Racial Disparities in Diabetes Distress and Technology Use in Adolescents with Type 1 Diabetes

December 14, 2021

Information

Annabelle Wilcox, PA-SIII

Advisor: Stuart Weinzimer, MD

ID7288

To CiteDCA Citation Guide

00:00Hello everyone so I'm Annabelle I did the
00:04alternative thesis project and so I was
00:07able to develop a project and carry it out.
00:09I'm with my advisors and I will be
00:11presenting the manuscripts today so I
00:13just want to thank my fellow Co authors,
00:15Dr Venture I'm doctor Nally and my
00:17advisor Dr Weinzimer without their
00:19support throughout the whole process.
00:22I definitely would not have made
00:23it here today so I thank them for
00:26their guidance and constant support.
00:27OK so here's the outline of the
00:30talk that I'll go through today.
00:32So starting with some background information,
00:34diabetes technology has advanced.
00:36We now have continuous glucose monitors,
00:39insulin pumps that connect to wireless
00:42devices give real time glucose data
00:44and all this technological advancement
00:46is coming at a time where there's
00:48also increasing prevalence of type
00:50one diabetes and minority youth.
00:51But despite this,
00:53and despite knowing that diabetes technology
00:55results in better outcomes lower anyone,
00:57see by better glycemic control,
01:00my minority youth are at higher risk
01:02for work short term outcomes and also
01:04less likely to be using this technology
01:07to manage their glycemic control.
01:09So study found that type one diabetes
01:12exchange pressure registry found that
01:13the odds of a white child being an
01:15insulin pump or 3.6 times higher than
01:17that of a black child and 1.9 times
01:19higher than that of a Hispanic child.
01:21So that really just shows you
01:23the disparity that exists.
01:24There's also a significant difference in
01:26anyone see between the two racial groups.
01:28Even when we control for
01:30socioeconomic status.
01:30So it seems like there's other
01:33factors that are contributing to
01:34this outside of socioeconomic status.
01:36So the question that I wanted to
01:38answer is what could be contributing.
01:40So this disparity in technology
01:42use anyone see?
01:43And that racial and ethnic
01:45minority adolescents?
01:46So one thing that's been associated
01:49with decreased adherence to treatment
01:51recommendations and a suboptimal
01:53anyone see his diabetes distress.
01:55So this is a measure of the
01:57negative emotions experience for
01:59managing and living with diabetes.
02:01It's thoughts.
02:01We do.
02:02The lack of understand from others
02:03and just the daily demands of
02:05living with a chronic illness.
02:06So there's been no studies that have
02:08directly compared diabetes distress.
02:10Between non Hispanic youth or sorry
02:12non Hispanic white youth and racial
02:15and ethnic minority adolescents.
02:17So the aim of this study was to describe
02:19the differences in diabetes technology used,
02:21IBS, stress and barriers to management
02:23between adolescents with type one diabetes.
02:26Specifically,
02:26comparing between racial and ethnic minority
02:29youth and then non Hispanic white youth.
02:32Secondarily,
02:32we also wanted to compare on the same
02:34measures between those who are using
02:36technology and not using technology,
02:38and then also between adolescents and
02:40their primary caregiver or parent.
02:43So I hypothesize that diabetes distress
02:45will be negatively associated with
02:46diabetes technology use and will be
02:48higher in the racial and ethnic minority
02:50adolescents with type one diabetes.
02:53And so quickly just to
02:54go through the methods.
02:55It was a cross sectional study design.
02:57We used Qualtrics,
02:58which is a HIPAA compliant software,
02:59and the survey was given both
03:02to parents and adolescents.
03:03Inclusion criteria was type one diabetes.
03:05But sorry, type one diabetes of at least
03:08six months in between ages of 13 and 17.
03:10And we recruited through email
03:12and phone to patients at the
03:14Yale Children Diabetes Center.
03:16Used three scales to measure diabetes,
03:18distress in various management for
03:20the paid peed scale measures diabetes,
03:22distress and adolescence.
03:23They paid.
03:24PR is the same,
03:25but for parents and then the
03:27prisms questionnaire identify
03:28specific barriers to management,
03:30so it is split into five
03:32different categories.
03:33Understanding and organizing care regimen,
03:35pain and bother health care team,
03:37family interactions and peer interactions.
03:40And so each of these questionnaires
03:41were given and they all have an
03:43established cutoff point to measure
03:45clinically significant diabetes.
03:46Stress or as a barrier as a clinically
03:49significant burden to diabetes management.
03:52I'm sorry,
03:53independent variables.
03:53We separated the adolescents
03:55into two groups based off of
03:57their self identified race,
03:58race and ethnicity.
03:59So non Hispanic white group and then
04:01the racial or ethnic minority group
04:02adolescence identified both as white
04:04as that minority were placed into
04:07the minority group for analysis,
04:09and then we made the following three
04:10comparisons so non Hispanic white
04:12versus minority diabetes technology
04:14users versus non technology users
04:16and so non or technology users was
04:18using a CGM continuous Booklist
04:19monitor and or an insulin pump put
04:21them into the technology user.
04:23And then parents versus adolescence.
04:27We measured diabetes,
04:29technology use diabetes outcome
04:31variable SO81C DK and then the
04:34diabetes distress and barrier
04:36skills that I just went through.
04:39And we used SAS for data analysis.
04:44I'm set to go through the
04:47results of the adolescents.
04:48We had 45 complete the survey,
04:5128 of who identified as non Hispanic white
04:54and 17 as a racial or ethnic minority.
04:57Comparing the demographics
04:58between the two groups,
04:59there was no significant difference in age,
05:01income or insurance status
05:02between the non Hispanic,
05:04white and minority adolescents.
05:05But it is important to note that
05:08in our sample both groups had as
05:11income on average higher than 75,000
05:14and were most or most commonly
05:15to have private health insurance.
05:20So comparing the diabetes technologies
05:22between our racial and ethnic groups,
05:24there was no significant difference
05:26in overall diabetes technology used.
05:28So looking just at whether or not they
05:30used any technology versus no technology.
05:32But when we compare it,
05:33specific diabetes technology combinations,
05:35we did find a significant difference.
05:38So the minority group,
05:39which is highlighted in yellow and a
05:41non spanic white which is in green.
05:43They might already be for far less likely
05:44to be using diabetes technology for both
05:46aspects of their diabetes management.
05:48So for using both the CGI Vanderpump.
05:50And they were more likely to be using
05:52technology for only one or the other.
05:56We asked adolescents for reasons,
05:57but behind nonuser discontinuation
05:59of diabetes technology and in
06:01the non Hispanic White Group,
06:02it was exclusively due
06:03to personal preference.
06:04But in the minority group,
06:05the reasons were a little bit more complex,
06:08so they cited insurance coverage issues,
06:10provider recommendations,
06:11difficulty with the device,
06:12or difficulty with diabetes management.
06:17So comparing diabetes, distress and
06:19outcome variables between the two groups,
06:20there was a significant difference
06:22in anyone see which is consistent
06:23with previous literature.
06:25So we're not or are minor minority group had
06:27a higher A1C than honest panic White Group,
06:30but there was no significant difference
06:33in diabetes distress for any of the
06:35barriers on the PRISM questionnaire.
06:37However, there was a very high
06:38overall rate of diabetes.
06:39Distress in both groups,
06:40so 86% of the non Hispanic White Group
06:43and 82% of the minority group met clinical
06:46significance for diabetes distress.
06:48And then similarly on the prison question,
06:50there was a high rate of adolescents
06:53that met diabetes distress for all the
06:54categories except for health care team
06:56was only one that wasn't the majority.
07:00Comparing between technology user
07:01versus non technology user groups,
07:03again there was a significant
07:04difference in A1C between the two.
07:06So the non technology users had
07:08a significantly higher A1C but no
07:10difference in diabetes distress and
07:12then looking at specific burdens.
07:14The only significant difference was
07:16understanding and organizing care.
07:18So the non technology user groups
07:19found that as a more significant
07:21burden to their diabetes management.
07:25And then finally comparing
07:27adolescents versus parents.
07:28So there was a significant difference
07:30here between now and diabetes distress.
07:32So the adolescents had a much higher
07:34rate of clinically significant,
07:36clinically significant diabetes,
07:38distress, then the parent group did.
07:41And then comparing the specific barriers,
07:43the adolescent scored much higher for
07:45family interactions as a contributing
07:48barrier to their diabetes management.
07:50This is again just shows that
07:52difference between adolescent in Paris,
07:53so adolescent and orange,
07:54parent in blue.
07:55And then we have positive diabetes distress
07:57on the left hand side of the graph.
07:59So 82% of adolescents and only
08:0115% of parents met clinically
08:03significant diabetes distress.
08:06So the conclusions that we were able to
08:08draw from this our population show that
08:10there was a difference in technology,
08:12user groups or technology you use with
08:14the minority group less likely to be
08:16using technology for both aspects of their
08:19diabetes management and having a higher A1C.
08:21This is consistent with
08:23previous literature and so,
08:24and they also cited more complex regional
08:27reasons behind NONUSER discontinuation.
08:29So in the clinical setting it's important
08:31to identify this and identify reasons
08:33behind non use or discontinuation in
08:35the minority population or better.
08:37Understand what's resulting in that
08:38and able to help them implement
08:41technology into their care.
08:42If that will give them,
08:43give them improved management.
08:46And we also saw a very high frequency
08:49of diabetes distress across both
08:50groups of our adolescents.
08:52So this shows that this is a significant
08:54mental burden of managing diabetes,
08:56and it may be impacted glucose control
08:58and quality of life amongst all
09:00adolescents with type one diabetes
09:02and the reason behind this might be
09:04universal stressors that are crossing
09:06both racial and ethnic boundaries.
09:08So that might be social stigma or fear
09:12of feeling different from their peers.
09:16And diarrhea stress in these
09:17various management are modifiable,
09:18so we're able to identify them
09:20in the clinical setting,
09:21there's the potential to help improve
09:23support for adolescents with type one
09:25diabetes and identify those that are
09:27having higher rates of diabetes distress,
09:29so we can help give them more support and
09:32improve their glycemic control and then,
09:35between comparing between adolescents
09:36and their parents,
09:38is another tool that can be very
09:39helpful in the clinical setting
09:41on parents are often the primary
09:43caregiver and support for children.
09:44So when it's high discrepancy and diabetes.
09:46Stress there's the potential to improve
09:49understanding of that discrepancy and
09:51support for adolescents as they make
09:53that transition from childhood into
09:55adulthood while managing a chronic disease.
09:58And then finally,
09:59it's important to note that while
10:01these the advancements in technology
10:03are improving by segment control
10:05or associated with a lower A1C,
10:07and they're not enough to mitigate
10:08diabetes distress,
10:09and that was seen in our study here.
10:11So family support and communication
10:14remains essential even as we
10:16continue to advance technology.
10:19So some future directions,
10:20just further research on both patients
10:23and providers to understand why there
10:25may be provider recommendations against
10:27discontinuation of technology and
10:29minority and and other reasons that
10:32are resulting in the discrepancy and
10:35then also including a diversity and
10:37diabetes treatment settings and locations.
10:38So we only recruited from Yale,
10:40which is a large academic center
10:42in a high high use of technology.
10:44But comparing other areas would also
10:47benefit to be able to make that comparison.
10:49And understand where the disparities
10:52are occurring.
10:52And then also assessing diabetes
10:54test with a qualitative study can
10:56help understand what specifically
10:57is contributing to the high rate
10:59of diabetes distress.
11:00So here are some strengths and
11:01just to highlight a couple,
11:02it was the first study that
11:04compared diabetes distress between
11:05ontspanning white and minority adolescents.
11:07And then we also included both
11:09parents and adolescents into once
11:10we're able to directly compare
11:12their level of diabetes distress.
11:16Some limitations are here again
11:17just to highlight a couple of them.
11:19We only recruited patients that
11:21had scheduled appointments,
11:22so this may be missing patients
11:23that have high level diabetes,
11:24distress or not using technology
11:27we only recruited from Yale,
11:28so again that has a potentially
11:30has a higher rate of diabetes
11:32technology then it's representative
11:33of the minority population.
11:35Our survey was only in English
11:36so that limits anyone who is non
11:38English speaking and then it was
11:40administered during the pandemic so
11:41that also may be contributing to a
11:43high level of distress in adolescence.
11:47Here are my references.
11:48Just a big thank you to Rosanna
11:49and Megan for all their support
11:51with alternative thesis.
11:52I really appreciate you giving
11:54us the opportunity to pursue it.