Insulin Pump Use Research Articles

511-P: Perspective on Technology Training in Individuals with Type 1 Diabetes

The importance of training on diabetes technology has significantly changed with rapidly increasing use of technology in diabetes care, including use of insulin pumps, continuous glucose monitors, and automated insulin delivery (AID) systems. This study aimed to assess patient perspectives on technology training, and how nutrition, exercise and other aspects of health are discussed during healthcare appointments. We conducted an IRB approved 42 question online survey for people living with type 1 diabetes (T1D) . Participants were recruited from the T1D Exchange Online Community by email over a 3 week period. Survey questions covered education on diabetes technology, nutrition, mental health and other medical conditions. Of the 666 adult respondents, 581 reported receiving care from an endocrinologist and 533 used an insulin pump. With regard to advanced pump features, 55% reported their provider educated them on use of temporary basal rates for exercise, while 38% learned about temporary rates from a T1D online community, and 6.2% learned from a friend. Less than 50% of participants using an AID system talked with their provider about settings adjustments around exercise. Provider education around nutrition focused mainly on carb counting vs. other topics (low carb diet, food choices, effect on blood sugar; p=0.03) . Only 30% reported receiving education from their provider on use of advanced pump features around meals, and only 13% reported their provider discussed healthy eating often or always at clinic visits. Participants expressed a strong desire to receive education on low carb diets and different food choices as their primary need. People with T1D continue to seek and receive advice for important topics related to diabetes management from online communities. They also seek information regarding nutrition and technology that is not discussed frequently at visits with their provider. Further development of educational materials for providers and people with T1D should address these needs. Disclosure C.C.Andre: None. X.Liao: None.

49-LB: Use of Financial Incentives to Promote Adolescent Type 1 Diabetes Self-Management—A Pilot Randomized Controlled Trial

Background: Providing individuals with immediate, consistent inducements for health behaviors that do not provide proximal tangible benefits may promote adherence to diabetes self-management behaviors. Objective: To evaluate whether financial incentives lead to improvement in glycemic control and self-management behaviors in adolescents with type 1 diabetes. Methods: We conducted a randomized controlled crossover study with 12-18 year olds with type 1 diabetes. Adolescents self-selected target self-management behaviors (e.g., increase continuous glucose monitor [CGM] sensor wear time) and outcome goals (e.g., improve time in range [TIR]) and could earn up to $180 in each 3-month intervention cycle. Adolescents cycled through 3 study arms every 3 months: gain-framed payment where adolescents earned money for meeting behavioral goals, loss-framed payment where adolescents lost a portion of a weekly payment for not meeting behavioral goals, and usual care. Adolescents earned or lost $1.75 per day in the financial incentives arms, and a $2.75 weekly bonus for meeting their outcome-based goal. Goals were modeled against study arms with generalized linear mixed models to account for the longitudinal nature of the crossover design. Results: Out of 39 participants (mean age 16.1 years, 54% male, mean baseline HbA1c 9.42%, 38% insulin pump use, 95% CGM use) , 34 completed the trial. Mean HbA1c aggregated over all interventions was lower compared to baseline at 9.07% (p=0.13) and there was no difference in HbA1c among the 3 arms. Compared to the mean TIR for those under usual care of 39%, mean TIR under gain- and loss-frames were 45% (p<0.01) and 43% (p<0.01) , respectively. Compared to a mean 41% behavioral goal attainment within usual care, mean behavioral goal attainment under gain- and loss-frames were 50% (p<0.01) and 45% (p<0.01) , respectively. Conclusions: Financial incentives can improve adolescent self-management behaviors and time in range in the short term and merits further longitudinal study to evaluate the effects on glycemic control and health care utilization. Disclosure F. Malik: n/a. T. Chen: None. M. Manzueta: None. J. Yi-frazier: None. C. Pihoker: None. J. L. Leblanc: None. S. K. Shah: None. D. Wright: None. Funding American Diabetes Association (1-18-ICTS-100)

97-LB: The DERMIS Study—Preliminary Evaluation of Skin Changes at Continuous Subcutaneous Insulin Infusion (CSII) Sites in Type 1 Diabetes (T1D)

Background: CSII is used with increased frequency; however, there are no studies evaluating human skin histology related to its use. Objectives: 1) to investigate the skin histology and metabolite changes at CSII sites and 2) associate possible changes with clinical characteristics in a cohort of patients with T1D. Methods: We conducted a cross-sectional study which included individuals with T1D using CSII. Skin and blood samples in addition to clinical data were collected. Histological, immunohistochemical (IHC) , and metabolomic analyses were performed using skin biopsies from three sites: 1) current 2) recent and 3) never used site (control) for CSII. Results: A total of 30 participants were enrolled in the study (age 48.3 ± 17.9 years, female 66.7%, diabetes duration 30.4 ± 16.0 years, insulin pump use 15.7 ± 11.7 years, BMI 25.3 ± 3.4 kg/m2, HbA1c 6.66 ± 0.79%, mean glucose from CGM 150.7 ± 26.4 mg/dL, coefficient of variation 31.2 ± 4.4%, insulin dose 0.53 ± 0.17 IU/kg) . Histologic data showed a significant increase in inflammation, fibrin, fat necrosis, vascularity, eosinophils, and IHC staining of IGF-1 and TGFβ3 at both CSII sites compared to control sites (all p<0.001) . Targeted tissue analysis demonstrated an increase in critical metabolites at current sites compared to control, including histamine (p=0.013) , uracil (p<0.001) , and a trend in UDP-GlcNAc (p=0.063) . Inflammation is positively correlated with insulin dose (p=0.005) , in addition to mean glucose (p<0.01) and coefficient of variation (p<0.01) from the CGM. Conclusion: Biologic changes were observed in skin histology and metabolites at CSII sites that may be associated with inflammation, oxidative stress response, protein synthesis and wound healing. These could have a clinical impact on insulin availability and diabetes control. Disclosure J. D. Baran: n/a. D. Khakpour: None. A. Kalus: None. M. Shinohara: Other Relationship; Aztex, Cabaletta Bio, Elorac. X. Dong: None. D. S. Hippe: Research Support; Canon America Medical Systems, GE Healthcare Systems, Philips Healthcare. I. B. Hirsch: Consultant; Abbott Diabetes, Bigfoot Biomedical, Inc., GWave, Roche Diabetes Care, Research Support; Beta Bionics, Inc., Insulet Corporation, Medtronic. Funding Leona M. and Harry B. Helmsley Charitable Trust

1152-P: Achieving Diabetic Management Targets in People with Type 1 Diabetes

Background: Optimal diabetes care and risk factor management are important to delay micro- and macrovascular complications in individuals with type 1 diabetes (T1D) . Ongoing improvement of management strategies requires the evaluation of target achievement and identification of determinants in individuals who do (or do not) achieve these targets. Methods: Cross-sectional data were collected from individuals with T1D visiting Diabeter and the University Medical Center Groningen, the Netherlands, in 2018. Targets were defined as HbA1c <7%, LDL-c <2.6mmol/l (no CVD present) or <1.8mmol/l (CVD present) , or blood pressure (BP) <140/90mmHg. Determinants between individuals who did (or did not) achieve targets were compared by presence of CVD. Results: Data from 1,737 individuals were available. Mean age was 27 [IQR 22-43] years and 50% female. Mean HbA1c was 63 mmol/mol (7.9%) , LDL-c was 2.67mmol/l, and BP 131/76mmHg. In individuals with CVD, 24%, 33%, and 46% achieved HbA1c, LDL-c, and BP targets respectively. In individuals without CVD these percentages were, 29%, 54%, and 77%, respectively. Individuals with CVD who did or did not achieve HbA1c targets did not differ significantly. Individuals who achieved LDL-c targets had a longer diabetes duration (42 vs. 37 years, p=0.03) , lower eGFR (eGFR 56 vs. 70 ml/min/kg2) and were prescribed more lipid lowering medication (94% vs. 77%, p=0.05) . Individuals who achieved BP targets were younger (58 vs. 62 years, p=0.05) . In comparison, individuals without CVD who achieved HbA1c targets differed in age (28 vs. 25 years, p=<.001) , sex (45% vs. 53% female, p=0.02) , and insulin pump use (60% vs 52%, p=0.01) amongst others. Those who achieved LDL-c targets had lower BMI (24.1 vs. 26.1kg/m2, p=<.001) . BP targets were achieved by younger individuals with less microvascular complications (14% vs. 33%, p=<.001) . Conclusions: Opportunities for improvement diabetes management exist for the achievement of glycaemic, lipid and BP targets but differ between individuals with and without CVD. Disclosure R.D.M.Varkevisser: None. E.Birnie: None. C.E.Vollenbrock: None. D.Mul: None. P.Van dijk: None. M.M.Van der klauw: Advisory Panel; Pfizer Inc. H.J.Veeze: Employee; Medtronic. H.Aanstoot: Consultant; Lilly Diabetes, Medtronic. B.H.Wolffenbuttel: Advisory Panel; Novo Nordisk A/S, Other Relationship; Novo Nordisk.

1004-P: Executive Dysfunction Predicts Lower Self-Care Readiness in Teens with Type 1 Diabetes

Aim: Management of type 1 diabetes (T1D) is a complex multi-step process in which executive function (EF) skills (planning, organization, problem solving) are critical for optimal control. In teens with T1D, EF may be important in transitioning from parent-supervised care to self-care. Methods: In an 18-month study, teens aged 13-17 years with T1D and parents completed the Diabetes Family Responsibility Questionnaire (DFR) and Readiness for Independent Self-Care Questionnaire (RISQ) every 6 months. Teen EF was assessed by parent proxy-report using Behavior Rating Inventory of Executive Function (BRIEF) . T-score ≥60 defined risk of executive dysfunction for the Global EF Composite (GEC) , Behavioral Regulation Index (BRI) and Metacognition Index (MI) . EF, demographic, and T1D treatment variables were used to predict change in RISQ over time using longitudinal mixed models with false discovery rate adjustment. Results: 169 teens (54% male) participated with baseline age 15.9±1.3 years, T1D duration 8.4±3.7 years, HbA1c 8.6±1.2%, 74.6% insulin pump use, and 21.3% continuous glucose monitor (CGM) use. 31.4% of teens had a parent-reported GEC score ≥60. After adjusting for age, gender, and parent-reported DFR (pDFR) , those with GEC ≥60 had parent-reported RISQ (pRISQ) 4.1 points lower than those with GEC <60, p=0.016. BRI (adjusted for age, CGM use, pDFR, and HbA1c) did not predict change in pRISQ while MI (adjusted for age, gender, and pDFR) did; those with MI ≥60 had pRISQ 5.3 points lower than those with MI <60, p<0.001. In models using teen-reported DFR and RISQ (tRISQ) , GEC and MI similarly predicted lower tRISQ. In all models, lower age (p<0.05) and greater parent involvement (p<0.001) also predicted lower RISQ. Conclusion: EF, especially metacognition, appears important for acquisition of self-care behaviors for teens with T1D. Evaluating EF during adolescence may identify teens with executive dysfunction who may need extra support during the transition process. Disclosure R.J.Vitale: None. L.J.Tinsley: None. L.K.Volkening: None. L.M.Laffel: Advisory Panel; Medtronic, Roche Diabetes Care, Consultant; Boehringer Ingelheim International GmbH, Dexcom, Inc., Dompé, Insulet Corporation, Janssen Pharmaceuticals, Inc., Lilly Diabetes, Novo Nordisk, Provention Bio, Inc. Funding NIH T32DK007529NIH P30DK036836NIH R01DK095273JDRF 2-SRA-2014-253-M-B

580-P: Clinical and Psychological Differences in Depression in Distressed Teens with Type 1 Diabetes (T1D)

Introduction: Teens with T1D are at risk for depression and diabetes distress. While diabetes distress is typically more predictive of A1C, less is known about teens experiencing both concerns. In teens with T1D with elevated diabetes distress, we explored clinical and psychological differences between those with or without depression. Methods: At baseline of a psychosocial intervention trial, teens (N=173) with PAID-T scores ≥30 (elevated diabetes distress) reported demographics and Patient Reported Outcomes (PROs) of depression, general/T1D resilience, diabetes quality of life (QoL) , and family conflict. A1C and pump use were extracted from medical records. Using Fisher’s exact, X-square, and Wilcoxon rank sum tests, we compared demographics, pump use, A1C, and PROs by depression status (clinical cutoff of PHQ-8 ≥10) . Results: Distressed teens with depression (34%) were more likely to be female and have unemployed caregivers. Compared to participants without depression, distressed teens with depression reported lower resilience and QoL and higher distress and family conflict. There were no differences in mean HbA1c or insulin pump use. Conclusions: Screening for depression is an important clinical initiative-teens with general and T1D-specific mood concerns are at risk for multiple psychosocial challenges that may warrant intervention and may be impacted by social determinants of health. Disclosure S.R.Scott: None. J.Yi-frazier: None. M.B.O'donnell: None. C.Zhou: None. F.Malik: n/a. C.Pihoker: None. D.Desalvo: Consultant; Dexcom, Inc., Insulet Corporation, Research Support; Insulet Corporation. M.Bradford: None. A.Rosenberg: None. M.E.Hilliard: None. Funding NIH 1R01DK121224-01

282-OR: The Emotional Burden of Diabetes during Emerging Adulthood: “Cost. Everything Else Is Secondary.”

Emerging adults (EA) with type 1 diabetes (T1D) have multiple developmental stage-specific challenges in diabetes management, including the transition to financial independence. The recently validated Problem Areas in Diabetes-EA (PAID-EA) survey is the first measure of diabetes distress (DD) in EA to include financial concerns. A sample of 287 participants with T1D ages 18-30 years completed an online survey including the 25-item PAID-EA, measures of DD and depressive symptomology, and clinical and demographic questions. To evaluate content validity, 2 open-ended questions asked for the most important worry mentioned and what worries were missed in the questions. Responses were analyzed using directed qualitative content analysis. As cost emerged as a major contributor to DD, responses to the PAID-EA item 21 (“I worry about the cost of diabetes”) were analyzed using Chi-square or Fisher’s exact test to assess participant factors associated with cost-related DD. Most participants (89%) provided open-ended responses (78% female, mean age 24 years) . Cost was the most frequent code in the qualitative analysis: 15% reported DD related to cost and 6% to insurance. Responses included worries about aging out of parents’ insurance and limitations on career choices to ensure payment for diabetes supplies. In all survey respondents, 90% replied “Agree” or “Somewhat agree” to PAID-EA item 21. Responses to this item did not differ by gender, age (< vs. >=25) , continuous glucose monitor use (Y/N) , insulin pump use (Y/N) , student status (full time vs. part time vs. no) , income (< vs ≥$75k) , or insurance status (parent vs. own vs. uninsured) . A greater proportion of those with HbA1c ≥ 7% endorsed worry about cost than with HbA1c < 7% (94% vs. 87%, p = 0.008) . Diabetes cost was a major contributor to DD in this sample of EA with T1D. Worry about diabetes costs was endorsed by nearly all participants, especially those not meeting glycemic targets. Managing the cost of diabetes care for EA may be an avenue to reduce DD. Disclosure R.J.Vitale: None. K.Wentzell: None. L.M.Laffel: Advisory Panel; Medtronic, Roche Diabetes Care, Consultant; Boehringer Ingelheim International GmbH, Dexcom, Inc., Dompé, Insulet Corporation, Janssen Pharmaceuticals, Inc., Lilly Diabetes, Novo Nordisk, Provention Bio, Inc. Funding NIH T32DK007260NIH T32DK007529NIH P30DK036836

53-OR: Diabetes Stigma and Clinical Outcomes in Adolescents and Young Adults: The SEARCH for Diabetes in Youth Study

We examined the association between diabetes stigma and glycemic control, treatment regimen, and acute and chronic complications in adolescents and young adults (AYAs) with type 1 (T1D) and type 2 diabetes (T2D) in the SEARCH for Diabetes in Youth Study, 2016-2019. A 5-question survey assessed frequency of perceived stigma experience, from which we created a total stigma score. We used multivariable linear modeling, stratified by T1D and T2D, to examine the association of diabetes stigma with clinical factors, adjusting for sociodemographic, clinic site, duration of diabetes, health insurance type, treatment regimen, and HbA1c. Of 16respondents, 78% had T1D, 56% were female, and 48% were non-Hispanic White. Mean (SD) age at study visit was 21.7 (5.1) years (range - 24.9 years) . Mean (SD) HbA1c was 9.2% (2.3) . Higher stigma scores were associated with female sex and higher HbA1c (both p <0.01, table) . No statistically significant association between stigma score and insulin pump or continuous glucose monitor use was observed. In participants with T2D, higher stigma scores were associated with insulin use (p = 0.04) . Independent of HbA1c, higher stigma scores were associated with acute complications for AYAs with T1D and chronic complications for AYAs with T1D and T2D (table) . Diabetes stigma in AYAs is associated with worse diabetes outcomes and therefore is important to address in diabetes care. Disclosure K.B.Eitel: None. E.T.Jensen: Consultant; Regeneron Pharmaceuticals Inc. A.D.Liese: None. S.M.Marcovina: None. E.J.Mayer-davis: None. K.Reynolds: Research Support; Amgen Inc., Merck & Co., Inc., Novartis Pharmaceuticals Corporation. C.Pihoker: None. A.J.Roberts: None. R.Dagostino: Consultant; Aetion, Inc., AstraZeneca, Biogen, Bristol-Myers Squibb Company, Daiichi Sankyo, Merck & Co., Inc. R.A.Bell: None. A.Bellatorre: None. C.E.Barrett: None. A.Cristello: None. D.Dabelea: None. L.M.Dolan: None. Funding The SEARCH for Diabetes in Youth Cohort Study (1R01DK127208-01, 1UC4DK108173) is funded by the National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases and supported by the Centers for Disease Control and Prevention.

Persistent Socioeconomic Disparities in Insulin Pump Uptake Despite Universal Health Coverage—Nonmonetary Drivers in Insulin Pump Use

Persistent Socioeconomic Disparities in Insulin Pump Uptake Despite Universal Health Coverage—Nonmonetary Drivers in Insulin Pump Use

Diabetes Education and Support Tele-Visit Needs Differ in Duration, Content, and Satisfaction in Older Versus Younger Adults.

Background:Diabetes education and support are critical components of diabetes care. During the COVID-19 pandemic, when telemedicine took the place of in-person visits, remote Certified Diabetes Care and Education Specialist (CDCES) services were offered to address diabetes education and support. Specific needs for older adults, including the time required to provide education and support remotely, have not been previously reported.Methods:Adults with diabetes (primarily insulin-requiring) were referred to remote CDCESs. Utilization was individualized based on patient needs and preferences. Topics discussed, patient satisfaction, and time spent in each tele-visit were evaluated by diabetes type, age, sex, insurance type, glycosylated hemoglobin (HbA1c), pump, and continuous glucose monitor (CGM) usage. t-Tests, one-way analysis of variance, and Pearson correlations were employed as appropriate.Results:Adults (n = 982; mean age 48.4 years, 41.0% age ≥55 years) with type 1 diabetes (n = 846) and type 2 diabetes mellitus (n = 136, 86.0% insulin-treated), 50.8% female; 19.0% Medicaid, 29.1% Medicare, 48.9% private insurance; mean HbA1c 8.4% (standard deviation 1.9); and 46.6% pump and 64.5% CGM users had 2203 tele-visits with remote CDCESs over 5 months. Of those referred, 272 (21.7%) could not be reached or did not receive education/support. Older age (≥55 years), compared with 36–54 year olds and 18–35 year olds, respectively, was associated with more tele-visits (mean 2.6 vs. 2.2 and 1.8) and more time/tele-visits (mean 20.4 min vs. 16.5 min and 14.8 min; p < 0.001) as was coverage with Medicare (mean 2.8 visits) versus private insurance (mean 2.0 visits; p < 0.001) and lower participant satisfaction. The total mean time spent with remote CDCESs was 53.1, 37.4, and 26.2 min for participants aged ≥55, 36–54, and 18–35 years, respectively. During remote tele-visits, the most frequently discussed topics per participant were CGM and insulin pump use (73.4% and 49.7%). After adjustment for sex and diabetes type, older age was associated with lack of access to a computer, tablet, smartphone, or internet (p < 0.001), and need for more education related to CGM (p < 0.001), medications (p = 0.015), hypoglycemia (p = 0.044), and hyperglycemia (p = 0.048).Discussion:Most remote CDCES tele-visits were successfully completed. Older adults/those with Medicare required more time to fulfill educational needs. Although 85.7% of individual sessions lasted <30 min, which does not meet current Medicare requirements for reimbursement, multiple visits were common with a total time of >50 min for most older participants. This suggests that new reimbursement models are needed. Education/support needs of insulin-treated older adults should be a focus of future studies.

362 Group Model Building to characterize the experiences of older adults with type 1 diabetes (T1D) with continuous glucose monitoring (CGM) therapy and uncover suboptimal response patterns

OBJECTIVES/GOALS: As the number of older adults (≥65 years) with T1D grows, there are limited data to guide care. In a six-month trial, CGM reduced hypoglycemia in older adults, yet there are challenges for widespread uptake. Our objective is to characterize older adults experiences with using CGM and define suboptimal responses signaling a need for resources or support. METHODS/STUDY POPULATION: The study will engage key stakeholders (i.e., older adults with T1D, caregivers [recruited as patient-caregiver dyads], and providers [endocrinologists, geriatricians, diabetes educators]) for a Group Model Building (GMB). GMB is a participatory approach to system dynamics in which participants share perceptions and experiences with a problem and collaboratively explore the system structure that shapes those trends. A series of 8 GMB workshops will be held with 3-8 participants. The final study n will be determined by thematic saturation. Workshops comprise 1) a questionnaire, 2) a GMB session, and 3) a focus group discussion. GMB will follow a replicable process to generate a model of the complex web of causal determinants affecting CGM-related experiences, including optimal and suboptimal CGM responses. RESULTS/ANTICIPATED RESULTS: To date, the study has enrolled 33 participants, including 28 older adults living with T1D and 5 caregivers (mean age = 74 years, range 67-83 years). Twenty-four patient participants will be active CGM users and 4 will be CGM non-users. The study will report on patient data capture from the questionnaire and EMR, including demographics, experiences, familiarity, and confidence surrounding CGM use; diabetes duration; insulin pump use; history of severe hypoglycemia. Analysis of aggregated data will generate causal loop diagrams that integrate pertinent theoretical frameworks, lived experiences, and CGM outcomes. Maps will be used to identify a set of suboptimal CGM responses (i.e., key outcome trajectories) that signal a need for action, with a diagram of factors that interact to produce each response. DISCUSSION/SIGNIFICANCE: Delivering CGM to older adults with T1D demands new approaches. This study will yield critical evidence to tailor support and resources for effective CGM use in older adults. Findings may be translated into suite of pragmatic interventions to bolster CGM use and matched to individual patients expected to benefit using a precision medicine framework.

Associations of insulin pump and continuous glucose monitoring use with pregnancy-related outcomes in women with type 1 diabetes

AimsTo examine insulin pump and continuous glucose monitoring (CGM) use with pregnancy-related outcomes in women with type 1 diabetes. MethodsWe abstracted medical records of 646 pregnancies in 478 women with type 1 diabetes, with information on insulin pump versus multiple daily injection (MDI) use and CGM use. We analyzed the associations of pump vs. MDI use, CGM use vs. non-use and pregnancy-related outcomes using mixed effect models. ResultsPump use was associated with lower HbA1c levels in the first [β (95% CI) = -0.33 (-0.51, −0.15) %] and second trimester [β (95% CI) = -0.13 (-0.24, −0.02) %], increased birth weight [β (95% CI) = 0.14 (0.02, 0.26) kg], birth weight percentile [β (95% CI) = 4.87 (0.49, 9.26) %], higher odds of large for gestational age [OR (95% CI) = 1.65 (1.06, 2.58)] and macrosomia [OR (95% CI) = 1.81 (1.03, 3.18)]. CGM use was associated with lower first [β (95% CI) = -0.38 (-0.64, −0.13) %] and third trimester [β (95% CI) = -0.17 (-0.33, −0.00) %] HbA1c levels. ConclusionsWomen with type 1 diabetes who used pump or CGM had better glycemic control during pregnancy; however, pump use was associated with higher birth weight measures.

Insulin Pump-related Inpatient Admissions in a National Sample of Youth With Type 1 Diabetes.

Insulin pump use in type 1 diabetes management has significantly increased in recent years, but we have few data on its impact on inpatient admissions for acute diabetes complications. We used the 2006, 2009, 2012, and 2019 Kids' Inpatient Database to identify all-cause type 1 diabetes hospital admissions in those with and without documented insulin pump use and insulin pump failure. We described differences in (1) prevalence of acute diabetes complications, (2) severity of illness during hospitalization and disposition after discharge, and (3) length of stay (LOS) and inpatient costs. We identified 228 474 all-cause admissions. Insulin pump use was documented in 7% of admissions, of which 20% were due to pump failure. The prevalence of diabetic ketoacidosis (DKA) was 47% in pump nonusers, 39% in pump users, and 60% in those with pump failure. Admissions for hyperglycemia without DKA, hypoglycemia, sepsis, and soft tissue infections were rare and similar across all groups. Admissions with pump failure had a higher proportion of admissions classified as major severity of illness (14.7%) but had the lowest LOS (1.60 days, 95% CI 1.55-1.65) and healthcare costs ($13 078, 95% CI $12 549-$13 608). Despite the increased prevalence of insulin pump in the United States, a minority of pediatric admissions documented insulin pump use, which may represent undercoding. DKA admission rates were lower among insulin pump users compared to pump nonusers. Improved accuracy in coding practices and other approaches to identify insulin pump users in administrative data are needed, as are interventions to mitigate risk for DKA.

An Opportunity for Improvement: Evaluation of Diabetes Technology Education Among Adult Endocrinology Training Programs.

Despite increases in continuous glucose monitor (CGM) and insulin pump use in adults with diabetes, there is room for expansion. Technology adoption may be influenced by the training environment and fellowship education. However, little is known about adult endocrinology trainee comfort with, understanding of, or methods by which trainees receive education about diabetes technology. Mixed methods, sequential explanatory evaluation using survey and semi-structured interviews of endocrinology trainees and fellowship leadership in Accreditation Council for Graduate Medical Education (ACGME)-accredited adult endocrinology fellowship programs to assess trainee and leadership comfort with, perceived knowledge of, and current methods for diabetes technology education. Seventy-seven respondents completed the survey. The majority of training programs have curricula for training on insulin pumps (74%) and CGM (75.3%); 52% of fellows felt curricula are adequate. First- and second-year fellows were more comfortable with CGM than insulin pump use. Only half of third-year fellows felt comfortable with starting insulin pump therapy or recommending insulin dose adjustments based on CGM rate of change arrows. Qualitative interviews identified the importance of both direct instruction and experiential learning in diabetes technology education. Almost half of trainees feel that curricula for learning to use and manage insulin pumps and CGM are inadequate and feel uncomfortable with critical aspects of technology use, demonstrating the need for increased attention to trainee education in the use of diabetes technology. Based on a better understanding of current and preferred methods for instruction, this study provides direction for future development of initiatives to improve fellow education in this field.

2021 Clinical Practice Guidelines for Diabetes Mellitus in Korea

The Committee of Clinical Practice Guidelines of the Korean Diabetes Association (KDA) updated the previous clinical practice guidelines for Korean adults with diabetes and prediabetes and published the seventh edition in May 2021. We performed a comprehensive systematic review of recent clinical trials and evidence from real-world practice among the Korean population. The guidelines are intended for use at sites across the country by all healthcare providers (including physicians, diabetes experts, and certified diabetes educators) who treat diabetes. The recommendations for screening and antihyperglycemic agents have been revised and updated. Continuous glucose monitoring with insulin pump use and screening and treatment for non-alcoholic fatty liver disease were added in the type 2 diabetes sections. The KDA recommends active vaccination for COVID-19 in patients with diabetes. An abridgement that contains practical information for patient education and systematic clinic management was published separately.

Inequity in Adoption of Advanced Diabetes Technologies Among Medicare Fee-for-service Beneficiaries.

Health inequity is often associated with race-ethnicity. To determine the prevalence of insulin pump therapy and continuous glucose monitoring (CGM) among Medicare beneficiaries with type 1 diabetes (T1D) by race-ethnicity, and to compare diabetes-related technology users with nonusers. The prevalence of technology use (pump, CGM) was determined by race-ethnicity for enrollees in coverage years (CY) 2017-2019 in the Medicare fee-for-service database. Using CY2019 data, technology users were compared with nonusers by race-ethnicity, sex, average age, Medicare eligibility criteria, and visit to an endocrinologist. Community. Beneficiaries with T1D and at least 1 inpatient or 2 outpatient claims in a CY. Pump or CGM therapy, visit to an endocrinologist. Diabetes-related technology use by race-ethnicity groups. Between 2017 and 2019, CGM and insulin pump use increased among all groups. Prevalence of insulin pump use was < 5% for Black and Other beneficiaries yet increased from 14% to 18% among White beneficiaries. In CY2019, 57% of White patients used a pump compared with 33.1% of Black and 30.3% of Other patients (P < 0.001). Black patients were more likely than White patients to be eligible because of disability/end-stage renal disease or to be Medicare/Medicaid eligible (both P < 0.001), whether using technology or not. Significant race-ethnicity differences (P < 0.001) existed between technology users and nonusers for all evaluated factors except visiting an endocrinologist. Significant race-ethnicity associated differences existed in T1D management. The gap in diabetic technology adoption between Black and White beneficiaries grew between 2017 and 2019.

Practical aspects of diabetes technology use: Continuous glucose monitors, insulin pumps, and automated insulin delivery systems

There have been tremendous advances in diabetes technology in the last decade. Continuous glucose monitors (CGM), insulin pumps, and automated insulin delivery (AID) systems aim to improve glycemic control while simultaneously decreasing the burden of diabetes management. Although diabetes technologies have been shown to decrease both hypoglycemia and hyperglycemia and to improve health-related quality of life in individuals with type 1 diabetes, the impact of these devices in individuals with cystic fibrosis-related diabetes (CFRD) is less clear. There are unique aspects of CFRD, including the different underlying pathophysiology and unique lived health care experience and comorbidities, that likely affect the use, efficacy, and uptake of diabetes technology in this population. Small studies suggest that CGM is accurate and may be helpful in guiding insulin therapy for individuals with CFRD. Insulin pump use has been linked to improvements in lean body mass and hemoglobin A1c among adults with CFRD. A recent pilot study highlighted the promise of AID systems in this population. This article provides an overview of practical aspects of diabetes technology use and device limitations that clinicians must be aware of in caring for individuals with CF and CFRD. Cost and limited insurance coverage remain significant barriers to wider implementation of diabetes technology use among patients with CFRD. Future studies exploring strategies to improve patient and CF provider education about these devices and studies showing the effectiveness of these technologies on health and patient-reported outcomes may lead to improved insurance coverage and increased rates of uptake and sustained use of these technologies in the CFRD community.

Sex differences over time for glycemic control, pump use and insulin dose in patients aged 10–40 years with type 1 diabetes: a diabetes registry study

IntroductionTo evaluate sex differences in people with type 1 diabetes concerning changes in glycemic control and trends in insulin pump use and insulin dose over two decades in adolescents and...

AACE2021-A-1011: Recurrent Diabetic Ketoacidosis: Can We Prevent It?

Diabetic ketoacidosis begets another attack. It's often a challenge in treating diabetic children. Factors associated with recurrent diabetic ketoacidosis include psychological disturbance, depression, antidepressant use, abnormal eating pattern, social deprivation, female sex especially in teen age, and uncontrolled diabetes. Recurrent diabetic ketoacidosis is an independent predictor of short term mortality at 2-6 years. This retrospective study included review of medical records of 32 type 1 diabetic patients, 19 females and 13 males who were admitted with diabetic ketoacidosis to King Fahad hospital, Madina, Saudi Arabia. They aged 14 to 32 years. Data included for each patient included age, sex, number of attacks of diabetic ketoacidosis in last 2 years (from August 2018 to August 2020), HbA1c, and use of insulin pump or antidepressants. All cases presented with metabolic ketoacidosis and ketonuria. The largest number of attacks was 4 admissions per year in a female who was on antidepressant and has HbA1c 10.4% in her last admission. The mean HbA1c in females was 9.45% and in males 9.59%. 4 female patients are on insulin pump and 2 female patients have end stage renal disease. Adverse effects of recurrent diabetic ketoacidosis admissions include social burden, economic cost and patient morbidity/mortality. Suggested strategy for prevention of recurrent diabetic ketoacidosis include education of patient and care givers, multidisciplinary team composed of endocrinologist/diabetologist, dietician, psychiatrist, psychologist, social worker and diabetic educator. Continuous glucose monitors can also prevent or reduce recurrence of diabetic ketoacidosis.

Outcomes of hybrid closed-loop insulin delivery activated 24/7 versus evening and night in free-living prepubertal children with type 1 diabetes: A multicentre, randomized clinical trial.

To assess the safety and efficacy of hybrid closed-loop (HCL) insulin delivery 24/7 versus only evening and night (E/N), and on extended 24/7 use, in free-living children with type 1 diabetes. Prepubertal children (n=122; 49 females/73 males; age, 8.6± 1.6 years; diabetes duration, 5.2± 2.3 years; insulin pump use, 4.6± 2.5 years; HbA1c 7.7% ± 0.7%/61 ± 5 mmol/mol) from four centres were randomized for 24/7 versus E/N activation of the Tandem Control-IQ system for 18 weeks. Afterwards, all children used the activated system 24/7 for 18 more weeks. The primary outcome was the percentage of time spent in the 70-180 mg/dL glucose range (TIR). HCL was active 94.1% and 51.1% of the time in the 24/7 and E/N modes, respectively. TIR from baseline increased more in the 24/7 versus the E/N mode (52.9%± 9.5% to 67.3%± 5.6% [+14.4%, 95% CI 12.4%-16.7%] vs. 55.1%± 10.8% to 64.7%± 7.0% [+9.6%, 95% CI 7.4%-11.6%]; P= .001). Mean percentage time below range was similarly reduced, from 4.2% and 4.6% to 2.7%, and the mean percentage time above range decreased more in the 24/7 mode (41.9% to 30.0% [-11.9%, 95% CI 9.7%-14.6%] vs. 39.8% to 32.6% [-7.2%, 95% CI 5.0%-9.9%]; P= .007). TIR increased through the whole range of baseline levels and always more with 24/7 use. The results were maintained during the extension phase in those initially on 24/7 use and improved in those with initial E/N use up to those with 24/7 use. Neither ketoacidosis nor severe hypoglycaemia occurred. The current study shows the safety and efficacy of the Tandem Control-IQ system in free-living children with type 1 diabetes for both E/N and 24/7 use; 24/7 use shows better outcomes, sustained for up to 36 weeks with no safety issues.