Identifying and Reducing Disparities in Outcomes Among Economically Vulnerable and Minority Young Adults with Type 1 Diabetes

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There is a critical need to further understand disparities in care and improve outcomes in young adults (YA) with type 1 diabetes (T1D) of low socioeconomic (SES) and minority status. Only 13% of YA (ages 18-30) with T1D nationally achieve the American Diabetes Association-recommended HbA1c target of <7.0%, substantially increasing long-term risk exposure and mortality later in life. Young adults have unique challenges, including the developmental transition to adulthood and healthcare transition to adult care, making it a critical period to intervene early. Compared to their white peers, YA with T1D of low SES and minority race/ethnicity are at disproportionately higher risk for adverse outcomes, including worse glycemic control and increased rates of recurrent diabetic ketaoacidosis and psychiatric comorbidity. This may be in part due to unrecognized and unaddressed social determinants of health. Despite these stark discrepancies and poor overall outcomes in YA, very little research has focused on these high-risk YA with T1D. Thus, the overall objectives of this proposal are to 1) identify social determinants of health that contribute to poor outcomes in high-risk YA with T1D and 2) develop and implement innovative tailored solutions to address disparities that extend beyond the traditional healthcare environment. Shivani Agarwal, M.D., M.P.H. is an adult endocrinologist and early diabetes and health services researcher who has previously developed a successful adult-based healthcare transition intervention for YA with T1D, which will be enhanced to address high-risk YA needs based on information gleaned from this proposal. In Specific Aim 1, data from YA in the national T1D Exchange Clinic Network will be used to identify social determinants that impact glycemic control in low SES and minority compared to higher SES non-minority YA with T1D. In Specific Aim 2, qualitative interviews will be conducted locally to determine care-related needs and challenges for high-risk YA with T1D, and solicit potential solutions. In Specific Aim 3, based upon an improved understanding of how social determinants affect care engagement, care processes, and glycemic control in high-risk YA with T1D, Dr. Agarwal will use a multidisciplinary multiple stakeholder advisory panel to enhance her transition intervention model to address disparities. She will also test the enhanced intervention’s efficacy on retention in adult care in a pilot randomized controlled trial. When complete, these studies will offer new insight on meaningful, addressable determinants of health in high-risk YA with T1D, to inform a new model for healthcare transition to address disparities. This work will form the basis for an R01 application of a multi-site randomized controlled trial testing the efficacy of a comprehensive diabetes transition program against usual care. Dr. Agarwal seeks to acquire important skills in disparities and diabetes investigation in addition to quantitative, qualitative, and intervention methods through the proposed career development award. Her ultimate goal is to become an independent disparities and health services investigator focused on improving health in young adult diabetes populations.