Summary

Responding to the challenge of equitable onboarding of children and young people (CYP) with type 1 diabetes (T1D) to Automated Insulin Delivery (AID) systems, the team at Birmingham Children’s Hospital designed a hybrid model of diabetes education. It blends digital and face-to-face flipped learning, improving glucose management and equitable access across diverse patient demographics. The results demonstrate equal glucose control across ethnic groups, socioeconomic strata, and school age. A training package based on the model has been used across the CYP Networks and internationally.

Innovation

2022 analysis showed that 44 children and CYP with T1D onboarded were predominantly from white, middle-class backgrounds. At a November 2022 service improvement meeting, objectives were set: by November 2024, ensure every CYP desiring an AID system can access one, tripling the monthly onboarding rate from four to 12 CYP, and ensure onboarding reflects the demographic 60% from ethnic minority groups and 60% from the most deprived socioeconomic quintiles. The team drew on ‘CGM Academy’ success that highlighted the necessity of providing equitable educational support rather than mere equality. More CYP from ethnic minority backgrounds and very disadvantaged social circumstances require intensive, tailored educational interventions. Conversely, CYP with families with higher educational levels could use self-directed learning through a flipped classroom model. For those capable of independent learning, a competency-based educational approach was introduced, utilising Google Forms, a comprehensive workbook and a succinct ‘Survive and Thrive’ (S&T) guide. For those needing more direct support, face-to-face education was provided with interpreters, using the same materials but with personalised support. HCP tools were developed, such as starting dose calculators and interactive assessment tools. To measure effectiveness, a comparative analysis was made between CYP onboarded before the hybrid model (pre-April 2023) (Group A) and those onboarded in the six months after (April-September 2023) (Group B).

Equality, Diversity and Variation

Although only 38% of the cohort were white, they constituted 60% of the CYP onboarded. Additionally, half came from the two least-deprived quintiles, despite making up only 10% of the cohort. Three barriers were noted. First, CYP from less educated and non-native-language-speaking families struggled with the prerequisite tasks necessary for onboarding, such as understanding detailed processes and completing competency-based activities. Second, the previous face-to-face educational approach spanned five sessions per AID onboarding, limiting capacity and inadvertently favouring those more educationally capable. Third, there was unequal access to smartphones. CYP from disadvantaged backgrounds should not be stigmatised but supported more robustly with pre-onboarding tasks. The new model combines virtual, self-guided education for those who can navigate the onboarding process, with enhanced, personalised support for those who need it. This support includes completing preparatory work alongside them, facilitating interactions with interpreters and ensuring materials are accessible. Patients selected their AID system during an in-person session before implementing the virtual hybrid model. However, those without a compatible mobile phone faced limited options, preventing the AID system from automatically uploading data. These patients had to visit the centre to download data from their devices, creating an unintentional disparity in support and choice for families unable to afford mobile phones. In April 2023, 30 phones were purchased with charity funds, enabling patients to select any AID system and benefit from automatic uploads. This significantly improved access for 25 most-deprived families. A charity grant secured an additional 40 phones – part of an ongoing plan to purchase 20 phones per year.

Results

Group A comprised 74 CYP (53% male) with median age of 13.9 years and Group B 91 CYP (54% male) with median age of 12.7 years. From baseline to 90-days, Group A lowered mean time above range (TAR, >10.0 mmol/L) from 47.6% to 33.2% and increased time in range (TIR, 3.9-10.0 mmol/L) from 50.4% to 64.7%. From baseline to 90 days, Group B lowered TAR from 51.3% to 34.5% and increased TIR from 46.5% to 63.7%. There was no difference from baseline to 90 days for time below range (<3.9 mmol/l) for Group A and Group B. TAR, TIR and TBR for both groups were comparable. Group B consisted of CYP with higher socioeconomic deprivation, greater ethnic diversity, and lower carer education achievement. Most of Group B (n=79, 87%) chose virtual flipped-learning, halving diabetes educator time and increasing onboarding cadence five-fold. Therefore, the new programme increased onboarding cadence and capacity to offer equitable AID system onboarding. Enhancing equity in access to hybrid closed loop (HCL) systems using the model achieved a 16% improvement in TIR (3.9-10.0 mmol/L). Retrospective analysis (2019-2024) of CYP transitioning from CGM to HCL considered data on demographics and glucose metrics collected from patient records and manufacturers’ online databases. Ninety-day CGM data pre- and post-HCL were compared. A total of 169 CYP (53% male) with mean age of 12.4 years and T1D duration of 6.0 years were included. The majority (n=95/56%) were of non-white ethnicity [South Asian (SA), n=59/35% and Black (B), n=26/15%] and 44% White (W) (n=74). Categories were: most deprived (T1, n=56/33%), second most deprived (T2, n=56/33%), least deprived (T3, n=57/34%), with 20 (12%) CYP who required an interpreter. At baseline, W, SA and B had comparable TBR, TIR and mean blood glucose (MBG). After 90 days of HCL, these groups had comparable TBR, TIR and MBG. At baseline, T1, T2 and T3 had similar TBR, TIR and MBG. After 90 days of HCL, there were no significant differences for TBR, TIR and MBG across T1, T2 and T3, respectively. These results show that equitable onboarding to CGM and HCL reduced ethnic and socioeconomic disparities in glucose control among CYP with T1D.

User Feedback

Engagement with all stakeholders throughout ensured that the programme was tailored to the needs of CYP and their families and supported by HCPs. Engaging with 10 CYP and their families already using AID systems was critical. Their feedback was invaluable, particularly their suggestion to condense the workbook into the S&T guide.

Dissemination and Sustainability

The results were published in BMJ Diabetes Research & Care, shared at conferences, ICB meetings, the CYP Network National HCL Study Day (2023) and the National Canadian Pediatric Diabetes Study Day (2024). Access was provided to all generic, adaptable materials, further supporting international outreach. A ‘Train the Trainers’ initiative is planned by the national CYP Network Technology group.