Addressing type 1 diabetes health inequities in the United States: Approaches from the T1D Exchange QI Collaborative

• DOI: 10.1111/1753-0407.13235
• Publication Date: 2021-12-07T10:40:56Z
• Authors: Osagie Ebekozien; Ann Mungmode; Oriyomi Odugbesan; Shideh Majidi; Priya Prahalad; Nudrat Noor; Nicole Rioles; Shivani Agarwal; Ruth S. Weinstock; Robert Rapaport; Manmohan Kamboj
• Keywords: type 1 diabetes; Social Determinants of Health; Health Inequities; real‐world evidence; Health Status Disparities; RC648-665; Diseases of the endocrine glands. Clinical endocrinology; United States; quality improvement; 03 medical and health sciences; Diabetes Mellitus, Type 1; 0302 clinical medicine; Commentaries; Humans; solution; disparities; health equity

Approximately 1.6 million people in the United States have type 1 diabetes (T1D).1 The incidence of T1D is increasing across all populations, most significantly among Hispanic and non-Hispanic Black (NHB) patients.2, 3 Unfortunately, widespread inequities exist health outcomes patients with States.4-7 In 2016, Exchange Quality Improvement Collaborative (T1DX-QI) was established.8 T1DX-QI a learning network9 over 40 centers States. Participating use continuous quality improvement (QI) methods10-12 real-world electronic medical record (EMR) data4, 6 for population improvement. coordinated by Exchange, Boston-based nonprofit coordinating center. goals were described separate commentary.13 has successfully used QI principles implementation science to improve clinical processes, including increased glucose monitors (CGM), insulin pumps, depression screening, improved access care, population-level glycemic outcomes.9-12 2020, established its equity program address systematically comprehensively outcomes.14 This commentary describes practical approaches being employed inequities. These can be valuable examples researchers providers interested addressing (Figure 1). uses unique EMR database de-identified data on 35 000 perform analysis. Recent analyses revealed troubling unnecessary device outcomes.4, Majidi et al,4 an analysis 18 (73% White [NHW]; 8% NHB, 9% Hispanic, 10% other), found significant differences glycosylated hemoglobin (HbA1c) NHB compared NHW (NHB 10.3%; 9.2%; 8.3%; P < .001). also had lowest rate CGM 17%; 37%; 40%; .001) pump 41%; 56%; 60%; Desalvo al,6 using pediatric from T1DX-QI, that youth private insurance, less than as well public insurance. amplified onset COVID-19 pandemic, uncovered Surveillance study.5, 15, 16 Ebekozien al5 about four times odds hospitalized COVID patients. addition, Noor al15 strong association between race-ethnicity, risk hospitalization not technology. addition driving initiatives, these are support advocacy efforts. shares state national advocates influence policy decisions positively impact systemic changes, such efforts increase management technologies like CGM. Implicit or unconscious bias well-documented provider-level contributor care generally management17 play role technology care. collaboratively adapted D-Provider Bias tool (D-PIB)17 measure implicit racial related recommendations seven pilot sites. Over 200 clinic team members assessed trained phase. Future publications will include results assessment evaluate effectiveness provider training intervention management. approach test changes sustain successful interventions.11, 12 Due thoughtful emphasis process extensive applicability help suitable adaptations. developed Equity Framework,18 which method designed promote interventions. framework consists 10 steps. Steps reviewing baseline inequities, inviting families participate activities, examining local systems processes factors contributing inequitable outcomes. It now ongoing Health Project sites goal reducing use. Data collected analyzed at identify opportunities use, continue submit monthly data, stratified race ethnicity, monitor progress toward project goals. relevant extracted EMR, flowsheets, other appropriate documentation sources. Portal, launched 2019, online platform business intelligence software.19 clinics securely share patient-level central warehouse then transmitted portal. assess, benchmark, visually chart their same metric definitions. Clinics following: (1) Dashboard Tab, clinic-to-clinic ranking metrics; (2) Compare fully customizable benchmarking features, allows compare outcome trends clinics; (3) Reports built-in statistical control charts filter demographic indicators, race, insurance coverage; (4) Library Tab case studies, publications, tools resources. New features released 2021 allow display ethnicity visualize key metrics, HbA1c, diabetic ketoacidosis events, percentage eligible completing screening. feature builds existing functionality allowing single ethnic identity simultaneously multiple series ease comparison. Portal real-time review quickly improvement, optimizing critical strategy 2021, HEAL Advisory Committee, network experienced research leaders. this group provide thought leadership around T1DX initiatives.14 Committee contributes best practices regarding equitable through strategies. activities developing new measures, providing advice feedback applying evaluation rigor, assisting formulating policies, sharing nationally. engages levels involve them Patients regularly invited projects led pilot. Two T1DX-HEAL parents T1D. They advise action steps alongside staff. Additionally, intentionally partners endocrinology serving diverse populations. recently contracted reside urban safety-net hospitals primarily serve underserved vulnerable communities color, whose primary language English, un- underinsured individuals.20 six actionable Although extremely complex issue, intentionality engagement stakeholders, closing gaps achievable. We appreciate advisory committees. acknowledge Medtronic Diabetes funding Pilot Program. Special thanks Leona M. Harry B. Helmsley Charitable Trust funds Collaborative. O.E. member Board. He principal investigator funded Eli Lilly, Diabetes, Abbot, Dexcom. All industry-funded board roles paid directly his organization Exchange. R.S.W. participates multicenter trials her institution, sponsored Medtronic, Insulet, Boehringer Ingelheim, Novo Nordisk, Kowa, Dexcom contributed studies. R.R. associate editor Journal Diabetes. Other authors no disclosures.