Endocrinology Providers Research Articles

8757 Contingency Planning in the Event of Insulin Pump Failure or Malfunction - a Quality Improvement Initiative

Abstract Disclosure: S. Avula: None. H. Hashmi: None. A.R. Ankireddypalli: None. S. Inkollu: None. M. Salim: None. A. Ahmed: None. J. Kohlenberg: None. T. Harindhanavudhi: None. Background: People using insulin pump therapy are at risk of adverse outcomes, including hyperglycemia and diabetic ketoacidosis, in the event of pump failure or malfunction. A standing prescription for subcutaneous basal insulin, which can be filled as needed, has the potential to prevent these adverse outcomes. Aim: We aimed to increase the percentage of standing prescriptions for subcutaneous basal insulin by 20 % over 6-month duration for people using insulin pump therapy. Methods: Pre-intervention: We retrospectively obtained baseline electronic health record data for people with diabetes on insulin pump therapy in our health system (M Health Fairview, University of Minnesota) from January 1, 2022, to December 31, 2022. Intervention: Over a six-month duration, a multifaceted intervention was implemented. (1) During the rooming process for endocrinology appointments, the medical assistants inquired if the person using insulin pump therapy had a standing prescription for basal insulin in the event of insulin pump failure or malfunction. If not, the medical assistant encouraged the person with diabetes to review this with their Endocrinologist. (2) Informational brochures, placed in the exam rooms, encouraged people using insulin pump therapy to discuss a standing order for basal insulin. (3) Emails were sent to all endocrinology providers to encourage discussion of the provision of a standing prescription for basal insulin for people on insulin pump therapy. Post - intervention: We recorded the number of people with a standing prescription for subcutaneous basal insulin from 5/1/2023 to 5/14/2023. Results: The total number of patients with diabetes on insulin pumps prior to the intervention was 256. Of 256 patients with insulin pump therapy, 109 patients (42.6%) had standing basal insulin prescribed. A post-intervention chart review of patients with diabetes on an insulin pump was conducted for a total of 69 patients, of which 56 patients (81.2%) had backup basal insulin prescribed. The estimation of difference was - 0.3858 (p= <0.05; 95% CI for difference -0.4961, -0.2754). Conclusion: This multipronged approach increased the prescription availability and awareness among providers and patients for a standing order of basal insulin in the event of insulin pump failure or malfunction from 42% to 81%. Limitations of this study include the limited duration of intervention and the need to send repeated reminders to all providers, including clinic staff. The next plan is to create a best practice alert in EMR to alert providers to have a backup basal insulin plan for anyone on an insulin pump. Create a custom dot phrase of insulin backup plan in EMR. Presentation: 6/3/2024

No Association Between Medicare Advantage Providers' Network Restrictiveness and Star Rating Between 2013 and 2017: An Observational Study.

Medicare beneficiaries are increasingly enrolling in Medicare Advantage (MA), which employs a wide range of practices around restriction of the networks of providers that beneficiaries visit. Though Medicare beneficiaries highly value provider choice, it is unknown whether the MA contract quality metrics which beneficiaries use to inform their contract selection capture the restrictiveness of contracts' provider networks. We evaluated whether there are meaningful associations between provider network restrictiveness (across primary care, psychiatry, and endocrinology providers) and contracts' overall star quality rating, as well as between network restrictiveness and contracts' performance on access to care measures from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. Medicare Advantage contracts with health maintenance organization (HMO), local preferred provider organization (PPO), and point of service (POS) plans with available data. A cross-sectional analysis using multivariable linear regressions to assess the relationship between provider network restrictiveness and contract quality scores in 2013 through 2017. Statistical significance in the relationship between network restrictiveness and contract performance on quality measures. Across all study years, we included 562 unique contracts and 2801 contract-years. We find no evidence of consistent relationships between MA physician network restrictiveness and contract star rating. For primary care, psychiatry, and endocrinology, respectively, a 10 percentage point increase in restrictiveness was associated with a 0.02 (95% confidence interval [CI] -0.01 to 0.04), 0.0008 (95% CI, -0.01 to 0.02), and -0.01 (95% CI, -0.01 to 0.001) difference in star rating (p-value > 0.05 for all). Similarly, we find no evidence of consistent relationships between network restrictiveness and access to care measures. Our findings suggest that existing MA contract quality measures are not useful for indicating differences in network restrictiveness. Given the importance of provider choice to beneficiaries, more specific metrics may be needed to facilitate informed decisions about MA coverage.

Understanding Providers' Readiness and Attitudes Toward Autoantibody Screening: A Mixed-Methods Study.

Screening for autoantibodies associated with type 1 diabetes can identify people most at risk for progressing to clinical type 1 diabetes and provide an opportunity for early intervention. Drawbacks and barriers to screening exist, and concerns arise, as methods for disease prevention are limited and no cure exists today. The availability of novel treatment options such as teplizumab to delay progression to clinical type 1 diabetes in high-risk individuals has led to the reassessment of screening programs. This study explored awareness, readiness, and attitudes of endocrinology providers toward type 1 diabetes autoantibody screening.

A-090 Impact of Changing Total Calcium Methodology on Observed Hypercalcemia Prevalence at an Academic Health System

Abstract Background The UC Davis Health clinical chemistry laboratory implemented a new total laboratory automation (Roche Diagnostics, Indianapolis, IN) system in February 2022—replacing a prior system (Beckman Coulter, Brea, CA) that was in place since 2007. In August 2022, primary care and endocrinology providers contacted laboratory leadership to report an increase in patients with calcium values flagged as abnormally elevated, resulting in increased communications from patients to primary care providers and increased referrals to endocrinology. This change in testing methodology produced a shift in the upper reference interval limit from 10.5 mg/dL to 10.0 mg/dL. The new testing methodology determined total calcium photometrically vs by indirect potentiometry via the outgoing method. We hypothesize photometric-based total calcium measurements to be more sensitive. Methods We conducted a retrospective study to investigate the reported increase in hypercalcemic values—our electronic health system’s (EHR) EPIC’s self-service reporting tool (“SlicerDicer”) was utilized for data acquisition and visualization. Although the reference interval had already been verified prior to implementation, a “normal study” study was conducted to re-confirm manufacturer derived intervals. One hundred thirty-six samples from apparently healthy adults (age ≥ 18 years) were banked for this study. Parathyroid hormone (PTH) values were then measured to confirm levels were within normal limits. Additional observational data was also collected for PTH levels pre- and post-new automation line implementation. Quality control (QC) and proficiency testing (PT) data was also reviewed during this time. Results In the four months preceding implementation of the new automation line, 1211 patients had total calcium values flagged as elevated, compared to 5146 patients during a similar post implementation time period (302.8/month vs 1286.5/month), or an increase of 324.9%. During these same time periods, patients with abnormal PTH were observed at 270.8/month pre-implementation compared to 393/month post (45.2% increase). An increase in patients with concurrently performed calcium and PTH was also observed (30.3%; 583.8/month vs 760.8/month), though a greater increase was seen in patients with concurrently elevated calcium and abnormal PTH (294.5%; 22.8/month vs 89.8/month). One hundred twenty samples with normal PTH values were included in the total calcium normal study, which reported a mean (SD) value of 9.3 (0.33) mg/dL, confirming the manufacturer-derived intervals of 8.7–10 mg/dL. No biases, shifts, or trends were observed in PT or QC data in the four months preceding and post analyzer change. Conclusion Increased hypercalcemic events post-automation line implementation is likely not due to analytical error or inappropriate reference intervals, but rather due to increased sensitivity of methodology. Hypercalcemic cases determined by our new methodology were corroborated by corresponding abnormal PTH values. The perceived increased sensitivity could be due to known limitations of indirect potentiometry (i.e., lack of selectivity, difficulty detecting all forms of calcium, etc.). Further investigation is warranted to determine the overall impact of changing this one assay on the health system.

A system approach to improving guideline-directed therapy for cardio-renal-metabolic conditions: The “beyond diabetes” initiative

ObjectiveDespite demonstrating improvements in cardiovascular disease, kidney disease, and survival outcomes, guideline-directed antihyperglycemic medications such as sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like-peptide-1 receptor agonists (GLP1-RA), are underutilized. Many obstacles constrain their use including lack of systematic provider and patient education, concern for medication side effects, and patient affordability. MethodsWe designed a multimodality, systems-based approach to address these challenges with the goal of increasing medication utilization across the largest healthcare system in New York State. This multispecialty collaborative included provider and patient education, an electronic health record-enabled platform to identify eligible patients, and access to pharmacists for medication guidance and addressing insurance coverage barriers. Surveys were administered following grand rounds lectures and knowledge-based questionnaires were given before and after case-based sessions for housestaff, with results analyzed using a two-sided Student's t-test. Rates of first prescriptions of SGLT2i/GLP1-RA in combined and individual analyses were compared between the pre- and post-education periods (6 months prior to 3/31/2021 and 6 months post 8/19/2021), and the change in prescriptions per 100 eligible-visits was assessed using the incidence density approach. ResultsAmong grand rounds participants, 69.3% of respondents said they would make changes to their clinical practice. Knowledge increased by 14.7% (p-value <0.001) among housestaff following case-based sessions. An increase in SGLT2i/GLP1-RA prescribing was noted for eligible patients among internal medicine, cardiology, nephrology, and endocrinology providers, from 11.9 per 100 eligible visits in the pre-education period to 14.8 in the post-education period (absolute increase 2.9 [24.4%], incidence risk ratio 1.24 [95% CI 1.18–1.31]; p-value <0.001). Increases in prescribing rates were also seen among individual medical specialties. ConclusionsOur “Beyond Diabetes” initiative showed an improvement in provider knowledge-base and was associated with a modest, but statistically significant increase in the use of SGLT2i and GLP1-RA throughout our healthcare system.

Going into town or staying home: Rural patient experience and preference with home-based versus clinic-based telehealth.

Telehealth is a model of care with potential to improve access, and in turn outcomes, for people living in rural areas. Since 2013, our endocrine clinic-based telehealth program has provided care at rural community hospitals in Nebraska and Iowa. At the start of the COVID-19 pandemic, when regulations around telehealth were adjusted, patients previously seen via clinic-based telehealth had the option to continue clinic-based visits or have a home-based telehealth visit. There is no literature comparing patient experiences between home-based and clinic-based telehealth. The purpose of this study was to understand rural patient preferences regarding endocrinology home-based versus clinic-based telehealth visits. This was a survey study of adult, rural patients who experienced both a clinic-based and home-based telehealth visit with their established endocrinology provider. Respondents were asked about demographics, their reason for visit, preference for home versus clinic-based telehealth, and how they would have received care if telehealth were not an option. Forty-two patients (40.8%) responded to the survey, with 27 patients (64.3%) preferring home-based telehealth. There were no significant differences between the groups. However, 47.5% of patients would not have sought specialty care if telehealth were not an option. This survey of endocrine patients experienced in both clinic-based and home-based telehealth indicates that, while most respondents preferred home-based telehealth, there are distinct advantages to each model and patients appreciate having options. We believe it is important to maintain both lines of service to provide patient-centered care and improve access to specialty care.

Exploring the Impact of Legislation Aiming to Ban Gender-Affirming Care on Pediatric Endocrine Providers: A Mixed-Methods Analysis.

Access to gender-affirming medical care is associated with better mental health outcomes in transgender and gender diverse youth. In 2021 and 2022, legislation aiming to ban gender-affirming medical care for youth was proposed in 24 states. This study aimed to (1) assess the impact of this legislation on pediatric providers based on legislative status of their state of practice and (2) identify the themes of concerns reported by them. A mixed-methods study was conducted via an anonymous survey distributed to pediatric endocrinology providers. Survey responses were stratified based on US state of practice, with attention to whether legislation aiming to ban gender-affirming care had been considered. Data were analyzed both quantitatively and qualitatively. Of 223 respondents, 125 (56.0%) were currently providing gender-affirming medical care. A total of 103 (45.7%) respondents practiced in a state where legislation aiming to ban gender-affirming care had been proposed and/or passed between January 2021 to June 2022. Practicing in legislation-affected states was associated with negative experiences for providers including (1) institutional pressure that would limit the ability to provide care, (2) threats to personal safety, (3) concerns about legal action being taken against them, (4) concerns about their career, and (5) institutional concerns about engagement with media. Major qualitative themes emerging for providers in legislation-affected states included safety concerns and the impact of laws on medical practice. This study suggests that legislation aiming to ban health care for transgender youth may decrease access to qualified providers in affected states.

1042-P: Qualitative Study—Provider Awareness and Attitudes towards Type 1 Diabetes Antibody Screening

Background: This study explores awareness and attitudes of endocrinology providers toward type 1 diabetes (T1D) autoantibody screening and identifies perceived benefits and barriers to screening. Methods: Three focus groups were conducted with thirteen eligible endocrinology providers recruited from the T1D Exchange Quality Improvement Collaborative. Focus groups were transcribed, coded, and analyzed using NVivo qualitative software. A force field analysis was conducted, analyzing high, medium, and low impact forces that were identified in the study. Results: All providers considered themselves “pro-screening” and comfortable discussing autoantibody screening with patients. High impact driving forces included early diabetes management, DKA prevention at diagnosis, and clinical guidance and diagnosing abilities. Medium and low impact forces included awareness and clarity of diagnosis, opportunity to get involved in research, and results for insurance approval. High impact restraining forces included anxiety of diagnosis for patients and family members, cost of screening, and staffing or clinic limitations. Medium and low impact forces included time and coordination for patients and families, mildly invasive procedure, and insurance coverage. Conclusion: Findings highlight perceived benefits and barriers to autoantibody screening, illustrating provider insight and awareness. Disclosure E.L.Ospelt: None. K.Obrynba: None. O.Ebekozien: Advisory Panel; Medtronic, Research Support; Eli Lilly and Company, Dexcom, Inc. H.Hardison: None. N.Rioles: None. N.Noor: None. G.Nelson: None. C.J.Levy: Advisory Panel; Dexcom, Inc., Research Support; Abbott Diabetes, Dexcom, Inc., Insulet Corporation, Tandem Diabetes Care, Inc., T1D Exchange. A.M.Mckee: Advisory Panel; Medtronic, Novo Nordisk. Z.Antal: None. J.C.Wong: Research Support; Dexcom, Inc., Tandem Diabetes Care, Inc.

1290-P: Diabetes Provider Perceptions of Barriers and Benefits to Type 1 Diabetes Autoantibody Screening among Patients and Relatives

Background: This study highlights perceived benefits and barriers to type 1 diabetes (T1D) autoantibody screening rates in U.S. endocrinology practices. Methods: Fifty eligible endocrinology providers participated in a 15-question survey distributed via Qualtrics. Participants were recruited from the T1D Exchange Quality Improvement Collaborative. Data was cleaned, sorted, and analyzed. Summary statistics, including frequencies and proportions for categorical variables were evaluated and plotted using bar charts. z Results: Overall, 82% of providers stated interest towards autoantibody screening in their clinics. The following were ranked as benefits of autoantibody screening: opportunity for early diabetes management (90%), enrollment in research projects (84%), clinical guidance and diagnosing abilities (80%), and DKA prevention at diagnosis (76%). Providers identified multiple barriers to autoantibody screening in clinical practice including the associated cost and anxiety for patients, as well as limited staff time and resources (Figures 1, 2). Conclusion: The majority of surveyed providers feel confident recommending autoantibody screening for patients and those at risk for diabetes. However, clinic limitations exist that may affect the feasibility of this in practice. These barriers should be targeted with specific interventions moving forward. Disclosure E.L.Ospelt: None. C.Sullivan: None. S.Majidi: None. I.Lorincz: None. O.Ebekozien: Advisory Panel; Medtronic, Research Support; Eli Lilly and Company, Dexcom, Inc. H.Hardison: None. N.Rioles: None. N.Noor: None. S.Crossen: None. A.Smego: None. G.Aleppo: Advisory Panel; Medscape, Consultant; Bayer Inc., Insulet Corporation, Research Support; Dexcom, Inc., Eli Lilly and Company, Emmes, Insulet Corporation, Fractyl Health, Inc., WellDoc, Speaker's Bureau; Dexcom, Inc. J.Friedman: None. D.Eng: None.

Diagnosis of adrenal insufficiency in children: a survey among pediatric endocrinologists in North America.

Adrenal insufficiency (AI) is a life-threatening condition where an accurate diagnosis is critical. While the ACTH stimulation test is the diagnostic test of choice, there remains uncertainty around its protocols and interpretation of results. In this context, the objective of this study was to understand practices of North American pediatric endocrinology providers on the diagnosis of AI in children. An anonymous electronic survey was sent to members of the Pediatric Endocrine Society. A total of 221 participants were included. The majority practiced in academic centers (78%). All respondents ordered ACTH stimulation tests. While 85% used high-dose ACTH stimulation tests (HDST) to diagnose primary AI, there was less consistency in the choice of tests (HDST vs. low-dose ACTH stimulation test; LDST) when diagnosing secondary AI. When interpreting results, 95% used peak cortisol levels, 70% considered the clinical picture, and 49% used relative increase in cortisol levels. Median (IQR) cortisol cutoff level after ACTH stimulation test that was considered sufficient was 18 (15.5-18) μg/L [496 (428-496) nmol/L]; 17% used different cutoffs for LDST, and 18% used different cutoffs for newborns. Finally, 47% were unaware of the assay that was used in their institution for cortisol measurements. Pediatric endocrinology providers use ACTH stimulation tests variably, including in the choice between HDST vs. LDST, test protocols, and interpretation of results.

ODP176 Delivery of Type 2 Diabetes Care Using Telemedicine: Provider Experiences and Perspectives

Abstract Background During the COVID- 19 pandemic, the use of telemedicine (virtual synchronous visits via phone or video format) to deliver health care increased significantly. Objective Explore endocrine provider experience and perspective on the use of telemedicine visits, compared to face-to-face encounters, to manage patients with type 2 diabetes (T2DM). Methods A survey was designed based on published literature and further refined based on stakeholder feedback through individual interviewing and pilot testing with Endocrinology providers. Survey domains included self-reported demographics, clinical time spent conducting telemedicine visit, perceived benefits and utility and barriers to incorporating telemedicine into practice. The anonymous uncompensated survey was completed via REDCap by Endocrinology providers at a leading academic medical center in the USA. Results were analyzed using descriptive statistics. Significance was tested using two tailed Mann-Whitney U Tests (α= 0.5). Results Forty-five surveys were electronically distributed. The response rate was 58% (N=26) with 85% being physicians and 15% nurse practitioners. Majority (85%) of the respondents identified as female and 42% had been practicing for &amp;gt;10 years. Since March 2020, 69% of providers reported spending more than 25% of their clinical time on telemedicine visits. Respondents under the age of 40 and those with less than 10 years of experience spent significantly less time on video visits compared to providers over the age of 40 (p= 0. 036 and providers with more than 10 years of experience (p = 0. 049). When comparing face-to-face visits to telephone visits for established patients, 58% of providers felt telephone based virtual visits were not as effective, whereas 4% felt video based virtual visits were not as effective. When comparing face-to-face visits for new patients to telephone visits, 92% of providers felt telephone based virtual visits were not as effective, whereas 39% felt video based virtual visits were not as effective. Most (92%) of respondents felt telemedicine increased patient access to care though there was a difference in the perceived quality of care delivered based on visit modality, with video visits preferred over telephone. Although the loss of physical exam opportunities was concerning to most respondents (92%), the level of concern was lower with video visits. The most frequently reported barriers to incorporating telemedicine were changes to clinic workflow (73%), low reimbursement (62%), and patient complexity (50%). All respondents plan to continue to offer telemedicine visits once the pandemic is over. Conclusion Telemedicine is an increasingly used tool for the management of T2DM. The type of visit and level of familiarity with the patient were cited as important factors for matching patient to mode of delivery. Understanding provider perspectives on facilitators, barriers, and benefits of telemedicine is useful for developing best practices and hybrid models of delivery of T2DM care. Presentation: No date and time listed

LBSMON194 Diagnosing Adrenal Insufficiency In Children: A Survey Among Pediatric Endocrinologists In North America

Abstract Accurately diagnosing adrenal insufficiency (AI) is of vital importance, but it can be challenging, particularly in children. While the ACTH stimulation test remains the gold standard test for diagnosing AI, its protocols and interpretation of results remain controversial. There are no international recommendations specific for the pediatric age group. Objective to understand current practices of North American pediatric endocrinologists, regarding the diagnosis of AI in children, with focus in interpreting results of ACTH stimulation tests. Methods an anonymous, electronic survey was sent to members of the Pediatric Endocrine Society in February of 2022. Email reminders were sent over the following month, and the survey was closed after 6 weeks. RedCap was used to administer the survey and store data. Results 221 survey responses were included. 52% of participants had more than 10 years of clinical experience, and 78% practiced in academic centers. All respondents ordered ACTH stimulation tests for the diagnosis of AI; 82% also used morning cortisol levels, 77% used cortisol levels during stress, and 14% used random cortisol. For the diagnosis of primary AI, 85% chose high-dose ACTH stimulation tests (HDST). For secondary AI, 62% ordered low-dose ACTH stimulation tests (LDST), 22% HDST, and the remainder used both. The most frequently used time points for the HDST were 0 and 60 minutes, and for the LDST, 0, 30 and 60 minutes. For interpretation of ACTH stimulation test results, 95% considered peak cortisol levels, 70% also took into context the clinical picture, and 48% considered the relative increase in cortisol levels from baseline. 17% of respondents used different cutoff values for LDST vs. HDST; 18% used specific cutoffs for newborns. Median (IQR) cortisol levels after ACTH stimulation tests for diagnosing AI was 18 (15.5-18) ug/L; 54% of participants used 18 ug/dL, 40% considered levels between 10 and 18 ug/L, and 7% used cutoffs between 18 and 20 ug/L. Finally, 43% of providers did not know what type of cortisol assay was used in their laboratory. Discussion In North America, pediatric endocrinology providers use ACTH stimulation protocols variably, including decisions about HDST vs. LDST, time points for cortisol measurement, and interpretation of results. Notably, there was a wide distribution of responses concerning cortisol cutoffs. Also, a significant proportion of providers who ordered and interpreted results of ACTH stimulation tests did not know which biochemical assay was employed. These exploratory results highlight the need for pediatric-specific recommendations on ACTH stimulation protocols, based on the best available evidence. Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

937-P: Multicenter application of EFR (Endocrine Final Recommendation) Note Embedded in EMR Improves the Accuracy of Diabetes Discharge Regimen in Hospitalized Patients with Diabetes

Patients with diabetes who are hospitalized often have changes in diabetes treatment regimen during hospitalization. In the ReCoDED study done at our institution, it was found that discharge instructions provided by Endocrine teams were not always accurately translated into discharge recommendations by primary teams. To address this issue, we implemented a “diabetes discharge recommendations note” (EFR Note) which clearly specifies discharge instructions for primary teams, which we embedded in the institution’s EMR in January 2019. Preliminary data evaluating the efficacy of the EFR Note at our academic center showed significantly improved accuracy in the discharge regimen. In this study, we investigated the patient data from two other centers, specifically inner-city community hospitals, from January to December 2021. We identified 40 patients through EMR for whom an EFR Note was utilized (EFR Group) and randomly selected 40 patients from the same centers for comparison (Control Group) . There were no significant differences in baseline characteristics between the two groups (All p values &amp;gt; 0.25) Results: We find that the accuracy of diabetes regimens provided by primary teams at discharge was significantly higher when EFR Note was utilized, relative to control (88% vs. 60%; χ2 (1) = 6.46, p = 0.011) . The most common error was incorrect insulin type/dosing, accounting for 76% of all errors. Insulin dosing errors were similarly less prevalent in the EFR Group relative to control (8% vs. 33%; χ2 (1) = 6.33, p = 0.012) . Conclusion: These results demonstrate that tools like EFR Note with specific instructions regarding discharge regimen can ameliorate deficiencies in discharge process. We plan to take steps to enhance awareness regarding the efficacy of EFR Note among endocrinology providers at multiple centers within our institution to facilitate a safer transition from inpatient to outpatient setting. Disclosure J.Lloyd: None. T.Abdulwahid: None. J.Levin: None. D.Pinkhasova: None.

1055-P: Low Rate of Preconception Counseling and Near Absence of Contraception Provision by Endocrinologists for Women with Diabetes

Preconception counseling for reproductive-age women with type 1 and type 2 DM improves maternal-fetal outcomes. Endocrinologists are in a unique position to provide such important counseling and contraception or applicable referrals. In response to an increasing number of women referred to our prenatal clinic with poor glycemic control and unplanned pregnancies, we instituted a quality improvement initiative to improve preconception care at our academic center. We conducted a chart review of 96 women of reproductive age with at least one in-person visit for DM from July 2020-Oct 2021. Patients who were pregnant or had undergone sterilization were excluded. Fifty patients (mean age 34.5+/-6.7 yrs) met inclusion criteria. Of these, 66% had T1DM, 32% had T2DM and 26% had a HgbA1c ≤6.5%, recommended for pregnancy. Each woman had a mean of 2.1+/-1.2 visits with an endocrinology provider during these 15 mos. Only 4% had contraception specifically documented during a visit, although medical staff or other providers had documented contraception use in 56% of cases. No women received a contraception prescription. Endocrinologists did not document provision of preconception counseling to any of these women, although 14% had previously undergone counseling with a maternal fetal medicine provider. No women were referred to an OB-Gyn provider. Our data suggest that endocrinology providers infrequently provide preconception or contraception counseling or referrals for women with diabetes and underscores the striking need for a QI initiative. To this end, we are implementing a multifaceted intervention to educate providers on key aspects of preconception counseling and contraception provision, facilitate specialist referrals, simplify documentation, and provide patient education materials. We will assess the efficacy of our intervention with the ultimate goal of improving outcomes for this rapidly growing population of women with diabetes and their offspring. Disclosure R.Jeffers: None. L.Sayres: None. L.Abushamat: None. C.Nielsen: None. A.Zaman: None. L.A.Barbour: None.

515-P: Harnessing Simulation-Based Corrective Mentoring in Continuing Medical Education to Improve Clinical Decision Making and Identify Persisting Educational Needs

Rationale: Due to the vast number of treatment options and clinical presentations of patients with T2DM, providers are challenged to individualize treatment. Incorporating corrective mentoring into decision-based continuing medical education (CME) is a proven method to improve clinical decision-making while simultaneously elucidating persisting educational needs. Methods: Vindico Medical Education and Syandus partnered to develop four virtual clinical scenarios designed to encourage optimal decision making for patients with T2DM by providing immediate feedback via simulated corrective mentoring. Results: A total of 765 primary care providers (PCPs) and 103 endocrinology providers participated in the simulation. Across all four simulations, only 15% of decisions were optimal on the first selection. At baseline, the most challenging topics were evaluating comorbidities and optimizing the use of SGLT-2 inhibitors (13% and 3% optimal decisions made, respectively) . However, after corrective mentoring, there was a 400% relative increase in optimal decisions made. Relative to PCPs, endocrinology providers were 11% more likely to eliminate non-ideal treatment options for a patient with T2DM, obesity, and ASCVD. Similarly, endocrinologists were 14% more competent than PCPs regarding the use of an SGLT-2 inhibitor for a patient with T2DM and worsening kidney disease. The reason for these findings may be that, relative to endocrinologists, PCPs are nearly twice as concerned with optimizing A1C control versus managing comorbidities such as kidney disease or obesity. Conclusion: The use of corrective mentoring in simulation-based CME is an impactful way to encourage clinical decision-making in alignment with the latest evidence-based care. Moreover, these data highlight the need to educate PCPs on the importance of considering comorbidities when individualizing treatment for patients with T2DM. Disclosure K.Robinson: None. D.Seifert: Other Relationship; Amgen Inc., Merck &amp; Co., Inc. J.Frederick: None. R.A.Esgro: None. Funding Independent Educational Grants from Boehringer Ingelheim Pharmaceuticals, Inc. and Lilly USA, LLC; and Merck &amp; Co., Inc.

Fertility Counseling Practices for Patients with Turner Syndrome in Pediatric Endocrine Clinics: Results of a Pediatric Endocrine Society Survey.

Turner syndrome (TS) is associated with a high risk of primary ovarian insufficiency. Current guidelines recommend early fertility counseling for affected youth and their families. This study assessed clinical providers' (MD, NP, or PA) fertility counseling practices for girls with TS. TS providers were invited to complete a survey via the Pediatric Endocrine Society listserv. Descriptive statistics summarized variables of interest. Correlations were used to identify associations between barriers/practice characteristics and fertility preservation (FP) referral. Thematic analysis was used to examine qualitative responses. 119 providers completed the survey. Seventy percent reported discussing fertility implications of TS routinely in pediatric care. Fifty-six percent reported often or always referring patients with spontaneous menarche to FP specialists, whereas only 19% reported often or always referring their patients without spontaneous menarche (p < 0.001). Barriers associated with FP referral frequency included unfamiliarity with FP options, belief that FP is not a possible goal for their patients, and absence of a local reproductive endocrinologist. Qualitatively, four referral barrier themes were identified: (1) questionable utility of referral, (2) lack of perceived interest among patients/families, (3) provider barriers (e.g., lack of knowledge), (4) logistical/structural barriers to accessing fertility-related care. Pediatric endocrinology providers report inconsistently discussing fertility implications of TS. The frequency of referral to an FP specialist and factors/barriers affecting the decision to refer remain variable. Future research should focus on expanding provider education, addressing barriers to high-quality fertility counseling and referral for patients with TS, and investigating FP outcomes in TS.

Screening and counseling for nicotine use in youth with diabetes.

To assess current practice patterns and identify knowledge gaps among pediatric endocrinologists in the United States regarding screening and counseling for combustible tobacco and e-cigarette use in youth with diabetes. Electronic cigarettes (e-cigarettes) are the most used tobacco product among adolescents and may be associated with an increased risk of progression to combustible cigarette smoking, cardiovascular disease, and stroke. Diabetes mellitus is a known risk factor for cardiovascular disease, and nicotine products can increase this risk. We sought to assess current practice patterns and identify knowledge gaps among pediatric endocrinologists in the United States regarding screening and counseling for combustible tobacco and e-cigarette use in youth with diabetes. We conducted an anonymous, online-based survey of Pediatric Endocrine Society members who provide care to youth with Type 1 or Type 2 diabetes. The survey collected information about provider demographics and smoking habits, knowledge and attitudes regarding screening and counseling for combustible tobacco and e-cigarette use, and current practice patterns. The survey was completed by 106 individuals of whom 64 reported providing care to youth with diabetes mellitus and ever asking about combustible tobacco or e-cigarette use. The majority of respondents were female, attending providers, and working in academic medical centers. None reported a history of formal training in e-cigarette counseling but recognized the harms of e-cigarette use. Nearly all (98%) who ever screen for nicotine use reported routinely screening for combustible tobacco use, while 18% never screen for e-cigarette use (p < 0.01). Over 80% of respondents reported feeling confident or very confident about discussing the harms of combustible tobacco, compared to 58% reporting the same confidence in discussing harms of e-cigarette use (p < 0.0001). Over 90% of respondents agreed that pediatric endocrinology providers should ask about nicotine use with over half agreeing that counseling reduces the risk of initiating nicotine product use, and 30% reported lack of change with counseling as a barrier to discussing nicotine use. Lack of visit time was the most reported barrier to discussing nicotine use. More providers cited lack of knowledge regarding e-cigarettes compared to combustible tobacco as a barrier to discussing its use. Pediatric endocrinology providers recognize the harms of e-cigarette use, but more frequently ask about combustible tobacco use compared to e-cigarette use. This may be related to lower reported confidence and provider knowledge in counseling about e-cigarette use. Increased utilization of existing resources and expanding opportunities for providers to learn more about e-cigarettes may increase provider confidence and comfort in screening and counseling.

The Do-It-Yourself Artificial Pancreas.

A growing number of people with diabetes are turning to self-built systems to dose and deliver insulin. These do-it-yourself artificial pancreas systems (DIY-APS) use commercially available insulin pumps and continuous glucose monitors and add an algorithm that independently modulates insulin dosing. Frustrated by the pace of diabetes technology development, a group of patients and diabetes advocates developed this technology without formal safety studies and without approval by the US Food and Drug Administration (FDA). Loop, OpenAPS, and AndroidAPS are the three available platforms, and patients worldwide are choosing them over other options. Patients generally report positive outcomes, but in May 2019, the FDA publicly warned against the use of such systems. Endocrinology providers are, therefore, faced with a difficult decision of whether to support patients interested in using a DIY-APS. This article describes the current state of DIY-APS, regulatory considerations, and our recommendations for endocrinology providers regarding this technology. [Pediatr Ann. 2021;50(7):e304-e307.].

Use of glucagon-like peptide-1 receptor agonists for pediatric patients with obesity and diabetes: The providers' perspectives.

Glucagon-like peptide-1 receptor agonists (GLP-1RA) have been widely used in adults with Type 2 diabetes (T2D) and obesity. We sought to evaluate the experience of pediatric endocrinology providers with GLP-1RA and factors that guide them on whether and how to prescribe these medications. We surveyed the members of the Pediatric Endocrine Society regarding the use of GLP-1RA in their practice. The respondents (n= 102) were predominantly from academic centers (84%) and 75%reported using GLP-1RA in pediatric patients, mostly to treat T2D and obesity. Patient tolerance for the medication was reported to be the driving factor determining the duration of treatment. Gastrointestinal side effects were observed more commonly than local reactions or elevation of pancreatic enzymes. Lack of clinical experience was reported to be a major barrier for prescribing GLP-1RA, particularly among those with more than 5 years of clinical experience. Finally, liraglutide was used more often (93%) than other GLP-1RA. The use of GLP-1RA has increased in pediatric patients. Recent Food and Drug Administration approval of liraglutide for pediatric obesity will likely further increase its prescription rate. Providers should be vigilant about side effects and adjust the doses of GLP-1RA accordingly. More efforts should be made by professional societies to educate pediatric endocrinology providers about the proper use of GLP-1RA and enhance their confidence in prescribing these medications.

862-P: Impact of COVID-19 on Pediatric Endocrinology Practice and Diabetes Care in Children: A Survey

Objective: As the global pandemic caused by the SARS-CoV-2 virus continues unabated, healthcare delivery has been altered significantly impacting patients and providers. We examined the impact of COVID-19 on pediatric endocrinology practice and the challenges faced in pediatric diabetes care. Methods: A 27-item electronic survey was designed, pilot-tested, and deployed to pediatric endocrinology providers using the e-mail discussion lists of the American Academy of Pediatrics, Section on Endocrinology, and the Pediatric Endocrinology Clinical Case Mailing List (May and June 2020). The survey had questions regarding changes in practice, telemedicine use, and observed changes in diabetes disease manifestation. Results: 114 unique responses were analyzed, 79.3% were female respondents. Most (95.6%) providers surveyed were practicing in the United States, and 87.7% reported a decline in their patient volume. Telemedicine use was common [97% (95% CI: 92.4% - 99.4%)] and recent [83.3% (95% CI: 75.2% - 89.7%)] with 98% utilizing remote glycemia monitoring tools. Children with diabetes in underserved and remote locations faced significant barriers to telemedicine use such as lack of connectivity (61%), and devices (59%). Negative consequences on health due to the pandemic included, delay in diabetes diagnosis (33.3%), lack of follow-up (22.0%) and higher diabetic ketoacidosis cases (22.0%). Increased anxiety was commonly reported (66%). Conclusion: The COVID-19 pandemic has led to decline in patient volumes, with rapid adaptation to telemedicine use. Providers noted negative effects due to the pandemic on diabetes care including mental health. Benefits from telemedicine use were observed with a digital divide in underserved populations. Disclosure M. Chambers: None. M. Sinha: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases