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. 2023 Apr 3;6(4):e238881.
doi: 10.1001/jamanetworkopen.2023.8881.

Disparities in Hemoglobin A1c Levels in the First Year After Diagnosis Among Youths With Type 1 Diabetes Offered Continuous Glucose Monitoring

Ananta Addala  1 , Victoria Ding  2 , Dessi P Zaharieva  1 , Franziska K Bishop  1 , Alyce S Adams  1   3   4   5 , Abby C King  3   6 , Ramesh Johari  7 , David Scheinker  1   5   7   8 , Korey K Hood  1   5 , Manisha Desai  2 , David M Maahs  1   3   5 , Priya Prahalad  1   5 ; Teamwork, Targets, Technology, and Tight Control (4T) Study Group
Collaborators, Affiliations

Disparities in Hemoglobin A1c Levels in the First Year After Diagnosis Among Youths With Type 1 Diabetes Offered Continuous Glucose Monitoring

Ananta Addala et al. JAMA Netw Open. .

Abstract

Importance: Continuous glucose monitoring (CGM) is associated with improvements in hemoglobin A1c (HbA1c) in youths with type 1 diabetes (T1D); however, youths from minoritized racial and ethnic groups and those with public insurance face greater barriers to CGM access. Early initiation of and access to CGM may reduce disparities in CGM uptake and improve diabetes outcomes.

Objective: To determine whether HbA1c decreases differed by ethnicity and insurance status among a cohort of youths newly diagnosed with T1D and provided CGM.

Design, setting, and participants: This cohort study used data from the Teamwork, Targets, Technology, and Tight Control (4T) study, a clinical research program that aims to initiate CGM within 1 month of T1D diagnosis. All youths with new-onset T1D diagnosed between July 25, 2018, and June 15, 2020, at Stanford Children's Hospital, a single-site, freestanding children's hospital in California, were approached to enroll in the Pilot-4T study and were followed for 12 months. Data analysis was performed and completed on June 3, 2022.

Exposures: All eligible participants were offered CGM within 1 month of diabetes diagnosis.

Main outcomes and measures: To assess HbA1c change over the study period, analyses were stratified by ethnicity (Hispanic vs non-Hispanic) or insurance status (public vs private) to compare the Pilot-4T cohort with a historical cohort of 272 youths diagnosed with T1D between June 1, 2014, and December 28, 2016.

Results: The Pilot-4T cohort comprised 135 youths, with a median age of 9.7 years (IQR, 6.8-12.7 years) at diagnosis. There were 71 boys (52.6%) and 64 girls (47.4%). Based on self-report, participants' race was categorized as Asian or Pacific Islander (19 [14.1%]), White (62 [45.9%]), or other race (39 [28.9%]); race was missing or not reported for 15 participants (11.1%). Participants also self-reported their ethnicity as Hispanic (29 [21.5%]) or non-Hispanic (92 [68.1%]). A total of 104 participants (77.0%) had private insurance and 31 (23.0%) had public insurance. Compared with the historical cohort, similar reductions in HbA1c at 6, 9, and 12 months postdiagnosis were observed for Hispanic individuals (estimated difference, -0.26% [95% CI, -1.05% to 0.43%], -0.60% [-1.46% to 0.21%], and -0.15% [-1.48% to 0.80%]) and non-Hispanic individuals (estimated difference, -0.27% [95% CI, -0.62% to 0.10%], -0.50% [-0.81% to -0.11%], and -0.47% [-0.91% to 0.06%]) in the Pilot-4T cohort. Similar reductions in HbA1c at 6, 9, and 12 months postdiagnosis were also observed for publicly insured individuals (estimated difference, -0.52% [95% CI, -1.22% to 0.15%], -0.38% [-1.26% to 0.33%], and -0.57% [-2.08% to 0.74%]) and privately insured individuals (estimated difference, -0.34% [95% CI, -0.67% to 0.03%], -0.57% [-0.85% to -0.26%], and -0.43% [-0.85% to 0.01%]) in the Pilot-4T cohort. Hispanic youths in the Pilot-4T cohort had higher HbA1c at 6, 9, and 12 months postdiagnosis than non-Hispanic youths (estimated difference, 0.28% [95% CI, -0.46% to 0.86%], 0.63% [0.02% to 1.20%], and 1.39% [0.37% to 1.96%]), as did publicly insured youths compared with privately insured youths (estimated difference, 0.39% [95% CI, -0.23% to 0.99%], 0.95% [0.28% to 1.45%], and 1.16% [-0.09% to 2.13%]).

Conclusions and relevance: The findings of this cohort study suggest that CGM initiation soon after diagnosis is associated with similar improvements in HbA1c for Hispanic and non-Hispanic youths as well as for publicly and privately insured youths. These results further suggest that equitable access to CGM soon after T1D diagnosis may be a first step to improve HbA1c for all youths but is unlikely to eliminate disparities entirely.

Trial registration: ClinicalTrials.gov Identifier: NCT04336969.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Addala reported receiving grants from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) during the conduct of the study. Dr Zaharieva reported receiving grants from the Leona M. and Harry B. Helmsley Charitable Trust, an International Society of Pediatric and Adolescent Diabetes (ISPAD)-JDRF Research Fellowship, personal fees from Medtronic, and speaking honoraria from Dexcom, Medtronic Diabetes, Ascensia Diabetes, and Insulet Canada. Dr Adams reported receiving grants from the NIDDK during the conduct of the study. Dr Johari reported receiving grants from the Stanford University Maternal and Child Health Research Institute and a Stanford Impact Labs Design Fellowship during the conduct of the study. Dr Hood reported receiving personal fees from Cecelia Health and Dexcom Inc and consulting fees from the Lilly Innovation Center, LifeScan Diabetes Institute, and MedIQ outside the submitted work. Dr Desai reported receiving grants from the National Institutes of Health (NIH) during the conduct of the study. Dr Maahs reported receiving funding support from the NIH, JDRF, National Science Foundation, and Leona M. and Harry B. Helmsley Charitable Trust; consulting fees from Abbott, the Leona M. and Harry B. Helmsley Charitable Trust, Sanofi, Novo Nordisk, Eli Lilly, and Insulet; and research support (paid to Stanford University) from Medtronic, Dexcom, Insulet, Bigfoot Biomedical, Tandem, and Roche outside the submitted work. Dr Maahs also reported serving as president of ISPAD and on the advisory boards of Medtronic, LifeScan Diabetes Institute, Sanofi, and Eli Lilly outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Hemoglobin A1c (HbA1c) Values for Youths in the Pilot-4T and Historical Cohorts Over the First 12 Months by Ethnicity and Insurance Status
A, Hispanic vs non-Hispanic ethnicity. B, Public vs private insurance. Solid lines represent the Pilot-4T cohort; dashed lines represent the historical cohort. The horizontal black dashed line indicates target HbA1c level.
Figure 2.
Figure 2.. Linear Mixed-Effects Regression Model of Linear Slopes Metrics for Youths in the Pilot-4T Cohort Comparing Hemoglobin A1c (HbA1c) Increase by Ethnicity and Insurance Status
A, Hispanic vs non-Hispanic ethnicity. B, Public vs private insurance. The analysis is adjusted for age and sex, with ethnicity and insurance status comparisons additionally adjusted for insurance status and ethnicity, respectively.
Figure 3.
Figure 3.. Continuous Glucose Monitoring (CGM) Metrics for Youths in the Pilot-4T Cohort Stratified by Ethnicity and Insurance Status
A and B, Hispanic (A) or non-Hispanic (B) ethnicity over the 12-month study period. C and D, Public insurance (C) or private insurance (D) status over the 12-month study period. The CGM metrics included sensor glucose time in range (70-180 mg/dL), hypoglycemia (54-69 mg/dL), and clinically significant hypoglycemia (<54 mg/dL). To convert glucose to mmol/L, multiply by 0.0555.
See this image and copyright information in PMC

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