Assessing Allied Health-Care Professional Time in Pediatric Type 1 Diabetes: Associations With Clinical Factors, Technology and Social Determinants

Objectives: The factors associated with allied health-care professional (HCP) time spent face-to-face with patients in clinic have not been well described in type 1 diabetes (T1D) given the introduction of resource-intensive technologies and gaps in socioeconomic circumstances. The objective of this study was to evaluate clinical and social factors associated with nonphysician HCP time in a pediatric T1D practice. Methods: Nonphysician HCP workload data, including time spent in direct clinical care over a 1-year period and nonclinic contacts, were linked to data from 723 pediatric subjects with T1D and evaluated in relation to key demographic, social and diabetes treatment factors. Results: HCPs spent 145.7 min per patient on a median of 3 clinic visits, with certified diabetes educators (CDEs) being responsible for most clinic interactions compared with psychosocial staff. CDE time varied considerably according to T1D duration, with new-onset patients (≤1 year) taking a median of 392.0 min compared with 114.5 min for their established counterparts (p<0.0001). Among the established group (n=629), CDE time was strongly associated with continuous subcutaneous insulin infusion therapy initiation, psychosocial service use, glycated hemoglobin (A1C) and degree of marginalization (p<0.0001). Overall, CDE time increased by 8.6 min for each 1.0% increase in A1C (p=0.022) and by 16.3 min for each 1-U increase in marginalization (p=0.01). Conclusions: We observed HCP time was associated with multiple clinical factors in addition to overall marginalization. Although initial investments in education and continuous subcutaneous insulin infusion training were considerable, our results suggest that these lead to a decrease in time spent in clinic over time, and is largely driven by lower A1C.