OBJECTIVE: Depression is common among adolescents, but rates increase significantly in the presence of chronic health conditions. Outpatient screening for depression is recommended but rarely formally conducted due to barriers of implementation. METHODS:To provide a model for depression screening of youth with chronic health conditions, a standard process using a selfadministered electronic version of the Children' s Depression Inventory (CDI) was developed. Quality improvement methodology and traditional analytic approaches were used to test the feasibility and outcomes of routine screening in patients 13 to 17 years of age with type 1 diabetes. RESULTS:Of the 528 eligible adolescents, 509 (96%) received at least 1 depression screen during the first year. The process was tested and refined in over 1200 patient encounters, which resulted in an increase in depression screening rates from ,5% to a median of 85% over the initial 12 months. Both patients and staff reported acceptance of screening on qualitative surveys. Elevated CDI scores ($16) were found in 8% of the sample; moderate scores (10-15) in 12% of the sample. Low risk scores were found in 80% of the sample. Higher CDI scores correlated with lower blood glucose monitoring frequency and higher hemoglobin A1c, confirming the link between more depression symptoms and poorer diabetes management and control. Suicidal ideation was endorsed in 7% of the population.CONCLUSIONS: Systematic depression screening in adolescents with type 1 diabetes can be reliably implemented with clinically significant results. A systematic approach, such as described in this study, can serve as a model for other chronic health conditions. Pediatrics

Canadian Aboriginals, like others globally, suffer from disproportionately high rates of diabetes. A comprehensive evidence-based approach was therefore developed to study potential antidiabetic medicinal plants stemming from Canadian Aboriginal Traditional Medicine to provide culturally adapted complementary and alternative treatment options. Key elements of pathophysiology of diabetes and of related contemporary drug therapy are presented to highlight relevant cellular and molecular targets for medicinal plants. Potential antidiabetic plants were identified using a novel ethnobotanical method based on a set of diabetes symptoms. The most promising species were screened for primary (glucose-lowering) and secondary (toxicity, drug interactions, complications) antidiabetic activity by using a comprehensive platform of in vitro cell-based and cell-free bioassays. The most active species were studied further for their mechanism of action and their active principles identified though bioassay-guided fractionation. Biological activity of key species was confirmed in animal models of diabetes. These in vitro and in vivo findings are the basis for evidence-based prioritization of antidiabetic plants. In parallel, plants were also prioritized by Cree Elders and healers according to their Traditional Medicine paradigm. This case study highlights the convergence of modern science and Traditional Medicine while providing a model that can be adapted to other Aboriginal realities worldwide.

Objective: Depression contributes to suboptimal health outcomes amongst people with type 1 diabetes (T1D). The ADA standards of care recommend regular psychosocial screening, however these guidelines are not universally implemented. Aim: Demonstrate feasibility of expanding depression screening across clinics in the national T1D Exchange Learning Collaborative (T1DX-LC) using a quality improvement (QI) approach. Methods: Six clinics in T1DX-LC participated in bi-monthly calls and three learning sessions for depression screening. Sites shared existing resources and used QI methodology to design iterative plan-do-study-act cycles to develop or refine existing processes and adopt interventions in their respective contexts around the following themes: 1) consistent screening and referral criteria, 2) integration of screening into work flow, 3) acceptance from families and staff, 4) adequate social work and psychology referral resources, and 5) incorporation of health information technology. Results: Screening increased from baseline of 10% across sites to 60% of eligible patients at all sites over 18 months (Figure). Discussion: Through the T1DX-LC, a network of centers were successful at completing depression screening in alignment with ADA standards of care. Sites expanded screening to individuals with type 2 diabetes and additional centers are joining the screening intervention. Disclosure S. Majidi: None. M.C. Jolly: None. G.T. Alonso: None. D.A. Buckingham: None. A.B. Cabrera: None. M.A. Clements: Speaker's Bureau; Self; Medtronic. Advisory Panel; Self; Glooko, Inc.. A. Garrity: None. K.A. Gibbs: None. B. Glick: None. K. Hong: None. M.K. Kamboj: None. K.L. Lambert: None. J. Lee: Consultant; Self; Unitio. P.V. Nadkarni: None. R. McDonough: None. A.L. Ohmer: None. N. Rioles: None. K.R. Stanek: None. S. Thomas: None. R.S. Weinstock: Research Support; Self; Medtronic MiniMed, Inc., Mylan, Kowa Pharmaceuticals America, Inc., Diasome Pharmaceuticals, Inc., Calibra Medical, Dexcom, Inc., Ultradian Diagnostics LLC., JAEB Center For Health Research, JDRF, National Institute of Diabetes and Digestive and Kidney Diseases. S. Corathers: None.

IMPORTANCE A shift in the setting of care delivery for children with a new diagnosis of type 1 diabetes led to a reorganization of treatment. OBJECTIVE To determine whether a new diagnosis of pediatric diabetes can be successfully managed in a day hospital model. DESIGN, SETTING, AND PARTICIPANTS This quality improvement study used retrospectively collected data on pediatric patients with a new diagnosis of diabetes who completed an inpatient program for education and insulin titration prospectively compared with patients completing a diabetes day hospital program. Baseline data were collected over 12 months (January-December 2015) and intervention data collected over 14 months (March 2016-May 2017). The study was conducted at a single institution and judged as a nonhuman participant project. The referral local base included a 100-mile radius. Patient inclusion was a new diagnosis of diabetes, age 5 years or older, and no biochemical evidence of diabetic ketoacidosis. Ninety-six patients completed the day hospital program and 192 patients completed an inpatient program. EXPOSURES All patients received 2 consecutive days of insulin titration and education in either a day hospital or inpatient setting. MAIN OUTCOMES AND MEASURES Primary outcomes included the mean length of stay, patient charge, and insurance denial/reimbursement rates. The hypothesis was that a day hospital program would be associated with a reduced length of stay, which would directly affect patient charges and insurance denials. RESULTS Among the 96 day hospital patients, the mean (SD) age was 12.2 (4.7) years (range 5-20.3), with no patients experiencing diabetic ketoacidosis or hypernatremia. Among the 192 inpatient patients, the mean (SD) age was 9.4 (4.7) years (range, 1.6-20.1). The mean (SD) length of stay reduction in the day hospital was 46 (14.1) to 14 (5.1) hours. The mean day hospital patient charge was $2800, compared with a mean (SD) baseline carge of $24 103 ($9401). Within the first year, there was a cumulative reduction in patient charges of more than $2.1 million. CONCLUSIONS AND RELEVANCE This study's findings suggest that a diabetes day hospital setting was associated with reductions in length of stay and patient charges, with an increase in insurance reimbursements and a decrease in insurance denials. This study demonstrates an effective way to streamline new-onset diabetes education, which may reduce length of stay and patient charges. Reimbursement rates for patients with a new diagnosis of diabetes increased from 52% to 72% and reimbursement denial rates decreased from 80% to 0%.