The T1D Exchange Quality Improvement Collaborative (T1DX-QI) Learning Session event 2023 took place in New York City on November 14 and 15 — “T1DX-QI: Sustaining Performance Improvement in Diabetes Care.” 

The T1DX-QI has grown from just over a dozen participating clinics in 2019 to 55 participating clinics in 2023, serving over 100,000 patients across the U.S. with type 1 and type 2 diabetes. 

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

Goals and Accomplishments in 2023 

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

  • Grown to 55 participating clinics, including 9 focused on T2D 
  • 95+ active research projects striving to improve patient care 
  • Reaching 65,000 pediatric and 35,000 adult patients with T1D 
  • Reaching over 35,000 patients with T2D 
  • Improving overall HbA1c trends across all participating clinics 
  • Published research in over 65+ top medical journals since 2019 
  • Published 45 quality improvement projects in 2023 
  • 24 manuscripts accepted and published so far in 2023 
  • Shared 120+ presentations at international conferences 
  • Expanding the Health Equity Advancement Lab (HEAL) Program 
  • EMR data mapping data at 36 participating centers 

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

“We are changing the tide and moving the needle,” explained Osagie Ebekozien, MD, MPH, CHPQ and Chief Medical Officer of T1D Exchange, pointing to T1DX-QI efforts to improve patient care, including: decreasing A1cs, increasing CGM and insulin pump use in underserved populations, and standardizing screenings for depression, eating disorders, and social determinants of health. 

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

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

DAY 1 Session Highlights 

Here are highlights from presentations during Day 1. 

Mind the Gap: Reducing Inequities in Diabetes Technology Theory for Improvement  

CINCINNATI CHILDREN’S MEDICAL CENTER: Nana-Hawa Yayah Jones, MD; Amy Grant, DNP, RN, CPN; Sarah Corathers, MD; Laura Smith, PhD, CDCES; Jennifer Kelly, RN, BSEd, MSN, APRN; Amanda Riley, MS, RD, LD, CDCES; Desireé N. Williford, PhD, MPH; Catherine Fazio, Kyle Kaplan, MPH; Amanda Howell, MPH, CPH 

Background: 

“Patients in racial and ethnic minority groups encounter more financial burdens, increased healthcare utilization, and higher morbidity and mortality rates,” explains the abstract. “Diabetes is a common chronic disease that is no stranger to these gaps. It is well established that diabetes technology (i.e., continuous glucose monitors [CGM]) not only improves quality of life but also accelerates patients towards glycemic targets.”  

“Yet, at Cincinnati Children’s, there was a 27% difference in the utilization of CGM between Black and White patients and 21% difference between those with public and private insurance. Using quality improvement methodology, we aim to ultimately eliminate the need for caution by supporting families, collaborating with the community, and removing systemic barriers to care.” 

Goals: 

  • Increase the % of Black patients on CGM from 54% to 70% by December 31, 2023 
  • Increase the % of Hispanic patients on CGM from 41% to 70% by December 31, 2023 

Interventions include: 

  • Provide education and training about CGM 
  • Share patient experiences with other patients considering CGM 
  • Utilize coordinator roles for the CGM process, financial counseling, insurance navigation, etc. 
  • Assess technology barriers 
  • Assess social determinants of health 
  • Standardize offering CGM at diagnosis 
  • Use creative solutions for patients without a smartphone 
  • Provide diversity, equity, and inclusion training for staff 
  • Expand CGM trial program 
  • Make list of patients not on a CGM 

Results: 

  • CGM usage in Black patients increased from 38% to 63% 
  • CGM usage in White patients increased from 65% to 86% 
  • CGM usage in patients on public insurance increased from 55% to 86% 
  • CGM usage in patients on private insurance increased from 73% to 92% 

“Multi-faceted, multidisciplinary and targeted interventions using quality improvement methodology resulted in improved CGM utilization,” explains the abstract, “while simultaneously improving glycemic control in T1D patients by race and insurance.” 

Establishing Social Determinants of Health Screening to Improve Pediatric Diabetes Patient Outcomes 

LE BONHEUR CHILDREN’S HOSPITAL & DIABETES CLINIC: Blake Adams BSN, Margaret Shepherd BS, Fatina Caldwell-Jones DNP, Grace Nelson MD Department of Pediatrics, College of Medicine, The University of Tennessee Health Science Center 

Background: 

“Despite the existing research correlating social factors with worse glycemic control, our clinic was not previously screening for Social Determinants of Health (SDOH) in our diabetic patient population,” explains the abstract.  

“To address this disparity, we decided to implement SDOH screening for our type 1 and type 2 diabetes patients based on a set of specific criteria.”  

Goals: 

  • Screen 10% of type 1 and type 2 diabetes patients 
  • Offer resources and/or referrals to those who screened positive from June 2023 to August 2023 

Interventions include: 

  • Meet bimonthly with a multidisciplinary team to establish the following screening parameters 
  • Established parameters: type 1 and type 2 diabetes patients with a diagnosis of greater than 6 months who had an A1C of 9.5% or greater, had not been seen in the clinic for 6 months or longer, or were within a 3-month window of the anniversary of their diagnosis date 
  • Partnered with the University of Michigan and utilized their “Partners in Care” survey 
  • 1st PDSA cycle: patients were offered a referral to the clinic’s medical social worker through a written question featured at the end of the screen 
  • 2nd PDSA cycle: the question at the end of the screen was removed, and practitioners verbally offered referrals to patients who screened positive without standardization 
  • 3rd PDSA cycle: in the third PDSA cycle, a question was added to the survey that asked patients to rate the urgency of their needs 
  • 4th PDSA cycle: practitioners and clinic staff were re-educated on implementation of the methods introduced in the previous cycle and offered a list of available resources to the end of the survey for families 
  • Written resources were also made available for practitioners to offer patients who screened positive  
  • To standardize the process, a section was added to the end of the screen for practitioners to record if resources and/or a referral were verbally offered 

Results: 

  • Increased our clinic’s SDOH screening rate from 0% to approximately 4.3% 
  • Of the patients that were eligible for screening, 51.6% completed screens 
  • 38.5% of the completed screens were positive 
  • 84.0% of the patients who screened positive were offered social work referrals and/or appropriate resources 
  • On average, patients screening positive for adverse SDOH had higher A1C levels as well as more hospitalizations and emergency room visits in the last six months than the patients who screened negative  
  • In the first PDSA cycle, 0% of the patients who screened positive accepted a referral when the referral was offered through a written method 
  • In the final PDSA cycle, 66.7% of patients who screened positive accepted a referral when the referral was offered verbally  

“We did see an improvement in our percentage of PWD being screened for SDOH, however we haven’t reached our goal of 10%,” explains the abstract. “Lastly, patients screening positive for SDOH seemed to be more open to receiving assistance when asked verbally versus through written communication, suggesting that social work referrals should be offered verbally to diabetic patients rather than through written communication as a standard of care.” 

Elevated Anxiety Levels Associated with Higher A1cs 

T1D EXCHANGE & MULTIPLE CENTERS: Margaret Gillis, BS, Emma Ospelt, MPH, Saketh Rompicherla, MS, Ann Mungmode, MPH, Nicole Rioles, MA, Alissa Roberts, MD, Caleb Schmid, MD, Tamara Hannon, MD, G. Todd Alonso, MD, Osagie Ebekozien, MD, MPH — CLINICS INCLUDE: Seattle Children’s Hospital, Oregon Health and Sciences University, University of Colorado, Barbara Davis Center, and University of Mississippi School of Population Health 

Background: 

“This multi-center study aims to investigate the association between anxiety and glycemic outcomes for people with type 1 diabetes,” explains the abstract.  

The generalized anxiety disorder scale (GAD-7) is a 7-question anxiety screener with scores 0-21, categorized as the following:  

  • 0-4 minimal 
  • 5-9 mild 
  • 10-14 moderate 
  • 15-21 severe  

Methods: 

  • Electronic medical record (EMR) data from April 2017-June 2023 was analyzed 
  • 738 distinct people with type 1 diabetes (PwT1D) from 9 clinics with ages ranging between 12-75 years 
  • Anxiety was classified as minimal vs elevated (Mild, moderate, and severe) 
  • Most recent GAD-7 score was used along with a corresponding A1c 
  • Chi-square test and Fisher’s Exact test were used to see significant differences between the two groups 
  • Logistic regression was used with A1c <7% and >9% as the binary outcome and anxiety level as the predictor variable for an unadjusted model and an adjusted model with variables for race/ethnicity, insurance type, gender, and device use 

Results: 

  • Individuals with A1c >9% made up a significantly greater portion (p <0.01) of the elevated anxiety group (41%) vs. minimal anxiety (30%) 
  • Anxiety level was not significantly associated with odds of A1c <7% in the unadjusted and adjusted models 
  • Odds ratio (OR) is >1 for both the unadjusted and adjusted model, showing that PwT1D in the elevated group have increased odds of having an A1c >9% compared to the minimal anxiety group 

“People with type 1 diabetes and elevated anxiety levels showed higher A1c levels compared to those with minimal anxiety, supported findings are in existing literature,” explains the abstract. “Further analysis should be done to determine a causal relationship between anxiety and glycemic outcomes, as stated in existing literature. Prospective research should be done to find effective post-screening interventions in people with T1D.” 

Implementing an Early T1D Clinic for Patients with Stage 1 and Stage 2 Type 1 Diabetes  

BARBARA DAVIS CENTER: Kimber MW Simmons, MD, MS; Lexie Chesshir, BSN, RN, CDCES; Holly K O’Donnell, PhD; Paige Trojanowski, PhD; Taylor M Triolo, MD; G. Todd Alonso, MD; Rebecca Campbell, BS; Andrea K Steck, MD; Peter Gottlieb, MD; Brigitte Frohnert, MD, PhD  

Background: 

“Teplizumab was approved for delaying onset of stage 3 type 1 diabetes in November 2022,” explains the abstract. “We designed an early T1D clinic to identify individuals eligible for treatment per stage 2 ADA criteria and provided proper guidance around treatment options.” 

Methods: 

  • In December 2023, we opened a weekly clinic staffed with a nurse, physician and psychologist 
  • Individuals with islet autoimmunity and concern for dysglycemia are offered metabolic staging, which includes a fasting glucose level, HbA1C, 2-hour OGTT, and 10-day CGM wear 
  • Patients are offered a health and behavior assessment to assess coping and T1D risk perception 
  • Metabolic staging results are obtained during clinic and treatment options are discussed 
  • If a patient desires Teplizumab therapy, we prescribe and initiate the prior authorization process 

Results: 

  • We have completed staging in 22 patients (TABLE)  
  • Using ADA T1D staging criteria, 17/22 (77%) patients are stage 2, 4/22 (18%) are stage 1, and one patient was diagnosed as stage 3 
  • Of those with stage 2, we have successfully infused a 14-day course of teplizumab in 6 patients 
  • One patient initially classified as stage 2 progressed to symptomatic T1D before treatment 
  • Eleven stage 2 patients have been authorized for teplizumab treatment, and five are under review for treatment by their insurance carriers 

“Individuals attending Early T1D clinic tolerated complete metabolic staging per ADA guidelines,” explains the abstract. “We have successfully treated 6 eligible patients by using ADA criteria.” 

Read: DAY 2 highlights

Learn more: T1D Exchange Quality Improvement Collaborative