For more than a decade, personalized medicine has focused on harnessing genetics to sharpen diagnosis and customize treatment. With type 1 diabetes, however, we just don’t know most of the genes involved in disease onset or progression, and so researchers haven’t been able to make the same molecular inroads in personalized medicine in this field as they have with cancer.
That hasn’t stopped providers from trying to practice a different form of personalized medicine, says pediatric endocrinologist Sarah D. Corathers, Director, Diabetes Transition Program at Cincinnati Children’s Hospital in Ohio.
“While we are waiting for the research, we need to continue to aggressively improve the day-to-day life of people with type 1 diabetes,” she says.
While she is not dismissing the promise of genetic-focused personalized medicine for type 1 diabetes, she is redefining personalized care in how she approaches type 1 diabetes care. For her, it starts with surveying the ever-evolving inventory of drugs, meters, CGMs, pumps, and apps, and then sorting through what is available, affordable, and accessible to a patient at a specific moment in his or her life.
If you factor in lifestyle, mental health, and social influences, decisions are far from universal. Take the choice to use a continuous glucose monitor (CGM), now the latest technology on the diabetes market.
“CGM is a tool that is highly useful for (almost) anyone with T1D,” Dr. Corathers says.
However, there are exceptions. Some teens that Dr. Corathers sees, for example, refuse to wear a device because it draws attention to their diabetes. Others start on a CGM but then need a break from alarms or find the amount of data overwhelming. Still, others participate in athletics or activities and find the device simply too cumbersome for their lifestyles.
“Just because a new technology is available does not necessarily mean it is the best fit for every individual,” Dr. Corathers says.
With the advent of so many new and exciting technologies, doctors are looking for tools to help them make decisions about which devices to recommend to their patients. One valuable source of information is the T1D Exchange Quality Improvement Collaborative, a network of 10 diabetes clinics that have teamed up to improve the quality of care at their institutions. Facilitated by T1D Exchange, Collaborative members from each site meet regularly to share resources, refine metrics, methods, and materials that identify and fill gaps in care.
Dr. Corathers joined the Collaborative early in its inception in 2016. She first worked on a successful project to implement depression screening into regular clinic visits. She is now gravitating towards a more recent—and critically needed—effort to improve outcomes for adolescents and young adults where the risk for acute and chronic complications due to persistently elevated HbA1c level is highest.
“Adolescence is such a transformative, vulnerable period in our lives,” she says. “So, any time I can engage with this group, I find it both challenging and rewarding.”
With teens or any other patients, she says, a key to overcoming the challenges is to pay special heed to what patients are saying. For example, someone may visit his or her provider expressing high levels of anxiety. If the patient does not have a CGM or the anxiety is about the ability to manage type 1 diabetes, for example, it might be a good time for a healthcare provider to suggest a CGM.
On the other hand, Dr. Corathers finds that an almost equal number of patients already have a CGM and then report that they are more worried about highs and lows than before they adopted the technology. In this case, the technology may have upped anxiety, perhaps because the person previously was not aware of all the blood sugar variability that happened throughout the day. A healthcare provider then may tailor advice to suggest CGM settings be adjusted so alarms won’t go off until more substantial highs or lows are detected.
“We have to understand the utility of the tool, but then also follow up with qualitative questions around how that technology is being experienced in the lives of the person using it,” Dr. Corathers says.
The Collaborative is helping her personalize care by working to systematize this clinical dialogue and integrate important conversations into standard practice, first at all 10-member sites and then at diabetes clinics outside of the Collaborative.
“T1D Exchange has created an environment where clinicians and patients can learn from one other,” Dr. Corathers says. “And then we accelerate improvement by sharing our learnings and working collaboratively to advance care delivery, and ultimately patient outcomes.”
To learn more about the T1D Exchange Quality Improvement Collaborative, click here.