The relationship of glycemic control, insulin dose, and race with hypoglycemia in youth with type 1 diabetes.

INTRODUCTION: Black youth with T1D have been reported to experience more episodes of hypoglycemia than white patients, despite blacks having higher levels of HbA1c. We hypothesized that black patients may be prescribed higher daily doses of insulin putting them at greater higher risk for hypoglycemia. METHODS: We performed a retrospective analysis of data from a study of social and environmental factors influencing HbA1c in a biracial pediatric population with T1DM. Changes in patient insulin dose were made at clinic visit based on their self-monitored glucose (SMG) data. Insulin dose (units/kg/d) was compared with HbA1c, reported hypoglycemic episodes and occurrence of low blood glucose from SMG data. RESULTS: Age, duration of diabetes and BMI-z were similar for black and white patients. Black patients had higher levels of HbA1c and mean blood glucose (MBG). HbA1c was higher in blacks even after adjustment for MBG. Reported insulin dose increased with increasing HbA1c (ρ = 0.30, p = 0.0052) or MBG (ρ = 0.36, p < 0.0008). There was no difference in insulin dose between blacks and whites. Reported hypoglycemia was inversely associated with HbA1c and MBG, but there was no racial difference. Occurrence of low glucoses from meter data was slightly higher in whites (p = 0.047). CONCLUSION: Insulin dose increased with increasing HbA1c or MBG for both groups. Occurrence of hypoglycemia was inversely related to glycemic control. There was slightly higher occurrence low glucose meter readings in white patients. Reported racial disparities in occurrence of hypoglycemia and insulin dosing may be due to clinic specific factors.

Associations Between Depressive Symptoms, Fear of Hypoglycemia, Adherence to Management Behaviors and Metabolic Control in Children and Adolescents with Type 1 Diabetes.

We examined the relationship between two malleable risk factors, depressive symptoms and fear of hypoglycemia, in children and adolescents with Type 1 diabetes and their relationship to two important outcomes, adherence behaviors and metabolic control. To assess this relationship, we used a multidimensional measure of adherence, assessing frequency of both blood glucose monitoring and healthy behaviors including diet and exercise. We predicted that higher levels of depressive symptoms and higher levels of fear of hypoglycemia would be associated with worse metabolic control as mediated by poor adherence. Eighty-three children and adolescents ages 8 to 20 (M = 13.87, SD 3.21) were recruited from March 2014 to October 2014 at an outpatient diabetes clinic in a moderately sized Southeastern city within the USA. Nested models were evaluated using structural equation modeling. Adherence significantly mediated the relationship between depressive symptoms and metabolic control with more depressive symptoms leading to worse metabolic control. Adherence marginally mediated the relationship between fear of hypoglycemia and metabolic control; however, less fear of hypoglycemia was associated with worse metabolic control. In a combined model, adherence continued to significantly mediate the relationship between depressive symptoms and metabolic control, while also independently significantly mediating the relationship between fear of hypoglycemia and metabolic control. This finding was also contrary to the predicted relationship with less fear of hypoglycemia leading to worse metabolic control. The results indicate that youth with fewer depressive symptoms and more fear of hypoglycemia had better adherence to their treatment regimen, which was associated with better metabolic control. The results of this study highlight the importance of screening for depression and fear of hypoglycemia during routine clinic visits to optimize adherence and metabolic control.

Hemoglobin A1c, frequency of glucose testing and social disadvantage: Metrics of racial health disparity in youth with type 1 diabetes.

INTRODUCTION: Black youth with type 1 diabetes (T1D) have higher HbA1c than whites. To understand HbA1c differences, we examined the relationship of psycho-social factors and glucose testing with HbA1c. METHODS: Glucose tests per day (BGs/d) and mean blood glucose (MBG) were calculated from meter data of youth self-identified as black (n = 33) or white (n = 53) with T1D. HbA1c, family income, insurance status, concentrated disadvantage (CDI), psychological depression (DSC), mother educational attainment (MEA), and insulin delivery method (IDM) data was were analyzed. RESULTS: Black patients had significantly higher HbA1c, MBG and disadvantage measures compared to whites. BGs/d correlated with HbA1c, MBG, age and CDI. Race (p < 0.0158), age (p < 0.0001) and IDM (p < 0.0036) accounted for 50% of the variability (R2 = 0.5, p < 0.0001) in BGs/d. Regardless of age, black patients had lower BGs/d than whites. MBG (p < 0.0001) and BGs/d (p < 0.0001) accounted for 61% of the variance in HbA1c (p < 0.0001). CONCLUSIONS: BGs/d is easily assessed and closely associated with HbA1c racial disparity. BGs/d is intricately linked with greater social disadvantage. Innovative management approaches are needed to overcome obstacles to optimal outcomes.

Impact of standardized clinical assessment and management plans on resource utilization and costs in children after the arterial switch operation.

BACKGROUND: Standardized Clinical Assessment and Management Plans (SCAMPs) are a quality improvement initiative designed to reduce unnecessary utilization, decrease practice variation, and improve patient outcomes. We created a novel methodology, the SCAMP managed episode of care (SMEOC), which encompasses multiple encounters to assess the impact of the arterial switch operation (ASO) SCAMP on total costs. METHODS: All ASO SCAMP patients (dates March 2009 to July 2015) were compared to a control group of ASO patients (January 2001 to February 2009). Patients were divided into "younger" (<2 years) and "older" (2-18 years) subgroups. Utilization included all cardiology visits, tests, and procedures. Standardized costs were applied to each unit of utilization. RESULTS: There were 100 historical and 63 SCAMP patients in the younger subgroup, and 163 historical and 165 SCAMP patients in the older subgroup. In the younger subgroup, the SCAMP had a 28% reduction in outpatient clinic visits (P < .001), a 52% reduction in chest radiographs (P < .001), a 21% reduction in electrocardiograms (P < .001), and a 30% total reduction in costs. In the older subgroup, the SCAMP had a 21% reduction in outpatient clinic visits (P < .001), a 20% reduction in chest radiographs (P = .05), a 10% reduction in echocardiograms (P = .05), a 25% reduction in exercise stress tests (P = .01), and a 14% total reduction in costs. The total cost savings of the ASO SCAMP was $216 649 in the first 6 years of the SCAMP. There was no difference in clinical outcomes between the historical and SCAMP cohorts. CONCLUSION: SCAMPs can improve resource utilization and reduce costs after the ASO operation while maintaining quality of care.