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Feature Articles| October 12 2023
In Special Collection: Quality Improvement and Population Health
Kajal Gandhi
;
1Nationwide Children’s Hospital, Columbus, OH
Corresponding author: Kajal Gandhi, kajal.gandhi@nationwidechildrens.org
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Osagie Ebekozien;
Osagie Ebekozien
2T1D Exchange, Boston, MA
3University of Mississippi School of Population Health, Jackson, MS
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Nudrat Noor;
Nudrat Noor
2T1D Exchange, Boston, MA
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Ryan J. McDonough;
Ryan J. McDonough
4Childrens Mercy – Kansas City, Kansas City, MO
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Susan Hsieh;
Susan Hsieh
5Cook Children’s Hospital, Fort Worth, TX
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Brian Miyazaki;
Brian Miyazaki
6Children’s Hospital of Los Angeles, Los Angeles, CA
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Selorm Dei-Tutu;
Selorm Dei-Tutu
7Texas Children’s Hospital, Houston, TX
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Lauren Golden;
Lauren Golden
8NYU Langone, New York
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Marisa Desimone;
Marisa Desimone
9SUNY Upstate Medical University, Syracuse, NY
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Holly Hardison;
Holly Hardison
2T1D Exchange, Boston, MA
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Saketh Rompicherla;
Saketh Rompicherla
2T1D Exchange, Boston, MA
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Halis K. Akturk;
Halis K. Akturk
10Barbara Davis Center, Denver, CO
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Manmohan K. Kamboj;
Manmohan K. Kamboj
1Nationwide Children’s Hospital, Columbus, OH
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T1D Exchange Quality Improvement Collaborative
T1D Exchange Quality Improvement Collaborative
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Corresponding author: Kajal Gandhi, kajal.gandhi@nationwidechildrens.org
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Citation
Kajal Gandhi, Osagie Ebekozien, Nudrat Noor, Ryan J. McDonough, Susan Hsieh, Brian Miyazaki, Selorm Dei-Tutu, Lauren Golden, Marisa Desimone, Holly Hardison, Saketh Rompicherla, Halis K. Akturk, Manmohan K. Kamboj, T1D Exchange Quality Improvement Collaborative; Insulin Pump Utilization in 2017–2021 for More Than 22,000 Children and Adults With Type 1 Diabetes: A Multicenter Observational Study. Clin Diabetes 15 January 2024; 42 (1): 56–64. https://doi.org/10.2337/cd23-0055
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This large type 1 diabetes cohort study showed that insulin pump utilization has increased over time and that use differs by sex, insurance type, and race/ethnicity. Insulin pump use was associated with more optimal A1C, increased use of continuous glucose monitoring (CGM), and lower rates of diabetic ketoacidosis and severe hypoglycemia. People who used an insulin pump with CGM had lower rates of acute events than their counterparts who used an insulin pump without CGM. These findings highlight the need to improve access of diabetes technology through provider engagement, multidisciplinary approaches, and efforts to address health inequities.
Incidence rates of type 1 diabetes are increasing among children, particularly those in racial/ethnic minority groups (1,2). Registry studies have found that suboptimal glucose levels and adverse diabetes outcomes such as severe hypoglycemia and diabetic ketoacidosis (DKA) are common among many groups with type 1 diabetes (3,4). Although landmark studies have highlighted the importance of intensive diabetes management to reduce complications (5), other studies have shown that many children with type 1 diabetes do not have glucose levels in the target ranges recommended in national and international guidelines (6–8).
Optimal type 1 diabetes care often involves the use of various modalities of diabetes technology, and specifically insulin pumps and continuous glucose monitoring (CGM) systems. National studies have shown that the use of insulin pump therapy and CGM have increased over time (6,9). Previous data and trends show that effective use of diabetes technology can enhance diabetes care and improve long-term outcomes in pediatric and adult populations. A 2010 Cochrane systematic review and multiregistry pediatric type 1 diabetes study found a significant difference in A1C among insulin pump users compared with injection therapy users (10–12). Furthermore, the SEARCH for Diabetes in Youth study, the T1D Exchange clinic registry, and other research have demonstrated lower A1C levels among insulin pump and CGM users compared with injection therapy users and nonusers of CGM (6,13–16). Similar findings have been seen reported in adult populations with type 1 diabetes (17,18).
Insulin pump users have decreased rates of DKA, fewer severe hypoglycemia events, and reduced hospital days (6,19–21). Although diabetes technology remains an asset to optimal care, there are persistent health inequities, with the SWEET and T1D Exchange registries showing varying insulin pump use among various global type 1 diabetes centers and within various racial/ethnic minority groups (6,22,23).
National quality improvement (QI) initiatives have focused on increasing utilization rates of diabetes technology because of the evidence of its benefits and reductions of adverse diabetes outcomes with its use (24,25). However, ongoing data on real-world use of diabetes technology across the life span, from the pediatric to older-adult populations with type 1 diabetes, remain limited. This observational study examined trends in insulin pump use compared with multiple daily injection (MDI) insulin regimens and CGM utilization trends, as well as A1C and rates of adverse diabetes outcomes among a large, multicenter collaborative type 1 diabetes cohort in the United States.
Research Design and Methods
The T1D Exchange Quality Improvement Collaborative (T1DX-QI) is a multicenter initiative comprising more than 40 data-sharing clinical centers throughout the United States. The aim of the T1DX-QI is to engage in information-sharing on clinical practices and data collection to identify and lead QI initiatives to improve evidence-based diabetes care delivery with the hope of positively affecting diabetes outcomes (26).
Insulin pump, MDI, and CGM users were identified through the T1DX-QI electronic medical records database. The database includes people with type 1 diabetes from multiple centers in the T1DX-QI. Inclusion criteria were a diagnosis of type 1 diabetes, age >2 years, and at least one A1C result and one clinic encounter between 2017 and 2021.
Quantitative data were reported as mean ± SD, and categorical data were represented as frequencies and percentages. To analyze continuous variables, t tests were used, and χ2 tests were used to analyze categorical variables. Sex was identified as male or female. Insurance status was categorized as public, private, or other. Age was described as a categorical variable. DKA was defined as the presence of 1) hyperglycemia, with blood glucose >11 mmol/L (>198 mg/dL); 2) venous pH <7.3 or serum bicarbonate <15 mmol/L; and 3) ketonuria and ketonemia. Severe hypoglycemia was defined as a hypoglycemia event requiring external assistance.
Results
Throughout the 5 years of data collection, there was an overall increase in insulin pump utilization from 59% in 2017 to 66% in 2021 (Figure 1).
General characteristics of the entire cohort in 2021 show that there were statistically significant differences in sex, insurance coverage, and concurrent use of CGM between insulin pump and MDI regimen users. Diabetes technology use varied across age and race/ethnicity (Table 1). The insulin pump group was more likely to have female sex (P <0.001), to have private insurance (P < 0.001), and to use CGM. There were also differences in insulin pump and MDI use by race/ethnicity, as shown in Table 1 (P <0.001). When the use of insulin pump was compared with the use of an MDI regimen within racial/ethnic groups, insulin pump use was higher among non-Hispanic White (70 vs. 30%), as compared with non-Hispanic Black (41 vs. 59%) patients with type 1 diabetes (P <0.001), as shown in Supplementary Table S1.
TABLE 1
Patient Characteristics of Insulin Pump Versus MDI Regimen Users
Insulin Pump Group, n = 14,867 | MDI Group, n = 7,621 | P | |
---|---|---|---|
Age, years | 19.8 ± 12.7 | 19.3 ± 13.5 | 0.03 |
Age-group, years* <6 6–11 12–17 18–24 25–50 51–65 >65 | 331 (2) 2,313 (16) 5,682 (38) 3,952 (27) 1,827 (12) 520 (3) 242 (2) | 299 (4) 1,374 (18) 2,878 (38) 1,892 (25) 692 (9) 334 (4) 152 (2) | 0.001 <0.001 <0.001 0.5 0.005 <0.001 0.001 0.05 |
Female sex | 7,476 (50) | 3,472 (46) | <0.001 |
Race/ethnicity* Non-Hispanic White Non-Hispanic Black Hispanic Other | 10,960 (74) 938 (6) 1,105 (7) 1,864 (13) | 4,614 (61) 1,327 (17) 682 (9) 998 (13) | <0.001 <0.001 <0.001 <0.001 0.2 |
Insurance* Public Private Other | 3,699 (25) 7,935 (53) 3,233 (22) | 2,513 (33) 2,826 (37) 2,282 (30) | <0.001 <0.001 <0.001 <0.001 |
CGM user | 11,695 (79) | 3,630 (48) | <0.001 |
Most recent A1C, % | 8.2 ± 1.8 | 8.5 ± 2.1 | <0.001 |
Most recent A1C, mmol/mol | 66.1 ± 18.1 | 69.4 ± 25.4 | <0.001 |
DKA | 878 (6) | 712 (9) | <0.001 |
Severe hypoglycemia | 256 (2) | 252 (3) | <0.001 |
Insulin Pump Group, n = 14,867 | MDI Group, n = 7,621 | P | |
---|---|---|---|
Age, years | 19.8 ± 12.7 | 19.3 ± 13.5 | 0.03 |
Age-group, years* <6 6–11 12–17 18–24 25–50 51–65 >65 | 331 (2) 2,313 (16) 5,682 (38) 3,952 (27) 1,827 (12) 520 (3) 242 (2) | 299 (4) 1,374 (18) 2,878 (38) 1,892 (25) 692 (9) 334 (4) 152 (2) | 0.001 <0.001 <0.001 0.5 0.005 <0.001 0.001 0.05 |
Female sex | 7,476 (50) | 3,472 (46) | <0.001 |
Race/ethnicity* Non-Hispanic White Non-Hispanic Black Hispanic Other | 10,960 (74) 938 (6) 1,105 (7) 1,864 (13) | 4,614 (61) 1,327 (17) 682 (9) 998 (13) | <0.001 <0.001 <0.001 <0.001 0.2 |
Insurance* Public Private Other | 3,699 (25) 7,935 (53) 3,233 (22) | 2,513 (33) 2,826 (37) 2,282 (30) | <0.001 <0.001 <0.001 <0.001 |
CGM user | 11,695 (79) | 3,630 (48) | <0.001 |
Most recent A1C, % | 8.2 ± 1.8 | 8.5 ± 2.1 | <0.001 |
Most recent A1C, mmol/mol | 66.1 ± 18.1 | 69.4 ± 25.4 | <0.001 |
DKA | 878 (6) | 712 (9) | <0.001 |
Severe hypoglycemia | 256 (2) | 252 (3) | <0.001 |
Data are mean ± SD or n (%).
*
Adjusted for Bonferroni-corrected P value.
Insulin pump users were found to have a lower mean A1C than MDI users across all years from 2017 to 2021, with the most recent 2021 data showing mean A1C among insulin pump users of 8.2 ± 1.8% compared with a mean A1C in MDI users of 8.4 ± 2% (P <0.001), as shown in Table 2. This lower A1C trend among insulin pump users persisted across all age-groups, as shown in Figure 2.
TABLE 2
A1C (%) for Insulin Pump and MDI Regimen Users, 2017–2021 (N = 22,463)
Year | Insulin Pump Group | MDI Group | P |
---|---|---|---|
2017 | 8.4 ± 1.6 | 8.6 ± 1.9 | <0.001 |
2018 | 8.6 ± 1.7 | 8.8 ± 1.9 | <0.001 |
2019 | 8.4 ± 2.7 | 8.6 ± 2.4 | <0.001 |
2020 | 8.4 ± 1.9 | 8.5 ± 2.1 | <0.001 |
2021 | 8.2 ± 1.8 | 8.4 ± 2 | <0.001 |
Year | Insulin Pump Group | MDI Group | P |
---|---|---|---|
2017 | 8.4 ± 1.6 | 8.6 ± 1.9 | <0.001 |
2018 | 8.6 ± 1.7 | 8.8 ± 1.9 | <0.001 |
2019 | 8.4 ± 2.7 | 8.6 ± 2.4 | <0.001 |
2020 | 8.4 ± 1.9 | 8.5 ± 2.1 | <0.001 |
2021 | 8.2 ± 1.8 | 8.4 ± 2 | <0.001 |
Data are mean ± SD.
FIGURE 2
A1C among insulin pump users versus those using an MDI regimen across age-groups (N = 22,463).
FIGURE 2
A1C among insulin pump users versus those using an MDI regimen across age-groups (N = 22,463).
Close modal
When CGM use was added, mean A1C levels in the group using an insulin pump with CGM were lower compared with those using an insulin pump without CGM (8.1 ± 1.7 vs. 8.6 ± 1.8%, P <0.001). Furthermore, DKA occurred in fewer patients using an insulin pump with CGM than in those using an insulin pump without CGM (556 [5%] vs. 322 [10%], P <0.001), as shown in Table 3. This trend of fewer DKA events was also seen among MDI users with versus without CGM (396 [8%] vs. 316 [11%], P <0.001), as shown in Table 4.
TABLE 3
Subgroup Analysis to Examine Clinical Outcomes in Patients Using an Insulin Pump With (n = 11,695) and Without (n = 3,172) CGM
Patients Using Insulin Pump With CGM | Patients Using Insulin Pump Without CGM | P | |
---|---|---|---|
A1C, % | 8.1 ± 1.7 | 8.6 ± 1.8 | <0.001 |
A1C, mmol/mol | 64.5 ± 17.4 | 70 ± 19.2 | <0.001 |
Patients with DKA | 556 (5) | 322 (10) | <0.001 |
Patients with severe hypoglycemia | 180 (2) | 76 (2) | 0.004 |
Patients Using Insulin Pump With CGM | Patients Using Insulin Pump Without CGM | P | |
---|---|---|---|
A1C, % | 8.1 ± 1.7 | 8.6 ± 1.8 | <0.001 |
A1C, mmol/mol | 64.5 ± 17.4 | 70 ± 19.2 | <0.001 |
Patients with DKA | 556 (5) | 322 (10) | <0.001 |
Patients with severe hypoglycemia | 180 (2) | 76 (2) | 0.004 |
Data are mean ± SD or n (%).
TABLE 4
Subgroup Analysis to Examine Clinical Outcomes in Patients Using an MDI Regimen With (n = 4,825) and Without (n = 2,796) CGM
Patients Using MDI With CGM | Patients Using MDI Without CGM | P | |
---|---|---|---|
A1C, % | 8.7 ± 2.1 | 9.2 ± 2.3 | <0.001 |
A1C, mmol/mol | 72 ± 23 | 77 ± 25 | <0.001 |
Patients with DKA | 396 (8) | 316 (11) | <0.001 |
Patients with severe hypoglycemia | 137 (3) | 115 (4) | 0.003 |
Patients Using MDI With CGM | Patients Using MDI Without CGM | P | |
---|---|---|---|
A1C, % | 8.7 ± 2.1 | 9.2 ± 2.3 | <0.001 |
A1C, mmol/mol | 72 ± 23 | 77 ± 25 | <0.001 |
Patients with DKA | 396 (8) | 316 (11) | <0.001 |
Patients with severe hypoglycemia | 137 (3) | 115 (4) | 0.003 |
Data are mean ± SD or n (%).
Discussion
Although there is evidence that the use of diabetes technology such as insulin pumps and CGM systems improves glucose levels and diabetes care, there remain limited data on the use of diabetes technology as it relates to outcomes in the real-world population with type 1 diabetes. The T1DX-QI initiatives have successfully increased the use of CGM and insulin pumps, depression screening, and access to care (27). This observational study tracked insulin pump use over time and highlights the relationship between the use of diabetes technology and diabetes outcomes such as A1C, DKA, and severe hypoglycemia in a large, multicenter, pediatric and adult collaborative cohort with type 1 diabetes.
The data show that rates of insulin pump use are increasing over time, but there seems to be an inequity in that the greatest use is among individuals who are non-Hispanic White and those who have private insurance. This inequity appears consistent with health disparities that are known to exist among children with chronic conditions (28). Specifically, racial/ethnic disparities have been related to type 1 diabetes care, showing higher A1C levels, more varied engagement with daily diabetes care, more adverse diabetes outcomes, and lower diabetes technology utilization among individuals in racial/ethnic minority groups (23,29–37).
Various barriers to the adoption of diabetes technology have been identified, including limited insurance access, cost, family preferences, and lack of comfort with technology (38–41). Studies have shown that having private insurance is associated with more optimal glycemic control as evidenced by A1C, increased diabetes technology access, and lower rates of diabetes-related complications (42–46).
Interestingly, some previous studies have shown that the use of diabetes technology has lessened the impact of varied socioeconomic and insurance factors as predictors of diabetes outcomes (42,47). This finding suggests that access to and use of diabetes technology may assist with narrowing disparities in glycemic control. Fortunately, diabetes technology is becoming increasingly more accessible for people with type 1 diabetes and public insurance, so more studies are needed to examine the relationships among insurance and socioeconomic status, method of insulin delivery, and diabetes outcomes.
It is also important to consider that unconscious and conscious bias among diabetes care providers can exist and affect the initiation of diabetes technology, ultimately adversely affecting long-term diabetes outcomes, and this bias offers an opportunity for intervention (48,49). Among diabetes care providers, increasing trainees’ knowledge of and confidence in using diabetes technology can further increase access for patients (50). Novel approaches to addressing racial/ethnic disparities in diabetes technology use among established culturally sensitive diabetes initiatives are essential (51). The T1DX-QI has developed and undertaken initiatives to improve health inequities by proper data identification, measuring implicit bias from provider and institutional perspectives, and engaging community leaders and clinics in addressing these issues (52).
Evidence from previous research has shown that early adoption of insulin pump therapy in children (53,54) and access to hybrid closed-loop automated insulin delivery (AID) systems (55,56) improves diabetes outcomes, highlighting the need for tailored care incorporating diabetes technology. Furthermore, studies have shown that diabetes technology use is equally effective in older adults, with improved glycemic outcomes compared with the use of MDI regimens. However, anxiety around using diabetes technology in the setting of cognitive impairment can negatively affect the optimization of technology use in the older adult population (57–59).
One interesting finding of this study is that, although there was an increased number of insulin pump users versus MDI users in most age-groups, there was a relatively similar preference for insulin pump versus MDI therapy among the cohort who were 12–17 years of age. Recent studies have shown that a small proportion of adolescents with type 1 diabetes meet recommended glycemic goals, and this situation does not improve during the years of adolescence (6,60). Although insulin pump use and private insurance were associated with improved glycemic control in this and other studies, there is some evidence showing little improvement of glycemic control during the adolescent time period regardless of insulin delivery method or insurance type (60). The contributors to these outcomes can be multifactorial, including adolescents navigating increasing autonomy in diabetes care and diabetes self-management behaviors, uncertainty related to transitioning from pediatric to adult care, and parental involvement in insulin pump care. Thus, continued investigation is needed to understand diabetes management during this transitional life stage (61–63).
The use of technology for type 1 diabetes management can be increased through telemedicine (64–66). However, this solution may be limited because adoption of telemedicine remains dependent on technology and health literacy of both providers and patients/families, dependent on health care system support, and potentially affected by challenges in resource-limited settings (67).
For youth with type 1 diabetes, conflicts between parents and children regarding diabetes care can affect decisions regarding the choice of insulin delivery method (68), and coaching methods have been shown to aid in such decision-making (69). In addition, continued psychosocial assessments after the adoption of diabetes technology are crucial because technology use can have both positive and negative effects on diabetes management over time. For example, one study found that depression scores were similar in youth with new-onset diabetes and those initiating insulin pump therapy, suggesting the need not only for screening of those adjusting to a new diabetes diagnosis, but also for possible adjustment challenges in those with an established diabetes diagnosis. Furthermore, insulin pump therapy has been associated with improved quality of life and decreased diabetes burden for caregivers of individuals with type 1 diabetes (70,71). Continued development of unique interventional approaches will be needed to nurture relationships among patients, caregivers, and health care providers with regard to the adoption of diabetes technology.
Novel approaches have been shown to improve diabetes care in multidisciplinary and community settings, such as institutional programs that incorporate care coordination and behavioral therapy, interventions to improve pump management skills, and school-based programs to improve diabetes care in various settings. Promoting access to diabetes technology within these avenues is essential (72–74).
Conclusion
This article reports real-world data from a large cohort of children and adults with type 1 diabetes and shows that the use of an insulin pump with concurrent CGM can enhance diabetes care across many age-groups.
Limitations of this study include that the data were cross-sectional and that no causality could be established from these findings. Additionally, the use of newer diabetes technology devices such as the hybrid closed-loop AID systems, which can reduce hypoglycemia and increase time spent in the target glycemic range, was not included in this study. We anticipate that increased use of AID systems will further enhance diabetes care. Because the T1DX-QI is a multicenter initiative that primarily consists of clinics in academic settings in large, urban areas, future opportunities should include the involvement of diabetes centers or clinics in rural areas. This step will allow investigation of a more diverse patient population to address health inequities and provide additional insights into various clinical practices.
Future work should also focus on various strategies to increase diabetes technology use. These include increasing provider education about technology adoption, encouraging youth and adults with type 1 diabetes to be early adopters of technology early in the course of their diabetes, addressing health inequities by data-sharing, providing focused bias training and psychological support, and increasing access to type 1 diabetes care via telemedicine.
Article Information
Acknowledgments
The authors thank the Leona M. and Harry B. Helmsley Charitable Trust for funding the T1DX-QI. The authors also acknowledge the contributions of patients, families, diabetes care teams, and collaborators within the T1DX-QI who continually seek to improve care and outcomes for people living with diabetes.
Duality of Interest
O.E. is on the Medtronic Health Equity Advisor Board. H.K.A. has received research grants through the University of Colorado from Dexcom, Eli Lilly, IM Therapeutics, MannKind, REMD, and Senseonics. No other potential conflicts of interest relevant to this article were reported.
Author Contributions
K.G. wrote the first draft of the manuscript. O.E. conceptualized the study. O.E., N.N., and S.R. analyzed the data. All authors reviewed and edited the manuscript. N.N. is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Prior Presentation
A portion of the data included in this article was presented at the American Diabetes Association’s virtual 81st Scientific Sessions in June 2021.
This article contains supplementary material online at https://doi.org/10.2337/figshare.24205374.
This article is part of a special article collection available at https://diabetesjournals.org/collection/1849/Quality-Improvement-and-Population-Health.
References
1.
Centers for Disease Control and Prevention
National Diabetes Statistics Report: Estimates of Diabetes and Its Burden in the United States
.
Available from https://www.cdc.gov/diabetes/data/statistics-report/index.html. Accessed 19 November 2021
2.
Mayer-Davis EJ Lawrence JM Dabelea D SEARCH for Diabetes in Youth Study
Incidence trends of type 1 and type 2 diabetes among youths, 2002–2012
.
N Engl J Med
2017
;
376
:
1419
–
1429
3.
Miller KM Foster NC Beck RW T1D Exchange Clinic Network
Current state of type 1 diabetes treatment in the U.S.: updated data from the T1D Exchange clinic registry
.
Diabetes Care
2015
;
38
:
971
–
978
4.
Maahs DM Hermann JM Holman N National Paediatric Diabetes Audit and the Royal College of Paediatrics and Child Health, the DPV Initiative, and the T1D Exchange Clinic Network
Rates of diabetic ketoacidosis: international comparison with 49,859 pediatric patients with type 1 diabetes from England, Wales, the U.S., Austria, and Germany
.
Diabetes Care
2015
;
38
:
1876
–
1882
5.
Diabetes Control and Complications Trial Research Group Nathan DM Genuth S Lachin J
The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus
.
N Engl J Med
1993
;
329
:
977
–
986
6.
Foster NC Beck RW Miller KM
State of type 1 diabetes management and outcomes from the T1D Exchange in 2016–2018
.
Diabetes Technol Ther
2019
;
21
:
66
–
72
7.
Mayer-Davis EJ Kahkoska AR Jefferies C
ISPAD Clinical Practice Consensus Guidelines 2018: Definition, epidemiology, and classification of diabetes in children and adolescents
.
Pediatr Diabetes
2018
;
19
(
Suppl. 27
):
7
–
19
8.
American Diabetes Association
13. Children and adolescents: Standards of Medical Care in Diabetes—2021
.
Diabetes Care
2021
;
44
(
Suppl. 1
):
S180
–
S199
9.
Miller KM Hermann J Foster N T1D Exchange and DPV Registries
Longitudinal changes in continuous glucose monitoring use among individuals with type 1 diabetes: international comparison in the German and Austrian DPV and U.S. T1D Exchange registries
.
Diabetes Care
2020
;
43
:
e1
–
e2
10.
Misso ML Egberts KJ Page M O’Connor D Shaw J
Continuous subcutaneous insulin infusion (CSII) versus multiple insulin injections for type 1 diabetes mellitus
.
Cochrane Database Syst Rev
2010
;
CD005103
11.
Sherr JL Hermann JM Campbell F T1D Exchange Clinic Network; the DPV Initiative; and the National Paediatric Diabetes Audit and the Royal College of Paediatrics and Child Health Registries
Use of insulin pump therapy in children and adolescents with type 1 diabetes and its impact on metabolic control: comparison of results from three large, transatlantic paediatric registries
.
Diabetologia
2016
;
59
:
87
–
91
12.
Pala L Dicembrini I Mannucci E
Continuous subcutaneous insulin infusion vs modern multiple injection regimens in type 1 diabetes: an updated meta-analysis of randomized clinical trials
.
Acta Diabetol
2019
;
56
:
973
–
980
13.
Pihoker C Badaru A Anderson A SEARCH for Diabetes in Youth Study Group
Insulin regimens and clinical outcomes in a type 1 diabetes cohort: the SEARCH for Diabetes in Youth study
.
Diabetes Care
2013
;
36
:
27
–
33
14.
Danne T Schwandt A Biester T DPV Initiative
Long-term study of tubeless insulin pump therapy compared to multiple daily injections in youth with type 1 diabetes: data from the German/Austrian DPV registry
.
Pediatr Diabetes
2018
;
19
:
979
–
984
15.
Laffel LM Kanapka LG Beck RW CGM Intervention in Teens and Young Adults with T1D (CITY) Study Group CDE10
Effect of continuous glucose monitoring on glycemic control in adolescents and young adults with type 1 diabetes: a randomized clinical trial
.
JAMA
2020
;
323
:
2388
–
2396
16.
Paris CA Imperatore G Klingensmith G
Predictors of insulin regimens and impact on outcomes in youth with type 1 diabetes: the SEARCH for Diabetes in Youth study
.
J Pediatr
2009
;
155
:
183
–
9.e1
17.
Beck RW Riddlesworth T Ruedy K DIAMOND Study Group
Effect of continuous glucose monitoring on glycemic control in adults with type 1 diabetes using insulin injections: the DIAMOND randomized clinical trial
.
JAMA
2017
;
317
:
371
–
378
18.
Giménez M Lara M Conget I
Sustained efficacy of continuous subcutaneous insulin infusion in type 1 diabetes subjects with recurrent non-severe and severe hypoglycemia and hypoglycemia unawareness: a pilot study
.
Diabetes Technol Ther
2010
;
12
:
517
–
521
19.
Auzanneau M Karges B Neu A
Use of insulin pump therapy is associated with reduced hospital-days in the long-term: a real-world study of 48,756 pediatric patients with type 1 diabetes
.
Eur J Pediatr
2021
;
180
:
597
–
606
20.
Alonso GT Ebekozien O Gallagher MP
Diabetic ketoacidosis drives COVID-19 related hospitalizations in children with type 1 diabetes
.
J Diabetes
2021
;
13
:
681
–
687
21.
Karges B Schwandt A Heidtmann B
Association of insulin pump therapy vs insulin injection therapy with severe hypoglycemia, ketoacidosis, and glycemic control among children, adolescents, and young adults with type 1 diabetes
.
JAMA
2017
;
318
:
1358
–
1366
22.
Szypowska A Schwandt A Svensson J SWEET Study Group
Insulin pump therapy in children with type 1 diabetes: analysis of data from the SWEET registry
.
Pediatr Diabetes
2016
;
17
(
Suppl. 23
):
38
–
45
23.
Agarwal S Kanapka LG Raymond JK
Racial-ethnic inequity in young adults with type 1 diabetes
.
J Clin Endocrinol Metab
2020
;
105
:
e2960
–
e2969
24.
Lyons SK Ebekozien O Garrity A T1D Exchange Quality Improvement Collaborative Study Group
Increasing insulin pump use among 12- to 26-year-olds with type 1 diabetes: results from the T1D Exchange Quality Improvement Collaborative
.
Clin Diabetes
2021
;
39
:
272
–
277
25.
Prahalad P Ebekozien O Alonso GT T1D Exchange Quality Improvement Collaborative Study Group
Multi-clinic quality improvement initiative increases continuous glucose monitoring use among adolescents and young adults with type 1 diabetes
.
Clin Diabetes
2021
;
39
:
264
–
271
26.
Alonso GT Corathers S Shah A
Establishment of the T1D Exchange Quality Improvement Collaborative (T1DX-QI)
.
Clin Diabetes
2020
;
38
:
141
–
151
27.
Prahalad P Rioles N Noor N Rapaport R Weinstock RS T1DX-QI Collaborative
T1D Exchange Quality Improvement Collaborative: accelerating change through benchmarking and improvement science for people with type 1 diabetes
.
J Diabetes
2022
;
14
:
83
–
87
28.
Berry JG Bloom S Foley S Palfrey JS
Health inequity in children and youth with chronic health conditions
.
Pediatrics
2010
;
126
(
Suppl. 3
):
S111
–
S119
29.
Willi SM Miller KM DiMeglio LA T1D Exchange Clinic Network
Racial-ethnic disparities in management and outcomes among children with type 1 diabetes
.
Pediatrics
2015
;
135
:
424
–
434
30.
Chalew S Gomez R Vargas A
Hemoglobin A1c, frequency of glucose testing and social disadvantage: metrics of racial health disparity in youth with type 1 diabetes
.
J Diabetes Complications
2018
;
32
:
1085
–
1090
31.
Kahkoska AR Shay CM Crandell J
Association of race and ethnicity with glycemic control and hemoglobin A1c levels in youth with type 1 diabetes
.
JAMA Netw Open
2018
;
1
:
e181851
32.
Gallegos-Macias AR Macias SR Kaufman E Skipper B Kalishman N
Relationship between glycemic control, ethnicity and socioeconomic status in Hispanic and white non-Hispanic youths with type 1 diabetes mellitus
.
Pediatr Diabetes
2003
;
4
:
19
–
23
33.
Ebekozien O Agarwal S Noor N
Inequities in diabetic ketoacidosis among patients with type 1 diabetes and COVID-19: data from 52 US clinical centers
.
J Clin Endocrinol Metab
2021
;
106
:
e1755
–
e1762
34.
Lipman TH Willi SM Lai CW Smith JA Patil O Hawkes CP
Insulin pump use in children with type 1 diabetes: over a decade of disparities
.
J Pediatr Nurs
2020
;
55
:
110
–
115
35.
Majidi S Ebekozien O Noor N T1D Exchange Quality Improvement Collaborative Study Group
Inequities in health outcomes in children and adults with type 1 diabetes: data from the T1D Exchange Quality Improvement Collaborative
.
Clin Diabetes
2021
;
39
:
278
–
283
36.
O’Connor MR Carlin K co*ker T Zierler B Pihoker C
Disparities in insulin pump therapy persist in youth with type 1 diabetes despite rising overall pump use rates
.
J Pediatr Nurs
2019
;
44
:
16
–
21
37.
Saydah S Imperatore G Cheng Y Geiss LS Albright A
Disparities in diabetes deaths among children and adolescents: United States, 2000–2014
.
MMWR Morb Mortal Wkly Rep
2017
;
66
:
502
–
505
38.
Commissariat PV Boyle CT Miller KM
Insulin pump use in young children with type 1 diabetes: sociodemographic factors and parent-reported barriers
.
Diabetes Technol Ther
2017
;
19
:
363
–
369
39.
Wong JC Boyle C DiMeglio LA T1D Exchange Clinic Network
Evaluation of pump discontinuation and associated factors in the T1D Exchange clinic registry
.
J Diabetes Sci Technol
2017
;
11
:
224
–
232
40.
Messer LH Tanenbaum ML Cook PF
Cost, hassle, and on-body experience: barriers to diabetes device use in adolescents and potential intervention targets
.
Diabetes Technol Ther
2020
;
22
:
760
–
767
41.
Tanenbaum ML Hanes SJ Miller KM Naranjo D Bensen R Hood KK
Diabetes device use in adults with type 1 diabetes: barriers to uptake and potential intervention targets
.
Diabetes Care
2017
;
40
:
181
–
187
42.
Watson SE Kuhl EA Foster MB
The impact of insurance coverage and the family on pediatric diabetes management
.
Pediatr Diabetes
2017
;
18
:
315
–
319
43.
Wintergerst KA Hinkle KM Barnes CN Omoruyi AO Foster MB
The impact of health insurance coverage on pediatric diabetes management
.
Diabetes Res Clin Pract
2010
;
90
:
40
–
44
44.
Everett E Mathioudakis NN
Association of socioeconomic status and DKA readmission in adults with type 1 diabetes: analysis of the US National Readmission Database
.
BMJ Open Diabetes Res Care
2019
;
7
:
e000621
45.
Everett EM Copeland TP Moin T Wisk LE
National trends in pediatric admissions for diabetic ketoacidosis, 2006–2016
.
J Clin Endocrinol Metab
2021
;
106
:
2343
–
2354
46.
Rewers A Chase HP Mackenzie T
Predictors of acute complications in children with type 1 diabetes
.
JAMA
2002
;
287
:
2511
–
2518
47.
Everett EM Wisk LE
Relationships between socioeconomic status, insurance coverage for diabetes technology and adverse health in patients with type 1 diabetes
.
J Diabetes Sci Technol
2022
;
16
:
825
–
833
48.
FitzGerald C Hurst S
Implicit bias in healthcare professionals: a systematic review
.
BMC Med Ethics
2017
;
18
:
19
49.
Hall WJ Chapman MV Lee KM
Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: a systematic review
.
Am J Public Health
2015
;
105
:
e60
–
e76
50.
Marks BE Wolfsdorf JI Waldman G Stafford DE Garvey KC
Pediatric endocrinology trainees’ education and knowledge about insulin pumps and continuous glucose monitors
.
Diabetes Technol Ther
2019
;
21
:
105
–
109
51.
Pascual AB Pyle L Nieto J Klingensmith GJ Gonzalez AG
Novel, culturally sensitive, shared medical appointment model for Hispanic pediatric type 1 diabetes patients
.
Pediatr Diabetes
2019
;
20
:
468
–
473
52.
Ebekozien O Mungmode A Odugbesan O T1DX-QI Collaborative
Addressing type 1 diabetes health inequities in the United States: approaches from the T1D Exchange QI Collaborative
.
J Diabetes
2022
;
14
:
79
–
82
53.
Kamrath C Tittel SR Kapellen TM
Early versus delayed insulin pump therapy in children with newly diagnosed type 1 diabetes: results from the multicentre, prospective diabetes follow-up DPV registry
.
Lancet Child Adolesc Health
2021
;
5
:
17
–
25
54.
Lang EG King BR Miller MN Dunn SV Price DA Foskett DC
Initiation of insulin pump therapy in children at diagnosis of type 1 diabetes resulted in improved long-term glycemic control
.
Pediatr Diabetes
2017
;
18
:
26
–
32
55.
Breton MD Kanapka LG Beck RW iDCL Trial Research Group
A randomized trial of closed-loop control in children with type 1 diabetes
.
N Engl J Med
2020
;
383
:
836
–
845
56.
Clements MA Schwandt A Donaghue KC Australasian Diabetes Data Network (ADDN) Study Group, the T1D Exchange Clinic Network (T1DX), and the German/Austrian/Luxembourgian Diabetes-Patienten-Verlaufsdokumentation (DPV) initiative
Five heterogeneous HbA1c trajectories from childhood to adulthood in youth with type 1 diabetes from three different continents: a group-based modeling approach
.
Pediatr Diabetes
2019
;
20
:
920
–
931
57.
Briganti EM Summers JC Fitzgerald ZA Lambers LNJ Cohen ND
Continuous subcutaneous insulin infusion can be used effectively and safely in older patients with type 1 diabetes: long-term follow-up
.
Diabetes Technol Ther
2018
;
20
:
783
–
786
58.
Matejko B Cyganek K Katra B
Insulin pump therapy is equally effective and safe in elderly and young type 1 diabetes patients
.
Rev Diabet Stud
2011
;
8
:
254
–
258
59.
Toschi E Munshi MN
Benefits and challenges of diabetes technology use in older adults
.
Endocrinol Metab Clin North Am
2020
;
49
:
57
–
67
60.
Clements MA Foster NC Maahs DM T1D Exchange Clinic Network
Hemoglobin A1c (HbA1c) changes over time among adolescent and young adult participants in the T1D Exchange clinic registry
.
Pediatr Diabetes
2016
;
17
:
327
–
336
61.
Mitchell K Johnson K Cullen K Lee MM Hardy OT
Parental mastery of continuous subcutaneous insulin infusion skills and glycemic control in youth with type 1 diabetes
.
Diabetes Technol Ther
2013
;
15
:
591
–
595
62.
Lyons SK Libman IM Sperling MA
Clinical review: diabetes in the adolescent: transitional issues
.
J Clin Endocrinol Metab
2013
;
98
:
4639
–
4645
63.
Leung JMWS Tang TS Lim CE Laffel LM Amed S
The four I’s of adolescent transition in type 1 diabetes care: a qualitative study
.
Diabet Med
2021
;
38
:
e14443
64.
Garg SK Rodbard D Hirsch IB Forlenza GP
Managing new-onset type 1 diabetes during the COVID-19 pandemic: challenges and opportunities
.
Diabetes Technol Ther
2020
;
22
:
431
–
439
65.
Bouchonville MF Paul MM Billings J Kirk JB Arora S
Taking telemedicine to the next level in diabetes population management: a review of the Endo ECHO Model
.
Curr Diab Rep
2016
;
16
:
96
66.
Scott SN Fontana FY Züger T Laimer M Stettler C
Use and perception of telemedicine in people with type 1 diabetes during the COVID-19 pandemic: results of a global survey
.
Endocrinol Diabetes Metab
2020
;
4
:
e00180
67.
Choudhary P Bellido V Graner M
The challenge of sustainable access to telemonitoring tools for people with diabetes in Europe: lessons from COVID-19 and beyond
.
Diabetes Ther
2021
;
12
:
2311
–
2327
68.
Spaans EAJM Kleefstra N Groenier KH Bilo HJG Brand PLP
Adherence to insulin pump treatment declines with increasing age in adolescents with type 1 diabetes mellitus
.
Acta Paediatr
2020
;
109
:
134
–
139
69.
Lawson ML Shephard AL Feenstra B Boland L Sourial N Stacey D
Decision coaching using a patient decision aid for youth and parents considering insulin delivery methods for type 1 diabetes: a pre/post study
.
BMC Pediatr
2020
;
20
:
1
70.
McGill DE Volkening LK Pober DM Muir AB Young-Hyman DL Laffel LM
Depressive symptoms at critical times in youth with type 1 diabetes: following type 1 diabetes diagnosis and insulin pump initiation
.
J Adolesc Health
2018
;
62
:
219
–
225
71.
Mueller-Godeffroy E Vonthein R Ludwig-Seibold C German Working Group for Pediatric Pump Therapy (agip)
Psychosocial benefits of insulin pump therapy in children with diabetes type 1 and their families: the Pumpkin multicenter randomized controlled trial
.
Pediatr Diabetes
2018
;
19
:
1471
–
1480
72.
Harris MA Wagner DV Heywood M Hoehn D Bahia H Spiro K
Youth repeatedly hospitalized for DKA: proof of concept for novel interventions in children’s healthcare (NICH)
.
Diabetes Care
2014
;
37
:
e125
–
e126
73.
O’Donnell HK Vigers T Johnson SB
Pump It Up! A randomized clinical trial to optimize insulin pump self-management behaviors in adolescents with type 1 diabetes
.
Contemp Clin Trials
2021
;
102
:
106279
74.
Wagner DV Barry SA Stoeckel M Teplitsky L Harris MA
NICH at its best for diabetes at its worst: texting teens and their caregivers for better outcomes
.
J Diabetes Sci Technol
2017
;
11
:
468
–
475
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2024
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