Quality Improvement Learning Sessions

The T1D Exchange Quality Improvement Collaborative (T1DX-QI) has grown from just over a dozen participating clinics in 2019 to 54 participating clinics in 2022, serving over 100,000 patients across the U.S. The newest centers to join the T1DX-QI include Billings Clinic, UPMC, Oregon Health and Science University, Cleveland Clinic, and UC Davis.

Members from participating endocrinology clinics across the country come together to share insights on improving the care provided to people with diabetes — with the goal of improving quality of life and overall health.

Here are examples of the immensely valuable work presented by the T1DX-QI at our Learning Session event in 2022 in Miami, FL, on November 7 and 8.  

Interventions to Improve Technology Equity in Young Adults (YA) with Type 1 Diabetes 

Presenter: Priyanka Mathias, MD
Albert Einstein College of Medicine and Montefiore Medical Center 

Young adults are the fastest growing population with T1D, explains this research. This population also has the lowest rate of using diabetes technology despite the benefits. Compared to other age groups with T1D, young adults have: 

• Higher HbA1c levels 

• Higher hospitalization rates 
• Higher psychiatric comorbidity 
• Higher risk of mortality 

Despite adjusting for social and economic factors, the disparities in technology use in the young adult population are significant. This research established a goal of examining technology use in patients aged 18 to 35 years old from January 2019 to December 2021. 

Participant ethnicities were: 

• 55% Hispanic 
• 22% Non-Hispanic Black 
• 10% White 
• 13% Other/unknown 

This research focused on addressing those disparities using the SEAD model of care: 

• Talk directly to patients 
• Equity focus 
• Manage expectations 
• Build people up, emphasize positives 
• Manage negatives 

• Avoid doomsday talk 

Overall, using the SEAD model of care significantly increased CGM usage rates in young adults with T1D: 

• Overall increase: 31% to 69% 
• Hispanic increase: 12.5% to 71% 
• Non-Hispanic Black increase: 33% to 55% 

• White increase: 33% to 75% 

This research concluded that it’s very possible to increase CGM usage in the young adult population but requires a more intentional effort. 

Improving Screening for Depression in Adolescents with Diabetes 

Presenter: Angel Nip, MD (virtual)
Benioff Children’s Hospital and University of San Francisco 

This research focused on improving the screening process for adolescents with T1D. Depression is common among adolescents, but rates of depression in those with diabetes are significantly higher. Depression is also associated with higher HbA1c levels and increased rates of diabetes-related hospitalizations. 

Initial findings revealed that mental health screenings were not routinely completed for all patients within a clinic and some clinics had no formal screening tool in place at all. 

With the goal of achieving depression screening in more than 50% of adolescents with diabetes, a multidisciplinary task force is recommended. This task force should include providers, social workers, transition coordinators, office assistants, diabetes educators, and practice administrators. 

Proposed tactics to increase depression screening: 

• Increase screening for depression and referral to social workers for eligible patients 
• Use a consistent screening method with electronic documentation 
• Integrate screening method into routine clinic workflow involving clinic staff and visit planning 

• Increase adequate social work referrals based on screening results 
• Use increased referrals to justify increased staffing of social workers 
• When implemented, these proposed tactics ensured more than 50% of patients were screened for depression. 

Increasing Frequency of Clinic Visits among Medicaid Insured Children and Adolescents with Type 1 Diabetes 

Presenter: Carla Demeterco-Berggren, MD, MPH
Rady Children’s Hospital and University of California, San Diego 

This research aimed to improve the frequency of clinic visits in youth with type 1 diabetes on Medicaid. There is a known relationship between frequent clinic visits and achieving target HbA1c levels. While the recommendation is clinic visits once every three months, only about 50% of patients on Medicaid meet this frequency. 

Using electronic health records, they identified patients with Medicaid, identifying these ethnicities and racial groups: 

• 53% Hispanic 
• 16% African American 
• 3.2% Asian 

• 11% refused to identify 
• 16.1% White 

Interventions to increase clinic visit frequency include: 

• Monthly diabetes dashboard review 
• Care navigator outreach 

• Provider engagement 
• Rescue visits slots added to NP schedule 
• Care navigator appointment reminder calls 
• Health maintenance created in the EHR 
• Diabetes RN champion outreach call 

This study is ongoing and has not collected results at this time. 

A Program to Decrease Diabetic Ketoacidosis (DKA) Admissions: Diabetes Wellness Program (DWP) 

Presenter: Pediatric Diabetes Program, Roberto Izquierdo, MD
Upstate Golisano Children’s Hospital, Josline Diabetes, and Upstate Medical University 

Pediatric DKA admissions have risen by 40% in the US with the most vulnerable groups at the highest risk. This research focused on reducing DKA admissions in pediatric patients with T1D through the Diabetes Wellness Program (DWP). 

• Hospital charges per DKA admission have increased from $14,548 to $20,997 

• Length of hospital stay has decreased from 2.5 to 2.2 days 
• Patients with frequent ER visits have an average HbA1c over 14% 

For patients ages 8 to 21 years old with multiple DKA admissions, the following process taking place over the course of six weekly phone calls is proposed: 

• Ensure usage of MyChart 
• Keep BG low or download device data 

• Set SMART goals 
• Assess the need for nutritional support 
• Review ketone testing and sick-day education 
• Review hypoglycemia protocol: use of glucagon, checking BG frequently, driving safety guidelines 
• Review physical activity and BG management education 

• Review technology, blood sugar patterns, making small adjustments, establishing routines 
• Increase education on independent insulin dose adjustments 
• Discuss long-term habits for long-term success 
• Discuss “after-hours” game 

77% of the participants who completed this program significantly improved their quality-of-life scores based on results from the pre- and post-admission surveys. 

100% of participants reported that the DWP helped them: 

• Prevent future DKA admissions 
• Improve overall quality of life 
• Feel more confident in diabetes management 

This program is proving effective in reducing DKA hospitalizations. 

Supporting Successful Health Care Transition from Pediatric to Adult Diabetes Care 

Presenter: Faisal Malik, MD, MSHS, Sarah Corathers, MD
Seattle Children’s Research Institute and University of Washing School of Medicine, Cincinnati Children’s Hospital and University of Cincinnati Department of Pediatrics 

With the goal of transitioning pediatric patients with T1D to adult diabetes care, this research aimed to identify a successful timeline and necessary support. This is a critical timeframe when patient care can suffer due to a lack of transition support and process. 

• Over 70% of pediatric clinics have a formal transition policy. 

• Over 40% of adult clinics were unsure if they had a formal transition policy. 
• Less than 40% of pediatric clinics said their transition policy was created with input from patients. 
• Less than 40% of pediatric clinics use a transition readiness patient questionnaire. 
• Only 27% of pediatric clinics have a process in place to complete the transfer of care. 

Depending on the patient’s individual diabetes education and management habits, this transition can begin anywhere between 14 to 21 years old, based on success from the Adolescent and Young Adult Diabetes (AYA) program from University of Washington State School of Medicine (UWMDI). 

Factors to consider throughout the transition of pediatric to adult care include: 

• A clinic’s transition and care policies 
• Tracking and monitoring patient’s health data 
• Reflecting on each individual patient’s transition readiness 
• Planning that transition ahead of time and discussing with patient 

• The actual transition to adult care 
• Confirming transfer completion between clinics 

The providers on any successful transition team should include: 

• Endocrinologist 
• Dietician 

• Social worker 
• Diabetes educator 
• Psychologist 

The AYA program proposes using their Diabetes Program Registry READDY questionnaire to assess readiness and monitor the transition process for every patient. 

Technology, Device Use, and TIR/A1C Targets 

Presenters: Nudrat Noor, PhD, MPH, Mark Clements, MD, PhD, and Francisco Pasquel, MD, MPH (virtual), Children’s Mercy Kansas City Hospital and University of Missouri-Kansas City School of Medicine 

This research focused on the impact of diabetes technology on HbA1c levels and time-in-range (TIR). Cohort details include: 

• 1,867 participants 
• Median HbA1c level: 8.1% 
• 728 were eligible for depression screening / 452 actually screened 

• 79% used a CGM 
• 7.2% of non-CGM users checked blood sugar at least 4x per day 
• 68.8% used an insulin pump / 30.3% on multiple daily injections 
• 99.1% were effectively administering daily insulin 

HbA1c levels correlate closely with the “Six Habits” of diabetes self-management: 

• Using a CGM or checking blood sugar at least 4x per day with glucometer 

• Giving at least 3 rapid-acting boluses per day 

• Using an insulin pump 

• Delivering mealtime insulin before meals 

• Reviewing glucose data at least once between clinic visits 

• Self-adjusting insulin doses at least once between clinic visits 

• (Future habit to propose when ready: Improving overall diet) 

• (Future habit to propose when ready: Increase daily physical activity) 

The average HbA1c of patients engaged in all six habits = 8%. Patients with the fewest habits had average HbA1c levels around 12%.