Key points are not available for this paper at this time.
Importance: A low-burden electronic health record (EHR) workflow has been devised to systematize the collection and validation of 6 key diabetes self-management habits: (1) checks glucose at least 4 times/day or uses continuous glucose monitor (CGM); (2) gives at least 3 rapid-acting insulin boluses per day; (3) uses insulin pump; (4) delivers boluses before meals; (5) reviewed glucose data since last clinic visit, and (6) has changed insulin doses since the last clinic visit. Objective: To describe the performance of these habits and examine their association with hemoglobin A1c (HbA1c) levels and time in range (TIR). Design, Setting, and Participants: This cross-sectional study included individuals with known type 1 diabetes who were seen in a US pediatric diabetes clinic in 2019. Main Outcomes and Measures: Habit performance, total habit score (sum of 6 habits per person), HbA1c levels, and TIR. Results: Of 1344 patients, 1212 (609 50.2% males; 66 5.4% non-Hispanic Black; 1030 85.0% non-Hispanic White; mean SD age, 15.5 4.5 years) were included, of whom 654 (54.0%) were using CGM and had a TIR. Only 105 patients (8.7%) performed all 6 habits. Habit performance was lower among older vs younger patients (age ≥18 years vs ≤12 years: 17 of 411 4.1% vs 57 of 330 17.3%; P < .001), Black vs White patients (3 4.5% vs 95 9.2%; P < .001), those with public vs private insurance (14 of 271 5.2% vs 91 of 941 9.7%; P < .001), and those with lower vs higher parental education levels (<college degree vs ≥college degree: 35 of 443 7.9% vs 66 of 574 11.5%; P < .001). After adjustment for demographic characteristics and disease duration, for every 1-unit increase in total habit score, we found a mean (SE) 0.6% (0.05) decrease in HbA1c among all participants and a mean (SE) 2.86% (0.71) increase in TIR among those who used CGMs. Multiple regression models revealed that performing each habit was associated with a significantly lower HbA1c level (habit 1: -0.16% 95% CI, -1.91% to -1.37%; habit 2: -1.01% -1.34% to -0.69%; habit 3: -0.71% 95% CI, -0.93% to -0.49%; habit 4: -0.97% 95% CI, -1.21% to -0.73%; habit 5: -0.44% 95% CI, -0.71% to -0.17%; habit 6: -0.75% 95% CI, -0.96% to -0.53%; all P < .001). There were differences in HbA1c according to race, insurance, and parental education, but these associations were attenuated with the inclusion of the 6 habits, which had more robust associations with HbA1c levels than the demographic characteristics. Conclusions and Relevance: These findings suggest that a focus on increasing adherence to the 6 habits could be critical for improving disparities in glycemic outcomes; these metrics have been adopted by the Type 1 Diabetes Exchange Quality Improvement Collaborative for continuous quality improvement.
Lee et al. (Thu,) studied this question.