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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 the quality of care and outcomes for individuals living with type 1 diabetes (T1D). Growth has been tremendous, with 45 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 Brynn Marks, MD, MSHPEd
Brynn Marks, MD, MSHPEd, is a Pediatric Endocrinologist at Children’s National Hospital, Assistant Professor of Pediatrics at George Washington University School of Medicine and Health Sciences, and serves as the site primary investigator (PI) for the T1DX-QI at Children’s National. Marks will transition to the Children’s Hospital of Philadelphia (CHOP) in July, where she will be appointed as the Director of Technology of the Diabetes Center.
Why pediatric endocrinology?
“Living with type 1 diabetes, myself, had a huge impact on my decision to go into endocrinology,” explained Marks. “I wasn’t the perfect patient — I had my rough patches as a teenager, and I wasn’t taking the best care of myself. Having a supportive provider that helped me work towards better health motivated me to become an endocrinologist.”
“I also had a heart transplant when I was 27 (in the middle of my residency), and because of this, I’ve come to understand, and appreciate, the perspectives of people in similar shoes,” reflected Marks. “I really enjoy caring for people with complicated types of diabetes such as post-transplant diabetes and cystic fibrosis-related diabetes. It all circles back to my personal experiences, the challenges I’ve seen others face, and a desire to better support them.”
“While I like the academic piece of endocrinology, it’s also about getting to know families over time, working with them, and advocating for them. It’s the best thing I could ever do, and it’s a good hybrid mix for me,” said Marks. “Getting additional training in medical education and learning how to better educate providers and patients was the perfect way for me to do what I love — while making a difference for the T1D community.”
What has impacted your practice the most?
“Health disparities have been pretty eye-opening — at Children’s National, we serve an incredibly diverse population. These issues have become evident through my research and by getting to know families that are directly impacted by the effects of systemic racism.”
Over the past year, Marks secured funding from Tandem, allowing Control-IQ technology to be shared with patients who have been, historically, least likely to access it. “This project included individuals who identify as Non-Hispanic Black, have an A1c over 10%, and are publicly insured,” explained Marks.
“Some individuals have finished this 6-month study, and changes have been amazing to see in terms of glycemic control and patient-reported outcome measures. A 21-year-old woman entered the study with an A1c over 14%, finished with an A1c of 8.3%.” But as amazing as that number was to see, the woman’s reported experience was even more so. “It changed the way she’s interacting with her parents, she’s sleeping better, and there’s less stress at home — it’s really been a fresh start for her.”
Marks strongly believes that the use of diabetes technology is tied to outcomes, and continued research on how technology impacts an individual’s quality of life is a key driver for her. “My work provides an open view of the stark realities of access issues and disparities that exist in T1D care. The patient voice is important to hear and listening to the stories of those with access issues can help us to improve as a healthcare system,” reminds Marks.
“We’re actually pretty new to the T1DX-QI at Children’s National. Although we’ve been involved for less than a year, we’ve been working towards it for a while. The work of the collaborative is inspiring; it’s front and center at conferences — how could you not want to be a part of it? When the T1DX-QI was recruiting new centers, we jumped at the chance.”
While Children’s National isn’t fully data mapped with the T1DX-QI yet, Marks points out that “Diabetes centers are all trying to fix the same things — we want to improve care. The beauty of the Collaborative is that members don’t need to reinvent the wheel. We can take the lessons that others have learned before us and use them as inspiration. This creates more efficiency in working towards similar goals. It’s one of my favorite things that I’m involved with right now.”
“One of the beautiful things about the T1DX-QI is the deliberateness in its approach to equity. We’re really putting a spotlight on it and sharing our experiences and common goals. At Children’s National, our first QI project is underway, and is focused on tackling disparities in continuous glucose monitor (CGM) access and sustained use.”
Education-based diabetes research
As a passionate advocate for people with T1D, Marks’ research lens is pointed to knowledge improvements in diabetes technology use. It’s no surprise then that family-focused diabetes education is among Marks’ most recent work — she is working towards the K23 Mentored Patient-Oriented Research Career Development Award from the National Institutes of Health. While she previously developed an education-based app for providers, this work will serve to educate caregivers of children with T1D, too.
Technology Knowledge Optimization in Type 1 Diabetes (TeKnO T1D)
“When I was a fellow in Boston, I became the point person for diabetes tech questions,” said Marks. Where even at top centers, she found that the understanding of technology varied from provider to provider.
“I started with a survey at Boston Children’s for our diabetes team. This helped to inform what providers knew and how they learned about it. The Pediatric Endocrine Society supported this work and distributed a nationwide needs assessment through a survey to attending physicians and fellows. Many of whom reported learning from people with T1D and clinical representatives from various companies.”
“I used survey results to develop the TeKnO T1D curriculum, delivered through an app called Qstream.” The app works by pushing out two questions twice a week, explained Marks. The interactive, gamified, multiple-choice curriculum looks at real screenshots (CGM and pump downloads) and real-life scenarios such as hypoglycemia during soccer practice. The app provides immediate feedback with detailed explanations of the physiology behind the suggested approaches to management.
“It turns out endocrinologists are pretty competitive,” Marks said with a chuckle. “If you put an endocrinologist on a team that gets points for answering questions correctly, we get more engaged. It’s a fun learning atmosphere that keeps people interested.”
In terms of what QI work comes next, Marks responded, “Every time we look at data, we develop new ideas. While it’s hard to focus on one area, insulin pump use rates at Children’s National have gotten our attention.”
Children’s National has made significant strides with Medicaid support for CGM use among their population of patients, which is an essential tool for automated insulin delivery (AID) devices. ”But while this may be a covered benefit, disparities present in different ways at different centers. The amount of necessary paperwork to submit for approval of CGMs for those on public insurance takes increased effort from families and care teams. We also suspect that accessing supplies through durable medical equipment companies (rather than pharmacy benefits) may negatively impact CGM use and are seeking to better understand this.”
In response, Children’s National is building a CGM onboarding checklist to help streamline processes. “By centralizing this information, everyone who is a part of our diabetes care team can see where a patient sits in terms of approval. It’ll be easier to track, and we can better support the families in gaining access,” explained Marks. “We’ve seen a shift towards more pharmacy coverage, which is great,” said Marks, who hopes that this will translate into fewer prior authorizations and calls for families and providers.
Wherever Marks’ work takes her, one thing is clear — her love of technology and drive to help others access and master its use is the common thread that weaves her career together in perfect fashion. With her wholehearted belief in the power of education to master T1D technology use, everyone will benefit from her dedicated work.
Outside of work, you’ll likely find Dr. Marks exploring new trails. She has a love for the outdoors and the discovery of new places as an avid hiker and traveler. You can find her on Twitter at @BrynnMarks_MD.
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