Objective
The primary objecive for Aim 1 of our proposal is to develop and implement an EMR-based best practice advisory (BPA) using stakeholder feedback to standardize the approach for prescribing and documentation of advanced diabetes technologies (ADT) (CGM, insulin pump, AID) among adult and pediatric patients with T1D. The primary objective of Aim 2 of our proposal is to determine the effectiveness of an EMR-based BPA in reducing racial disparities in ADT use. The primary objective of Aim 3 of our proposal is to explore reasons for not prescribing ADT and whether they were patient or provider led, and association between reason provided and patient race/ethnicity.
Background Rationale
Advanced diabetes technologies (ADT), including continuous glucose monitors (CGMs), insulin pumps and automated insulin delivery(AID) have been associated with improved glycemic control, better quality of life, and reduced incidence of hospitalizations for hypoglycemia and diabetic ketoacidosis (DKA) in persons with type 1 diabetes (PwT1D). Despite these proven clinical benefits, there is significant inequity in patient access to these technologies in the United States. Racial disparities in access to diabetes technologies are significant and persist across the lifespan. Black youth and adults with T1D are half as likely to receive CGMs or insulin pumps, and if they receive these devices, they are less likely to have sustained use over time, which may contribute to poorer glycemic outcomes in this patient population. Studies have shown that racial disparities in use of diabetes technologies in patients with T1D cannot be fully explained by differences in socioeconomic status or social determinants of health. Despite many studies describing potential root causes of these disparities at the provider, patient, and system level, very few interventions have been developed or evaluated. One approach to reducing disparities in prescribing of diabetes technologies is to standardize clinical workflows using health information technology, a strategy that has been proven to be effective in reducing racial disparities in many clinical conditions.
Description of Project
Advanced diabetes technologies (ADT), including continuous glucose monitors (CGMs), insulin pumps and automated insulin delivery(AID) have been associated with improved glycemic control, better quality of life, and reduced incidence of hospitalizations for hypoglycemia and diabetic ketoacidosis (DKA) in persons with type 1 diabetes (PwT1D). Despite these proven clinical benefits, there is significant inequity in patient access to these technologies in the United States. Racial disparities in access to diabetes technologies are significant and persist across the lifespan. Black youth and adults with T1D are half as likely to receive CGMs or insulin pumps, and if they receive these devices, they are less likely to have sustained use over time, which may contribute to poorer glycemic outcomes in this patient population. Studies have shown that racial disparities in use of diabetes technologies in patients with T1D cannot be fully explained by differences in socioeconomic status or social determinants of health. Despite many studies describing potential root causes of these disparities at the provider, patient, and system level, very few interventions have been developed or evaluated. One approach to reducing disparities in prescribing of diabetes technologies is to standardize clinical workflows using health information technology, a strategy that has been proven to be effective in reducing racial disparities in many clinical conditions.
The overarching goal of this project, is to develop, implement, and evaluate an electronic medical record (EMR) based Best Practice Advisory (BPA) to address the problem of racial disparities in prescribing, initiation, and use of ADT in PwdT1D. In Aim 1, we will perform a qualitative mixed-methods evaluation using electronic questionnaires, semi-structured interviews, and focus groups of key stakeholders, including pediatric and adult endocrinologists and PwdT1D. The results of this qualitative research will inform the development of a BPA tool targeted at provider prescribing. Aim 2 will be a non-randomized matched-pair intervention study to compare rates of ADT use among non-Hispanic Black and Hispanic PwT1D following the implementation of the BPA at 6 T1D Exchange quality improvement collaborative (T1DX-QI) centers with matched control PwT1D receiving care at a T1DX-QI center not participating in the intervention. One of the goals of the development of the BPA will be to systematically track the reasons that providers deem patients to be inappropriate candidates or patients choose to decline ADT. By systematically collecting this information in a prospective fashion, Aim 3 will allow us to determine whether differences in prescribing/use of these technologies is related to patient race/ethnicity, and develop future interventions to address this
The primary objective for the BPA intervention study (Aim 2) is compare the proportion of non-white (non-Hispanic Black and Hispanic) PwT1D with progression in ADT use at 6 centers in the T1DX-QI (3 pediatric and 3 adult centers) where the BPA intervention is implemented with matched control non-white PwT1D at T1DX-QI centers not receiving the intervention over a 12-month period. To assess the difference in ADT use between White and non-white (non-Hispanic Black and Hispanic) PwT1D receiving care at the intervention centers compared with the racial difference in ADT use in matched control PwT1D. Secondary outcomes will include glycemic control (A1C) and hospitalizations for hypoglycemia, hyperglycemia, and DKA, which will be analyzed by race and diabetes technology use.
This project will advance our understanding of the role of EMR-based BPA in addressing racial disparities in T1D, a well-described phenomenon for which little solutions currently exist. If successful, the results can be disseminated and scaled to other health systems and through T1DX-QI. The implications of this research -- ensuring that minority patients living with T1D receive standard of care treatment – are profound.
Anticipated Outcome
This project will advance our understanding of the role of health informatics technology in addressing racial disparities in T1D management, a well-described phenomenon for which little solutions currently exist. If this project is shown to be successful, the results can be disseminated and scaled to other health systems, as well as through the T1D Exchange quality improvment (T1DX-QI) Collaborative.
Relevance to T1D
The implications of this research -- ensuring that minority patients living with T1D receive standard of care treatment – are profound.