Diabetes-specific Care Research Articles

Transition From Childhood to Adult Care in Patients with Type 1 Diabetes: 20 Years of Experience From the Tübinger Transition Study.

Transition from pediatric to adult care is difficult for patients with chronic diseases. In this study, factors associated with metabolic control in childhood-onset type 1 diabetes (T1D) after transfer to adult care were analyzed. Overall, 224 persons with T1D were contacted yearly from 1998 to 2019. They voluntarily answered a questionnaire about their current hemoglobin A1c (HbA1c) levels, diabetes-associated complications, kind of care, living conditions, and family situation. Then, mixed longitudinal-cross-sectional analyses were carried out. Overall, 190 patients answered at least once (mean age: 26.6 years). Diabetes complications were mentioned by 10 patients (5 microalbuminuria, 5 retinopathy). Most patients (92.6%) were in diabetes-specific care during the first year after transfer, with a trend to leave diabetes-specific care during the observation period. Patients in diabetes-specific care displayed lower HbA1c levels (%/mmol/mol) (7.1/54 vs. 7.5/58). An important predictor for HbA1c after transfer was HbA1c during the year before transfer (r=0.67, p <0.001). Patients living alone showed no difference in HbA1c levels from those living with their parents. Married patients had lower HbA1c levels (7.0/53 vs. 7.3/56, p<0.05) than unmarried ones. Patients with children (15.8%) presented lower HbA1c levels (6.9/52 vs. 7.3/56, p <0.01) than those without. Good metabolic results are favored in patients followed-up in specialized care, are married, and are parents. We recommend transfer to a diabetologist with experience in T1D at an individual age.

Healthcare system’s preparedness to provide cardiovascular and diabetes-specific care in the context of geopolitical crises in Burkina Faso: a trend analysis from 2012 to 2018

ObjectiveThis study aimed to evaluate the trends of the availability and readiness of the healthcare system to provide cardiometabolic (cardiovascular diseases (CVD) and diabetes) services in Burkina Faso in multiple...

Psychosocial and Demographic Factors That Influence HbA1c Testing Frequency in Diabetics: Data From the 2018 Behavioral and Risk Factor Surveillance Survey (BRFSS).

Background HbA1c testing is an essential measure of glycemic control in diabetic patients. This study aims to determine the social and psychological determinants that have a role in the frequency of HbA1c testing in diabetics. Methods We used data from the Behavior and Risk Factor Surveillance Survey to develop a hierarchical linear regression model to examine associations between annual HbA1c testing frequency and the following types of variables: demographics, socioeconomic factors (SES), living environment, healthcare access, psychosocial factors, clinical factors, and diabetes self-care and knowledge. Results The study included 18,505 diabetics from the BRFSS 2018 dataset with a mean age of 61.2 years. There were significant associations between age, gender, race, insurance status, SES, healthcare access,psychosocial factors, and HbA1c testing frequency. Being American Indian or Alaskan Native was associated with increased HbA1c testing frequency compared to Whites, and non-Hispanics. Higher education/income was associated with increased HbA1c testing frequency. Regular doctor visits for diabetes were associated with increased HbA1c testing frequency. Conclusions In our analysis of a national survey, income, education level, and diabetes-specific care variables were significantly associated with the frequency of HbA1c testing. These results help identify patient groups that need more attention in managing diabetes, including the use of HbA1c testing.

Are depressive symptoms associated with quality of care in diabetes? Findings from a nationwide population-based study

IntroductionWe investigated whether the presence of depressive symptoms among adults with diagnosed diabetes is associated with adverse quality of diabetes care.Research design and methodsThe study population was drawn from the...

Care Team Integration in Primary Care Improves One-Year Clinical and Financial Outcomes in Diabetes: A Case for Value-Based Care.

Despite significant treatment advances, diabetes outcomes remain suboptimal and health care costs continue to rise. There are limited data on the feasibility and financial implications of integrating a diabetes-specific care team in the primary care setting (ie, where the majority of diabetes is treated). This pragmatic quality improvement project investigated whether a cardiometabolic care team intervention (CMC-TI) could achieve greater improvements in clinical, behavioral, and cost outcomes compared to usual diabetes care in a large primary care group in Southern California. Over 12 months, n = 236 CMC-TI and n = 239 usual care patients with type 1 or 2 diabetes were identified using the electronic medical record. In the CMC-TI group, a registered nurse (RN)/certified diabetes educator care manager, medical assistant health coach, and RN depression care manager utilized electronic medical record-based risk stratification reports, standardized decision-support tools, live and remote tailored treatments, and coaching to manage care. Results indicated that the CMC-TI group achieved greater improvements in glycemic and lipid control, diabetes self-management behaviors, and emotional distress over 1 year compared with the usual care group (all P < .05). The CMC-TI group also had a significant 12.6% reduction in total health care costs compared to a 51.7% increase in the usual care group during the same period and inclusive of CMC-TI program costs. Patients and providers reported high satisfaction with CMC-TI. These findings highlight that team-based care management interventions that utilize nurses, medical assistant health coaches, and behavioral specialists to support diabetes patients can help primary care practices achieve value-based targets of improved health, cost, and patient experience.

Effects of a diabetes-specific care model for hip fractured older patients with diabetes: A randomized controlled trial.

To examine the effects of a diabetes-specific care model for hip fractured elderly with diabetes mellitus (DM). A randomized controlled trial was implemented in a 3000-bed medical center in northern Taiwan. Older adults (age ≥ 60) with DM who had hip-fracture surgery (N = 176) were recruited and randomly assigned to diabetes-specific care (n = 88) and usual care (n = 88). Usual care entailed one or two in-hospital rehabilitation sessions. Diabetes-specific care comprised an interdisciplinary care (including geriatric consultation, discharge planning, and in-home rehabilitation) and diabetes-specific care (including dietary and diabetes education, blood pressure control, dyslipidemia management, a glycemic treatment regimen, and rehabilitation exercises). Outcomes including heart rate variability; rehabilitation outcomes; activities of daily living and instrumental activities of daily living were assessed before discharge and 1, 3, 6, 12, 18, 24 months afterwards. Patients who received diabetes-specific care had significantly higher hip-flexion range of motion (b = 5.24, p < .01), peak-force quadriceps strength of the affected limb (b = 2.13, p < .05), higher total heart rate variability in terms of the time-domain parameter for the mean squared difference between two adjacent normal R-R intervals (b = 11.35, p < .05), and frequency-domain parameters, such as low frequency (b = 42.17, p < .05), and the high frequency-to-low frequency ratio (b = 0.11, p < .01). Our diabetes-specific care model enhanced hip-flexion range of motion, peak quadriceps strength of the affected limb, and overall heart rate variability, indicating dynamic responses to environmental changes during the 24 months following hospital discharge, above and beyond the effects of usual care.

Diabetes Distress: Assessment and Management of the Emotional Aspect of Diabetes Mellitus

Management of diabetes is well known to be a complex endeavor with many physical and psychological implications. Historically, primary focus has been on the physical complications of diabetes, with little attention being placed on the psychological repercussions. Patients with diabetes deal with intense psychological complications secondary to diabetes management, termed diabetes distress. Although related to emotions, this phenomenon differs from depression or anxiety. Management of diabetes distress includes a psychological approach with diabetes-specific care. Person-centered and positive strength-based language help build the clinician-patient relationship. Diabetes distress care is part of comprehensive diabetes management.

803-P: Modifiable Diabetes-Specific Factors and Glycemic Control in Economically Vulnerable and Racial/Ethnic Minority Young Adults with Type 1 Diabetes

Minority and socioeconomic disparity in glycemic control exists in young adults (YA) with type 1 diabetes (T1D). The contribution of social determinants of health versus diabetes-specific clinical care factors to these disparities remains unclear. We administered a survey on demographics, clinical factors, self-management, and social determinants to non-Hispanic black (NHB), Hispanic, and non-Hispanic white (NHW) YA from 6 centers in the T1D Exchange. We examined bivariate associations of variables with A1c and added significant factors to a linear regression model in sequential groups. A1c disparity was the outcome. We adjusted models for race-ethnicity, age, gender, and T1D duration. We recruited 300 YA (97 NHB, 103 Hispanic, 100 NHW) with mean age of 21±2 years and T1D duration of 11±5 years. NHB but not Hispanic YA had higher A1c vs. NHW (p&amp;lt;0.001) (NHB 10.5%, Hispanic 8.6%, NHW 8.1%). Only lower education attainment, lower pump use, receiving care in an adult system, and worse self-management were associated with A1c in the final model (Table 1), explaining 31% of the variance in A1c. Few social determinants were associated with A1c once examined with diabetes care factors. While social factors should be considered in the care of vulnerable YA, clinicians should continue to emphasize diabetes self-management and technology treatment options. Disclosure S. Agarwal: None. L. Kanapka: None. J. Raymond: Other Relationship; Self; Insulet Corporation. A.F. Walker: None. A. Gerard Gonzalez: None. D.F. Kruger: Advisory Panel; Self; Abbott, Boehringer Ingelheim Pharmaceuticals, Inc., Insulet Corporation. Consultant; Self; CeQur Corporation, Hygieia. Speaker's Bureau; Self; AstraZeneca, Dexcom, Inc., Eli Lilly and Company. Stock/Shareholder; Self; Dexcom, Inc. Other Relationship; Self; Novo Nordisk Inc. M.J. Redondo: None. M.R. Rickels: None. V.N. Shah: Advisory Panel; Self; Sanofi US. Consultant; Self; Dexcom, Inc. A. Butler: None. V. Miller: None. A. Verdejo: None. R.L. Gal: None. S.M. Willi: Advisory Panel; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Roche Diagnostic USA. Research Support; Self; Jaeb Center for Health Research, National Institute of Allergy and Infectious Diseases, Sanofi-Aventis. Other Relationship; Self; National Institute of Diabetes and Digestive and Kidney Diseases. J.A. Long: None. Funding The Leona M. and Harry B. Helmsley Charitable Trust; National Institute of Diabetes and Digestive and Kidney Diseases

1298-P: Unique Patterns of Racial/Ethnic Disparities among Vulnerable Young Adults with Type 1 Diabetes

Young adults (YA) with type 1 diabetes (T1D) are vulnerable to short and long-term complications as they incorporate disease self-management into the transition to adulthood. Relationships between race-ethnicity and socioeconomic status (SES) have not been examined in this population, despite poorer outcomes in minority and low SES subgroups. We administered a survey on demographics, clinical factors, self-management, and social determinants of health to non-Hispanic black (NHB), Hispanic, and non-Hispanic white (NHW) YA from 6 centers in the T1D Exchange. We compared survey responses and diabetes outcomes among the racial-ethnic groups using Fisher’s exact test or Wilcoxon rank-sum test, as appropriate. Participants (97 NHB, 103 Hispanic, 100 NHW) had a mean age of 21±2 years and T1D duration of 11±5 years. Low SES was more common in NHB and Hispanic vs. NHW YA (Medicaid 57% and 76% vs. 22%; high school education or less 66% and 70% vs. 24%, respectively; p&amp;lt;0.001). NHB and Hispanic YA had lower use of continuous glucose monitors (28% and 37%) and insulin pumps (18% and 39%) vs. NHW (71% and 72%) (p&amp;lt;0.001). Non-Hispanic black, but not Hispanic, YA had higher food insecurity, poorer self-management, greater diabetes-related distress, and more adverse childhood experiences than NHW (all p&amp;lt;0.001). NHB also had higher A1c levels (NHB 10.5%, Hispanic 8.6%, NHW 8.1%) and higher diabetes-specific health care utilization, with 46% of NHB having ≥1 hospital or ER admission in the past year vs. 17% and 12% in Hispanic and NHW (p&amp;lt;0.001 for NHB vs. NHW). Non-Hispanic black and Hispanic YA with T1D face similar economic disadvantages, yet NHB YA exhibit poorer glycemic control and higher acute healthcare utilization than Hispanic YA. NHB differed from Hispanic YA on self-management, psychosocial factors, and adverse childhood experiences. Factors contributing to these disparities (e.g., healthcare system interactions, cultural differences) should be explored to design effective interventions. Disclosure S. Agarwal: None. L. Kanapka: None. J. Raymond: Other Relationship; Self; Insulet Corporation. A.F. Walker: None. A. Gerard Gonzalez: None. D.F. Kruger: Advisory Panel; Self; Abbott, Boehringer Ingelheim Pharmaceuticals, Inc., Insulet Corporation. Consultant; Self; CeQur Corporation, Hygieia. Speaker's Bureau; Self; AstraZeneca, Dexcom, Inc., Eli Lilly and Company. Stock/Shareholder; Self; Dexcom, Inc. Other Relationship; Self; Novo Nordisk Inc. M.J. Redondo: None. M.R. Rickels: None. V.N. Shah: Advisory Panel; Self; Sanofi US. Consultant; Self; Dexcom, Inc. A. Butler: None. V. Miller: None. R.L. Gal: None. S.M. Willi: Advisory Panel; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Roche Diagnostic USA. Research Support; Self; Jaeb Center for Health Research, National Institute of Allergy and Infectious Diseases, Sanofi-Aventis. Other Relationship; Self; National Institute of Diabetes and Digestive and Kidney Diseases. J.A. Long: None. Funding The Leona M. and Harry B. Helmsley Charitable Trust; National Institute of Diabetes and Digestive and Kidney Diseases

The impact of concordant and discordant comorbidities on patient‐assessed quality of diabetes care

To examine the impact of concordant and discordant comorbidities on patients' assessments of providers' adherence to diabetes-specific care guidelines and quality of chronic illness care. A population-based survey of 3761 adults with type 2 diabetes, living in Queensland, Australia was conducted in 2008. Based on self-reports, participants were grouped into four mutually exclusive comorbid categories: none, concordant only, discordant only and both concordant and discordant. Outcome measures included patient-reported providers' adherence to guideline-recommended care and the Patient Assessment of Chronic Illness Care (PACIC), which measures care according to the Chronic Care Model. Analyses using the former measure included logistic regressions, and the latter measure included univariate analysis of variance, both unadjusted and adjusted for sampling region, gender, age, educational attainment, diabetes duration and treatment status. Having concordant comorbidities increased the odds of patient-reported providers' adherence for 7 of the 11 guideline-recommended care activities in unadjusted analyses. However, the effect remained significant for only two provider activities (reviews of medication and/or complications and blood pressure examinations) when adjusted. A similar pattern was found for the both concordant and discordant comorbidity category. The presence of discordant comorbidities influenced only one provider activity (blood pressure examinations). No association between comorbidity type and the overall PACIC score was found. Comorbidity type is associated with diabetes-specific care, but does not seem to influence broader aspects of chronic illness care directly. Providers need to place more emphasis on care activities which are not comorbidity-specific and thus transferable across different chronic conditions.

Prioritization of care in adults with diabetes and comorbidity.

Approximately half of adults with diabetes have at least one comorbid condition. However, diabetes care guidelines focus on diabetes-specific care, and their recommendations may not be appropriate for many patients with diabetes and comorbidity. We describe Piette and Kerr's typology of comorbid conditions, which categorizes conditions based on if they are clinically dominant (eclipse diabetes management), symptomatic versus asymptomatic, and concordant (similar pathophysiologic processes as diabetes) versus discordant. We integrate this typology with clinical evidence and shared decision-making methods to create an algorithmic approach to prioritizing care in patients with diabetes and comorbidity. Initial steps are determining the patient's goals of care and preferences for treatment, whether there is a clinically dominant condition or inadequately treated symptomatic condition, and the risk of cardiovascular disease. With these data in hand, the clinician and patient prioritize diabetes treatments during a shared decision-making process. These steps should be repeated, especially when the patient's clinical status changes. This patient-centered process emphasizes overall quality of life and functioning rather than a narrow focus on diabetes.

Usual Source of Care as a Health Insurance Substitute for U.S. Adults With Diabetes?

OBJECTIVEThe purpose of this study was to examine the effects of health insurance and/or a usual source of care (USC) on receipt of diabetic-specific services and health care barriers for U.S. adults with diabetes.RESEARCH DESIGN AND METHODSSecondary analyses of data from 6,562 diabetic individuals aged ≥18 years from the nationally representative Medical Expenditure Panel Survey from 2002 to 2005 were performed. Outcome measures included receipt of seven diabetic services plus five barriers to care.RESULTSMore than 84% of diabetic individuals in the U.S. had full-year coverage and a USC; 2.3% had neither one. In multivariate analyses, the uninsured with no USC had one-fifth the odds of receiving A1C screening (odds ratio 0.23 [95% CI 0.14–0.38]) and one-tenth the odds of a blood pressure check (0.08 [0.05–0.15]), compared with insured diabetic individuals with a USC. Similarly, being uninsured without a USC was associated with 5.5 times the likelihood of unmet medical needs (5.51 [3.49–8.70]) and three times more delayed urgent care (3.13 [1.53–6.38]) compared with being insured with a USC. Among the two groups with either insurance or a USC, diabetic individuals with only a USC had rates of diabetes-specific care more similar to those of insured individuals with a USC. In contrast, those with only insurance were closer to the reference group with fewer barriers to care.CONCLUSIONSInsured diabetic individuals with a USC were better off than those with only a USC, only insurance, or neither one. Policy reforms must target both the financing and the delivery systems to achieve increased receipt of diabetes services and decreased barriers to care.

Integrating systematic chronic care for diabetes into an academic general internal medicine resident-faculty practice.

The quality of care for diabetes continues to fall short of recommended guidelines and results. Models for improving the care of chronic illnesses advocate a multidisciplinary team approach. Yet little is known about the effectiveness of such models in an academic setting with a diverse patient population and resident physicians participating in clinical care. To implement a chronic illness management (CIM) practice within an academic setting with part-time providers, and evaluate its impact on the completion of diabetes-specific care processes and on the achievement of recommended outcomes for patients with diabetes mellitus. Retrospective cohort study Patients with the diagnosis of diabetes mellitus who receive their primary care in an academic general internal medicine resident-faculty practice. Process and outcomes measures in patients exposed to the CIM practice were compared with non-exposed patients receiving usual care. Five hundred and sixty-five patients met inclusion criteria. Patients in the CIM practice experienced a significant increase in completion of care processes compared to control patients for measurement of annual low-density lipoprotein (LDL) cholesterol (OR 3.1, 95% CI 1.7-5.7), urine microalbumin (OR 3.3, 95% CI 2.1-5.5), blood pressure (OR 1.8, 95% CI 1.1-2.8), retinal examination (OR 1.9, 95% CI 1.3-2.7), foot monofilament examination (OR 4.2, 95% CI 3.0-6.1) and administration of pneumococcal vaccination (OR 5.2, 95% CI 3.0-9.3). CIM-exposed patients were also more likely to achieve improvements in clinical outcomes of glycemic and blood pressure control reflected by hemoglobin A1c less than 7.0% (OR 1.7, 95% CI 1.02-3) and blood pressure less than 130/80 (OR 2.8, 95% CI 2.1-4.5) compared to controls. A systematic chronic care model can be successfully integrated into an academic general internal medicine practice and may result in improved processes of care and some clinical outcomes for diabetic patients. This study provides a model for further hypothesis generation and more rigorous testing of the quality benefits of structured chronic illness care in diverse outpatient practices.

A Medical Home for Children With Insulin-Dependent Diabetes: Comanagement by Primary and Subspecialty Physicians—Convergence and Divergence of Opinions

The purpose of this work was to examine pediatricians' and endocrinologists' views about management for routine preventive and acute care, diabetes-specific care, and family education and care coordination for children with insulin-dependent diabetes. We conducted a mixed-mode survey of all of the pediatricians in 1 medicaid managed care network and all of the pediatric and adult endocrinologists who treat children with diabetes in North Carolina. Of the 201 pediatricians surveyed, 132 responded (65%). Among the 61 endocrinologists who treat children, 59% replied. Nearly all of the respondents agreed that primary care physicians should have responsibility for routine primary care (eg, well-child checkups, treating minor illnesses or injuries, and immunizations). Likewise, large majorities favored endocrinologists as leads for diabetes-specific care (eg, 94% for training in use of an insulin pump and 82% for training in use of a glucometer). Many generalists and subspecialists reported that specific aspects of diabetes care should be comanaged (eg, 31% for tracking of hemoglobin A1c). However, large proportions of pediatricians and endocrinologists expressed differing opinions about the primary responsibility for family education and care coordination and for specific diabetes services. For example, 80% of endocrinologists saw subspecialists as leads for monitoring blood sugar levels, whereas 52% of pediatricians favored comanagement. An effective medical home model of care depends on establishing clear lines of responsibility between the primary care physician and subspecialist. Our findings suggest that primary care physicians and subspecialists agree on who should lead most aspects of care for patients with insulin-dependent diabetes and that some aspects of care should be comanaged. However, primary care physicians and subspecialists did not agree either between or within disciplines on who should be more responsible for the basic aspect of monitoring of blood sugar levels. Approaches that recognize the appropriate division of care between primary care physicians and subspecialists, facilitate comanagement when it is needed, and reward the collaboration required to provide medical homes for patients should be investigated as models of care.

Comparison of Preventive Care Provided to Dialysis Patients by Nephrologists and to Patients Followed in General Medical Clinics: Compliance with American College of Physicians Guidelines

Most end-stage renal disease (ESRD) patients do not have primary-care providers, and preventive medicine often is provided by their nephrologists. Little has been written about their success in providing this care. We studied all patients on dialysis at our hospital and compared their preventive care to a control group followed in the general medical clinic. The general medical group showed higher compliance with Pap smears (89% vs 48%), mammography (87% vs 62%), fecal occult blood testing (75% vs 50%), and pneumococcal vaccination (55% vs 28%). The ESRD group had better compliance with influenza vaccination (70% vs 55%) and lipid profile (100% vs 75%). When the subgroup of patients on hemodialysis (HD) was compared with patients on peritoneal dialysis (PD), it was shown that HD patients were more likely than PD patients to receive preventive care. We also compared diabetes-specific care. The ESRD group had a higher rate of HbA 1C (100% vs 78%) and lipid monitoring (100% vs 76%), diabetes education (100% vs 84%), and podiatry visits (70% vs 38%). There was no difference in ophthalmologic examination or influenza vaccination. We found that nephrologists provide preventive care to ESRD patients with success approximately equal to primary-care physicians in our institution, although in different parameters. Ready access to dialysis patients and their blood and unit-specific policies contribute to compliance that is above national averages. Further improvements can be made by additional preventative measures policies, by physician and patient education, and by monitoring primary-care compliance in the chart.

The care of older persons with diabetes mellitus: families and primary care physicians.

To determine the extent to which family members participate in the day-to-day management of diabetes mellitus in older persons, and in older diabetics' medical encounters, and to identify patient and family member characteristics associated with this participation. A longitudinal observational study, with baseline data being reported herein. Three primary care practice settings in Seattle, Washington, Boston, Massachusetts, and Indianapolis, Indiana. Family members of patients 70 years of age or older participating in the Patient Outcomes Research Team (PORT) Study of type II diabetics. The two dependent variables represent, respectively, the extent of family members' assistance with diabetes-related care and participation in older diabetics' medical encounters. The 357 family members enrolled were older (mean age = 66.3 years), were mostly women (76.2%), and were usually the spouses of diabetic patients (71.3%). Between 22% and 50% of family members reported helping with various aspects of diabetes care; 35.6% of family members participated regularly in their diabetic patients' medical encounters. A multiple linear regression model relating family assistance with diabetes-related care to patient and family member characteristics included four variables: patients' physical function, and the family member's relationship to the patient, assistance with basic activities of daily living (ADLs), and understanding of diabetes management issues (all P < .05). A multiple logistic regression model relating family member participation in the medical encounter to patient and family member characteristics also included four variables: patient age and physical function, and family member assistance with instrumental activities of daily living (IADLs) and with diabetes-related care (all P < .05). The family members studied frequently assisted older diabetics with diabetes-specific care; more than one-third were regular participants in older diabetics' medical encounters. Family member involvement in the day-to-day management of diabetes and in the medical encounter was more likely when patients were functionally disabled. Health care systems and physicians need to educate their older patients, and involved family members when patients are frail, about diabetes-related care issues and support them in their roles in the management of diabetes as well as other chronic diseases.

Management of diabetes in pediatric resident continuity clinics.

General pediatricians provide comprehensive care for many children with insulin-dependent diabetes mellitus. To assess and improve our ambulatory training program, we first evaluated diabetes-specific care behaviors by residents in their continuity clinics and then introduced a structured visit encounter form. Based on established guidelines provided to the residents, a chart audit indicated appropriate measurement of glycosylated hemoglobin 40% of the time, cholesterol 90% of the time, urine protein 50% of the time, and thyroxine 66.7% of the time. Height was plotted 23% of the time, blood pressure was noted 66% of the time, and ophthalmologic referrals were documented 60% of the time. Requests for assistance from nonphysician members of a multidisciplinary diabetes team were minimal. After introduction of the structured visit encounter form, care behaviors did not improve. New training approaches to prepare general pediatric residents to provide excellent diabetes care are needed.