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On November 8th and 9th 2021 the T1D Exchange Quality Improvement Collaborative (T1DX-QI) held another semi-annual learning session. Held virtually, this learning opportunity was attended by T1DX-QI staff and top leaders in pediatric and adult diabetes care and delivery who work at the T1DX-QI’s participating 43 centers across the U.S. A key focus for this learning opportunity was to acknowledge and promote the work in health equity in diabetes care and delivery which T1D Exchange is spearheading and fostering. Work in health equity, now one of the pillars in the T1D Exchange strategic plan, is emblematic of the dynamic cross sharing that goes on at these T1DX-QI events.
Grab a front row seat and gain insights into how this group of collaborators are addressing health equity in diabetes care and delivery. This includes increasing the use of diabetes technologies, such as continuous glucose monitors (CGMs), and/or insulin pumps, to manage diabetes; and to use policy advocacy to improve coverage for these supplies.
Recap of Plenary, The Urgency for Equity in Type 1 Diabetes (T1D) Care
In his plenary, Osagie Ebekozien, MD, MPH, CPHQ, Executive Vice President, Chief Medical Officer at T1D Exchange, walked participants through the journey of the T1DX-QI since its inception five years ago. “We have become very aware through data analysis, of the disparities in diabetes care among people with diabetes of color, including the relatively low utilization of diabetes technologies and the clinical ramifications, such as higher A1cs,” said Osagie. As Osagie spoke, he shared from a personal and professional perspective why health equity in diabetes care is so pressing.
Osagie went on to describe and elaborate on the six health equity focus areas of the T1DX-QI:
- Collaborative Partnership: Over the next few years T1D Exchange will intentionally prioritize adding T1DX-QI sites to the network, applying criteria that the sites serve a diverse cohort of people.
- Real World Health Equity Data Insights: T1D Exchange will use T1DX-QI data to assess and longitudinally study optimal means to support changes in the T1DX-QI centers with a health equity lens. T1D Exchange will use this real-world data to support policy advocacy, such as the work that has gone on with Texas Medicaid (see below in recaps of breakout sessions). Osagie highlighted several recent publications. A publication by Majidi et al, with data from the T1DX-QI cohort that details one of the largest samples to demonstrate inequities in diabetes care and delivery and thus, health outcomes in children and adults with T1D. Another publication by DeSalvo et al, analyzed CGM use among the T1DX-QI population. A significant finding was that insurance type was not a significant factor in who received coverage for CGM. Other recent publications from the T1DX-QI also have a health equity lens. Read the abstracts.
- Equitable Quality Improvement: Seven T1DX-QI teams have been involved with QI projects to test out strategies that decrease health inequities. Some of this work is going on within the partnership between T1D Exchange and Medtronic program. QI projects include looking at data at the site level and training at T1DX-QI sites on health equity and implicit bias. For example, specific and measurable goals have been set with an “aim statement” to achieve CGM and insulin pump access and equity. The T1DX-QI goal for 2022 is to take learnings to improve care among everyone with diabetes across the entire T1DX-QI network. Read about some of this work below in recaps from two health equity focused breakout sessions.
- Equitable Benchmarking with the QI Portal: The T1D Exchange data portal intentionally now supports equitable action. Advancements now allow use of Electronic Medical Record (EMR) data collected at T1DX-QI sites to identify gaps in care. Sites will be able to disaggregate data by race and ethnicity. This will assist in screening for and documenting Social Determinants of Health, such as food insecurity, testing proof of concepts to close gaps in care and more.
- Equitable Pragmatic Clinical Trials: T1D Exchange envisions this as an area with an opportunity to bridge the gap in care by conducting both traditional and QI research to study and tease out best practices. Using implementation science these best practices will then be integrated into care at T1DX-QI sites and beyond.
- Equity Thought Leadership through the T1DX-QI HEAL Program: T1D Exchange has assembled an advisory group that combines internal and external experts in health equity, including people with diabetes and community and research leaders. Several goals are to revise or develop new measures for health equity, advise on new pilot initiatives, make recommendations on equitable policies and to take these learning and best practices to all people with diabetes.
In closing his plenary, Osagie made several important points. He noted, “We are still very far from where we should be in caring for people with diabetes with an equity lens in part because the issues of health equity, including structural and systemic racism, are so ingrained into our system.” Osagie added, “This work is urgent and we, as the T1DX-QI, can by sharing our data more widely, bring intentionality to improving diabetes care for everyone.” He left participants with the charge to do more, because there’s a lot more to be done.
Recaps from Health Equity-Focused Breakout Sessions
In each of the six presentations detailed below, participants watched short presentations provided by colleagues reporting on research conducted at their site or for the T1DX-QI-at-large (read complete abstracts). After these presentations, T1DX-QI clinicians engaged in collegial dialog, posing questions to the presenters and sharing knowledge and ideas for future research and actions. Topics covered delved into research and projects Osagie described in his plenary detailed above.
Day 1 Breakout Sessions
Improving Healthcare Equity among T1D Patients using Glucose Technology
Speaker: Kajal Gandhi, DO, MPH
T1DX-QI site: Nationwide Children’s Hospital, Columbus OH
Project Intention: Reduce inequity in access and use of insulin pumps and CGMs among children with T1D from diverse racial and ethnic groups. This is an ongoing study.
- Using T1DX-QI site data they determined racial and ethnic disparities in use of CGMs and insulin pumps among their pediatric population, particularly among Hispanic and Black patients. There is a need to improve access to these diabetes technologies and lower the use gap.
- Researchers have identified the key drivers for the racial/ethnic gaps and developed interventions to address these including:
- offer early access to a CGM at T1D diagnosis through a sample program
- provide ongoing insulin pump and CGM education for patients and caregivers
- make available verbal and written translation services
Pediatric T1D Caregiver’s Technology Use: Black Parent’s Perspective
Speaker: Mariaester Makacio-Morillo, MD
T1DX-QI site: University of Miami
Project Intention: Complete semi-structured interviews and a focus group to obtain a better understanding of the barriers that keep Black children with T1D from using insulin pumps and CGMs.
- Results from small sample of parents (7) showed:
- use of technology made child feel different from peers
- caregivers and users are intimidated by devices
- caregivers and users embarrassed about not understanding the technology
- technology had not previously been prescribed by providers
- Study provided insights for providers to understand unique barriers Black people face with diabetes technology. These insights can assist providers in developing ways to help this population increase their use of insulin pumps and CGMs.
- Recognize there is implicit provider bias to technology adoption.
- The research group will now attempt to replicate this work with a group of Hispanic caregivers.
- Results from small sample of parents (7) showed:
Improvement in Equity of CGM Prescriptions after Targeted Interventions
Speaker: Priyanka Mathias, MD
T1DX-QI site: Albert Einstein College of Medicine/Montefiore Medical Center (under SEAD – Supporting Emerging Adults with Diabetes program) (this site is taking part in the T1DX-HEAL Program noted above)
Project Intention: Develop interventions to improve the number of CGM prescriptions among racial-ethnic minority populations and examine rates over time.
- Researchers retrospectively examined CGM prescription rates in their clinic and demonstrated racial and ethnic disparities among their population of adults with T1D (18 – 35 years old).
- Researchers implemented several interventions to improve use of CGMs:
- train nursing staff on CGM placement, downloads and patient education
- hire social needs and technology prescriptions coordinator to assist staff and patients
- improve prescribing workflows
- enable device trials for patients
- expand provider awareness of inequities
- Implementing targeted interventions, including those noted above, substantially increased CGM prescription rates. The largest increase was in Black patients.
Day 2 Breakout Sessions
T1D Technology Equity Improvement Project: Baseline Analysis of Insulin Pump Use
Speaker: Ori Odugbesan, MD, MPH
T1DX-QI site: T1D Exchange
Project Intention: Obtain a baseline trend analysis of insulin pump use among six T1DX-QI sites to determine racial and ethnic disparities for the T1DX-QI improvement efforts to improve pump equity project.
- Median insulin pump use in Non-Hispanic Whites was 45%, 17% in Non-Hispanic Black patients, and 26% in Hispanic patients.
- The T1DX-QI is working with these six sites using an Equity Framework to develop and scale interventions to reduce the racial and ethnic disparities in insulin pump use with the insulin pump equity aim statement.
Increasing Access to Continuous Glucose Monitors for Alabama’s Children with Diabetes
Speaker: Jessica Schmitt, MD
T1DX-QI site: University of Alabama at Birmingham
Project Intention: Reduce insurance-based disparities for access to CGM and improve access to CGM for children with T1D with chronic hyperglycemia
- Data suggests that prescribing diabetes technology is inequitable and insurance coverage, or lack thereof, is given as a reason by providers and patients that CGMs are not prescribed.
- Using Plan, Do, Study, Act cycles (PDSA) this group aimed to reduce the disparity in CGM prescriptions by 10%. The following were several interventions implemented into practice: provider education with weekly emails, availability of “RESCUE” clinics for easier access to care, reminder calls, access to trial a CGM in clinic to have the experience of wearing the device, and advocacy at policy level with Medicaid in Alabama.
- Using PDSA this group achieved a change in Medicaid coverage and reduced disparities in CGM access for patients using Medicaid vs. private insurance. They exceeded their initial goal of 50%, first reaching, then sustaining rates of 85%.
Medicaid Coverage of CGM in Texas: A QI Success Story in Advocacy
Speaker: Bonnie McCann-Crosby, MD
T1DX-QI site: Texas Children’s Hospital, Houston TX
Project Intention: Undertake a QI advocacy project to obtain CGM coverage from Texas Medicaid for pediatric patients with T1D.
- Starting in 2014 this group’s QI team undertook numerous steps aimed at advocating for changes to be made in the Texas Medicaid policy regarding CGM coverage.
- Their work initiated with a medical records review to identify the difference in rates of CGM between public and privately insured children with T1D.
- The QI team led a series of advocacy efforts with Texas Medicaid over the years. Several PDSA cycles, including a CGM evidence-based practice summary, submission of a topic nomination application to support CGM as a covered benefit to Texas Medicaid, and many letters of support sent by clinicians, care team members, patients and families.
- In 2020 Texas Medicaid approved CGM as a benefit for pediatric patients with T1D. Rates of CGM use in this population rose from 8% in 2014 to 64% in 2021.
In conclusion, as you can observe and as stated by Osagie, “We are moving the needle on health equity.” This is being accomplished through the work of the T1DX-QI at large and at the T1DX-QI’s 43 participating centers. The T1D Exchange work in health equity is on pace to demonstrate how diabetes care and delivery should be provided to all people with diabetes, including people of color. Daniel DeSalvo, MD, a provider at Texas Children’s Hospital, offered a poignant call to action during one of the breakout sessions on health equity, “As diabetes care providers we have a voice. Let’s use our platforms as experts to nudge the behavior of our provider colleagues.”
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