Health inequities are prevalent and take on many forms amongst racial and ethnic groups in the pediatric and adult type 1 diabetes (T1D) community. In response, T1D Exchange is engaging in multiple strategies to understand and reduce their impacts. While working solutions may be difficult to formulate and implement, inequities must be disentangled to improve health outcomes in these identified populations.

“HEAL is critical to transforming type 1 diabetes treatment by bringing together a diverse and well-experienced group of health professionals focused on achieving health equity. The group centers those who experience worse outcomes at a population level and asks why; they pay particular attention to racial inequities and what is changeable to improve the quality of life for those living with type 1 diabetes,” Makaila Manukyan, HEAL Advisor, Senior Project Manager, Office of Equity, Vitality, and Inclusion, Boston Medical Center.

The newest component of the T1D Exchange Quality Improvement Collaborative (T1DX-QI) HEAL program, the HEAL Advisory Committee, has officially kicked off with members strategically working on ways to improve the framework of care for people living with T1D. With a vision to “achieve equity for patients with type 1 diabetes by piloting innovative approaches in the T1D Exchange Quality Improvement Collaborative,” this group of professionals is set to make a difference.

“We see biases in a number of places in healthcare, and so when we see the stark inequities in technology use, especially in black and Hispanic T1D patients when compared with white T1D patients, it’s definitely a factor worth examining,” explained Ann Mungmode, MPH, CPHQ, Quality Improvement Program Manager at T1D Exchange.

T1D Exchange: Achieving Optimal Health Outcomes for All

There’s no question that everyone is deserving of safe and equitable access to care, but there are known factors outside of a person’s control that can impact this. While data is important and necessary to validate this gap, adaptive changes within the healthcare system are needed, because overcoming these obstacles is rarely something that an individual can accomplish on their own.

Without accountability for persisting inequities that result in higher A1c values, increased DKA episodes, more severe hypoglycemic events, and increased mortality rates — as a healthcare system, we’re failing. Regardless of breakthroughs in T1D management tools and technology, T1D Exchange data highlights inequities in its prescribed use — with COVID-19 only serving to widen this established healthcare gap.

“I am looking forward to serving alongside others in the Advisory Committee because I believe together, we possess the necessary knowledge and commitment to achieve much-needed change to ensure that African American and Latinx individuals, and people who are economically disadvantaged, receive high-quality care to have the healthiest possible outcomes. This work is essential because of the laser-focus on equity for marginalized populations with T1D. I know that it is important to continue work to ensure the healthiest possible outcomes for all people with diabetes. Yet, the pervasive data on inequities in care and outcomes show us that there are specific vulnerabilities that need to be addressed with concerted attention, effort, and resources,” said Dr. Ashley Butler, HEAL Advisor, Baylor College of Medicine, Texas Children’s Hospital.

For those living with T1D equitable care can be complicated, and it entails much more than access to insulin. All individuals with T1D should have an equal opportunity to achieve the best possible health outcomes, regardless of race or ethnicity, including access to technological T1D advancements.

Health Inequity and Social Determinants of Health

One thing is clear: Issues rooted in the delivery of healthcare are multifactorial, and they can have a significant impact on diabetes health and outcomes, so understanding them is important. Let’s define three common terms that are used within population health.

  • Health disparities are when demographic factors such as race, ethnicity, sex, age, or socioeconomic status affect an individual’s ability to achieve good health. For example, health disparities may lead to increased rates of infant mortality, obesity, cancer, or dementia.
  • Social determinants of health (SDOH) are conditions of the environment in which people are born, live, work, go to school, etc. For example, people living without access to fresh, healthy foods have an increased risk of multiple health conditions, and possibly lower life expectancies.
  • Health inequities are avoidable differences in treatment within a group of people. For example, continuous glucose monitor (CGM) and insulin pump use have been found to be lower in people of color.

What is Implicit Bias?

“As human beings, we’re built to have biases, it’s how the brain functions to make quick judgments about what’s safe and what isn’t. However, as we’ve evolved over time —those biases are a little less relevant, but we still have that hardware baked in,” said Mungmode, who went on to explain that automatic assumptions based on perception can sway provider-patient interactions. Perhaps this impacts technology recommendations or readiness for education, for example.

“We’re looking at tools to offer providers and standardizations in clinical practice to ensure that even when those biases exist — which they will, we’re human and we won’t necessarily remove biases — that they’re recognized and addressed, so they don’t lead to inequitable health outcomes.”

Components of T1DX-QI HEAL Program

The T1DX-QI HEAL program has a multi-pronged approach with different elements or initiatives to improve health equity. “There are multiple strategies because inequities can occur due to individual or interpersonal reasons, institutional practices and systems, and structural elements that exist in society,” explained Mungmode.

  • The T1DX-QI Pilot is focused on learning how clinics can improve their current practices to have more equitable health outcomes. Part of this pilot has been looking at provider bias in assigning CGM and pump technology; this includes interpersonal variables as well.

    This pilot began mid-year 2021, with the partnership and commitment of Medtronic, to better understand and improve health equities in people living with T1D. With seven clinical sites engaged, baseline data has been gathered to examine equity in CGM and insulin pump use, and Plan-Do-Study-Act (PDSA) cycles to reduce existing gaps in technology use. The pilot is about a year in length, so it should be complete by mid-year 2022.

  • Data analyzation is utilized to quantify, analyze, and display inequities in T1D health. T1D Exchange has access to electronic health record data from across many clinics, not just those participating in the T1DX-QI pilot. There’s also a QI Portal that clinics have access to as members of the T1DX-QI. Once they’ve data mapped with T1D Exchange, that information is transformed into aggregate measures, so they can compare trends over time and key health outcomes such as A1c and diabetes device use.

    Most importantly, it allows for benchmarking and comparison across other sites in the T1DX-QI — which can be very insightful. In terms of HEAL measures, providers can display data by race and ethnicity, aggregate the outcomes, and determine if inequities exist — and if they’re narrowing this gap through improvement measures.

  • The HEAL Advisory Committee is a group of about 20 clinical healthcare professionals committed to addressing health equity, and individuals living with T1D. This work kicked off in October 2021 and the committee is set to have quarterly meetings; they’ll provide mentoring for T1D Exchange, advise on the initiatives and how they can be pushed further ahead, and advocate for national change through shared learning.

“We established the HEAL Advisory Committee as part of our broader T1DX-QI Health Equity Strategy,“ said Osagie Ebekozien, Executive Vice President, Chief Medical Officer, T1D Exchange, “We’re honored to bring together such great leaders in the field because effectively addressing health equity is a team sport.”