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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 Collaborative.
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 Daniel DeSalvo, MD
Daniel DeSalvo, MD is an Assistant Professor at Baylor College of Medicine and a Pediatric Endocrinologist at Texas Children’s Hospital. Dr. DeSalvo serves as the Type 1 Diabetes Clinic Lead, Diabetes Transition Clinic Co-lead, and is the Director of Strategic Collaboration at Texas Children’s Diabetes and Endocrine Care Center.
Why pediatric endocrinology?
“I was diagnosed with T1D when I was 19 years old and attending Baylor University in Texas, and it really changed my career trajectory,” explained Dr. DeSalvo. “I was a political science major, planning to go to law school.” But with a newfound desire to provide compassionate and empathetic care for others, he switched to pre-med — and the rest is history.
DeSalvo explained that time spent with patients and families is what delights him the most. “It’s a precious gift to shepherd someone on their T1D journey — to understand who they are as a person, what their passions are, and to support them, so they can fulfill their hopes and dreams. I tell our fellows that relationship-based care is just as impactful as evidence-based medicine.”
“Patients spend 99.9% of the time on their own, so empowering them during a clinic visit is so important. We want to help everyone achieve positive clinical outcomes, and the quality improvement work helps to inform and structure the clinical experience. Alleviating the burden of diabetes and optimizing quality of life is what inspires me, and I’m just so content with the work that I get to do.”
Texas Children’s Hospital and the QIC
“Texas Children’s Hospital was part of the genesis of the QIC. We were one of the first 10 centers involved in the Collaborative, so I’ve been engaged from the get-go. Our mission at Texas Children’s Hospital aligns closely with that of the T1D Exchange, in terms of measurably improving clinical and quality of life outcomes for people with T1D,” explained DeSalvo, who serves as the site PI for Texas Children’s Hospital and also as co-chair of the QIC Data Governance Committee.
“Growing together as a Collaborative has been such a joy — we’ve learned so much from what other sites are doing from a data sharing perspective, but also from one another with the QI work that we’re all doing.”
Dr. DeSalvo explained that his research is two-pronged: The first is on advancing T1D technology, the second is on decreasing the burden of T1D, while optimizing health and quality of life.
His efforts are focused on novel management strategies for T1D, and DeSalvo is bringing them to life by partnering with engineers to develop platforms that collect and analyze data streams.
DeSalvo also works in the Resilience And Diabetes (RAD) Behavioral Research Lab at Baylor, which is led by Marisa Hilliard, PhD. “This specialized approach empowers patients to tap into their innate resilience, optimizing clinical outcomes such as: A1c, glucose metrics, time in range, and quality of life measures,” explained DeSalvo. “I’m also working with Hilliard on the PRISM study (Promoting Resilience in Stress Management).”
Additionally, “we have a Helmsley-funded, health-related quality of life study, and we’re also doing important work on health equity, access issues, and clinical outcomes. Inequities exist in many areas, especially with cost and coverage issues, implicit biases, and access to technologies that can improve clinical outcomes for people living with T1D from all backgrounds,” said DeSalvo.
QI improvements at Texas Children’s Hospital
“I like to use baseball analogies; I’m a huge Houston Astros fan,” said DeSalvo. “So off the bat, one of the things that I love about our local QI program here in Texas is that we haven’t just given patients and families a seat at the table — but a voice to be leaders in co-creating PDSA cycles (Plan-Do-Study-Act), aims and initiatives, and improvements in process metrics and outcomes with T1D.
“For example, we’ve made significant strides in CGM use by following in the footsteps of our QIC partners. By engaging families from Texas Children’s Hospital, and amplifying our advocacy voice through letter campaigns, meetings, creating evidence-based guidelines, and some key partnerships — we pushed for Medicaid CGM access in Texas — and achieved this goal in April, 2021.”
And in turn, CGM usage rates increased from less than 20% in 2015, to now more than 90% of patients starting within the first 3 months of diagnosis — with clinic-wide numbers hovering over 60%, said DeSalvo. “We’ve really changed our paradigm. And all newcomers, regardless of insurance status, are starting on CGM in the first few days of diagnosis. These incredible outcomes are because of our partnership with the Collaborative and families here in Texas.”
What’s your biggest clinic win?
“At TCH, we had a high school student who was having about 5-10 DKA admissions per year, and over about a 3-year period, an average A1c of about 14%. He had diabetes distress and burnout, was struggling in school, and had other challenging life circumstances. Our entire team decided to do everything we could to help. We saw him in-clinic on a weekly basis for 2 months, then on a monthly basis for 6 months and now, every 3 months.”
“With our team behind him, he was able to turn things around. He went to a diabetes camp, started on a CGM and eventually a closed-loop system — and his A1c improved to less than 7% with minimal hypoglycemia. He graduated from high school, is now in college, and is working in a hospital, hoping to become a diabetes educator. Diabetes is a journey; he still has bumps along the way, but it’s a success story that he gets the credit for.”
How do you address transitions of care?
“At Texas Children’s Hospital, we have DiaBetter Together through the RAD Lab. This is a unique transition program with a warm handoff — not just across a metaphorical bridge, but a literal bridge in our case. Patients who are transitioning from pediatric care can go to the Baylor young adult diabetes clinic, whose mission is to support individuals aged 17 to 26 on their T1D journey. There are also trained peer mentors involved in this program.”
“I would say the next thing is to really change the paradigm from reactive to proactive diabetes care. By using predictive analytics and remote patient monitoring to be able to identify who is at risk whether it is DKA or deteriorating glycemic control — and to have the resources and personnel to do targeted outreach that is tailored to the patient and family.”
“Outcomes can mean a lot of things — improving A1c, reducing DKA and diabetes distress or burnout, amongst others. By understanding aggregate data and deploying meaningful and actionable measures, we can help to scale this work. With the QIC, we’re sharing what we’re learning; we’re not reinventing the wheel.”
Outside of work, Dr. DeSalvo enjoys spending time with his 2 children playing baseball, soccer, and flag football. He’s an exercise enthusiast and loves running, cycling, swimming, and competing. Time spent with family, being active outdoors, traveling, exploring, trying new foods, reading, and listening to podcasts are other favorite pastimes.
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