No abstract

The COVID-19 pandemic has caused sustained disruptions in access to usual diabetes care. In response to the high number of cancelations, an academic, urban diabetes program transitioned to virtual visits and launched an initiative to provide outreach to patients who canceled an appointment between Mar 16 and Jun 19, 2020. Members of the diabetes team used a standardized approach to prevent delayed care or disengagement. Method of contact was defined as Reached (two-way communication between clinician and patient by phone or EHR portal message), Message Left (e.g., voicemail) and No Contact. Engagement was defined as booking a follow up appointment and keeping the appointment. A total of 787 patients were determined to have canceled visits due to the pandemic. Mean (SD) age was 61.7 yrs (14.2), 53.7% female, 67.3% white, baseline A1c 7.96% (1.81). Of the 648 visits booked, 519 (80%) were kept. Patients who were reached were more likely to book (OR = 2.43, p<0.001) and keep an appointment (OR = 2.39, p<0.001) compared to no contact or message left. Older age was a significant predictor of booking (OR = 1.014 for each year older, p=0.037). Patients on insulin were more likely to keep their appointment (OR = 1.70, p=0.008), while patients with higher HbA1c were less likely to (OR = 0.87 for each 1.0% increase in HbA1c, p=0.011). These findings suggest that for systems designed to optimize engagement during care disruption, one-way communication is no better than no contact, and two-way communication increases the likelihood that patients will maintain access to care. In addition, while higher risk patients (e.g., older age or on insulin) may be more incentivized to stay engaged, targeted outreach may be needed for those with chronic poor glycemic control. Disclosure G. Cromwell: None. M. Hudson: None. C. K. Mckitrick: None. M. Donahue: None. C. M. Smith: None. K. M. Fowler: None. K. L. Del valle: None. D. C. Simonson: Stock/Shareholder; Spouse/Partner; Phase V Technologies, Inc. M. E. Mcdonnell: Stock/Shareholder; Spouse/Partner; Abbott Diabetes.

Patients with type 1 (T1D) and type 2 diabetes (T2D) on insulin experience significant diabetes related distress (DD) which is known to negatively impact overall health and ability to self-manage the disease. Mindfulness Based Stress Reduction (MBSR) is an 8-week in-person group-taught program that has been shown to be effective in improving outcomes in chronic diseases. However, MBSR research in diabetes has been limited and has not included complex diabetes. We hypothesized that MBSR would lower DD and improve glycemic control in patients with uncontrolled insulin-treated diabetes. We conducted a nonrandomized pilot feasibility study of MBSR in insulin-treated patients with A1c above goal. Subjects completed the Diabetes Distress Scale (DDS) and Problem Areas in Diabetes (PAID) surveys at baseline, 3 months, and 6 months post intervention. Of 335 patients screened, 10 were enrolled. Patient characteristics included mean age 50.8 years; 60% female; 100% white non-Hispanic; mean baseline A1c= 8.6% +/-0.8. Duration of diabetes was 14 years +/-9; 30% T1D, 70% T2D; 100% on insulin; 70% injected insulin at least 3 times per day. Subjects attended 26 hours of in-class contact. Nine subjects completed the study; one was excluded due to interim pregnancy. All had decreased total DDS scores. There were statistically significant reductions in two DDS domains: emotional (-1.2, p=0.01) and regimen-related distress (-1.2, p=0.004). At 6 months, the mean A1c reduction was -0.4% +/- 0.9. The reduction in PAID score correlated with A1c reduction (r= 0.5). In conclusion, uncontrolled insulin treated diabetes patients who participated in MBSR experienced a sustainable improvement in emotional and regimen-related distress which was accompanied by lower A1c. Results suggest the need for a large clinical trial designed to optimize accessibility to a broader population of patients and to test the cost-effectiveness of this nonpharmacologic intervention. Disclosure R. Rein: None. M. Searl: None. S. Bhandari: None. K.E. Cote: None. I. Hashmi: None. K.L. Del Valle: None. M.E. McDonnell: None.

Intensive management (IM) is recognized as an important approach in treatment of poorly controlled diabetes. However, it is unknown what factors determine response to usual diabetes specialty care (UC) vs. IM and understanding these will improve allocation of costly resources. We sought to identify predictors of response in UC and IM, a high-resource 6-month service designed for those who fail UC that includes telemedicine, remote data sharing, and in-person visits. A response metric was defined as an A1c reduction of >/=0.5 within 12 months of the initial visit. We analyzed two groups with baseline A1c >8: 1) UC patients referred to a diabetes specialty clinic between 12/2016 and 8/2017 (N= 163) and 2) IM patients, who were referred after failing metric between 10/2015 and 6/2018 (N=62). The majority met metric (UC-Met: 74%, IM-Met: 61%). In UC and IM, there were no differences between those who met metric and those who did not in age, gender, race or ethnicity. The UC-Met vs. UC-Notmet were similar across quality parameters (SBP, statin prescription, LDL), prior A1c pattern (peak and nadir A1c), and the presence of cognitive impairment. However, IM-Notmet had more cognitive dysfunction (20% vs. 2.6%, p=0.04) and substance abuse (16% vs. 5%, p=0.35) than IM-Met. Those in IM-Met had a lower A1c nadir in the last decade (6.87 vs. 7.26, p=0.04). Prevalence of psychiatric disease was high in both IM groups (60% IM-Notmet and 53% IM-Met). In conclusion, specialty diabetes services delivered via UC was effective in 74% of patients. The majority of those who fail to achieve clinically significant A1c lowering benefit from resource-intensive programs, especially those who achieved lower A1c levels in the past. However, cognitive impairment and active substance abuse appear to be risk factors for lack of response to high intensity programs, suggesting that resources designed to manage these conditions should be prioritized in affected individuals with diabetes. Disclosure K.L. Del Valle: None. A. Grizales: None. M. Donahue: None. A. Turchin: Advisory Panel; Self; Monarch Medical Technologies. Research Support; Self; Eli Lilly and Company. Stock/Shareholder; Self; Brio Systems. M.E. McDonnell: None.