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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 41 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 G. Todd Alonso, MD
G. Todd Alonso, MD is an Associate Professor at the University of Colorado Denver, the Medical Director of Pediatric Services, and Director of the QI Team for pediatric and adult clinics at Barbara Davis Center in Denver, Colorado. He is a pediatric endocrinologist with a focus on providing care for children and adolescents living with T1D. Dr. Alonso describes his role at the Barbara Davis Center as the intersection of quality improvement, electronic medical records (EMR), and the delivery of care.
“By the time I was a medical student, I knew that I wanted to work with children,” said Alonso, “I also discovered early on that I wanted to work in a pediatric specialty area.” And as a rising second year medical student in a pediatric endocrinology clinic, it all clicked. “Treatments were logical and promising, and there was much more in the pipeline — I was really excited to be a part of it,” explained Alonso.
When asked what he enjoys most about his career, Dr. Alonso responded, “I’m so gratified by everything that I get to do, it’s hard to pick just one thing.” He went on to explain, “I love having long-term relationships with patients and families that can span a decade or more, and I also enjoy being on service. When I walk into the room of a newly diagnosed child it can be a very sad time, but being there for the family at that moment is powerful. I’m lucky to be a part of an awesome clinical team that supports families through this time.”
T1D Exchange Quality Improvement Collaborative (T1DX-QI) involvement
“The Barbara Davis Center was one of the founding members of the T1DX-QI in 2016,” said Alonso who is the primary investigator for Barbara Davis and serves as the Co-Chair of the T1DX-QI Data Science Committee. “We knew that T1D Exchange was offering a wonderful opportunity, and that it would be a great group to work with. We see ourselves as leaders in diabetes care, partly because we have a big clinic population — we provide care for over 4,000 children with T1D — but we also have a really robust faculty with different areas of interest, so there’s a lot of research going on here, too.”
“It’s been fantastic to see how the Collaborative has grown and to be a part of that building process. I’ve made a lot of professional connections with like-minded endocrinologists who are doing similar work, but may have different solutions to related problems. I come back with effective ideas to implement every time we engage,” said Alonso.
Current areas of research
Alonso explained that his primary academic interest is in improving the delivery of care to children and adults with T1D. “My interest is where the rubber meets the road — where we have the evidence for interventions that work — and we want to get them into the hands of our patients.”
For example, “We know that when we put kids on CGM, their blood sugars are better. So how do we get patients on it faster, and sooner, and help them to be more successful with it. That’s what I’m interested in – it’s a lot of process improvement.”
Alonso is on the front end of identifying ways to streamline T1D care, allowing more time to be spent with his patients. He reminds, “Some things may not be of academic interest, but they do make a big impact upon delivery of care.” Take school health plans for instance; a few years ago, Barbara Davis Center discovered their clinic generated over 1,200 plans in the month of August alone. They have about 1,000 clinic visits per month, and the other requests are generated from voicemails needing service; this seemed like a logical area to automate — and they’ve saved hundreds of hours by doing so, freeing up time to do things that are value-adds for families.
“This is the head space that I’m usually in — the ideal state of efficiency is connecting with the patient and family more. And many of these ideas are generated from my involvement in the Collaborative,” said Alonso.
“We’ve done really great work and seen some proof-of-concept. The most valuable things that come out of being a part of the T1DX-QI is sharing successes and failures, spreading best practices, and working together on common goals. I think we’re just at the beginning of tapping the potential.”
Dr. Alonso offered the Loss to Follow-Up (LTFU) work as an example. He explained that every practice has people who are disconnected from their care, and if they don’t see them, they have no chance to help. Dr. Alonso co-chaired a LTFU committee, hoping to make the biggest possible impact with the highest-risk individuals who were struggling the most — while benefiting from previous work accomplished by Dr. Corathers and her team in Cincinnati. “We ran a project over a 9-month period where we reduced the rate of LTFU for 0 to 12-year-olds,” said Dr. Alonso.
“In the long run, it’s not just about sharing data, and learning what the mean A1c is for example — it’s interesting and it’s a nice paper to write — but that doesn’t directly benefit the children. What’s most valuable is understanding what others have done, how they did it, and what things led up to it.” He explained that if these results are because more children are using CGM, then the focus becomes: “How did they get more kids on CGM”? By sharing best practices, data tracking, and working together as a team, Dr. Alonso assures that improved, measurable outcomes will follow.
Diabetes camp involvement
“I love being at diabetes camp. Our camp at 9,000 feet in the Rocky Mountains is beautiful, and I get a very different perspective of T1D when I’m there. It’s the one week a year where I give children insulin injections, change insulin pump sites, and help with low blood sugars — in fact, it’s the only time I’ve given glucagon.”
Alonso explained that diabetes camp is powerful on many levels. “I’m doing the job that I ask parents to do — and that means a lot to me. I get to worry about blood sugars at night, and doing this for these children impacts me personally. It’s so empowering for the kids, and being with peers can help to change the way they think about diabetes. I’ve missed camp for 100 reasons during COVID.”
“Again, there’s been a shift of A1c trends across our clinic. I haven’t seen this published anywhere in the U.S. — and I don’t know of any multi-center collaboration outside our group who has current U.S. data. At Barbara Davis Center, our mean A1c data has dropped by about 0.5% over the last 18 months.” Alonso’s hypothesis is that this is almost entirely attributable to CGM use, but they’re engaging in multiple projects to differentiate just how much is related to CGM — and how much may be layering hybrid closed-loop systems on top. “Both are valuable independently, but we need a deeper dive to understand their relationship.”
As a collaborative, Dr. Alonso explains that one major focus is boosting CGM use, increasing wear time, and helping people to be successful through education and support. These are all parts of the puzzle. “Understanding how we move the needle is important, but part of it is helping patients and families to feel more empowered; I think that telemedicine is going to play a big role in that, and we need to learn how to utilize it best. It can open up a whole different type of diabetes visits — without the hassle of getting to the clinic.”
In his free time, Dr. Alonso is likely to be at a baseball tournament with his wife and four boys. He enjoys skiing, ultimate frisbee, coaching, and playing with his kids — and even driving the a school carpool. His seasonal hobby is creative pumpkin carving; this year’s project is Voldemort.
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