Faculty Bibliography

OBJECTIVE:Early initiation of continuous glucose monitor (CGM) after type 1 diabetes (T1D) diagnosis has been associated with lower hemoglobin A1C (HbA1c) in single-institution studies. This multicenter study evaluated the association between the timing of CGM initiation and HbA1c at 3 years postdiagnosis. RESEARCH DESIGN AND METHODS/METHODS:Data were obtained from the T1D Exchange Quality Improvement Collaborative (T1DX-QI) electronic health record database from 25 pediatric centers and included children and adolescents ≤18 years old diagnosed with T1D in 2019 and 2020. CGM initiation and glycemic outcomes were followed for 3 years after diagnosis. Locally estimated scatterplot smoothing plots evaluated the relationship between timing of CGM initiation and HbA1c over time, and logistic regression models were used to adjust for potential confounders. RESULTS:There were 4,164 people included in this analysis, mean age was 12.6 (SD 3.5) years, and 37% had public health insurance. Of the 93% (n = 3,877) who initiated CGM within 3 years of T1D diagnosis, 21% did so at 0-3 months, 14% at 3-6 months, 14% at 6-12 months, and 51% after 12 months. Median HbA1c at 3 years postdiagnosis was lower for the 0-3 and 3-6 months groups compared with the 6-12 months and non-CGM user groups (7.9%, 7.9%, 8.4%, and 9.5%, respectively). Adjusted odds of HbA1c >9% were lowest for the 0-3 months group followed by the 3-6 months group. CONCLUSIONS:In summary, early initiation of CGM within the first 6 months of diagnosis is associated with improved HbA1c outcomes at 3 years postdiagnosis.

This large type 1 diabetes cohort study showed that insulin pump utilization has increased over time and that use differs by sex, insurance type, and race/ethnicity. Insulin pump use was associated with more optimal A1C, increased use of continuous glucose monitoring (CGM), and lower rates of diabetic ketoacidosis and severe hypoglycemia. People who used an insulin pump with CGM had lower rates of acute events than their counterparts who used an insulin pump without CGM. These findings highlight the need to improve access of diabetes technology through provider engagement, multidisciplinary approaches, and efforts to address health inequities.

BACKGROUND/UNASSIGNED:We used real-world electronic health record (EHR) data to examine HbA1c levels among children and adults with type 1 diabetes (T1D) who are classified as continuous glucose monitor (CGM) users after T1D diagnosis and switch to self-monitoring of blood glucose (SMBG) during follow-up, versus people who opt for SMBG after T1D diagnosis and switch to CGM during follow-up visits. METHODS/UNASSIGNED:We conducted an observational, case-crossover study using electronic medical record (EMR) data from the T1D Exchange Quality Improvement Collaborative. The primary outcome in this study was HbA1c. Baseline HbA1c levels were taken at the index date, corresponding to initial device classification, and compared with HbA1c value recorded at the clinic visit following device switch. RESULTS/UNASSIGNED:< .001). CONCLUSION/UNASSIGNED:We found that people who switched to CGM use had significantly improved HbA1c levels compared to those who switched to glucose monitoring with SMBG.

Background and Aims: Background: There is growing evidence that Hybrid Closed Loop Systems (HCLS) are associated with a lower risk of severe hypoglycemia (SH) in people with type 1 diabetes. In this study, we use real-world data from the T1D Exchange (T1DX-QI) EMR database to investigate the association between HCLS use and patient-reported SH events using propensity score matching.
Method(s): In this analysis, we examined SH events across propensity score-matched HCLS user and HCLS non-user groups. All available data for the pediatric (6 years and older) and adult population with T1D from March 2018-March 2022 were included in this analysis. Patient-reported SH events are defined as SH events reported by the patient at their most recent clinic visit and were classified as a binary variable (Yes/No), with those reporting one or more SH events being classified under 'Yes' Similarly, HCLS device use was defined as the use of HCLS reported by the patient at their most recent clinic encounter.
Result(s): Propensity scores were estimated using a logit model, including age, gender, race/ethnicity, and insurance status as covariates. Matching was done using 1:1 matching with the nearest neighbor approach and a caliper of 0.1. There were 1537 matched people with T1D in the HCLS user and non-users group. Analysis showed that HCLS users were less likely than HCLS non-users to report >1 SH event (OR [95% CI]: 0.2 [0.1, 0.4] when controlling for covariates.
Conclusion(s): In this population-level real-world data analysis, we found HCLS use among people with T1D associated with lower patient-reported SH events

Background: Patient outcomes of COVID-19 have improved throughout the pandemic. However, because it is not known whether outcomes of COVID-19 in the type 1 diabetes (T1D) population improved over time, we investigated differences in COVID-19 outcomes for patients with T1D in the United States. Methods: We analyzed data collected via a registry of patients with T1D and COVID-19 from 56 sites between April 2020 and January 2021. We grouped cases into first surge (April 9, 2020, to July 31, 2020, n = 188) and late surge (August 1, 2020, to January 31, 2021, n = 410), and then compared outcomes between both groups using descriptive statistics and logistic regression models. Results: Adverse outcomes were more frequent during the first surge, including diabetic ketoacidosis (32% vs 15%, P< .001), severe hypoglycemia (4% vs 1%, P= .04), and hospitalization (52% vs 22%, P< .001). Patients in the first surge were older (28 [SD,18.8] years vs 18.0 [SD, 11.1] years, P< .001), had higher median hemoglobin A1c levels (9.3 [interquartile range {IQR}, 4.0] vs 8.4 (IQR, 2.8), P< .001), and were more likely to use public insurance (107 [57%] vs 154 [38%], P< .001). The odds of hospitalization for adults in the first surge were 5 times higher compared to the late surge (odds ratio, 5.01; 95% CI, 2.11-12.63). Conclusion: Patients with T1D who presented with COVID-19 during the first surge had a higher proportion of adverse outcomes than those who presented in a later surge.

Despite immense strides in therapeutic advances, clinical outcomes continue to be less than ideal for people with type 1 diabetes. This discrepancy has prompted an outpouring of quality improvement (QI) initiatives to address the medical, psychosocial, and health equity challenges that complicate ideal type 1 diabetes care and outcomes. This article reviews a framework for QI in diabetes care that guided the development of the T1D Exchange Quality Improvement Collaborative to improve care delivery and health outcomes in type 1 diabetes. Evaluation of the methodology, outcomes, and knowledge gained from these initiatives will highlight the importance of continued QI initiatives in diabetes care.

PURPOSE OF REVIEW/OBJECTIVE:The goal of this article is to review recent research of technology use, including insulin pumps, continuous glucose monitors, and smartpens, for pregnant women with preexisting type 1 diabetes. RECENT FINDINGS/RESULTS:Recent research shows that there may be benefits from technology use in type 1 diabetes pregnancies given the changes in insulin sensitivity throughout the span of pregnancy as well as allowing for more monitoring to allow for sooner titration of insulin doses. SUMMARY/CONCLUSIONS:There may be utility in incorporation of technology during pregnancy with appropriate medical guidance. Additional research would be helpful to further assess the ability of newer automated insulin systems to aid in tight glucose management goals during pregnancy and show value in receiving FDA approval.

CONTEXT:Diabetes mellitus is associated with increased COVID-19 morbidity and mortality, but there are few data focusing on outcomes in people with type 1 diabetes. OBJECTIVE:The objective of this study was to analyze characteristics of adults with type 1 diabetes for associations with COVID-19 hospitalization. DESIGN:An observational multisite cross-sectional study was performed. Diabetes care providers answered a 33-item questionnaire regarding demographics, symptoms, and diabetes- and COVID-19-related care and outcomes. Descriptive statistics were used to describe the study population, and multivariate logistic regression models were used to analyze the relationship between glycated hemoglobin (HbA1c), age, and comorbidities and hospitalization. SETTING:Cases were submitted from 52 US sites between March and August 2020. PATIENTS OR OTHER PARTICIPANTS:Adults over the age of 19 with type 1 diabetes and confirmed COVID-19 infection were included. INTERVENTIONS:None. MAIN OUTCOME MEASURES:Hospitalization for COVID-19 infection. RESULTS:A total of 113 cases were analyzed. Fifty-eight patients were hospitalized, and 5 patients died. Patients who were hospitalized were more likely to be older, to identify as non-Hispanic Black, to use public insurance, or to have hypertension, and less likely to use continuous glucose monitoring or insulin pumps. Median HbA1c was 8.6% (70 mmol/mol) and was positively associated with hospitalization (odds ratio 1.42, 95% confidence interval 1.18-1.76), which persisted after adjustment for age, sex, race, and obesity. CONCLUSIONS:Baseline glycemic control and access to care are important modifiable risk factors which need to be addressed to optimize care of people with type 1 diabetes during the worldwide COVID-19 pandemic.

BACKGROUND:levels among young adults with type 1 diabetes (T1D) and whether this association differed by age or exposure to adverse childhood experiences (ACEs). METHODS:levels were abstracted from medical records. Respondents were categorized by age, high and low dispositional mindfulness (median split on Cognitive and Affective Mindfulness Scale-Revised), and exposure to any of 10 ACEs. RESULTS:levels. CONCLUSIONS:only among 27- to 31-year-olds. In early adulthood, the impact of mindfulness-based interventions on glycemic control may vary by age and childhood trauma history.

PURPOSE OF REVIEW/OBJECTIVE:The increasing prevalence of type 2 diabetes is driving the boundaries of clinical diabetes care outside of the traditional office setting. The purpose of this paper will be to review recent technological advances in the medical management of people with type 2 diabetes, spanning the spectrum of care from access to healthcare providers/educators, to continual virtual support methods, on-line management tools, and technologically integrated medication delivery systems. RECENT FINDINGS/RESULTS:Recent findings support a potential positive impact of technology on access to care, clinical outcomes, convenience, patient well-being, and patient acceptance. This includes the use of Bluetooth-enabled glucose meters, continuous glucose monitors, mHealth apps, smartpens, and insulin pumps. However, there are impediments to the implementation of some technologies due to cost and lack of insurance coverage. There is evidence to support the use of technology to improve the management and treatment of people with type 2 diabetes. Further research is required to demonstrate the long-term clinical benefit and financial viability of technology in the management of type 2 diabetes.