Addressing disparities in technology use among patients with type 1 diabetes: a review.

PURPOSE OF REVIEW: The benefits of continuous glucose monitors (CGMs) and insulin pumps in the management of type 1 diabetes (T1D) are widely recognized. However, glaring disparities in access exist, particularly in marginalized and economically disadvantaged groups that stand to benefit significantly from diabetes technology use. We will review recent data describing drivers of these disparities and approaches to address the disparities. RECENT FINDINGS: Several qualitative studies were published in recent years that have investigated the drivers of disparities reported over the past decades. These studies report that in addition to typical barriers seen in the diabetes technology, marginalized patients have unique challenges that make insulin pumps and CGMs less accessible. SUMMARY: Barriers to technology use in these groups include stigmatization, lack of support, financial constraints, provider biases, stringent insurance policies, and clinic infrastructure. To address inequities, multifaceted strategies across community, healthcare, and provider sectors are essential. Key initiatives include enhancing public awareness, refining health policies, ensuring access to high-quality care, and emphasizing patient-centered approaches. The equitable use of technology can narrow the gap in T1D outcomes. The social and economic implications of suboptimal T1D management further underscore the urgency of these efforts for both improved health outcomes and cost-efficient care.

Risk Factors for Hyperosmolar Hyperglycemic State in Pediatric Type 2 Diabetes.

Background: There is a paucity of data on the risk factors for the hyperosmolar hyperglycemic state (HHS) compared with diabetic ketoacidosis (DKA) in pediatric type 2 diabetes (T2D). Methods: We used the national Kids' Inpatient Database to identify pediatric admissions for DKA and HHS among those with T2D in the years 2006, 2009, 2012, and 2019. Admissions were identified using ICD codes. Those aged <9yo were excluded. We used descriptive statistics to summarize baseline characteristics and Chi-squared test and logistic regression to evaluate factors associated with admission for HHS compared with DKA in unadjusted and adjusted models. Results: We found 8,961 admissions for hyperglycemic emergencies in youth with T2D, of which 6% were due to HHS and 94% were for DKA. These admissions occurred mostly in youth 17-20 years old (64%) who were non-White (Black 31%, Hispanic 20%), with public insurance (49%) and from the lowest income quartile (42%). In adjusted models, there were increased odds for HHS compared to DKA in males (OR 1.77, 95% CI 1.42-2.21) and those of Black race compared to those of White race (OR 1.81, 95% CI 1.34-2.44). Admissions for HHS had 11.3-fold higher odds for major or extreme severity of illness and 5.0-fold higher odds for mortality. Conclusion: While DKA represents the most admissions for hyperglycemic emergencies among pediatric T2D, those admitted for HHS had higher severity of illness and mortality. Male gender and Black race were associated with HHS admission compared to DKA. Additional studies are needed to understand the drivers of these risk factors.

A Longitudinal View of Disparities in Insulin Pump Use Among Youth with Type 1 Diabetes: The SEARCH for Diabetes in Youth Study.

Objective: To evaluate changes in insulin pump use over two decades in a national U.S. sample. Research Design and Methods: We used data from the SEARCH for Diabetes in Youth study to perform a serial cross-sectional analysis to evaluate changes in insulin pump use in participants <20 years old with type 1 diabetes by race/ethnicity and markers of socioeconomic status across four time periods between 2001 and 2019. Multivariable generalized estimating equations were used to assess insulin pump use. Temporal changes by subgroup were assessed through interactions. Results: Insulin pump use increased from 31.7% to 58.8%, but the disparities seen in pump use persisted and were unchanged across subgroups over time. Odds ratio for insulin pump use in Hispanic (0.57, confidence interval [95% CI] 0.45-0.73), Black (0.28, 95% CI 0.22-0.37), and Other race (0.49, 95% CI 0.32-0.76) participants were significantly lower than White participants. Those with ≤high school degree (0.39, 95% CI 0.31-0.47) and some college (0.68, 95% CI 0.58-0.79) had lower use compared to those with ≥bachelor's degree. Those with public insurance (0.84, 95% CI 0.70-1.00) had lower use than those with private insurance. Those with an annual household income <$25K (0.43, 95% CI 0.35-0.53), $25K-$49K (0.52, 95% CI 0.43-0.63), and $50K-$74K (0.79, 95% CI 0.66-0.94) had lower use compared to those with income ≥$75,000. Conclusion: Over the past two decades, there was no improvement in the racial, ethnic, and socioeconomic inequities in insulin pump use, despite an overall increase in use. Studies that evaluate barriers or test interventions to improve technology access are needed to address these persistent inequities.

Racial Disparities in Access and Use of Diabetes Technology Among Adult Patients With Type 1 Diabetes in a U.S. Academic Medical Center.

OBJECTIVE: Recent studies highlight racial disparities in insulin pump (PUMP) and continuous glucose monitor (CGM) use in children and adolescents with type 1 diabetes (T1D). This study explored racial disparities in diabetes technology among adult patients with T1D. RESEARCH DESIGN AND METHODS: This was a retrospective clinic-based cohort study of adult patients with T1D seen consecutively from April 2013 to January 2020. Race was categorized into non-Black (reference group) and Black. The primary outcomes were baseline and prevalent technology use, rates of diabetes technology discussions (CGMdiscn, PUMPdiscn), and prescribing (CGMrx, PUMPrx). Multivariable logistic regression analysis evaluated the association of technology discussions and prescribing with race, adjusting for social determinants of health and diabetes outcomes. RESULTS: Among 1,258 adults with T1D, baseline technology use was significantly lower for Black compared with non-Black patients (7.9% vs. 30.3% for CGM; 18.7% vs. 49.6% for PUMP), as was prevalent use (43.6% vs. 72.1% for CGM; 30.7% vs. 64.2% for PUMP). Black patients had adjusted odds ratios (aORs) of 0.51 (95% CI 0.29, 0.90) for CGMdiscn and 0.61 (95% CI 0.41, 0.93) for CGMrx. Black patients had aORs of 0.74 (95% CI 0.44, 1.25) for PUMPdiscn and 0.40 (95% CI, 0.22, 0.70) for PUMPrx. Neighborhood context, insurance, marital and employment status, and number of clinic visits were also associated with the outcomes. CONCLUSIONS: Significant racial disparities were observed in discussions, prescribing, and use of diabetes technology. Further research is needed to identify the causes behind these disparities and develop and evaluate strategies to reduce them.

Insulin Pump-related Inpatient Admissions in a National Sample of Youth With Type 1 Diabetes.

BACKGROUND: Insulin pump use in type 1 diabetes management has significantly increased in recent years, but we have few data on its impact on inpatient admissions for acute diabetes complications. METHODS: We used the 2006, 2009, 2012, and 2019 Kids' Inpatient Database to identify all-cause type 1 diabetes hospital admissions in those with and without documented insulin pump use and insulin pump failure. We described differences in (1) prevalence of acute diabetes complications, (2) severity of illness during hospitalization and disposition after discharge, and (3) length of stay (LOS) and inpatient costs. RESULTS: We identified 228 474 all-cause admissions. Insulin pump use was documented in 7% of admissions, of which 20% were due to pump failure. The prevalence of diabetic ketoacidosis (DKA) was 47% in pump nonusers, 39% in pump users, and 60% in those with pump failure. Admissions for hyperglycemia without DKA, hypoglycemia, sepsis, and soft tissue infections were rare and similar across all groups. Admissions with pump failure had a higher proportion of admissions classified as major severity of illness (14.7%) but had the lowest LOS (1.60 days, 95% CI 1.55-1.65) and healthcare costs ($13 078, 95% CI $12 549-$13 608). CONCLUSIONS: Despite the increased prevalence of insulin pump in the United States, a minority of pediatric admissions documented insulin pump use, which may represent undercoding. DKA admission rates were lower among insulin pump users compared to pump nonusers. Improved accuracy in coding practices and other approaches to identify insulin pump users in administrative data are needed, as are interventions to mitigate risk for DKA.

Relationships Between Socioeconomic Status, Insurance Coverage for Diabetes Technology and Adverse Health in Patients With Type 1 Diabetes.

INTRODUCTION: Insulin pumps and continuous glucose monitors (CGM) have many benefits in the management of type 1 diabetes. Unfortunately disparities in technology access occur in groups with increased risk for adverse effects (eg, low socioeconomic status [SES], public insurance). RESEARCH DESIGN & METHODS: Using 2015 to 2016 data from 4,895 participants from the T1D Exchange Registry, a structural equation model (SEM) was fit to explore the hypothesized direct and indirect relationships between SES, insurance features, access to diabetes technology, and adverse clinical outcomes (diabetic ketoacidosis, hypoglycemia). SEM was estimated using the maximum likelihood method and standardized path coefficients are presented. RESULTS: Higher SES and more generous insurance coverage were directly associated with CGM use (ß = 1.52, SE = 0.12, P < .0001 and ß = 1.21, SE = 0.14, P < .0001, respectively). Though SES displayed a small inverse association with pump use (ß = -0.11, SE = 0.04, P = .0097), more generous insurance coverage displayed a stronger direct association with pump use (ß = 0.88, SE = 0.10, P < .0001). CGM use and pump use were both directly associated with fewer adverse outcomes (ß = -0.23, SE = 0.06, P = .0002 and ß = -0.15, SE = 0.04, P = .0002, respectively). Both SES and insurance coverage demonstrated significant indirect effects on adverse outcomes that operated through access to diabetes technology (ß = -0.33, SE = 0.09, P = .0002 and ß = -0.40, SE = 0.09, P < .0001, respectively). CONCLUSIONS: The association between SES and insurance coverage and adverse outcomes was primarily mediated through diabetes technology use, suggesting that disparities in diabetes outcomes have the potential to be mitigated by addressing the upstream disparities in technology use.

National Trends in Pediatric Admissions for Diabetic Ketoacidosis, 2006-2016.

BACKGROUND AND OBJECTIVES: Diabetic ketoacidosis (DKA) rates in the United States are rising. Prior studies suggest higher rates in younger populations, but no studies have evaluated national trends in pediatric populations and differences by subgroups. As such, we sought to examine national trends in pediatric DKA. METHODS: We used the 2006, 2009, 2012, and 2016 Kids' Inpatient Database to identify pediatric DKA admissions among a nationally representative sample of admissions of youth ≤20 years old. We estimate DKA admission per 10 000 admissions and per 10 000 population, charges, length of stay (LOS), and trends over time among all hospitalizations and by demographic subgroups. Regression models were used to evaluate differences in DKA rates within subgroups overtime. RESULTS: Between 2006 and 2016, there were 149 535 admissions for DKA. Unadjusted DKA rate per admission increased from 120.5 (95% CI, 115.9-125.2) in 2006 to 217.7 (95% CI, 208.3-227.5) in 2016. The mean charge per admission increased from $14 548 (95% CI, $13 971-$15 125) in 2006 to $20 997 (95% CI, $19 973-$22 022) in 2016, whereas mean LOS decreased from 2.51 (95% CI, 2.45-2.57) to 2.28 (95% CI, 2.23-2.33) days. Higher DKA rates occurred among 18- to 20-year-old females, Black youth, without private insurance, with lower incomes, and from nonurban areas. Young adults, men, those without private insurance, and from nonurban areas had greater increases in DKA rates across time. CONCLUSIONS: Pediatric DKA admissions have risen by 40% in the United States and vulnerable subgroups remain at highest risk. Further studies should characterize the challenges experienced by these groups to inform interventions to mitigate their DKA risk and to address the rising DKA rates nationally.

Association of Area Deprivation and Diabetic Ketoacidosis Readmissions: Comparative Risk Analysis of Adults vs Children With Type 1 Diabetes.

OBJECTIVE: Recurrent diabetic ketoacidosis (DKA) is associated with mortality in adults and children with type 1 diabetes (T1D). We aimed to evaluate the association of area deprivation and other patient factors with recurrent DKA in pediatric patients compared with adults. RESEARCH DESIGN AND METHODS: This cross-sectional study used the Maryland Health Services Cost Review Commission's database to identify patients with T1D admitted for DKA between 2012 and 2017. Area deprivation and other variables were obtained from the first DKA admission of the study period. Multivariable logistic regression analysis was performed to determine predictors of DKA readmissions. Interactions (Ints) evaluated differences among the groups. RESULTS: There were 732 pediatric and 3305 adult patients admitted with DKA. Area deprivation was associated with higher odds of readmission in pediatric patients than in adults. Compared with the least deprived, moderately deprived pediatric patients had an OR of 7.87-(95% CI, 1.02 to 60.80) compared with no change in odds in adults for four or more readmissions (Pint < 0.01). Similar odds were observed in the most deprived pediatric patients, which differed significantly from the OR of 2.23 (95% CI, 1.16 to 4.25) in adults (Pint of 0.2). Moreover, increasing age, female sex, Hispanic ethnicity, and discharge against medical advice conferred a high odds for four or more readmissions in pediatric patients compared with adults. CONCLUSION: Area deprivation was predictive of recurrent DKA admissions, with a more pronounced influence in pediatric than adult patients with T1D. Further studies are needed to understand the mechanisms behind these associations and address disparities specific to each population.

Association of socioeconomic status and DKA readmission in adults with type 1 diabetes: analysis of the US National Readmission Database.

Objective: To identify patient and hospital predictors of recurrent diabetic ketoacidosis (DKA) admissions in adults in the USA with type 1 diabetes, focusing on socioeconomic indicators. Research design and methods: This cross-sectional study used the National Readmission Database to identify adult patients with type 1 diabetes admitted for DKA between 2010 and 2015. The index DKA admission was defined as the first admission within the calendar year and the primary outcome was recurrent DKA admission(s) within the same calendar year. Multivariable logistic regression analysis was performed using covariates of patient and hospital factors at the index admission to determine the odds of DKA readmission(s). Results: Among 181 284 index DKA admissions, 39 693 (22%) had at least one readmission within the calendar year, of which 33 931 (86%) and 5762 (14%) had 1-3 and ≥4 DKA readmissions, respectively. When compared with the highest income quartile, patients in the first and second income quartiles had 46% (95% CI 30% to 64%) and 34% (95% CI 19% to 51%) higher odds of four or more DKA readmissions, respectively. Medicaid and Medicare insurance were both associated with a 3.3-fold adjusted risk (95% CI 3.0 to 3.7) for ≥4 readmissions compared with private insurance, respectively. Younger age, female sex, and discharge against medical advice were also predictive. Conclusions: Lower socioeconomic status and Medicaid insurance are strong predictors of DKA readmissions in adults with type 1 diabetes in the USA. Further studies are needed to understand the mediators of this association to inform multilevel interventions for this high-risk population. Significance of the study: The association of socioeconomic status (SES) and hospital admission for DKA has been studied in pediatrics with type 1 diabetes, but the data in adults are limited, and studies evaluating recurrent DKA admissions are scarcer. To our knowledge, this is the first study to describe predictors of recurrent DKA admissions in adults with type 1 diabetes on a national level in the USA. We found that those at highest risk of recurrent DKA are young women with low SES who had Medicaid or Medicare insurance. These findings should prompt further studies to explore the mediators of these disparities in patients with type 1 diabetes, as recurrent DKA results in high healthcare utilization and increased risk of long-term complications.

Development and Implementation of a Subcutaneous Insulin Clinical Decision Support Tool for Hospitalized Patients.

BACKGROUND: Insulin is one of the highest risk medications used in hospitalized patients. Multiple complex factors must be considered in determining a safe and effective insulin regimen. We sought to develop a computerized clinical decision support (CDS) tool to assist hospital-based clinicians in insulin management. METHODS: Adapting existing clinical practice guidelines for inpatient glucose management, a design team selected, configured, and implemented a CDS tool to guide subcutaneous insulin dosing in non-critically ill hospitalized patients at two academic medical centers that use the EpicCare® electronic medical record (EMR). The Agency for Healthcare Research and Quality (AHRQ) best practices in CDS design and implementation were followed. RESULTS: A CDS tool was developed in the form of an EpicCare SmartForm, which generates an insulin regimen by integrating information about the patient's body weight, diabetes type, home and hospital insulin requirements, and nutritional status. Total daily recommended insulin doses are distributed into respective basal and nutritional doses with a tailored correctional insulin scale. Preimplementation, several approaches were used to communicate this new tool to clinicians, including emails, lectures, and videos. Postimplementation, a support team was available to address user technical issues. Feedback from stakeholders has been used to continuously refine the tool. Inclusion of the programming in the EMR vendor's community library has allowed dissemination of the tool outside our institution. CONCLUSIONS: We have developed an EMR-based tool to guide SQ insulin dosing in non-critically ill hospitalized patients. Further studies are needed to evaluate adoption and clinical effectiveness of this intervention.

Inpatient Glycemic Management of Non-cardiac CVD: Focus on Stroke and PVD.

PURPOSE OF REVIEW: Hyperglycemia occurs frequently in hospitalized patients with stroke and peripheral vascular disease (PVD). Guidelines for inpatient glycemic management are not well established for this patient population. We will review the clinical impact of hyperglycemia in this acute setting and review the evidence for glycemic control. RECENT FINDINGS: Hyperglycemia in acute stroke is associated with poor short and long-term outcomes, and perioperative hyperglycemia in those undergoing revascularization for PVD is linked to increased post-surgical complications. Studies evaluating tight glucose control do not demonstrate improvement in clinical outcomes, although the risk for hypoglycemia increases substantially. Additional studies are needed to evaluate tight glucose goals relative to our current standard of care and the role of permissive hyperglycemia. Given the limited data to guide glycemic management in these patient populations, it is recommended that general guidelines for inpatient glycemic control be followed. Special considerations should be made to address factors that may impact glucose management, including neurological deficits and clinical changes that occur in the postoperative state.

Development and validation of a prediction model for insulin-associated hypoglycemia in non-critically ill hospitalized adults.

OBJECTIVE: To develop and validate a multivariable prediction model for insulin-associated hypoglycemia in non-critically ill hospitalized adults. RESEARCH DESIGN AND METHODS: We collected pharmacologic, demographic, laboratory, and diagnostic data from 128 657 inpatient days in which at least 1 unit of subcutaneous insulin was administered in the absence of intravenous insulin, total parenteral nutrition, or insulin pump use (index days). These data were used to develop multivariable prediction models for biochemical and clinically significant hypoglycemia (blood glucose (BG) of ≤70 mg/dL and <54 mg/dL, respectively) occurring within 24 hours of the index day. Split-sample internal validation was performed, with 70% and 30% of index days used for model development and validation, respectively. RESULTS: Using predictors of age, weight, admitting service, insulin doses, mean BG, nadir BG, BG coefficient of variation (CVBG), diet status, type 1 diabetes, type 2 diabetes, acute kidney injury, chronic kidney disease (CKD), liver disease, and digestive disease, our model achieved a c-statistic of 0.77 (95% CI 0.75 to 0.78), positive likelihood ratio (+LR) of 3.5 (95% CI 3.4 to 3.6) and negative likelihood ratio (-LR) of 0.32 (95% CI 0.30 to 0.35) for prediction of biochemical hypoglycemia. Using predictors of sex, weight, insulin doses, mean BG, nadir BG, CVBG, diet status, type 1 diabetes, type 2 diabetes, CKD stage, and steroid use, our model achieved a c-statistic of 0.80 (95% CI 0.78 to 0.82), +LR of 3.8 (95% CI 3.7 to 4.0) and -LR of 0.2 (95% CI 0.2 to 0.3) for prediction of clinically significant hypoglycemia. CONCLUSIONS: Hospitalized patients at risk of insulin-associated hypoglycemia can be identified using validated prediction models, which may support the development of real-time preventive interventions.

A Novel Approach for Fully Automated, Personalized Health Coaching for Adults with Prediabetes: Pilot Clinical Trial.

BACKGROUND: Prediabetes is a high-risk state for the future development of type 2 diabetes, which may be prevented through physical activity (PA), adherence to a healthy diet, and weight loss. Mobile health (mHealth) technology is a practical and cost-effective method of delivering diabetes prevention programs in a real-world setting. Sweetch (Sweetch Health, Ltd) is a fully automated, personalized mHealth platform designed to promote adherence to PA and weight reduction in people with prediabetes. OBJECTIVE: The objective of this pilot study was to calibrate the Sweetch app and determine the feasibility, acceptability, safety, and effectiveness of the Sweetch app in combination with a digital body weight scale (DBWS) in adults with prediabetes. METHODS: This was a 3-month prospective, single-arm, observational study of adults with a diagnosis of prediabetes and body mass index (BMI) between 24 kg/m2 and 40 kg/m2. Feasibility was assessed by study retention. Acceptability of the mobile platform and DBWS were evaluated using validated questionnaires. Effectiveness measures included change in PA, weight, BMI, glycated hemoglobin (HbA1c), and fasting blood glucose from baseline to 3-month visit. The significance of changes in outcome measures was evaluated using paired t test or Wilcoxon matched pairs test. RESULTS: The study retention rate was 47 out of 55 (86%) participants. There was a high degree of acceptability of the Sweetch app, with a median (interquartile range [IQR]) score of 78% (73%-80%) out of 100% on the validated System Usability Scale. Satisfaction regarding the DBWS was also high, with median (IQR) score of 93% (83%-100%). PA increased by 2.8 metabolic equivalent of task (MET)-hours per week (SD 6.8; P=.02), with mean weight loss of 1.6 kg (SD 2.5; P<.001) from baseline. The median change in A1c was -0.1% (IQR -0.2% to 0.1%; P=.04), with no significant change in fasting blood glucose (-1 mg/dL; P=.59). There were no adverse events reported. CONCLUSIONS: The Sweetch mobile intervention program is a safe and effective method of increasing PA and reducing weight and HbA1c in adults with prediabetes. If sustained over a longer period, this intervention would be expected to reduce diabetes risk in this population. TRIAL REGISTRATION: ClincialTrials.gov NCT02896010; https://clinicaltrials.gov/ct2/show/NCT02896010 (Archived by WebCite at http://www.webcitation.org/6xJYxrgse).

Update on management of diabetic foot ulcers.

Diabetic foot ulcers (DFUs) are a serious complication of diabetes that results in significant morbidity and mortality. Mortality rates associated with the development of a DFU are estimated to be 5% in the first 12 months, and 5-year morality rates have been estimated at 42%. The standard practices in DFU management include surgical debridement, dressings to facilitate a moist wound environment and exudate control, wound off-loading, vascular assessment, and infection and glycemic control. These practices are best coordinated by a multidisciplinary diabetic foot wound clinic. Even with this comprehensive approach, there is still room for improvement in DFU outcomes. Several adjuvant therapies have been studied to reduce DFU healing times and amputation rates. We reviewed the rationale and guidelines for current standard of care practices and reviewed the evidence for the efficacy of adjuvant agents. The adjuvant therapies reviewed include the following categories: nonsurgical debridement agents, dressings and topical agents, oxygen therapies, negative pressure wound therapy, acellular bioproducts, human growth factors, energy-based therapies, and systemic therapies. Many of these agents have been found to be beneficial in improving wound healing rates, although a large proportion of the data are small, randomized controlled trials with high risks of bias.

PREVENTION AND MANAGEMENT OF INSULIN-ASSOCIATED HYPOGLYCEMIA IN HOSPITALIZED PATIENTS.

OBJECTIVE: To determine whether appropriate therapeutic changes in insulin doses are made to prevent and manage insulin-associated hypoglycemic events in non-critically ill hospitalized patients. METHODS: This retrospective study was conducted in hospitalized adults on medical or surgical floors with insulin-associated hypoglycemia, excluding treatment with insulin infusions, insulin pumps, and parenteral nutrition. The first hypoglycemic event after 48 hours of admission was the index event. Over the 1-year study period, a total of 457 insulin-associated hypoglycemic events were included as index events. RESULTS: An indication for an insulin dose adjustment was identified in 32 and 42% of patients on day -2 and day -1, respectively, before the index hypoglycemic event, of which 35 and 55%, respectively, had an insulin dose reduction ≥10%. Following the hypoglycemic event, 44% of patients had an insulin dose reduction of ≥20%. Therapeutic reduction of the total daily insulin dose by ≥20% was associated with increased odds of normoglycemia and lower odds of hyperglycemia but was not associated with lower odds of recurrent hypoglycemia on the day following the index hypoglycemic event. There was a high prevalence of hypoglycemic risk factors in this population, with kidney disease and nil per os status being the most prevalent contributing factors. CONCLUSION: Adherence to the current practice recommendation to reduce insulin doses in patients with borderline hypoglycemia and following overt hypoglycemia was modest. Further studies are needed to understand the associated risks and to define appropriate therapeutic changes for insulin treated patients with borderline and overt hypoglycemia. ABBREVIATIONS: AKI = acute kidney injury BG = blood glucose CKD = chronic kidney disease ESRD = end-stage renal disease ICU = intensive care unit NPH = Neutral Protamine Hagedorn NPO = nil per os OR = odds ratio TDD = total daily dose.