Pediatric Diabetes Centers Research Articles

Ketone Management in Pediatric Diabetes Centers in the USA: Current Practices and a Call for Improved Standardization

Introduction: Diabetic ketoacidosis (DKA) is the leading cause of mortality among youth with type 1 diabetes (T1D). Guidelines for DKA prevention exist; however, specific guidance about when to check ketones and how to manage youth using insulin pumps and automated insulin delivery (AID) systems is lacking. Methods: A 35-item online survey exploring clinical ketone management practices for youth with T1D in the USA was distributed to diabetes healthcare professionals (HCPs). Survey responses, including multiple-choice and Likert scale questions, were summarized and rates of agreement and disagreement (Likert scale 4, 5 vs. 1, 2, 3) are reported. Results: In total, 123 HCPs (51% physicians, 26% diabetes educators, 19% nurse practitioners) from 47 institutions completed the survey. Seventy percent worked at academic specialty centers. Ninety-seven percent reported >50% continuous glucose monitoring use in their clinic and 72% reported >50% insulin pump use. Although 79% reported having ketone management protocols, the level and duration of hyperglycemia at which ketone monitoring was advised ranged from >200 to 350 mg/dL and from 0 min to >6 h of duration. While 72% had distinct ketone management protocols for pump users, only 29% had specific protocols for AID. Sixty-two percent agreed that DKA due to infusion site failure was a significant problem in their practice, and 70% agreed there was a need to standardize ketone management guidelines. Conclusions: The preventable nature and high incidence of DKA highlight the need to build consensus for clinical ketone management and to develop tools to facilitate management, especially as the use of diabetes technologies continues to increase.

Incidence of Type 1 Diabetes in Children Aged 0-14 Years in Trentino-Alto Adige Region and Determinants of Onset with Ketoacidosis.

To assess the incidence and the temporal trend of type 1 diabetes (T1D) and diabetic ketoacidosis (DKA) during the period 2014-2023 in youths aged 0-14 years in the Trentino-Alto Adige region, Italy. A retrospective review of all incident cases of T1D diagnosed at the two Pediatric Diabetes Centers of Bolzano and Trento was matched with diabetes exemptions (No. 344). Demographic, clinical, and socioeconomic status (SES) data at first hospitalization were collected from subjects who agreed to participate (No. 272). The incidence of T1D was 21.5/100,000 person/years, with a peak of 31.1 in 2021 during the COVID-19 pandemic. The mean age at the onset was 8.8 ± 3.9 years. Seventy-nine percent of the subjects were Italians, primarily residents in rural areas, and SES was equally represented. The mean incidence of DKA was 36.9%. The logistic regression analysis showed that the independent characteristics of the patients with DKA were of a younger age and displayed higher glycated hemoglobin (HbA1c) values. No relation of DKA with seasonality, ethnicity, or first-degree relative (FDR) with T1D or SES was detected. Our study revealed an incidence of T1D in the Trentino-Alto Adige region comparable to other areas in the North of Italy. The DKA rate negatively correlated with age; therefore, targeted prevention educational campaigns to increase awareness are needed.

Use of Degludec in Youth With Type 1 Diabetes and Recurrent Diabetic Ketoacidosis

This article describes a pediatric diabetes center quality improvement initiative to switch youth with type 1 diabetes and diabetic ketoacidosis (DKA) from insulin glargine to longer-duration insulin degludec to determine whether this change would reduce DKA recurrence. Overall the change in DKA recurrence with degludec was not statistically significant. However, subgroup analysis showed that race/ethnicity and insurance status were significantly associated with change in DKA rates. The association of degludec and decreased rates of repeat DKA in Hispanics and privately insured individuals require further exploration.

Skin Reactions in Children with Type 1 Diabetes Associated with the Use of New Diabetes Technologies—An Observational Study from a Regional Polish Pediatric Diabetes Center

The study aimed to estimate the prevalence of skin problems in children and adolescents with type 1 diabetes (T1D) using insulin pumps (IPs) and/or continuous glucose monitoring (CGM) in our center and analyze their association with various factors. As part of the international ISPAD JENIOUS-initiated SKIN-PEDIC project, we interviewed and examined patients who visited the regional pediatric diabetes center in Opole (Poland) for four weeks regarding the use of IP and/or CGM and the presence of skin problems. Body mass index (BMI) and glycemic parameters were obtained retrospectively from medical records. Among 115 individuals (45.2% girls, 83.5% IP users, 96.5% CGM users), old scars were the most common skin problem (IP users 53.1%; CGM users 66.4%), while ≥2 types of skin problems co-occurred (IP users 40.6%; CGM users 27.3%). Longer IP use was associated with a higher prevalence of skin problems (50% for IP < 1 year, 98.1%-IP 1–3 years, 100% for IP > 3 years; p < 0.001), pointing out extra attention with IP use > 1 year. No significant associations were found between skin problems and gender, age, BMI centile and glycemic parameters. Dermatological complications were common among children using IP and CGM in our center, highlighting the need for vigilant monitoring and early intervention to manage these skin-related issues effectively.

Effectiveness of switching from first-generation basal insulin to Glargine 300 U/mL in children and adolescents with type 1 diabetes: results from the ISPED CARD database.

Glargine 300 U/mL (Gla-300) has been recently approved for use in children and adolescents with type 1 diabetes (T1D). However, real-world effectiveness data are scarce, and aim of this analysis was to assess clinical outcomes in young patients with T1D switching from 1st generation basal insulin (1BI) to Gla-300. ISPED CARD is a retrospective, multicenter study, based on data anonymously extracted from Electronic Medical Records. The study involved a network of 20 pediatric diabetes centers. Data on all patients aged < 18years with T1D switching from 1BI to Gla-300 were analyzed to assess clinical characteristics at the switch and changes after 6 and 12months in glycated hemoglobin (HbA1c), fasting blood glucose (FBG), and standardized body mass index (BMI/SDS). Titration of basal and short-acting insulin doses was also evaluated. Overall, 200 patients were identified. The mean age at the switch to Gla-300 was 13years, and mean duration of diabetes was 3.9years. Average HbA1c levels at switch were 8.8%. After 6months, HbA1c levels decreased by - 0.88% (95% CI - 1.28; - 0.48; p < 0.0001). The benefit was maintained after 12months from the switch (mean reduction of HbA1c levels - 0.80%, 95% CI - 1.25; - 0.35, p = 0.0006). Trends of reduction in FBG levels were also evidenced both at 6months and 12months. No significant changes in short-acting and basal insulin doses were documented. The study provides the first real-world evidence of the effectiveness of Gla-300 in children and adolescents with T1D previously treated with 1BI. The benefits in terms of HbA1c levels reduction were substantial, and sustained after 12months. Additional benefits can be expected by improving the titration of insulin doses.

From pediatric to adult care: a survey on the transition process in type 1 diabetes mellitus and the diabetes services in Italy.

The present study assessed the transitioning process of young adults with type 1 diabetes mellitus (T1D) in Italy. We asked Pediatric Diabetes Centers (PDC) and Adult Diabetes Centers (CAD) to fill in a web-based survey on the current state of services, the number of transitioning adolescents with T1D within the last year, observations on limitations, and future directions. 93 centers (46 PDCs, 47 CADs) joined the study. The total number of subjects with T1D being followed by a PDC was 16,261 (13,779 minors and 2483 young adults), while CADs had 25,500 patients. The survey showed an uneven situation. Only some services had a dedicated diabetes team (78% of PDCs, 64% of CADs). 72% of PDCs and 58% of CADs reported a protocol dedicated to transition. The median age for transition was 19 (range 16-25years); the time required for preparing transition, indicated by both PDCs and CADs, was 5.5months. A high percentage of CADs (80%) confirmed receiving sufficient clinical information, mainly through paper or computerized reports. The transition process is hampered by a lack of resources, logistical facilities, and communication between services. While some services have a protocol, monitoring of results is only carried out in a few cases. Most specialists expressed the need to enhance integration and continuity of treatment. The current situation could be improved. Applying standard guidelines, taking into consideration both clinicians' and patients' necessities, would lead to a more successful transition process.

Diabetic Ketoacidosis in Type 1 Diabetes Onset in Latin American Children

ObjectiveTo describe the patterns of diabetic ketoacidosis (DKA) occurrence in children newly diagnosed with type 1 diabetes (T1DM) across several Latin American pediatric diabetes centers from 2018 to 2022. MethodsA retrospective chart review included children under 18 with new-onset T1DM from 30 Latin American pediatric diabetes centers (Argentina, Chile, and Peru) between 30 December 2018 and 30 December 2022. Multiple logistic regression models examined the relationships between age, gender, medical insurance, BMI, and DKA at new-onset T1DM. As far as we know, there are no large studies in Latin American countries exploring the patterns of DKA in new-onset T1DM. ResultsA total of 2,026 (983 females) children, median age 9.12 (5.8 -11.7) years with new-onset-T1DM were included. Approximately 50% had no medical insurance. Mean glucose values were 467 mg/dL, pH 7.21, bicarbonate 13 mEq/L, HbA1c 11.3%, and BMI 18. The frequency of DKA was 1,229 (60.7%), out of which only 447 (36%) were severe. There was a significant decrease in the frequency of DKA as age increased: 373 (70.2%) in children under 6, 639 (61.6%) in those between 6 and 12, 217 and (47.5%) in those over 12. Children with medical insurance (58.8%) had a significantly lower frequency of DKA than those without (62.7%). The multiple logistic regression models showed that DKA was significantly and inversely associated with age [OR, 0.72 (95% CI 0.60–0.86)], BMI [OR, 0.95 (95% CI 0.92–0.99)], and medical insurance [OR, 0.75 (95% CI 0.60–0.94)] adjusted for sex. ConclusionLatin American children with new-onset T1DM exhibited a substantial occurrence of DKA. Younger ages and the lack of medical insurance were significantly associated with DKA in new-onset T1DM.

Correlation between centre size, metabolic variation and mean HbA1c in major paediatric diabetes centres.

To exploit a relatively homogeneous national health care context and a national diabetes database to address the questions: Is there an optimal clinic/centre size in determining outcomes?; and Can improvement in median centre outcomes be driven by reducing variability in outcome? Using the Australasian Diabetes Database Network, data from seven tertiary hospital paediatric diabetes clinics for patients with type one diabetes from Australia were recorded from 6-month uploads: September 2017, March 2018, September 2018 and March 2019. Data from 25 244 patient visits included demographic variables, HbA1C, number of patient visits and insulin regimens. There was no association between centre size and median HbA1C. On the other hand, there was a significant association between or median absolute deviation of HbA1C outcomes and the median HbA1C result between centres. On average every two thirds of a median absolute deviation increase in clinic HbA1C was associated with a 1.0% (10.9 mmol/mol) increase in median clinic HbA1C. Our data have shown that it is likely difficult for centres to have a low median HbA1C if there is high variance of HbA1C's within centres or within centre treatment groups. This appears to be true regardless of centre size. These findings need to be carefully considered by teams who wish to lower their clinic median HbA1C.

Use of teplizumab in children and adolescents at risk of type 1 diabetes: perspectives of parents and caregivers from an Italian Pediatric Diabetes Center.

In view of the imminent introduction of a novel category of disease-modifying treatments for type 1 diabetes (T1D) in European countries, it becomes imperative to understand the existing awareness and viewpoints of parents and caregivers of children and adolescents predisposed to T1D. This study aims to evaluate the perspectives of a cohort of parents and caregivers regarding using teplizumab to delay the onset of T1D in predisposed children and adolescents. This single-center study used a survey-based approach. Parents or caregivers of children and adolescents with T1D having at least one additional child without T1D answered 15 questions assessing their awareness about teplizumab, their potential willingness to provide consent for its administration in case of eligibility, and their expectations regarding potential outcomes. Approximately half of the participants (52.6%) expressed readiness to consent to teplizumab administration for their child if the prescription criteria were met in the future. Only 6.3% of parents claimed detailed knowledge about this innovative medication. Notably, parents with prior experience of diabetic ketoacidosis (DKA) demonstrated a higher inclination to consent to teplizumab treatment (p = 0.018). Our findings underscore the necessity for comprehensive awareness campaigns spreading the current evidence concerning teplizumab in terms of both effectiveness and possible side effects. Additionally, our study reinforces the pivotal role of DKA prevention in successfully integrating disease-modifying treatments into clinical practice.

Incidence, Phenotypes, and Genotypes of Neonatal Diabetes: A 16-Year Experience. The Rare Genetic Etiologies of Neonatal Diabetes Are Common in Sudan

Neonatal diabetes (ND) is a rare subtype of diabetes occurring in the first 6 months of life. High incidence has been reported among populations with high rates of consanguineous marriage. However, there is paucity of reported data from sub-Saharan African countries. We report the incidence, genotype, and phenotype of ND in a large cohort from Sudan and compare these findings to regional and international data. All infants with onset of diabetes in the first 6 months of life, attending one of the only two tertiary pediatric diabetes centers in Sudan, Gaafar Ibn Auf Pediatric Tertiary Hospital and Sudan Childhood Diabetes Center, during the period of January 2006 to December 2022 were included. Medical records were reviewed for demographic and clinical information. Genetic testing was performed for 48 patients by the Exeter Genomics laboratory in the UK and for one patient by the University of Cambridge, Metabolic Research Laboratories, UK. The estimated incidence was 4.8 per 100,000 live births. Forty-nine ND patients from 45 unrelated families were identified, and a genetic diagnosis was confirmed in 37 patients (75.5%) from 33 unrelated families. Consanguinity was reported in 34 families (75.6%). The commonest genetic cause for permanent neonatal diabetes was EIF2AK3 recessive variants causing Wolcott–Rallison syndrome (18.92%). Pathogenic variants in two recently identified genes, ZNF808 and NARS2, were found in three patients each (8.11%). Activating variants in KCNJ11 and ABCC8 were identified in four (10.81%) and two (5.41%) patients, respectively. Apart from hyperglycemia, the commonest clinical presentations included dehydration, failure to thrive, and diabetic ketoacidosis. ND in Sudan has a different pattern of etiologies compared to Western and Asian populations yet similar to some Arab countries with EIF2AK3 mutations being the commonest cause. Pathogenic variants in recently identified genes reflect the impact of genome sequencing on increasing the rate of genetic diagnosis.

Continuous improvement of quality of care in pediatric diabetes: the ISPED CARD clinical registry

Abstract Aim In Italy, the ISPED CARD initiative was launched to measure and improve quality of care in children and adolescents with type 1 diabetes. Methods Process and outcome indicators and the related information derived from electronic medical records were identified. A network of pediatric diabetes centers was created on a voluntary basis. Results Overall, 20 centers provided data on 3284 patients aged &lt; = 18 years. HbA1c was monitored ≥ 2/year in 81.2% of the cases. BMI was monitored ≥ 1/year in 99.0%, lipid profile in 45.3%, and blood pressure in 91.7%. Pubertal status, albuminuria, eye examination, and screening of celiac disease and thyroiditis were underreported. From 2017 to 2021, average HbA1c levels decreased from 7.8 ± 1.2 to 7.6 ± 1.3%, while patients with LDL cholesterol &gt; 100 mg/dl increased from 18.9 to 36.7%. Prevalence of patients with elevated blood pressure and BMI/SDS values also increased. In 2021, 44.7% of patients were treated with the newest basal insulins, while use of regular human insulin had dropped to 7.7%. Use of insulin pump remained stable (37.9%). Conclusions This report documents the feasibility of the ISPED CARD initiative and shows lights and shadows in the care provided. Improving care, increasing number of centers, and ameliorating data recording represent future challenges.

Autonomous artificial intelligence increases screening and follow-up for diabetic retinopathy in youth: the ACCESS randomized control trial

Diabetic retinopathy can be prevented with screening and early detection. We hypothesized that autonomous artificial intelligence (AI) diabetic eye exams at the point-of-care would increase diabetic eye exam completion rates in a racially and ethnically diverse youth population. AI for Children’s diabetiC Eye ExamS (NCT05131451) is a parallel randomized controlled trial that randomized youth (ages 8-21 years) with type 1 and type 2 diabetes to intervention (autonomous artificial intelligence diabetic eye exam at the point of care), or control (scripted eye care provider referral and education) in an academic pediatric diabetes center. The primary outcome was diabetic eye exam completion rate within 6 months. The secondary outcome was the proportion of participants who completed follow-through with an eye care provider if deemed appropriate. Diabetic eye exam completion rate was significantly higher (100%, 95%CI: 95.5%, 100%) in the intervention group (n = 81) than the control group (n = 83) (22%, 95%CI: 14.2%, 32.4%)(p < 0.001). In the intervention arm, 25/81 participants had an abnormal result, of whom 64% (16/25) completed follow-through with an eye care provider, compared to 22% in the control arm (p < 0.001). Autonomous AI increases diabetic eye exam completion rates in youth with diabetes.

Lisdexamphetamine versus methylphenidate for paediatric patients with attention-deficit hyperactivity disorder and type 1 diabetes (LAMAinDiab): protocol for a multicentre, randomised cross-over clinical trial in an outpatient telemedicine-supported setting

IntroductionAttention deficit hyperactivity disorder (ADHD) affects 5%–10% of paediatric population and is reportedly more common in children with type 1 diabetes (T1D), exacerbating its clinical course. Proper treatment of ADHD...

Social Determinant of Health Impact on Diabetes Device Use and Clinical Outcomes in Youth with Type 1 Diabetes

Background. Youth with Type 1 diabetes (T1D) who are Black, Hispanic, or lower socioeconomic status (SES) have lower rates of diabetes device use, higher hemoglobin A1c (HbA1c), and higher rates of diabetic ketoacidosis (DKA). However, the associations of individual-level social determinants of health (SDoH) and neighborhood-level factors with device use and clinical outcomes are unknown. Area deprivation index (ADI) is a neighborhood level measure of SES reported in deciles (range 1–10 with 10 representing most deprived neighborhood). Methods. We evaluated the association of ADI and other SDoH factors with pump/continuous glucose monitor (CGM) use, HbA1c, and DKA in 1,461 youth with T1D (50% female, age 12.8 ± 3.6 years, HbA1c 8.7 ± 2.1%, 52% pump, 70% CGM) seen between October 1, 2020 and September 30, 2021 at a large pediatric diabetes center. Multiple logistic regression and multiple linear regression analyses were used to determine statistically significant associations adjusting for potential confounders. Results. Youth were less likely to use an insulin pump if they lived in a higher ADI neighborhood, were Black or Hispanic, had Medicaid or were uninsured, or received government assistance (e.g., Supplemental Security Income, Supplemental Nutritional Assistance Program). Youth were less likely to use a CGM if they lived in a higher ADI neighborhood, were Black or Hispanic, had Medicaid or were uninsured. Youth had higher risk of DKA event in the past year if they used government assistance, whereas pump and CGM use were associated with lower DKA risk. HbA1c (%) increased by 0.09 (95% CI: 0.05, 0.13) per unit increase in ADI. HbA1c was 0.62 lower (95% CI: −0.82, −0.42) in pump users vs. nonusers and 0.78 lower (95% CI: −0.99, −0.56) in CGM users vs. nonusers. Conclusions. Interventions that tailor care plans to address SDoH in families living in deprived neighborhoods may be needed to increase successful technology uptake, optimize HbA1c, and prevent DKA.

Ten-year review of trends in children with type 1 diabetes in England and Wales.

This review describes the prevalence, incidence, and demographics of children and young people (CYP) with type 1 diabetes in England and Wales using data from the United Kingdom National Paediatric Diabetes Audit (NPDA) and has almost 100% submission from all paediatric diabetes centres annually. It is a powerful benchmarking tool and is an essential part of a long-term quality improvement programme for CYP with diabetes. Clinical characteristics of this population by age, insulin regimen, complication rates, health inequalities, access to diabetes technology, socioeconomic deprivation and glycaemic outcomes over the past decade is described in the review. The NPDA for England and Wales is commissioned by the United Kingdom Healthcare Quality Improvement Partnership as part of the National Clinical Audit for the United Kingdom National Service Framework for Diabetes. The rising incidence of Type 1 diabetes is evidenced in the past decade. Reduction in national median glycated hemoglobin for CYP with diabetes is observed over the last 10 years and the improvement sustained by various initiatives and quality improvement pro-grammes implemented with universal health coverage.

Associations between sleep characteristics and glycemic variability in youth with type 1 diabetes

ObjectiveThis study aimed to determine sleep characteristics and their associations with glycemic variability in youth with type 1 diabetes (T1D). Material and methodsThis cross-sectional study conducted at two pediatric diabetes centers in Istanbul, Turkey, included 84 children with T1D (mean age 10.5 years). Sleep characteristics and glycemic variability were determined by actigraphy, DSM-5 Level 2-Sleep Disturbance Scale Short Form and continuous glucose monitoring. Circadian preference was evaluated by the Children's Chronotype Questionnaire. Sleep disturbances were assessed by the. The sleep quality was determined by actigraphy-derived sleep measures. ResultsEighty-eight percent of participants had insufficient age-appropriate total sleep time (TST) (<9 h for 6–13-year-olds and <8 h for 14–17-year-olds). Chronotype was classified as intermediate in 50%, evening in 45.2%, and morning in 4.8%. A higher chronotype score indicating a stronger eveningness preference was associated with more time spent in hypoglycemia (β = 0.433, p = 0.002). On nights when participants had lower sleep efficiency and longer sleep onset latency, they had significantly higher overnight glycemic variability (β = −0.343, p = 0.016, β = 0.129, p = 0.017, respectively). Prolonged nocturnal wake duration was significantly associated with more time spent in daytime hypoglycemia (β = 0.037, p = 0.046) and higher overnight glycemic variability (J index, β = 0.300, p = 0.015). The associations between TST and glycemic variability indices were not significant. ConclusionsSleep quality rather than TST was significantly associated with glycemic variability in children with T1D. Eveningness preference might contribute to an increased risk of hypoglycemia. Addressing sleep patterns and chronotypes can be crucial in management plans for youth with T1D.

1144-P: Racial/Ethnic Disparities in Accessing the Latest Automated Insulin Delivery (AID) System

Background: AID systems improve glycemic control in youth with type 1 diabetes (T1D). There was a full market release of the OmniPod 5 (OP5) AID system in the United States on 8/1/2022 and it was FDA approved for ages ≥2 on 8/22/22. OP5 is available through pharmacy benefits and requires users to have a smartphone. We hypothesized that disparities exist in OP5 access. Methods: We assessed OP5 use at two pediatric diabetes centers among youth with T1D ages 2-21 who were using any version of an OmniPod (OP) insulin pump 3-months after the full market release. Differences in demographic characteristics of OP5 users compared to other OP pump users were assessed using Chi-squared and student’s independent two-sample t tests. Results: Of 1037 youth (mean age 12.8±4.4 years, 49.5% female, mean T1D duration 5.3±3.7 years), 510 (49.2%) were using OP5. Rates of OP5 use were higher among non-Hispanic White youth than among youth of all other racial/ethnic identities (53.2% vs 38.0%, p&amp;lt;0.0001). Youth using OP5 were more likely to be younger (12.3±4.0 years vs 13.2±4.7 years, p=0.0001) and to have a shorter T1D duration (4.9±3.5 vs 5.8±3.9 years, p=0.0002). There was a trend towards lower rates of uptake among publicly versus privately insured youth (43.1% vs 50.7%, p=0.054). There was no difference in OP5 use by sex (48.2% female vs 51.8% males, p=0.43). Conclusions: Minority youth were less likely to access the OP5 AID system 3-months after full-market release. Given the glycemic improvements associated with AID systems, it is important to promote equitable access to the latest diabetes technologies. Improving insurance coverage of technologies and supporting AID access without the need for a smartphone may support these goals. Disclosure B.E.Marks: Research Support; Tandem Diabetes Care, Inc., Dexcom, Inc., Medtronic. S.Meighan: Speaker's Bureau; Dexcom, Inc. E.A.Brown: None. A.Zehra: None. R.Suresh: None. J.L.Douvas: None. R.M.Wolf: Research Support; Dexcom, Inc., Boehringer Ingelheim Inc. Funding National Institutes of Health (K23DK129827)

1041-P: Health Care Transition Practices in the T1D Exchange Quality Improvement Collaborative

Background: Implementation of a structured health care transition (HCT) process is associated with positive outcomes in population health, experience of care, and health care utilization. Objective: To describe pediatric and adult clinic HCT practices in the T1D Exchange Quality Improvement Collaborative (T1DX-QI). Methods: Got Transition’s Six Core Elements of HCT offer a structured approach to the phases of transition support: 1) transition and care policy, 2) tracking and monitoring, 3) transition readiness, 4) transition planning, 5) transfer of care, and 6) transfer completion. T1DX-QI institutions (n=53) were surveyed to examine the integration of the Six Core Elements into diabetes HCT practices. Results: The survey response rate was 94.3% (n=50 clinics; 33 pediatric, 17 adult). A majority of T1DX-QI pediatric clinics (72.7%, n=24) report having a HCT policy compared to 29.4% (n=5) of adult clinics. Among pediatric institutions, 45.4% (n=15) maintain a tracking system to identify transition-aged youth, 39.4% (n=13) formally assess HCT readiness, 52% (n=17) document and update a plan of care for transition and 27.3% (n=9) have a process in place to confirm successful transfer of care completion with adult diabetes providers. Approximately two-thirds of T1DX-QI pediatric institutions (63.6%, n=21) have a formal structured HCT program and 29% (n=6) of these HCT programs report incorporating all 6 elements. Conclusions: Data from T1DX-QI centers highlight opportunities to further enhance transition preparation and receivership for emerging adults with type 1 diabetes. The Six Core Elements offer a potential avenue to structure improvement initiatives since many diabetes clinics only partially incorporate these elements in current practice. Partnerships between pediatric and adult diabetes centers should be considered as part of quality improvement efforts to facilitate incorporation of challenging HCT elements such as transfer of care completion. Disclosure F.Malik: None. G.T.Alonso: None. O.Ebekozien: Advisory Panel; Medtronic, Research Support; Eli Lilly and Company, Dexcom, Inc. S.Corathers: None. T1dx-qi collaborative: n/a. J.Cases-villablanca: None. M.E.Hilliard: None. S.Lyons: None. L.M.Jacobsen: None. A.J.Roberts: None. A.Mucci: None. S.Agarwal: Advisory Panel; Medtronic, Consultant; Beta Bionics, Inc., Research Support; Abbott Diabetes, Dexcom, Inc. C.Demeterco-berggren: Speaker's Bureau; Glooko, Inc. Funding The Leona M. and Harry B. Helmsley Charitable Trust

908-P: Incorporating Shared Decision Making (SDM) to Improve Adoption of Connected Insulin Pens (CIP)

Background: CIP can improve glycemic control and quality of life for people with diabetes on multiple daily injections (MDI). Despite its benefits, providers may sub optimally prescribe CIP. The purpose of this study is to use quality improvement methods to successfully implement a validated attitude assessment to foster SDM conversations around CIP. Method: The T1D Exchange recruited seven pediatric and adult diabetes centers to participate in this project from June - November 2022. The centers applied QI principles to implement the Diabetes Technology Attitude (DTA) questionnaire, a validated tool to facilitate SDM conversations. Positive responses prompted discussion about CIP. Each center contributed their data from a sample of people with Type 1 Diabetes (T1D) and Type 2 Diabetes on Insulin (T2D) who responded to the DTA. Result: Eighty-eight people with diabetes and CGM but not on CIP naive completed the SDM tool. Over 70% of both T1D and T2D patients agreed that diabetes technology made their lives easier, does ‘more good than bad,’ and that they feel lucky to live in a time with so much technology (Figure 1). Sixty-nine percent of the cohort were prescribed CIP as a result of intentional SDM conversations based on the DTA results. Conclusion: Validated SDM tools, such as DTA, can be a viable, low burden strategy to introduce conversations on the use of diabetes technology like CIP in clinical practice. Disclosure O.Odugbesan: None. A.K.Myers: Research Support; Neurocrine Biosciences, Inc. O.Ebekozien: Advisory Panel; Medtronic, Research Support; Eli Lilly and Company, Dexcom, Inc. D.T1d exchange quality improvement collaborative (t1: n/a. N.A.Xavier: Employee; Eli Lilly and Company, Speaker's Bureau; Boehringer Ingelheim and Eli Lilly Alliance. T.Wright: None. G.Nelson: None. J.Friedman: 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. G.O'malley: Research Support; Dexcom, Inc., Abbott Diabetes, Tandem Diabetes Care, Inc., Omnipod, Eli Lilly and Company. A.M.Mckee: Advisory Panel; Medtronic, Novo Nordisk. B.Miyazaki: None. Funding Eli Lilly and Company

1044-P: Advancing Quality Improvement Culture among 27 Pediatric and Adult Diabetes Centers

Background: The T1D Exchange Quality Improvement Collaborative (T1DX-QI) is a learning health system of over fifty endocrinology centers working to improve diabetes outcomes through Quality Improvement (QI). Centers join T1DX-QI with varying levels of QI culture and are assigned a QI Coach to support practice transformation. This study summarizes the results of 27 endocrinology centers involved in the T1DX-QI for over 12 months. Method: Centers completed a 20-question self-assessment survey to measure QI culture over time in four evidence-based areas: QI Team Structure (team roles); QI Foundation (data collection and training); QI Capacity (use of QI tools); and QI Success (scaling up small tests). Data was collected in 2021 and 2022 for the same centers. The overall difference in QI Capacity was calculated using a Chi-Square test. Results: Overall, QI Culture increased from 67% to 75% from 2021 to 2022 (p-value = 0.005). Figure 1 demonstrates that improvements were seen in three of the four evidence-based areas for both pediatric and adult centers in this time. Conclusion: Even with as little as one year of involvement with the T1DX-QI, centers experience an improvement in their QI Capacity. Disclosure A.Mungmode: None. L.Chao: None. J.Ilkowitz: None. O.Ebekozien: Advisory Panel; Medtronic, Research Support; Eli Lilly and Company, Dexcom, Inc. T1dx-qi collaborative: n/a. O.Odugbesan: None. V.Elisha: None. D.W.Steenkamp: Research Support; Abbott Diabetes, Novo Nordisk. M.K.Kamboj: None. D.Desalvo: Consultant; Dexcom, Inc., Research Support; Insulet Corporation. R.Y.Sonabend: None. A.Neyman: None. P.M.Mathias: None. Funding The Leona M. and Harry B. Helmsley Charitable Trust