Carla Demeterco-Berggren

The 2026 U.S. approval of teplizumab, for children and adolescents aged 8–17 years with recently diagnosed stage 3 type 1 diabetes, changes the first weeks after diagnosis. Clinicians must treat hyperglycemia and teach lifelong care skills while considering whether to preserve residual β-cell function. Teplizumab is the current clinical exemplar, although the implementation challenges extend beyond one agent. This article addresses who should lead care, how to approach eligibility and timing, how to assess β-cell reserve and infection risk, how to sequence treatment with diabetic ketoacidosis recovery and early education, and how to monitor treatment safely. Teplizumab-specific recommendations are identified, with broader principles framed for adaptation across health systems.

Most diabetes care is delivered in primary care, yet diabetes technologies remain inconsistently integrated. Workforce, training, time, data infrastructure, and insurance barriers contribute to inequitable access and adoption. This scientific statement provides evidence-informed recommendations for integrating diabetes technology into primary care practices. The American Diabetes Association (ADA) convened an interdisciplinary panel that met in person at the Diabetes Technology Meeting in October 2025. Panelists reviewed available evidence, published between 2020 and 2025, on diabetes technology implementation in primary care, with a focus on clear statements and recommendations addressing technology access and adoption, team-based workflows, continuous glucose monitoring, connected insulin delivery, and implementation barriers and opportunities. Virtual meetings were convened over the next 2 months to further develop and finalize statements and recommendations. Together, the ADA and interdisciplinary panel developed 16 consensus statements and 10 key recommendations. Diabetes technologies can be safely and effectively integrated into primary care practices when supported by standardized workflows, appropriate training, defined team roles, and access to specialty expertise. Equitable implementation also requires addressing coverage, affordability, digital literacy, broadband access, interoperability, and workforce development. Integrating diabetes technology into primary care is feasible and necessary to advance equitable, person-centered, data-informed care. Health systems, practices, payors, professional organizations, manufacturers, and policymakers should align resources, training, workflows, payment, and infrastructure to support sustainable implementation and improve outcomes for people with diabetes.

Most diabetes care is delivered in primary care, yet diabetes technologies remain inconsistently integrated. Workforce, training, time, data infrastructure, and insurance barriers contribute to inequitable access and adoption. This scientific statement provides evidence-informed recommendations for integrating diabetes technology into primary care practices. The American Diabetes Association (ADA) convened an interdisciplinary panel that met in person at the Diabetes Technology Meeting in October 2025. Panelists reviewed available evidence, published between 2020 and 2025, on diabetes technology implementation in primary care, with a focus on clear statements and recommendations addressing technology access and adoption, team-based workflows, continuous glucose monitoring, connected insulin delivery, and implementation barriers and opportunities. Virtual meetings were convened over the next 2 months to further develop and finalize statements and recommendations. Together, the ADA and interdisciplinary panel developed 16 consensus statements and 10 key recommendations. Diabetes technologies can be safely and effectively integrated into primary care practices when supported by standardized workflows, appropriate training, defined team roles, and access to specialty expertise. Equitable implementation also requires addressing coverage, affordability, digital literacy, broadband access, interoperability, and workforce development. Integrating diabetes technology into primary care is feasible and necessary to advance equitable, person-centered, data-informed care. Health systems, practices, payors, professional organizations, manufacturers, and policymakers should align resources, training, workflows, payment, and infrastructure to support sustainable implementation and improve outcomes for people with diabetes.

Objective: This pilot project served as a proof of concept to assess the operational feasibility of integrating presymptomatic type 1 diabetes screening and monitoring, using islet autoantibody (AAB) testing, into routine clinical care at two pediatric T1D Exchange Quality Improvement Collaborative (T1DX-QI) centers. Additionally, it identified care team perceptions of operational challenges and surveyed healthcare teams’ readiness in the T1DX-QI. Research design and methods: Over an 18-month period, this initiative focused on developing and optimizing workflows, provider and patient education, technological integration, and health equity, utilizing quality improvement methodologies. Focus groups were conducted to identify care team perceptions of operational challenges via Zoom. Prior to project start, a cross-sectional survey was administered among T1DX-QI centers to assess screening and monitoring readiness. Results: Workflows for screening and monitoring were tested over time at the two centers, both developing process maps. A total of 147 individuals were screened during 12 months of active screening. No episodes of diabetes-related ketoacidosis were reported among those screened with confirmed positive results. Key facilitators of implementation identified during focus groups included enhanced interdisciplinary communication, streamlined insurance processes, and improvements to electronic health record systems. Challenges included limited clinical resources, variable patient engagement, and inconsistent insurance coverage. Readiness survey results highlighted that pediatric centers were twice as likely to conduct screening and reported greater access to results from research screening programs. Conclusions: Findings from this pilot offer critical insights into the practical implementation of presymptomatic type 1 diabetes screening and monitoring programs in diverse clinical environments. Despite identified barriers, continuous quality improvement efforts, along with identified facilitators to success, led to an increase in the number of individuals screened and monitored. Future work will focus on expanding these efforts across diverse care settings, with strategies to support sustainability beyond pilot phases.

OBJECTIVE: Diabetes technology, including insulin pumps, is associated with improved outcomes in youth with type 1 diabetes (T1D). However, youth with public insurance consistently demonstrate lower use. In 2022, we launched a quality improvement (QI) initiative to address disparities in insulin pump use among publicly insured youth with T1D. Our initial aim was to increase pump use from 30% to 40% within 15 months. We now report sustained and expanded outcomes, with pump use reaching 73% by December 2025. RESEARCH DESIGN AND METHODS: Using a T1D-specific dashboard embedded within the electronic health record (EHR), we tracked monthly insulin pump use among publicly insured patients seen in our outpatient diabetes clinic. A multidisciplinary team designed and tested interventions through iterative plan-do-study-act cycles. Interventions included multilingual virtual and in-person insulin pump education classes, individualized one-on-one education sessions, Spanish-language educational materials, expanded class availability, targeted care navigation outreach to support scheduling and follow-up, provider implicit bias training, integration of pump screening questions into clinic intake workflows, and systematic collection of patient and family feedback through post–insulin pump class evaluations. RESULTS: Insulin pump use increased from 30% in April 2022 to 42% by June 2023, and further to 73% by December 2025, reflecting sustained improvement and successful scale-up over a 44-month period. CONCLUSIONS: An equity-centered, EHR-informed QI approach led to durable improvements in insulin pump use among publicly insured youth with T1D. These results demonstrate the potential for scalable, systems-based interventions to reduce disparities in diabetes technology access.

Quality Improvement Success Stories are published by the American Diabetes Association in collaboration with the American College of Physicians and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes an initiative to improve the rate of lipid profile screening in youth with type 2 diabetes at a tertiary children’s hospital in Southern California.

OBJECTIVE: Living with type 1 diabetes is challenging, but more barriers exist when one also identifies as LGBTQ+ (lesbian, gay, bisexual, transgender, queer, or other gender-expansive identities). Acknowledging the importance of identifying this population and providing personalized care, the Health Resources and Services Administration mandated institutions to document sexual orientation and gender identity (SOGI) data. To understand the current state of SOGI documentation in the T1D Exchange Quality Improvement Collaborative, a survey assessing LGBTQ+ supportive and inclusive care practices was given to affiliated sites. RESEARCH DESIGN AND METHODS: Thirty-three pediatric and 21 adult care centers were surveyed via Qualtrics. The survey included questions about their electronic health record documentation of patient-identified gender, pronouns, sexual orientation, and sex assigned at birth (SAAB). Care centers also reported on the legality of gender-affirming care in their municipalities, as well as their willingness to change SAAB after patients meet requirements. Fisher exact tests were used to evaluate response frequencies. RESULTS: All 33 of the pediatric centers and 81% (17 of 21) of the adult centers responded to the survey. Sixty-four percent of pediatric centers had established strategies to support SOGI documentation, whereas only 50% of adult centers had implemented strategies. Some adult centers could not confirm whether they documented SOGI. Differences were seen between the pediatric and adult endocrinology centers in their documentation of gender identity (P = 0.04) and pronouns (P = 0.02). CONCLUSION: Although most endocrinology centers documented gender identity and pronouns, fewer documented sexual orientation. Further work is needed to improve SOGI documentation and assess its impact on LGBTQ+ patients with diabetes.

Objective: Previous studies revealed that hemoglobin A1c (HbA1c) increased overall in the United States in the past decade. In addition, health inequities in type 1 diabetes (T1D) outcomes by race/ethnicity and insurance type persist. This study examines the trends in HbA1c from 2016 to 2022 stratified by race/ethnicity and insurance in a large multicenter national database. Research Design and Methods: We analyzed glycemic outcomes and diabetes device use trends for >48,000 people living with type 1 diabetes (PwT1D) from 3 adult and 12 pediatric centers in the T1D Exchange Quality Improvement Collaborative (T1DX-QI), comparing data from 2016 to 2017 with data from 2021 to 2022. Results: The mean HbA1c in 2021–2022 was lower at 8.4% compared with the mean HbA1c in 2016–2017 of 8.7% (0.3% improvement; P < 0.01). Over the same period, the percentage of PwT1D using a continuous glucose monitor (CGM), insulin pump, or hybrid closed-loop system increased (45%, 12%, and 33%, respectively). However, these improvements were not equitably demonstrated across racial/ethnic groups or insurance types. Racial/ethnic and insurance-based inequities persisted over all 7 years across all outcomes; comparing non-Hispanic White and non-Hispanic Black PwT1D, disparate gaps in HbA1c (1.2%–1.6%), CGM (30%), pump (25%–35%), and hybrid-closed loop system (up to 20%) are illuminated. Conclusion: Population-level data on outcomes, including HbA1c, can provide trends and insights into strategies to improve health for PwT1D. The T1DX-QI cohort showed a significant improvement in HbA1c from 2016 to 2022. Improvements in diabetes device use are also demonstrated. However, these increases were inconsistent across all racial/ethnic groups or insurance types, an important focus for future T1D population health improvement work.

The optimal care of type 1 diabetes involves consistent glycemic management to avoid short- and long-term complications. However, despite advancements in diabetes technology and standards, achieving adequate glycemic levels in children and adolescents remains a challenge. This study aimed to identify factors associated with achieving the recommended A1C target of <7% from the United States–based multicenter T1D Exchange Quality Improvement Collaborative cohort, including 25,383 children and adolescents living with type 1 diabetes.

Carla Demeterco-Berggren, Osagie Ebekozien, Carol J Levy, David M Maahs; Response to Letter to the Editor from Justin M. Gregory: Age and Hospitalization Risk i