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The T1D Exchange Quality Improvement Collaborative (T1DX-QI) was established in 2016 — with the support of The Leona M. and Harry B. Helmsley Charitable Trust — in an effort to refine best practices, and improve quality of care and outcomes, for individuals living with type 1 diabetes (T1D). Growth has been tremendous, with 50 endocrine clinics from across the U.S. participating in the Collaborative.
Fueled by top leaders in diabetes care, the T1DX-QI has become an engine of innovation and inspiration. By engaging with the shared, data-driven, and systematic methods of the T1DX-QI, clinics have seen unprecedented success in their approach to diabetes management.
With members working closely together to identify gaps in care, discover and refine best practices, and share research, the process has become knowledge sharing at its very best. While collated data gives clinics a clear sense of “where they are,” it also demonstrates “where they can be” by applying shared, evidence-based methods for improving care.
Interview with Shivani Agarwal, MD, MPH
Shivani Agarwal, MD, MPH, is an Adult Endocrinologist and Assistant Professor of Medicine at the Albert Einstein College of Medicine. Dr. Agarwal also serves as the site Primary Investigator (PI) for the T1D Exchange Quality Improvement Collaborative (T1DX-QI) at Albert Einstein College of Medicine.
What drew you to T1D care?
“I came to diabetes care with an interest from my public health degree, and research flowed naturally from that,” shared Agarwal. “I had the instinct that if I could help create systems and healthcare models that incorporated different parts of people’s lives with diabetes, including their in-clinic experience, perhaps we could begin to impact outcomes on a larger scale.”
She firmly believes in providing care that’s right for the individual — knowing this can vary greatly from patient to patient.
“I approach type 1 diabetes from a more holistic view, because often things may appear unrelated to diabetes, but most everything in life impacts it. Being a diabetologist has allowed me to do that. I could really take care of the whole person — and not just one small part of them.”
Equity, accessibility, and inclusion
“Wherever I’ve landed in my stage of training I’ve always tried to lift the voices of more vulnerable populations,” explained Agarwal, who has a laser focus on culture, policies, and systems — and how they contribute to health disparities.
“I’ve worked with underserved populations through volunteerism and public health initiatives. My medical work even dovetailed into this area,” said Agarwal whose medical training and public health degree took her to the Bronx, Baltimore, and Philadelphia.
While Agarwal never doubted her decision to become a physician, she was nudged in a different direction during her third year of medical school.
“I took a year off between years three and four to earn my MPH. I just saw so many broken parts of the system — it seemed that everyone was powerless as a cog of a larger system. It felt like an injustice that I had to help fix.”
Agarwal’s strategy was multipronged.
“I’ve always been interested in expanding healthcare teams to include non-traditional members, while figuring out reimbursement and ways to incorporate this into care. It was a lot of quality improvement work in conjunction with leadership, billers, and providers. I was discovering how to translate models of care into real-world scenarios, how to fix system problems, and get the people that could say yes or no — to say yes.”
On the heels of her MPH, as a fellow at the University of Pennsylvania, Agarwal got her feet wet in T1D care, quickly realizing she enjoyed the specialty.
“I started seeing a lot of young adults with similar stories —multiple endocrinologists, new ER visits when there hadn’t been before, and rising A1c values. And while this was happening on all socioeconomic levels, it was worse for people with resource constraints,” explained Agarwal.
Identifying yet another systems problem, she set out to fix it — and this is how the Supporting Emerging Adults with Diabetes (SEAD) program was born, a comprehensive multidisciplinary program with a mission to help young adults with T1D between the ages of 16 and 35. At present, Agarwal’s patient population is exclusively young adults from the SEAD program.
QI and Research
While Agarwal had great success fixing single-system problems, she wanted to broaden her reach, and this led her into research.
“I saw research as another tool to create change,” explained Agarwal. Through this work, she discovered the inequitable distribution of diabetes technology — and its impact on outcomes.
For Agarwal, it was an eye opening experience.
“With technology advancements, disparities widen,” she explained. “It doesn’t bridge disparities, the inequities grow even larger. And individuals that were left behind as early adopters are usually more hesitant to use technology moving forward — there are a lot of barriers. I knew it was a big problem that was actually worsening.”
“So again, I saw an injustice and knew it had to be fixed,” said Agarwal, who took the charge and approached the issues from multiple directions. “I really dove into the layers and that helped to tease the story to the surface.”
Her focus shifted from identifying disparities and their related modifiable and non-modifiable factors to interventions through the T1D Exchange Quality Improvement Collaborative (T1DX-QI).
“I really wanted to make an impact and it was during these years that I joined the T1DX-QI and became the PI at Penn Medicine. We were among the first T1DX-QI sites. I’m now the PI at the Einstein site. I was so happy to return, it was like coming back to family — and the work is so important.”
“It’s really exciting to initiate change from T1D research findings by improving or standardizing our approaches to T1D care” said Agarwal
“At Einstein, we have an under-resourced population that could benefit from cycles of change and iterative improvements that we can make in-clinic. None of this is possible without the exchange of ideas and having leadership on board. It’s been a catalyst for change at our center.”
Future work includes a few exciting grants that are already underway.
“I’m hoping to further develop care models, so they can become more standardized,” explained Agarwal. “And while young adults with T1D are the focus of my research, I do think the findings will advance quickly across the lifespan.”
The first is a JDRF-funded study looking at targeting diabetes distress in young adults with type 1 diabetes to improve glucose control.
“This is a randomized control trial testing whether using cognitive behavioral therapy targeted at diabetes distress and behavioral review of CGM versus CGM alone improves diabetes distress and A1C over 12 months. We’ve started the pilot, and it will open to the general population in June,” she explained.
The second is an NIH-funded study that’s starting in April that will be looking at community health workers who are specializing in diabetes and diabetes technology.
“They’ll introduce patients to technology, and help to support them with decision making,” said Agarwal. “In turn, this will help providers to offload the knowledge burden, so that there’s less barriers to entry.”
Outside of work, Dr. Agarwal enjoys to spend family time with her husband, Eugene, who works in education technology, and her two daughters, Kiran age 3 and Priyanka age 7. Together, they love going on long bike rides, cooking, trying new restaurants and foods from different cultures, and dreaming about traveling internationally together. When Dr. Agarwal gets rare alone time, she would love to pick up her hobbies again of photography and horseback riding.
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