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

Abstract

Approximately 1.6 million people in the United States have type 1 diabetes (T1D). 1 The incidence of T1D is increasing in the United States across all populations, most significantly among Hispanic and non-Hispanic Black (NHB) patients. 2,3 Unfortunately, widespread inequities exist in health outcomes among patients with T1D in the United States. [4][5][6][7] In 2016, the T1D Exchange Quality Improvement Collaborative (T1DX-QI) was established. 8 T1DX-QI is a learning health network 9 with over 40 centers across the United States. Participating centers use continuous quality improvement (QI) methods [10][11][12] and real-world electronic medical record (EMR) data 4,6 for T1D population health improvement.The T1DX-QI is coordinated by the T1D Exchange, a Boston-based nonprofit coordinating center. The goals of the T1DX-QI were described in a separate commentary. 13 The T1DX-QI has successfully used QI principles and implementation science to improve clinical processes, including increased use of continuous glucose monitors (CGM), insulin pumps, depression screening, improved access to care, and population-level glycemic outcomes. [9][10][11][12] In 2020, the T1DX-QI established its health equity program to address inequities systematically and comprehensively in T1D outcomes. 14 This commentary describes practical approaches being employed by the T1DX-QI to address health inequities. These approaches can be Robert Rapaport and Manmohan Kamboj are co-senior authors.

Implicit Racial–Ethnic and Insurance-Mediated Bias to Recommending Diabetes Technology: Insights from T1D Exchange Multicenter Pediatric and Adult Diabetes Provider Cohort

“… 26 The study was conducted among diabetes clinics in the T1D Exchange Quality Improvement Network (T1DX-QI), 27 as part of an ongoing Health Equity project to identify and address contributors to health inequities among patients with T1D. 26 , 28 T1DX-QI identified seven diabetes centers (five pediatric and two adult centers) from the learning network to participate in a virtual training module on health inequities and implicit bias. The providers participating in this survey were all from states with public insurance coverage for diabetes technology, however, the exact criteria to secure diabetes technology coverage likely varied by state.…”

“…For the clinical vignette component of the D-PIB, the providers were randomized to receive questions that varied by insurance status and patient names, as a proxy to racial identity. 28 , 30 To evaluate validity of this expansion to include race/ethnicity, we applied cognitive testing once again with our content experts to select the approach of utilizing names for the identification of racial–ethnic bias. 31–33 For the expansion to adult providers, we solicited our colleagues in adult endocrinology to finalize the age of a 33 year old.…”

Achieving Equity in Diabetes Research: Borrowing From the Field of Quality Improvement Using a Practical Framework and Improvement Tools

“…The T1DX-QI has found several ways to codesign QI projects with patients, including inviting patients or parent advisors to participate in projects on a patient-parent advisory committee. The T1DX-QI also convened a health equity advisory committee of HEAL (Health Equity Advancement Lab) advisors that meets quarterly to advise on equity-focused initiatives ( 26 ).…”

T1D exchange quality improvement collaborative: Accelerating change through benchmarking and improvement science for people with type 1 diabetes

“…Advances in diabetes technology, such as the availability and use of CGMs, have greatly improved the lives of people with T1D. Unfortunately, there are inequities in the use of and access to these devices 24,25 . In the T1DX‐QI EMR database, individuals who identified as Hispanic or Non‐Hispanic Black had lower rates of pump usage compared to individuals who identified as Non‐Hispanic White 26 .…”

“…Unfortunately, there are inequities in the use of and access to these devices. 24 , 25 In the T1DX‐QI EMR database, individuals who identified as Hispanic or Non‐Hispanic Black had lower rates of pump usage compared to individuals who identified as Non‐Hispanic White. 26 Several centers have benchmarked rates of CGM and insulin pump use in their own center and found similar trends.…”