Feasibility of Electronic Health Record Assessment of 6 Pediatric Type 1 Diabetes Self-management Habits and Their Association With Glycemic Outcomes
Authors: Joyce M. Lee, Andrea Rusnak, Ashley Garrity, Emily Hirschfeld, Inas H. Thomas, Michelle Wichorek, Jung Eun Lee, Nicole A. Rioles, Osagie Ebekozien, Sarah D. Corathers
Journal: JAMA Network Open (2021)

<h3>Importance</h3> 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. <h3>Objective</h3> To describe the performance of these habits and examine their association with hemoglobin A<sub>1c</sub>(HbA<sub>1c</sub>) levels and time in range (TIR). <h3>Design, Setting, and Participants</h3> This cross-sectional study included individuals with known type 1 diabetes who were seen in a US pediatric diabetes clinic in 2019. <h3>Main Outcomes and Measures</h3> Habit performance, total habit score (sum of 6 habits per person), HbA<sub>1c</sub>levels, and TIR. <h3>Results</h3> 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%];<i>P</i> &lt; .001), Black vs White patients (3 [4.5%] vs 95 [9.2%];<i>P</i> &lt; .001), those with public vs private insurance (14 of 271 [5.2%] vs 91 of 941 [9.7%];<i>P</i> &lt; .001), and those with lower vs higher parental education levels (&lt;college degree vs ≥college degree: 35 of 443 [7.9%] vs 66 of 574 [11.5%];<i>P</i> &lt; .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 HbA<sub>1c</sub>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 HbA<sub>1c</sub>level (habit 1: –1.65% [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<i>P</i> &lt; .001). There were differences in HbA<sub>1c</sub>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 HbA<sub>1c</sub>levels than the demographic characteristics. <h3>Conclusions and Relevance</h3> 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.