Reducing Inequity in the Use of Automated Insulin Delivery Systems by Adults With Type 1 Diabetes: Key Learnings From a Safety Net Diabetes Clinic Program.

BACKGROUND: Recent advancements in diabetes technology have significantly improved Type 1 diabetes (T1D) management, but disparities persist, particularly in the adoption of automated insulin delivery (AID) systems within minoritized communities. We aimed to improve patient access to AID system training and overcome clinical inertia to referral. METHODS: We report on a transformative program implemented at Boston Medical Center, the largest safety-net hospital in New England, aimed at reducing disparities in AID system utilization. We employed a multidisciplinary team and quality improvement principles to identify barriers and develop solutions. Strategies included increasing access to diabetes educators, creating a referral system, and developing telemedicine education classes. We also made efforts to raise clinician awareness and confidence in recommending AID therapy. RESULTS: At baseline, 13.5% of our clinic T1D population was using an insulin pump. The population referred included 97 people with T1D (49% female, mean A1c 8.7%, 68% public insurance beneficiaries, 25% Hispanic and 25% non-Hispanic Black). Results from the first year showed a 166% increase in AID system use rates, with 64% of referred patients starting on AID. Notably, 78% of patients with A1c >8.5% adopted AID systems, addressing a gap in representation observed in clinical efficacy trials. The initiative successfully narrowed disparities in AID use among minoritized populations. CONCLUSIONS: The program's success among minoritized patients underscores the significance of tailored, collaborative, team-based care and targeted educational initiatives. Our experience provides a foundation for future efforts to ensure equitable access to diabetes technologies, emphasizing the potential of local quality improvement interventions.

Advanced Diabetes Technology Remains Underutilized in Underserved Populations: Early Hybrid Closed-Loop System Experience at an Academic Safety Net Hospital.

We retrospectively evaluated outcomes of the Minimed Medtronic 670G system in an academic urban safety-net population of adults with type 1 diabetes, between September 2016 and January 2020. Among 32 patients prescribed the 670G, the majority were female (69%), white (69%), achieved advanced degrees (56%), were commercially insured (94%), and were experienced pump users (84%). Patients who initiated auto-mode demonstrated significant improvement in A1c after 1 year. However, 31% of patients never initiated auto-mode. Black and Hispanic patients comprised 50% of this group, despite similar insurance coverage, diabetes duration, educational level, and prior pump use. Hence, traditional barriers to technology use do not explain these racial/ethnic disparities. Of 22 patients who initiated auto-mode, 5 discontinued within 1 year. The most common reason for discontinuation was frustration with pump-sensor interactions. Future studies identifying barriers to and strategies for increasing use of advanced insulin delivery systems in underserved populations are needed.

Late to the Party: Importance of Dietary Fat and Protein in the Intensive Management of Type 1 Diabetes. A Case Report.

Insulin dosing in type 1 diabetes (T1D) has been focused primarily on carbohydrate intake, but recent evidence highlights the importance of dietary fat and protein in glycemic excursions. Several methods have been developed to incorporate dietary fat and protein into insulin dose calculations, including fat-protein units (FPUs) that estimate insulin requirements based on ingested fat and protein, as well as extended combination insulin boluses. However, insulin dosing based on meal fat and protein content is challenging to incorporate into clinical practice. We present the case of a 40-year-old man with T1D using continuous subcutaneous insulin infusions and continuous glucose monitoring. He followed a diet that restricted carbohydrate intake, with compensatory increases in dietary protein and fat. He had poor glycemic control with frequent postprandial hyperglycemia. He began incorporating FPUs into his insulin dosing calculations and used extended dual wave boluses to administer prandial insulin. Over the next 6 months he experienced a significant improvement in glycemic control. Fat and protein have both been shown to cause delayed postprandial hyperglycemia, leading to poor glycemic control with carbohydrate-focused insulin dosing in our patient on a high-fat, high-protein diet. It is difficult to incorporate dietary fat and protein into insulin dosing in the clinical setting. However, our patient experienced an improvement in glycemic control with the application of FPUs and dual wave boluses in prandial insulin dosing, showing that methods such as these can be used successfully in T1D management.