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The T1D Exchange Quality Improvement Collaborative (QIC) 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 QIC.
Fueled by top leaders in diabetes care, the QIC has become an engine of innovation and inspiration. By engaging with the shared, data-driven, and systematic methods of the QIC, 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 David M. Maahs, MD
David M. Maahs, MD is a Professor of Pediatrics at Stanford University and Division Chief of Pediatric Endocrinology at Lucile Packard Children’s Hospital. In addition to his medical training, Dr. Maahs has a PhD in epidemiology and an MA in English. Dr. Maahs served as Secretary-General for the International Society of Pediatric and Adolescent Diabetes (ISPAD) and is the President-elect, and with his extensive T1D research and publications, Dr. Maahs is a top-rated T1D expert worldwide.
Dr. Maahs has been an active member of the T1D Exchange since 2013. He is currently Director of International Collaborations and a previous co-chair of the Protocols and Publications Committee for the QIC.
Additionally, Maahs co-authored the 12th and 13th editions of Understanding Diabetes, a comprehensive T1D handbook provided for newly diagnosed children in the JDRF Bag of Hope. His research interests are focused on improving quality of care and preventing complications in individuals living with T1D.
Dr. Maahs’ trajectory towards medicine began after serving in the Peace Corps, and lucky for the T1D world, he discovered an enjoyment of endocrinology and diabetes during his pediatric rotations as a resident. Maahs shared that his interests also have roots in his familial experience, witnessing both of his grandparents shouldering diabetes. But his experience at Indian Health Service (IHS) Diabetes Clinic in Albuquerque, NM may have sealed the deal. “I really enjoyed the patients and mentorship that I received at IHS. I was involved in gestational diabetes research there, and really, all of these things led me in the direction of pediatric endocrinology,” explained Maahs.
“I think what I enjoy most about diabetes care is the continuity I get with patients and families. With a new diagnosis it can be a very vulnerable time, so we engage frequently. This creates a special bond — and the relationship grows over time.” He went on to explain that at Stanford, the diabetes team has a particular focus and methodology on how things get started in terms of education, resources, and support, “so these children and adolescents can have a happy, healthy life.”
International diabetes work
“Since 2013, one of my roles with the T1D Exchange has been in international collaborations. We work with the National Pediatric Diabetes Audit (NPDA) in England and Wales — and others in Germany, Austria, Luxembourg, Switzerland, Australia, Sweden, Denmark, and Norway.”
“We’re up to 25 publications with the Collaborative,” said Dr. Maahs, who went on to explain that this work has been eye opening in the perspective of what’s happening internationally in diabetes care.” By comparing ourselves to other countries, we’ve learned more about their strategic approach and outcomes — and how they’re doing better than we are in the U.S.”
“We’re beginning to see improvements because of Dr. Osagie Ebekozien and team and the QIC. Prior to this work, we didn’t have coordinated quality improvement, and things weren’t getting better — in fact, they got worse. With structured QI, we’re catching up and seeing improved clinical outcomes.” Dr. Maahs explained that in Germany, for example, they’ve had a quality improvement program in place for 25 years, so it’s no surprise that their A1c values are lower on average than in the U.S.
“This work has been really enjoyable, and it’s been in tandem with ISPAD projects, which is the only international pediatric diabetes group providing a global pediatric perspective,” explained Maahs. “At the most recent virtual conference, there were 1,500 people from 100 countries — it’s truly an international group — with advocacy, support, and fellowships for diabetes providers in developing countries. We’re hosting a diabetes provider from Turkey right now, and it’s a wonderful partnership.”
The Stanford Diabetes Center
The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) funds 16 different diabetes centers via program grants and research infrastructure, said Maahs. “At the Stanford Diabetes Research Center we have 4 different research cores and funding for pilot and feasibility awards, so it helps junior investigators to get started. At Stanford, we have more cohesive, organized, and visible research, which can increase involvement on campus. If someone can get a small grant early in their career, it can have a big impact. We’re doing really important work here.”
What quality improvements have you seen in the Stanford clinic?
“I’m working with Dr. Priya Prahalad who is our lead for the International SWEET Registry and QI lead for the Collaborative. We’re about 3 years into our 4T program: Teamwork, Targets, Technology, and Tight Control in newly diagnosed T1D pediatric patients. We’re starting CGM early for these kids — within a week after diagnosis with a follow-up nurse practitioner visit a week later.”
“By working with Stanford engineering colleagues we’ve been able to get CGM data into the medical record and also into a population health dashboard. So much data comes in from CGMs, so this helps the diabetes team to identify patients who need help and initiate communication with the family as needed.”
“We have 133 kids that went through this program and hope that our paper will be published in the next few weeks. We showed a 0.5 percent reduction in A1c at 1 year (compared to historical numbers), and our diabetes team is pretty excited about that.” Next steps include building a shareable program for colleagues to use across the U.S., so that everyone can benefit, explained Dr. Maahs.
Stanford is also looking at patient reported outcomes in terms of quality of life measures. “I was ready for it at the beginning” was published in Diabetic Medicine, because about 3 or 4 years ago, it was questionable how early a newly diagnosed patient should start on a CGM. “What we found out was that most parents reported using CGM early was really beneficial — and that kids would rather not poke their fingers 10 times a day.”
Expanding the Stanford 4T program is something that I’m really excited about. Additionally, we’re partners with the University of Florida Diabetes Institute, and Echo Diabetes (Extension for Community Healthcare Outcomes), working on a tele-education model to reach primary care docs in remote areas where there isn’t access to an endocrinologist. We’re trying to help raise the level of care received in primary care offices. I’m also very excited about the work ahead with ISPAD and the T1D Exchange International Collaborations.”
Outside of work, Dr. Maahs enjoys cycling, hiking, and cooking with his family — and hopes to get back to traveling and exploring new places soon.
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