-grade education level (73%) and mean baseline HbA1c 9.5% (80 mmol/mol), SD 1.3, and fasting plasma glucose 187.17 mg/dL, SD 64.75. A statistically significant time-by-group interaction effect indicated that the Dulce Digital group achieved a significantly greater reduction in HbA1c over time compared with UC (P = 0.03). No statistically significant effects were observed for secondary clinical indicators. The number of blood glucose values texted in by participants was a statistically significant predictor of month 6 HbA1c (P < 0.05). Satisfaction and acceptability ratings for the Dulce Digital intervention were high. CONCLUSIONS Use of a simple, low-cost text messaging program was found to be highly acceptable in this sample of high-risk, Hispanic individuals with type 2 diabetes and resulted in greater improvement in glycemic control compared with UC.

Background: Hypoglycemic confidence (HC) represents the degree to which an individual feels secure regarding his or her ability to stay safe from hypoglycemia-related problems. Self-report scales a...

Weight loss can significantly reduce an individual’s risk for T2D. However, it can be challenging to engage participants in the DPP long enough to lose weight. This analysis examines sociodemographic characteristics and health behaviors as predictors of participant engagement and weight loss/gain. Participants were recruited into the DPP through a referral from a provider, family/friend, or other. Classes were conducted through local ambulatory clinics and community settings in San Diego, CA. Baseline self-report surveys were administered prior to program start, and weight was assessed at every session. Participants (N=290) were mostly female (81%) with a mean age of 57 (±14), diverse [51% Hispanic, 9% Asian/Native Hawaiian or Pacific Islander (ANHPI), 4% Other], and reported household incomes Disclosure M. AuYoung: None. K. Luu: None. M. Ruiz: None. C. Walker: None. A. Philis-Tsimikas: Advisory Panel; Self; AstraZeneca, Lilly Diabetes, Novo Nordisk A/S, Sanofi. Employee; Spouse/Partner; Ionis Pharmaceuticals, Inc. Research Support; Self; Dexcom, Inc., Glooko, Inc., National Institute of Diabetes and Digestive and Kidney Diseases. Stock/Shareholder; Spouse/Partner; Ionis Pharmaceuticals, Inc., Novo Nordisk Inc. A.L. Fortmann: None.

Hispanics are disproportionately affected by chronic cardiometabolic conditions (e.g., obesity, diabetes). Unmet behavioral health needs (e.g., mental health problems, stress, lack of health care) contribute to these disparities. Sustainably reducing Hispanic health disparities demands innovative, cost-effective interventions that address both behavioral and physical health. A randomized controlled trial is underway to evaluate Mi Puente - i.e., a Behavioral Health Nurse (BHN) + volunteer Community Mentor (CM) intervention designed to reduce readmissions in N = 560 Hispanics with ≥ 2 cardiometabolic conditions and ≥ 1 behavioral health concern(s) hospitalized at a safety-net hospital near the U.S./Mexico border in San Diego, CA. Qualifying patients at high-risk for readmission are identified via automated electronic medical record reports. The BHN triages patients’ needs, provides education, and conducts tailored coaching and goal-setting. Post-discharge, the BHN conducts telephone follow-up at 1-week, and CMs provide referrals to community resources and transition support via phone for up to 1-month. Prevalent behavioral health concerns were: chronic stress (52.5%), health-related distress (37.3%), and lack of routine medical care (19.8%). Preliminary process data indicated that the BHN met with 82.5% of participants prior to discharge; challenges related to medication adherence (28.7%) and access to outpatient care (41.1%) were common. Approximately 80% received ≥1 CM phone call (M = 1.7± 1.1); the transition home and follow-up appointment(s) were frequently addressed (both 97.9%). Findings reveal high levels of unmet behavioral health needs among hospitalized Hispanics, and the feasibility of a sustainable, low-cost, team model that builds upon personnel commonly found in hospital settings - i.e., nurses and volunteers. Important “lessons learned” will be presented to inform future care transitions programs in high-risk, underserved groups. Disclosure J.I. Bravin: None. M.L. Anderson: None. T. Clark: None. K.L. Savin: None. D. Lara Ledesma: None. J.A. Euyoque: None. A.L. Fortmann: None. A. Philis-Tsimikas: Advisory Panel; Self; AstraZeneca, Lilly Diabetes, Novo Nordisk A/S, Sanofi. Employee; Spouse/Partner; Ionis Pharmaceuticals, Inc. Research Support; Self; Dexcom, Inc., Glooko, Inc., National Institute of Diabetes and Digestive and Kidney Diseases. Stock/Shareholder; Spouse/Partner; Ionis Pharmaceuticals, Inc., Novo Nordisk Inc. L. Gallo: None. Funding National Institutes of Health

To address the burgeoning primary care demand-capacity imbalance, team-based models using medical assistants (MAs) to provide evidence-based, disease self-management support have been proposed. Randomized controlled trials (RCT) have shown MA health coaching improves clinical outcomes in chronic disease populations; however, pragmatic research is needed to evaluate effectiveness and feasibility in real-world health settings. Thus, we adopted a unique, cluster RCT to compare MA health coaching with usual care in N=600 adults with T2D, plus HbA1c ≥8.0% and/or SBP ≥140 mmHg, and/or LDL-C ≥100 mg/dL. Importantly, this in-progress trial examines implementation and outcomes across two very distinct settings: a federally qualified health center (Site A; majority Hispanic/Spanish-speaking, low SES patients; M age = 58.2) and a large, private insurance-based health system (Site B; majority non-Hispanic white/English-speaking, middle/upper SES; M age = 73.4). To facilitate integration with routine clinic processes, existing MAs are trained to perform at top of license, and EMR-based risk stratification identifies qualifying patients presenting to clinic each day. MA health coaches join primary care visits to understand the care plan and provide self-management support in conjunction with medical visits and by phone for 1 year. Dosage and intervention components (medication reconciliation, assessment, goal setting, lab review) are tailored to patient needs. A process evaluation revealed differences between Sites A and B in session frequency (M = 7 ± 3 vs. 4 ± 2), duration (M = 20 ± 15 vs. 14 ± 10 minutes), and focus (healthful eating vs. blood pressure monitoring) (all ps Disclosure T. Clark: None. L. Gallo: None. J.A. Euyoque: None. K.L. Savin: None. J.I. Bravin: None. H. Sandoval: None. D. Lara Ledesma: None. A. Philis-Tsimikas: Advisory Panel; Self; AstraZeneca, Lilly Diabetes, Novo Nordisk A/S, Sanofi. Employee; Spouse/Partner; Ionis Pharmaceuticals, Inc. Research Support; Self; Dexcom, Inc., Glooko, Inc., National Institute of Diabetes and Digestive and Kidney Diseases. Stock/Shareholder; Spouse/Partner; Ionis Pharmaceuticals, Inc., Novo Nordisk Inc. A.L. Fortmann: None. Funding National Institutes of Health

Background: The global epidemic of diabetes calls for innovative interventions. This study evaluated the effectiveness of the Project Dulce model, with and without wireless technology, on glycemic control and other clinical and self-reported outcomes in patients with poorly controlled type 2 diabetes in Mexico. Subjects and Methods: Adults with type 2 diabetes and a glycated hemoglobin A1c (HbA1c) level of ≥8% were recruited from Family Medical Unit #27 of the Instituto Mexicano del Seguro Social (IMSS) in Tijuana, México, and randomly assigned to one of three groups: Project Dulce–only (PD); Project Dulce technology-enhanced with mobile tools (PD-TE); or IMSS standard of care/control group (CG). Clinical and self-reported outcomes were assessed at baseline, Month 4, and Month 10. Time-by-group interactions and within-group changes were analyzed. Results: HbA1c reductions from baseline to Month 10 were significantly greater in PD-TE (−3.0% [−33 mmol/mol]) and PD (−2.6% [−28.7 mmol/mol]) compared with CG (−1.3% [−14.2 mmol/mol]) (P = 0.009 and 0.001, respectively). PD-TE and PD also exhibited significant improvement in diabetes knowledge when compared with CG (P

Adherence to recommended self-management behaviors is particularly poor among Hispanics with type 2 diabetes (T2D), which increases risk for developing serious complications. In addition to minority status, research has also shown diabetes distress to predict poorer diabetes self-management. In contrast, social-environmental support for disease management has emerged as a potential protective factor, given associations of greater support with better diabetes self-care. This study aimed to compare the relative associations of support [Chronic Illness Resource Survey] and diabetes distress [Diabetes Distress Scale] with diabetes self-management [Summary of Diabetes Self-Care Activities]. A cross-sectional baseline analysis of N=126 Hispanic adults with poorly controlled T2D (HbA1c ≥ 7.5%) at federally-qualified health centers in Southern California was performed. When examined separately, lower diabetes distress (rs = -.26 and -.18) and higher support (rs = .49 and .22) were both significantly associated with better diet and exercise, respectively (ps < .05). However, when entered in joint linear regression models, only support remained a statistically significant predictor of diet (β = 0.46) and exercise (β = 0.18), ps < .05. The associations of diabetes distress with self-management behaviors decreased in magnitude by 30-58% after control for support, and were no longer statistically significant. While diabetes distress certainly impacts self-management behaviors, these findings indicate that support may be a relatively stronger correlate in this population - perhaps due to the emphasis the Hispanic culture places on interpersonal relationships. Findings point to social-environmental support for disease management (not just distress) as an important target for diabetes self-management interventions. However, further longitudinal research is needed to fully disentangle the associations among distress, support, and self-management behaviors. Disclosure T. Clark: None. J.A. Euyoque: None. A. Philis-Tsimikas: Research Support; Self; Dexcom, Inc.. Advisory Panel; Self; Dexcom, Inc., Eli Lilly and Company, Merck & Co., Inc., Novo Nordisk A/S, Sanofi. Research Support; Self; Novo Nordisk A/S, Sanofi, Mylan. Stock/Shareholder; Spouse/Partner; Novo Nordisk A/S. Employee; Spouse/Partner; Ionis Pharmaceuticals, Inc.. Stock/Shareholder; Spouse/Partner; Esperion Therapeutics, Ionis Pharmaceuticals, Inc.. Advisory Panel; Self; AstraZeneca. L. Gallo: None. A.L. Fortmann: None.

Aligning diabetes care with components of the Chronic Care Model (CCM) facilitates productive interactions between a proactive care team and an informed, activated patient, allows the care plan to be individualized, and can improve care and outcomes. The Patient Assessment of Chronic Illness Care (PACIC) survey assesses patient experience with CCM-based healthcare delivery components. In the Division of Diabetes and Endocrinology at Scripps Health, a large integrated health system in San Diego, CA, patients with T1DM have access to an interdisciplinary team of clinicians who provide care, education, and ongoing support. Guided by the CCM, an interactive care delivery system involving the endocrinologist, PCP, diabetes educator, RD, behavioral specialist and the patient was implemented to facilitate proactive and productive care but some interactions remained isolated. Between June and August 2017, the PACIC survey was administered by research assistants to N=47 adults with T1DM who have received care in the Division for at least 6 months. Overall, patients reported high satisfaction with care (M=4.77 out of 5; SD=0.56). Results also indicated high ratings for specific CCM elements, including Patient Activation, Delivery System Design/Decision Support, and Self-Management Support (M=4.29-4.55). Lower ratings were observed for Follow-Up/Coordination (M=3.81; SD=1.01), suggesting a need for enhanced post-visit contact with patients, referrals to community programs, dietitians, and counselors, and discussion of specialist appointments. In line with the Institute for Healthcare Improvement’s Triple Aim focused on improving the health of populations through optimization of health system performance, an RN with specialized experience in T1DM was added to the team as the Diabetes Care Manager to assist with follow-up and care coordination. The PACIC will be re-administered after 6 months to determine the impact on patient perceptions of follow-up/coordination between visits. Disclosure R. Morrisey: None. E. Kaczmar: None. A. Tsimikas: None. F.M. Arnold: None. T. Clark: None. J. McCallum: None. A.L. Fortmann: None.

By 2034, the number of U.S. individuals with diabetes is predicted to increase from 23.7 to 44.1 million, and annual diabetes-related spending is expected to grow from $113 to $336 billion. Current healthcare systems are often not equipped to support the growing diabetes population, and many individuals are not achieving clinical targets necessary for preventing diabetes complications and for improving long-term survival. To address this need, an innovative, Chronic Care Model (CCM)-based care management program was developed that used clinical risk stratification, standardized decision support tools, RN + health coach + PCP team-based care, and a depression care manager. N=236 T1D and T2D (96%) patients (M age = 61.9 ± 11.4 years; 51% male) were enrolled at a San Diego clinic that includes diverse payors and an integrated PCP group. This care management program was previously shown to achieve significant improvements in cardiometabolic outcomes (HbA1c, LDL-c) and health care costs relative to usual care at 1-year. The present analysis evaluated effects on diabetes self-management (Summary of Diabetes Self Care Activities) and distress (Diabetes Distress Scale), and patients’ experience with CCM-based healthcare delivery components (Patient Assessment of Chronic Illness Care). Statistically significant improvements were observed in healthful eating (5 vs. 4 days/week), exercise (5 vs. 3), blood glucose monitoring (5 vs. 4), foot-checking (5 vs. 3), and diabetes distress (14% vs. 24% with moderate distress) over 12 months (ps < .05). Patients’ perceptions of follow-up/care coordination, support for patient activation and self-management, and delivery design also improved over this period (ps < .05). Taken together, this population-based care management program represents an approach that can improve clinical, behavioral, psychosocial and cost outcomes, and health care delivery experience for people with diabetes in the primary care environment. Disclosure A.L. Fortmann: None. J.L. Preciado: None. C. Walker: None. R. Morrisey: None. K. Barger: None. D. Mills: None. M. Robacker: None. A. Philis-Tsimikas: Research Support; Self; Dexcom, Inc.. Advisory Panel; Self; Dexcom, Inc., Eli Lilly and Company, Merck & Co., Inc., Novo Nordisk A/S, Sanofi. Research Support; Self; Novo Nordisk A/S, Sanofi, Mylan. Stock/Shareholder; Spouse/Partner; Novo Nordisk A/S. Employee; Spouse/Partner; Ionis Pharmaceuticals, Inc.. Stock/Shareholder; Spouse/Partner; Esperion Therapeutics, Ionis Pharmaceuticals, Inc.. Advisory Panel; Self; AstraZeneca.

This study assessed perspectives on whole-genome sequencing (WGS) for rare disease diagnosis and the process of receiving genetic results. Semistructured interviews were conducted with adult patients and parents of minor patients affected by idiopathic diseases (n = 10 cases). Three main themes were identified through qualitative data analysis and interpretation: perceived benefits of WGS; perceived drawbacks of WGS; and perceptions of the return of results from WGS. Findings suggest that patients and their families have important perspectives on the use of WGS in diagnostic odyssey cases. These perspectives could inform clinical sequencing research study designs as well as the appropriate deployment of patient and family support services in the context of clinical genome sequencing.

Purpose The purpose of the study was to test the preliminary effectiveness, feasibility, and acceptability of a peer-led, culturally appropriate, Diabetes Prevention Program (DPP)–based lifestyle intervention for Latina women at high-risk for type 2 diabetes (T2DM). Methods Participants (N = 61) were overweight/obese (body mass index [BMI] ≥25) Latina women with no diabetes, at elevated risk either due to midlife age (45-65 years; n = 37) or history of gestational diabetes mellitus (n = 24). The study used a 1-group pretest-posttest design and offered 12 weeks of peer-led education sessions in a community setting. The intervention targeted physical activity and dietary behaviors to facilitate weight reduction and included culturally appropriate content, age-specific health information, and stress/emotion management strategies. Clinical and self-report assessments were conducted at baseline, month 3, and month 6. Results Mean participant age was 47.8 years (SD = 10.8). Most (91.2%) were born in Mexico, and 43.3% had a ninth-grade education or less. At month 6, participants achieved a mean reduction of 4.1% body weight (7 lb [3.2 kg]). Statistically significant improvements were observed for dietary behaviors, stress, and depression symptoms. Attrition was low, 5% (3 women). Focus groups indicated that intervention content increased knowledge, was applicable, highly valued, culturally relevant, and would be recommended to others. Conclusions This culturally tailored DPP adaptation was feasible and acceptable for 2 groups of Latina women at high-risk for T2DM and showed preliminary effectiveness in reducing weight and modifying self-reported dietary behaviors, stress, and depression symptoms. Further research is needed to identify ways to enhance weight loss and diabetes prevention in this at-risk, underserved population.

Objective The current study examined multiple stress indicators (chronic, perceived, traumatic) in relation to prevalent coronary heart disease, stroke, and major cardiovascular disease (CVD) risk factors (i.e., diabetes, dyslipidemia, hypertension, and current smoking) in the multisite Hispanic Community Health Study/Study of Latinos Sociocultural Ancillary Study (2010-2011). Methods Participants were 5313 men and women 18 to 74 years old, representing diverse Hispanic/Latino ethnic backgrounds, who underwent a comprehensive baseline clinical examination and sociocultural examination with measures of stress. Results Chronic stress burden was related to a higher prevalence of coronary heart disease after adjusting for sociodemographic, behavioral, and biological risk factors (odds ratio [OR; 95% confidence interval], 1.22 [1.10-1.36]) and related to stroke prevalence in the model adjusted for demographic and behavioral factors (OR [95% confidence interval], 1.26 [1.03-1.55]). Chronic stress was also related to a higher prevalence of diabetes (OR = 1.20 [1.11-1.31]) and hypertension (OR = 1.10 [1.02-1.19]) in individuals free from CVD (n = 4926). Perceived stress (OR = 1.03 [1.01-1.05]) and traumatic stress (OR = 1.15 [1.05-1.26]) were associated with a higher prevalence of smoking. Participants who reported a greater number of lifetime traumatic events also unexpectedly showed a lower prevalence of diabetes (OR = 0.89 [0.83-0.97]) and hypertension (OR = 0.88 [0.82-0.93]). Effects were largely consistent across age and sex groups. Conclusions The study underscores the advantages of examining multiple indicators of stress in relation to health because the direction and consistency of associations may vary across distinct stress conceptualizations. In addition, the study suggests that chronic stress is related to higher CVD risk and prevalence in Hispanics/Latinos, the largest US ethnic minority group.

Introduction This study examined tobacco smoke pollution (also known as thirdhand smoke, THS) in hotels with and without complete smoking bans and investigated whether non-smoking guests staying overnight in these hotels were exposed to tobacco smoke pollutants. Methods A stratified random sample of hotels with (n=10) and without (n=30) complete smoking bans was examined. Surfaces and air were analysed for tobacco smoke pollutants (ie, nicotine and 3-ethynylpyridine, 3EP). Non-smoking confederates who stayed overnight in guestrooms provided urine and finger wipe samples to determine exposure to nicotine and the tobacco-specific carcinogen 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone as measured by their metabolites cotinine and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), respectively. Findings Compared with hotels with complete smoking bans, surface nicotine and air 3EP were elevated in non-smoking and smoking rooms of hotels that allowed smoking. Air nicotine levels in smoking rooms were significantly higher than those in non-smoking rooms of hotels with and without complete smoking bans. Hallway surfaces outside of smoking rooms also showed higher levels of nicotine than those outside of non-smoking rooms. Non-smoking confederates staying in hotels without complete smoking bans showed higher levels of finger nicotine and urine cotinine than those staying in hotels with complete smoking bans. Confederates showed significant elevations in urinary NNAL after staying in the 10 most polluted rooms. Conclusions Partial smoking bans in hotels do not protect non-smoking guests from exposure to tobacco smoke and tobacco-specific carcinogens. Non-smokers are advised to stay in hotels with complete smoking bans. Existing policies exempting hotels from complete smoking bans are ineffective.

INTRODUCTION Secondhand smoke contains a mixture of pollutants that can persist in air, dust, and on surfaces for months or longer. This persistent residue is known as thirdhand smoke (THS). Here, we detail a simple method of wipe sampling for nicotine as a marker of accumulated THS on surfaces. METHODS We analyzed findings from 5 real-world studies to investigate the performance of wipe sampling for nicotine on surfaces in homes, cars, and hotels in relation to smoking behavior and smoking restrictions. RESULTS The intraclass correlation coefficient for side-by-side samples was 0.91 (95% CI: 0.87-0.94). Wipe sampling for nicotine reliably distinguished between private homes, private cars, rental cars, and hotels with and without smoking bans and was significantly positively correlated with other measures of tobacco smoke contamination such as air and dust nicotine. The sensitivity and specificity of possible threshold values (0.1, 1, and 10 μg/m(2)) were evaluated for distinguishing between nonsmoking and smoking environments. Sensitivity was highest at a threshold of 0.1 μg/m(2), with 74%-100% of smoker environments showing nicotine levels above threshold. Specificity was highest at a threshold of 10 μg/m(2), with 81%-100% of nonsmoker environments showing nicotine levels below threshold. The optimal threshold will depend on the desired balance of sensitivity and specificity and on the types of smoking and nonsmoking environments. CONCLUSIONS Surface wipe sampling for nicotine is a reliable, valid, and relatively simple collection method to quantify THS contamination on surfaces across a wide range of field settings and to distinguish between nonsmoking and smoking environments.

Background Attenuated nocturnal blood pressure (BP) dipping is a better predictor of cardiovascular disease (CVD) morbidity and mortality than resting BP measurements. Studies have reported associations between social support, variously defined, and BP dipping. Methods A systematic review of the literature was conducted to investigate associations of functional and structural social support with nocturnal BP dipping assessed over a minimum of 24 hours. Results A total of 297 articles were identified. Of these, 11 met criteria for inclusion; all studies were cross-sectional in design and included adult participants only (mean age = 19 to 72 years). Evidence was most consistent for an association between functional support and BP dipping, such that 5 of 7 studies reported statistically (or marginally) significant positive associations with BP dipping. Statistically significant functional support-BP dipping associations were moderate (standardized effect size (d) = 0.41) to large (d = 2.01) in magnitude. Studies examining structural support were fewer and relatively less consistent; however, preliminary evidence was observed for associations of marital status and social contact frequency with BP dipping. Statistically significant structural support findings were medium (d = 0.53) to large (d = 1.13) in magnitude. Conclusions Overall, findings suggest a link between higher levels of functional support and greater nocturnal BP dipping; preliminary evidence was also observed for the protective effects of marriage and social contact frequency. Nonetheless, the relatively small number of studies conducted to date and the heterogeneity of findings across meaningful subgroups suggest that additional research is needed to substantiate these conclusions.

D iabetes prevalence is predicted to rise dramatically during the next 20 years, and associated spending is expected to increase threefold.1–3 Cultural barriers contribute to this burden by preventing optimal care among diverse ethnic groups that are at elevated risk for high-cost complications.4–10 Culturally appropriate, clinically sound, and cost-effective models are needed to respond to the growing and diverse populations affected by diabetes worldwide. Chronic disease now accounts for 75% of the $2 trillion in annual medical costs in the Untied States, and adherence to prescription regimens among those with chronic conditions is estimated to range from 20 to 50%.11,12 Nonadherence to medications accounts for ~ $100 billion in annual health care costs.13,14 Health care reform is a driving force to identify low-cost and clinically effective interventions to improve health care quality and reduce costs. Nontraditional care management models, innovative technologies to improve patient adherence to prescribed medical regimens, and use of adherence-enhancing strategies in clinical practice would greatly enhance the health impact of efficacious treatments and prevention efforts and consequently reduce the burden of nonadherence-related health care costs. The most recognized approach for improving care through the current health care delivery system is the Chronic Care Model (CCM) developed by Ed Wagner et al.15–18 This model recognizes that a substantial portion of chronic care management takes place outside of formal health delivery settings. Patient self-management, delivery system design (including information systems and decision-support tools), and community resources are crucial components of this model. The CCM has been used successfully in staff-model health maintenance organizations, large group practices, and community health clinics, and its implementation has been shown in numerous studies to improve care in diabetes and other chronic diseases.19 The medical home model …

Stress is a hypothesized pathway in socioeconomic status (SES)-physical health associations, but the available empirical data are inconsistent. In part, this may reflect discrepancies in the approach to measuring stress across studies, and differences in the nature of SES-stress associations across demographic groups. We examined associations of SES (education, income) with general and domain-specific chronic stressors, stressful life events, perceived stress, and stressful daily experiences in 318 Mexican–American women (40–65 years old). Women with higher SES reported lower perceived stress and fewer low-control experiences in everyday life (ps < .05), but greater chronic stress (education only, p < .05). Domain-specific analyses showed negative associations of income with chronic housing and financial stress (ps < .05), but positive associations of SES with chronic work and care-giving stress (all ps < .05 except for income and caregiving stress, p < .10). Sensitivity analyses showed that most SES-stress associations were consistent across acculturation levels. Future research should adopt a multi-dimensional assessment approach to better understand links among SES, stress, and physical health, and should consider the sociodemographic context in conceptualizing the role of stress in SES-related health inequalities.

Some car rental companies in California and other states in the USA have established non-smoking policies for their vehicles. This study examined the effectiveness of these policies in maintaining smoke-free rental cars.A stratified random sample of 250 cars (non-smoker, smoker and unknown designation) was examined in San Diego County, California, USA. Dust, surfaces and the air of each vehicle cabin were sampled and analysed for residual tobacco smoke pollutants (also known as thirdhand smoke (THS)), and each car was inspected for visual and olfactory signs of tobacco use. Customer service representatives were informally interviewed about smoking policies.A majority of putative non-smoker cars had nicotine in dust, on surfaces, in air and other signs of tobacco use. Independent of a car's smoking status, older and higher mileage cars had higher levels of THS pollution in dust and on surfaces (p0.05), indicating that pollutants accumulated over time. Compared with smoker cars, non-smoker cars had lower levels of nicotine on surfaces (p0.01) and in dust (p0.05) and lower levels of nicotine (p0.05) and 3-ethynylpyridine (p0.05) in the air. Non-smoking signage in cars was associated with lower levels of THS pollutants in dust and air (p0.05).Existing policies and practices were successful in lowering THS pollution levels in non-smoker cars compared with smoker cars. However, policies failed in providing smoke-free rental cars; THS levels were not as low as those found in private cars of non-smokers with in-car smoking bans. Major obstacles include inconsistent communication with customers and the lack of routine monitoring and enforcement strategies. Strengthening policies and their implementation would allow car rental companies to reduce costs, better serve their customers and make a constructive contribution to tobacco control efforts.

Allostatic load provides a useful framework for conceptualizing the multi-system physiological impact of sustained stress and its effects on health and well-being. Research across two decades shows that allostatic load indices predict health outcomes including all cause mortality, and vary with stress and related psychosocial constructs. The study by Slopen and colleagues in this issue provides an example both of the utility of the allostatic load framework, and of limitations in related literature, such as inconsistencies in conceptualization and measurement across studies, and the frequent application of cross-sectional designs. The current article describes these limitations and provides suggestions for further research to enhance the value and utility of the allostatic load framework in biobehavioral medicine research.