{"doi":"10.1001/jamanetworkopen.2023.8881","title":"Disparities in Hemoglobin A<sub>1c</sub> Levels in the First Year After Diagnosis Among Youths With Type 1 Diabetes Offered Continuous Glucose Monitoring","abstract":"<jats:sec><jats:title>Importance</jats:title><jats:p>Continuous glucose monitoring (CGM) is associated with improvements in hemoglobin A<jats:sub>1c</jats:sub> (HbA<jats:sub>1c</jats:sub>) 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.</jats:p></jats:sec><jats:sec><jats:title>Objective</jats:title><jats:p>To determine whether HbA<jats:sub>1c</jats:sub> decreases differed by ethnicity and insurance status among a cohort of youths newly diagnosed with T1D and provided CGM.</jats:p></jats:sec><jats:sec><jats:title>Design, Setting, and Participants</jats:title><jats:p>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.</jats:p></jats:sec><jats:sec><jats:title>Exposures</jats:title><jats:p>All eligible participants were offered CGM within 1 month of diabetes diagnosis.</jats:p></jats:sec><jats:sec><jats:title>Main Outcomes and Measures</jats:title><jats:p>To assess HbA<jats:sub>1c</jats:sub> 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.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>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 HbA<jats:sub>1c</jats:sub> 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 HbA<jats:sub>1c</jats:sub> 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 HbA<jats:sub>1c</jats:sub> 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%]).</jats:p></jats:sec><jats:sec><jats:title>Conclusions and Relevance</jats:title><jats:p>The findings of this cohort study suggest that CGM initiation soon after diagnosis is associated with similar improvements in HbA<jats:sub>1c</jats:sub> 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 HbA<jats:sub>1c</jats:sub> for all youths but is unlikely to eliminate disparities entirely.</jats:p></jats:sec><jats:sec><jats:title>Trial Registration</jats:title><jats:p>ClinicalTrials.gov Identifier: <jats:ext-link xmlns:xlink=\"http://www.w3.org/1999/xlink\" ext-link-type=\"uri\" xlink:href=\"https://clinicaltrials.gov/ct2/show/NCT04336969\">NCT04336969</jats:ext-link></jats:p></jats:sec>","journal":"JAMA Network Open","year":2023,"id":611560,"datarank":0.5375278407684165,"base_score":3.58351893845611,"endowment":3.58351893845611,"self_citation_contribution":0.5375278407684165,"citation_network_contribution":0.0,"self_endowment_contribution":0.5375278407684165,"citer_contribution":0.0,"corpus_percentile":null,"corpus_rank":null,"citation_count":35,"citer_count":0,"citers_with_citation_signal":0,"citers_with_endowment":0,"datacite_reuse_total":0,"is_dataset":false,"is_dataset_confidence":null,"is_data_producer":false,"deposit_databanks":null,"is_oa":false,"file_count":0,"downloads":0,"has_version_chain":false,"published_date":null,"fair_score":null,"fair_percentile":null,"algorithm_id":"datarank_citation_only_1hop_v6","ranking_scope":"data_only","authors":[{"id":1573993,"name":"Victoria Ding","orcid":null,"position":1,"is_corresponding":false},{"id":645923,"name":"Dessi P. Zaharieva","orcid":"0000-0002-9374-8469","position":2,"is_corresponding":false},{"id":903751,"name":"Franziska K. Bishop","orcid":"0009-0001-3089-9454","position":3,"is_corresponding":false},{"id":625300,"name":"Alyce S. Adams","orcid":"0000-0002-0146-4996","position":4,"is_corresponding":false},{"id":817,"name":"Abby C. King","orcid":null,"position":5,"is_corresponding":false},{"id":645924,"name":"Ramesh Johari","orcid":"0000-0002-3960-0770","position":6,"is_corresponding":false},{"id":277073,"name":"David Scheinker","orcid":"0000-0001-5885-8024","position":7,"is_corresponding":false},{"id":515288,"name":"Korey K. Hood","orcid":"0000-0001-5730-7749","position":8,"is_corresponding":false},{"id":818,"name":"Manisha Desai","orcid":"0000-0002-6949-2651","position":9,"is_corresponding":false},{"id":42063,"name":"David M. Maahs","orcid":"0000-0002-4602-7909","position":10,"is_corresponding":false},{"id":645921,"name":"Priya Prahalad","orcid":"0000-0002-3894-4344","position":11,"is_corresponding":false},{"id":1573994,"name":"Nora Arrizon-Ruiz","orcid":null,"position":13,"is_corresponding":false},{"id":903750,"name":"Erica Pang","orcid":"0000-0001-8387-224X","position":14,"is_corresponding":false},{"id":1573995,"name":"Ana Cortes","orcid":null,"position":15,"is_corresponding":false},{"id":1573996,"name":"Andrea Bonilla-Ospina","orcid":null,"position":16,"is_corresponding":false},{"id":1025548,"name":"Rachel Tam","orcid":"0009-0009-8556-1109","position":17,"is_corresponding":false},{"id":1573997,"name":"Ilenia Balistreri","orcid":null,"position":18,"is_corresponding":false},{"id":1573998,"name":"Alondra Loyola","orcid":null,"position":19,"is_corresponding":false},{"id":1573999,"name":"Noor Alramahi","orcid":null,"position":20,"is_corresponding":false},{"id":600377,"name":"Eliana Frank","orcid":null,"position":21,"is_corresponding":false},{"id":1574000,"name":"Jeannine Leverenz","orcid":null,"position":22,"is_corresponding":false},{"id":1295900,"name":"Piper Sagan","orcid":null,"position":23,"is_corresponding":false},{"id":1574001,"name":"Anjoli Martinex-Singh","orcid":null,"position":24,"is_corresponding":false},{"id":1295903,"name":"Annette Chmielewski","orcid":null,"position":25,"is_corresponding":false},{"id":1295902,"name":"Barry Conrad","orcid":null,"position":26,"is_corresponding":false},{"id":1574002,"name":"Kim Clash","orcid":null,"position":27,"is_corresponding":false},{"id":1574003,"name":"Julie Senaldi","orcid":null,"position":28,"is_corresponding":false},{"id":1574004,"name":"Molly Tanenbaum","orcid":null,"position":29,"is_corresponding":false},{"id":1109602,"name":"Ransalu Senanayake","orcid":null,"position":30,"is_corresponding":false},{"id":933473,"name":"Ryan Pei","orcid":null,"position":31,"is_corresponding":false},{"id":1574005,"name":"Esli Osmanlliu","orcid":null,"position":32,"is_corresponding":false},{"id":576912,"name":"Annie Chang","orcid":"0000-0003-4692-6338","position":33,"is_corresponding":false},{"id":933072,"name":"Paul Dupenloup","orcid":"0000-0003-2584-080X","position":34,"is_corresponding":false},{"id":1250614,"name":"Jamie Kurtzig","orcid":null,"position":35,"is_corresponding":false},{"id":437498,"name":"Victor Ritter","orcid":"0000-0002-1676-9573","position":36,"is_corresponding":false},{"id":1292423,"name":"Blake Shaw","orcid":"0000-0002-0640-8985","position":37,"is_corresponding":false},{"id":900448,"name":"Emily Fox","orcid":"0000-0001-9415-4956","position":38,"is_corresponding":false},{"id":62276,"name":"Carlos Guestrin","orcid":"0000-0001-6348-5939","position":39,"is_corresponding":false},{"id":1574006,"name":"Johannes Ferstad","orcid":null,"position":40,"is_corresponding":false},{"id":1574007,"name":"Juan Langlios","orcid":null,"position":41,"is_corresponding":false},{"id":919915,"name":"Alex Wang","orcid":"0000-0002-7646-6611","position":42,"is_corresponding":false},{"id":1574008,"name":"Josesph Futoma","orcid":null,"position":43,"is_corresponding":false},{"id":1574009,"name":"Matthew Levine","orcid":null,"position":44,"is_corresponding":false},{"id":1327604,"name":"Arpita Singhal","orcid":"0000-0002-6515-6474","position":45,"is_corresponding":false},{"id":1410663,"name":"Yujin Jeong","orcid":"0009-0001-6669-5285","position":46,"is_corresponding":false},{"id":1574010,"name":"Matthew McKay","orcid":null,"position":47,"is_corresponding":false},{"id":1574011,"name":"Nataglie Pageler","orcid":null,"position":48,"is_corresponding":false},{"id":1574012,"name":"Simrat Ghuman","orcid":null,"position":49,"is_corresponding":false},{"id":1574013,"name":"Michelle Wiedmann","orcid":null,"position":50,"is_corresponding":false},{"id":378292,"name":"Connor Brown","orcid":"0000-0002-9113-6979","position":51,"is_corresponding":false},{"id":1574014,"name":"Bredan Watkins","orcid":null,"position":52,"is_corresponding":false},{"id":1109604,"name":"Glenn Loving","orcid":null,"position":53,"is_corresponding":false},{"id":515289,"name":"Diana Naranjo","orcid":"0000-0001-8039-0616","position":54,"is_corresponding":false},{"id":294877,"name":"Ananta Addala","orcid":"0000-0002-0508-4309","position":0,"is_corresponding":false}],"reference_count":0,"raw_metadata":{"has_enrichment":true,"resolved":true,"title":"Disparities in Hemoglobin A<sub>1c</sub> Levels in the First Year After Diagnosis Among Youths With Type 1 Diabetes Offered Continuous Glucose Monitoring","abstract":"<jats:sec><jats:title>Importance</jats:title><jats:p>Continuous glucose monitoring (CGM) is associated with improvements in hemoglobin A<jats:sub>1c</jats:sub> (HbA<jats:sub>1c</jats:sub>) 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.</jats:p></jats:sec><jats:sec><jats:title>Objective</jats:title><jats:p>To determine whether HbA<jats:sub>1c</jats:sub> decreases differed by ethnicity and insurance status among a cohort of youths newly diagnosed with T1D and provided CGM.</jats:p></jats:sec><jats:sec><jats:title>Design, Setting, and Participants</jats:title><jats:p>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.</jats:p></jats:sec><jats:sec><jats:title>Exposures</jats:title><jats:p>All eligible participants were offered CGM within 1 month of diabetes diagnosis.</jats:p></jats:sec><jats:sec><jats:title>Main Outcomes and Measures</jats:title><jats:p>To assess HbA<jats:sub>1c</jats:sub> 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.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>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 HbA<jats:sub>1c</jats:sub> 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 HbA<jats:sub>1c</jats:sub> 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 HbA<jats:sub>1c</jats:sub> 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%]).</jats:p></jats:sec><jats:sec><jats:title>Conclusions and Relevance</jats:title><jats:p>The findings of this cohort study suggest that CGM initiation soon after diagnosis is associated with similar improvements in HbA<jats:sub>1c</jats:sub> 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 HbA<jats:sub>1c</jats:sub> for all youths but is unlikely to eliminate disparities entirely.</jats:p></jats:sec><jats:sec><jats:title>Trial Registration</jats:title><jats:p>ClinicalTrials.gov Identifier: <jats:ext-link xmlns:xlink=\"http://www.w3.org/1999/xlink\" ext-link-type=\"uri\" xlink:href=\"https://clinicaltrials.gov/ct2/show/NCT04336969\">NCT04336969</jats:ext-link></jats:p></jats:sec>","is_dataset_classified":null,"base_score":3.58351893845611,"endowment":3.58351893845611,"datacite_reuse_total":0,"file_count":0,"downloads":0,"views":0,"has_version_chain":false,"is_dataset":false,"is_oa":false,"pmid":"37074715","pmcid":"PMC10116368","openalex_id":"https://openalex.org/W4366352301","authors":[],"funders":[{"funder_name":"NIDDK NIH HHS","grant_id":"P30 DK116074","title":null},{"funder_name":"NCATS NIH HHS","grant_id":"UL1 TR003142","title":null},{"funder_name":"NIDDK NIH HHS","grant_id":"R18 DK122422","title":null},{"funder_name":"NIDDK NIH HHS","grant_id":"P30 DK092924","title":null},{"funder_name":"National Institutes of Health","grant_id":"5P30DK116074-04","title":"Stanford Diabetes Research Center"},{"funder_name":"National Institutes of Health","grant_id":"5UL1TR001085-05","title":"Spectrum Stanford Center for clinical and Translational Research and Education"},{"funder_name":"National Institutes of Health","grant_id":"1R18DK122422-01A1","title":"Teamwork, Targets, Technology, and Tight Control in Newly Diagnosed Pediatric T1D: 4T Study"},{"funder_name":"National Institutes of Health","grant_id":"5P30DK092924-08","title":"Health Delivery Systems Center for Diabetes Translational Research"},{"funder_name":"National Institutes of Health","grant_id":"1R01AG071490-01A1","title":"Testing Multi-Level Remote Physical Activity Interventions in a National Sample of Older Women: The WHISH EnCore Trial"},{"funder_name":"National Institutes of Health","grant_id":"5K12DK122550-04","title":"Training Research Leaders in Type 1 Diabetes"},{"funder_name":"National Institutes of Health","grant_id":"3K23DK131342-03S1","title":"Reducing Disparities in Pediatric Diabetes: Building the Evidence Base to Inform Effective Diabetes Technology Interventions in Underrepresented Minorities"}],"total_grants":11,"fwci":5.88,"citation_percentile":0.97123269,"influential_citations":0,"citation_trend":[{"year":2023,"count":6},{"year":2024,"count":12},{"year":2025,"count":11},{"year":2026,"count":6}],"oa_status":"gold","license":"cc-by","oa_locations":[{"url":"https://jamanetwork.com/journals/jamanetworkopen/articlepdf/2803949/addala_2023_oi_230284_1681222987.14898.pdf","host_type":"journal"},{"url":"https://jamanetwork.com/journals/jamanetworkopen/articlepdf/2803949/addala_2023_oi_230284_1681222987.14898.pdf","host_type":"publisher"},{"url":"https://doi.org/10.1001/jamanetworkopen.2023.8881","host_type":"journal"},{"url":"https://pubmed.ncbi.nlm.nih.gov/37074715","host_type":"repository"},{"url":"https://www.ncbi.nlm.nih.gov/pmc/articles/10116368","host_type":"repository"},{"url":"https://europepmc.org/articles/PMC10116368","host_type":"Europe_PMC"},{"url":"http://dx.doi.org/10.1001/jamanetworkopen.2023.8881","host_type":""}],"fields_of_study":["Diabetes Management and Research","Hyperglycemia and glycemic control in critically ill and hospitalized patients","Diabetes and associated disorders","03 medical and health sciences","0302 clinical medicine","Male","Child","Female","Humans","Adolescent","Diabetes Mellitus, Type 1","Glycated Hemoglobin","Hypoglycemic Agents","Blood Glucose","Cohort Studies","Blood Glucose Self-Monitoring"],"mesh_terms":["Adolescent","Blood Glucose","Child","Diabetes Mellitus, Type 1","Female","Glycated Hemoglobin","Humans","Hypoglycemic Agents","Male","Blood Glucose Self-Monitoring","Cohort Studies"],"keywords":["Hemoglobin","Continuous glucose monitoring","Type 2 diabetes","Diabetes mellitus","Medicine","Plasma glucose","Type 1 diabetes","Hemoglobin A","Environmental health","Internal medicine","Endocrinology","Male","Glycated Hemoglobin","Blood Glucose","Adolescent","Blood Glucose Self-Monitoring","Cohort Studies","Diabetes Mellitus, Type 1","Humans","Hypoglycemic Agents","Female","Child","Original Investigation"],"sdg_mappings":[{"sdg_number":3,"sdg_label":"3. 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