FQHC Intervention for CGM Uptake in Hispanic Adults with T1D

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Abstract Low-income Hispanic adults with type 1 diabetes (T1D) experience a disproportionate burden of life-threatening, acute complications, both hypoglycemia and diabetes ketoacidosis, with high rates of related emergency department visits, hospitalizations, and death. Use of continuous glucose monitoring (CGM) may mitigate these inequities. Yet, Hispanics with T1D have exceptionally low levels of CGM use. This reflects social determinants of health (SODH), as framed by the multiple levels of the Socio-Ecological Model (SEM). The SEM’s healthcare provider level is a main driver in Hispanic disenfranchisement from CGM. With a severe shortage of endocrinologists, primary care providers are increasingly managing T1D although a high majority report inadequate confidence in titrating insulin and using CGM. With limited access to endocrinology, low-income, Hispanic adults with T1D thus often receive diabetes management in federally qualified health centers (FQHCs) with scant or no access to CGM. Hence, to foster equitable uptake of CGM in the most vulnerable Hispanic adults with T1D, a 4-year, mixed-methods, feasibility study with a pilot randomized controlled trial (RCT) is proposed to primarily assess the feasibility of the SEM-guided intervention (targeting the individual, family/social networks, and healthcare provider levels). The individual level of the intervention fosters essential acquisition of information, motivation, and behavioral skills for CGM uptake through two approaches: (1) 4-week, personalized, CGM sessions with a RN certified in diabetes education; and (2) followed by peer education visits between data collection points. The family/social networks level leverages the core Hispanic values of familismo and collectivismo to promote critical support in CGM uptake with a family member co-attending the 4-week sessions and participant engagement with a peer educator during scheduled visits, respectively. The provider level of the intervention is designed to promote enhanced cultural competency in intervention delivery and provide clinical support for CGM informed by rigorous training in T1D management and CGM via Project ECHO. In study phase 1 (Aim 1), the intervention, informed by stakeholder qualitative findings, will be refined and RCT deployment will be planned with 4 FQHC sites randomized to deliver the intervention (n=2) or control (n=2) conditions with a total enrollment goal of 30 Hispanics with T1D (sites having roughly equivalent enrollment rates). Project ECHO: CGM & T1D Care will also be delivered to intervention site providers. In phase 2 (Aim 2), the feasibility of the study protocol (e.g., recruitment and retention yields, data collection procedures, intervention implementation, and intervention acceptability, among others) will be routinely assessed. In phase 2 (Aim 3), significant intervention signals in terms of physiological (e.g., A1C and time within, above, and below range), psychosocial (e.g., quality of life, family support, physician trust), and behavioral (CGM adherence) outcomes from baseline to 3- and 6- months postbaseline will be assessed. The long-term goal of this study is to inform a large, multi-site RCT, and with successful results, provide a model for CGM uptake in Hispanic adults with T1D for FQHCs nationally