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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 daily life for people with type 1 diabetes (T1D). Growth has been tremendous, with 54 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 Vandana Raman, MD
Vandana (Vana) Raman, MD, is an Associate Professor of Pediatrics and a practicing pediatric endocrinologist and researcher at Primary Children’s Hospital in Salt Lake City, Utah. Dr. Raman is also the Chief of the Division of Pediatric Endocrinology & Diabetes and is the Program Director of Pediatric Endocrinology and Diabetes Fellowship at the University of Utah.
Dr. Raman also serves on the Drug and Therapeutics Committee, Education Committee, and the Fellows’ Education and Sub-Committee for the Pediatric Endocrine Society.
What led you to endocrinology?
“There were several things,” said Raman. “I’ve always enjoyed physiology, and I appreciate that endocrinology entails a degree of detective work.”
Raman explained that during her residency, Dr. Manu Kamboj, a pediatric endocrinologist and founding member of T1DX-QI, also served as an instrumental role model. “I always tell Dr. Kamboj that I’m an endocrinologist because of her.”
While these were key drivers in Raman’s decision-making, her calling became even clearer after volunteering at a summer camp for children with T1D.
“Witnessing the resilience and joy of campers was a transformational experience for me. At that time, I knew I wanted to be a pediatric endocrinologist for the rest of my life — even if it meant making a small impact in the lives of children and adolescents with T1D.”
With her positive intentions, advances in diabetes technology, and quality improvement strategies, Dr. Raman is celebrating in-clinic success stories like never before.
“There are some days the highest hemoglobin A1C I see is 7.5 percent — and I just want to cry — I couldn’t have imagined during my fellowship 15 years ago that this day would ever happen,” said Dr. Raman.
Unique program for high-risk adolescents with T1D
Dr. Raman serves as the Director of the Diabetes Intensive Management and Education (DIME) Clinic at Primary Children’s Hospital, a state-of-the-art program providing wrap-around care for high-risk adolescents with T1D.
The DIME Clinic features a multidisciplinary team of providers including endocrinology, social work, diabetes education, and behavioral health experts. Appointments are broken into two, 30-minute segments — with the first half functioning as a combined provider, social worker, and educator visit, and the latter with a psychologist providing targeted therapy for mental health needs.
“The model sort of happened by accident,” explained Raman. “Our first patient was running late, so we decided to see her together — and we loved it. We’ve adhered to this model over the past three years, and it’s worked out beautifully.”
“Every little part of DIME matters. With weekly nursing check-ins between bi-monthly multidisciplinary visits, there’s a closer relationship with more assistance. This has really helped the DIME Clinic to be quite impactful for our population — and we continue to get very good feedback.”
The program’s QI efforts speak for themselves, with DIME data presented during a poster session at the Pediatric Endocrine Society and a manuscript underway.
“While 85% of our patients have seen an improvement in A1c values, we’re also looking at other measures such as anxiety, quality of life, and diabetes distress scores — and noting significant improvements in all of these areas,” explained Raman.
Mental health and holistic care for T1D
“Emotional well-being is such a huge part of diabetes care. We’ve been using mental health screeners for several years now — for every patient, at each appointment. While it does mean extra forms to fill out, it’s so important for holistic care,” said Raman.
“At Primary Children’s, we have two social workers and a psychologist in-clinic. We’re so fortunate to have that leadership support, and because of this collaboration, it allows us to fast-track patients to behavioral health for necessary help and support.” Which is important, given that emotional responses to the daily demands of diabetes are commonplace, with higher rates of depression and other mental health issues in those living with T1D.
“Diabetes is hard, and teenage years can be hard, too. When you combine the two, that can make it even harder,” said Raman. “Mental health support is a vital part of our in-clinic care.”
Current areas of research and T1DX-QI Involvement
At Primary Children’s hospital Allison Smego, MD and Raman are co-PIs for T1DX-QI. While Primary Children’s is somewhat new in their affiliation with the T1DX-QI, Raman had prior involvement with the T1D Exchange during its inception as a registry, researching insulin pump and metformin use in children.
In terms of current research, Raman explained, “I’ve been involved with TrialNet and T1D research for some time, which I believe is really important work. Most recently, I have two main QI and research projects I’m working on with fellows. The first is on health equity and closing the technology gap in English and non-English speaking populations.”
“We’ve seen clear disparities in the use of diabetes technology — and we’re not the only center noting this, of course — there are many publications about this,” said Raman. In response, their clinic has prepared CGM and insulin pump handouts in the eight most common languages at their center.
“We hope to move towards health equity in technology adoption in our non-English speaking population, improving quality of life and glycemic outcomes,” explained Raman, who will be presenting research data at the PES meeting.
The second project has its sights set on increasing CGM and insulin pump use, incorporating shared learnings from other T1DX-QI institutions.
“We’ve seen great improvements over the last few years in the utilization of technology, and again, this is an active team effort. We’re almost at 70 percent pump use and 90 percent CGM use, and I think this is reflective of other measures that we’ve taken, too,” said Raman.
“We used to say you must do X, Y, and Z to get on a pump. Now I think almost everyone is a candidate — and it’s a cultural shift for doctors, too, as we have better pump and closed-loop technology,” said Raman. “One of the things, that again, I hope to collaborate with T1DX-QI on is to continue moving the needle for technology utilization rates and meeting A1C goals, and to learn from others who are doing this successfully.”
At the diabetes clinic, notable improvements in A1C measures are secondary to the adoption of technology, with 54 percent of patients reaching their target glucose range.
“The data is very encouraging. It’s important to remember that these aren’t just numbers, these are individual lives that we’re changing — slowly but surely,” said Raman.
A strengths-based approach to care
Raman spoke of the necessity, and effectiveness, of whole-person approaches in endocrinology care.
“In the DIME Clinic, we don’t just talk about diabetes. We explore what’s unique about each child — as an athlete, musician, skilled listener, or good friend, for example,” explained Raman. “We highlight these character strengths on the top of our summary sheet, and it serves as a reminder that diabetes isn’t a child or adolescent’s defining factor all of the time.”
“We’re really looking at all aspects of our patients, including how they’re doing socially and in school. Our strengths-based approach has worked really well at Primary Children’s Hospital DIME Clinic,” said Raman. By focusing on one or two goals per visit, the diabetes care team outlines achievable and actionable steps for families.
Primary Children’s Hospital has several projects in the pipeline, including the development of a transition clinic to offer more purposeful movement of patients advancing from pediatric to adult-centered care.
Raman explained that while transitions of care is a “work in progress,” it has developed into a more structured and formal doctor-to-doctor handoff. She hopes to streamline this process even further, incorporating adult visits prior to the full transition from pediatric care.
“We’re lucky to have a med-peds endocrinology fellow on this project, and together, we hope to develop a formal transition clinic this year,” explained Raman. “We know that proper preparation and timing of transition is key for a patient’s success in adult care,” said Raman, whose diabetes care team begins to lay the foundation with a readiness survey beginning at age 15.
Outside of work
Dr. Raman enjoys spending time outdoors with family and friends, preparing food for those she loves, and maintaining her strength and fitness through barre and Pilates.
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Meet the Expert: Looking Beyond A1c at a Patient’s Quality of Life
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