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Abstract

Diabetes affects Americans across the lifespan requiring individual and community-level interventions for prevention and management. Nonprofit hospitals are required to address community health needs under current tax law. The study objective was to assess what strategies children’s hospitals implemented in prevention and care of diabetes and determine how many hospitals used evidence-based strategies. We identified the most recent Children’s Hospital Needs Assessments and implementation strategies for each hospital. Data were thematically coded. Twenty-nine of the 233 U.S. children’s hospitals addressed diabetes in their community benefit investments. Of the 130 hospital programs, 48 (37%) aligned with the DSMES framework. Programs focused on prevention (32%), healthy eating (18%), education (15%), physical activity (12%), quality improvement (11%), and self-management (5%). Most children’s hospital interventions (85%) did not state a focus on reducing health disparities and none addressed problem solving or diabetes technology. Minimal hospitals are using evidence-based programming for diabetes management and are not targeting health disparities which undercuts their efforts. Hospitals are not adopting structural evidence-based approaches, missing key opportunities to implement strategies shown to reduce diabetes prevalence and lower A1c. This study suggests that children’s hospitals need improvement in their diabetes programming to better serve their communities.

Keywords

diabetes program implementation diabetes education qualitative methods prevention

Introduction

Over 37 million Americans live with diabetes.¹ Diabetes management is time intensive and increasingly costly.² Diabetes is a known predictor of heart and kidney disease, as well as blindness and neuropathy.³ Despite type 2 diabetes usually presenting in adults, new cases of diabetes in children are steadily increasing for both type 1 and type 2 diabetes⁴ with increased rates of type 2 diabetes for all racial and ethnic minority groups.⁵ Despite the rise in adult and pediatric cases, the number of endocrinologists in the United States is shrinking and does not meet the current need.⁶ The deficit of diabetes healthcare practitioners has led to clinic closures, delays in diabetes diagnosis, and delays in appointments.⁷ This gap in expertise often falls to hospital systems and hospital programming where the majority of healthcare dollars are concentrated in the United States.

Children’s hospitals provide unique support to communities due to their size, regional footprint, and financial stature.⁸ Most children’s hospitals are tax exempt and required to complete community health needs assessments (CHNAs) on a triennial basis, identifying community health needs and strategies to combat healthcare issues across the lifespan⁹. The need for children’s hospitals to implement community strategies and address upstream community health needs is critical, especially for vulnerable communities impacted by diabetes. One standard of evidence-based care and prevention is the Diabetes Self-Management Education and Support (DSMES) intervention, a cost-effective framework to address key drivers of diabetes self-efficacy and decision making.¹⁰ DSMES has been shown to improve diabetes related health behaviors and health outcomes.¹¹ The DSMES intervention includes activities to promote 1) healthy eating, 2) physical activity, 3) diabetes pathophysiology and treatment options, 4) healthy coping with psychosocial issues and concerns, 5) preventing, detecting, and treating acute and chronic complications, 6) medication usage, 7) monitoring and using patient-generated health data, and 8) problem solving.¹²

Prior research documents diabetes disparities exacerbated by socioeconomic status, location, and racial and ethnicity identity.^13
-15 To promote health equity, it is critical that hospitals adopt evidence-based strategies aimed at ameliorating these disparities. Moreover, despite a large body of literature addressing the burden of diabetes across the lifespan, it is currently unknown which strategies, if any, children’s hospitals use in prevention and care of diabetes in the communities they serve. This is a major gap in care and prevention because of the unique support that children’s hospitals provide to their communities. Further understanding of these strategies will determine areas of improvement and foundational examples of gold standards in care. The objectives of this project were to 1) determine what strategies children’s hospitals implement in the prevention and care of diabetes and 2) examine the extent to which these strategies are evidence-based.

Methods

Data and Sample

The data for this study are from a larger project which collected and analyzed the CHNAs and Implementation Strategy reports (ISs) of all children’s hospitals in the US. Non-profit hospitals are required to submit these reports which contain demographics, implementation strategies, areas of focus in the community. Our primary research aim was to determine the most common diabetes needs addressed and identified among children’s hospitals nationally. Our hospital population included all U.S. children’s hospitals in the Children’s Hospital Association 2015 annual membership survey (N = 233). Using a google search of hospitals’ websites, we identified the most recent publicly available CHNAs and implementation strategies for each hospital. Because these data were collected in 2018 and 2019, we chose to include the most recent round of hospitals’ triennial community benefit documents which spanned 2015 to 2019. Although hospitals are required by the Internal Revenue Service to make these reports freely available, in some cases these reports were not published on hospital websites. In this situation, we contacted the hospital by phone or email to request the documents. If hospitals did not respond after 3 attempts, they were not included in the sample, which resulted in a loss of 27 hospitals. To assess whether hospitals who did not make their reports available were similar to hospitals in the sample, we compared our final dataset to the entire population of children’s hospitals. We found similar numbers of beds in organizations within and missing from the sample and a similar percentage of hospitals that were freestanding vs. embedded within a parent hospital.

Data Analysis

To code the CHNAs and ISs, the third author and 3 research team members reviewed reports, coding dichotomously for whether chronic disease, and diabetes specifically, were identified in the list of community health needs identified by hospitals and whether this need was addressed in the hospitals’ corresponding implementation strategy. To ensure reliable coding of the original dataset, the research team underwent training prior to reviewing these highly structured documents. In the rare case that reports did not follow the usual structure, the team met to code these documents collaboratively and reach consensus. Once the primary dataset was complete, we underwent a second coding process to identify the specific strategies that hospitals adopted to address diabetes in their communities. Based on the DSMES categories, the third author used a deductive approach to categorize the 130 strategies reported by hospitals. For strategies that did not fit within the DSMES framework, the coder grouped these into separate categories using thematic analysis. The coder also assessed whether each strategy addressed the needs of pediatric populations specifically, whether type 1 or type 2 diabetes was specified in strategies, whether diabetes disparities were addressed, and whether strategies were ongoing or a one-time event.

Finally, we coded whether hospitals addressed individual, community, and structural determinants of diabetes or promoted capacity building. Individual-level strategies refer to strategies that target individual behavior (eg, physical activity, dietary patterns). Community-level strategies refer to strategies that were prepared for public health (eg, pediatric, low-income populations). Structural-level strategies refer to strategies that involve policies, laws, or macro-level factors (eg, support cities, schools, community-based organizations to provide healthy food options and to adopt healthy food policies, including procurement practices). Capacity building strategies refers to enhancing a hospital’s ability to provide diabetes prevention, treatment, and care (eg, evaluate and update diabetes outreach and educational materials, when necessary, to improve readability, comprehension, and cultural relevance). To ensure reliability during this secondary coding process, the first and second authors reviewed all coding and then the full research team met to discuss the final coding until consensus was reached.

Results

Of the 223 children’s hospitals, only 102 children’s hospitals addressed chronic disease through planned programming in their second round of community benefit reporting. From these 102 children’s hospitals, 29 hospitals adopted 1 or more programs to address diabetes. Of the 130 different programs these 29 hospitals adopted, 48 (37%) aligned with the evidence based DSMES framework. The most common DSMES categories aligned with hospital interventions were healthy eating (18%) and physical activity (12%). A smaller number of hospitals adopted interventions related to healthy coping with psychosocial issues (3%), understanding diabetes pathophysiology and treatment options (3%), and preventing, detecting, and treating diabetes complications (2%). No hospital programs were aligned with medication usage, patient-generated health data, or problem-solving.

The remaining programs, focused on prevention (32%), education (15%), quality improvement (11%), and self-management (5%) (Table 1). Children’s hospital programs most often targeted the community (67%) with the remaining programs split between existing patients (24%) and other groups such as hospital personnel or community-based organizations (9%) (see Figure 1 for additional subcategories). Many programs did not specify a focus on type 1 or type 2 diabetes (94%). Among those that did, 5% focused on type 2 diabetes and just 1% targeted type 1 diabetes.

Table 1.

DSMES Categories.

Category	N	Summary	Examples
DSMES categories
Healthy eating	23	Support cities, schools, community based organizations to provide healthy food options (including fruits/vegetables, accessible drinking water) and to adopt healthy food policies, including procurement practices	- Enroll community members into available food programs (ie, Cal Fresh, Supplemental Food Program for Women, Infants, and Children (WIC). FH-Fontana will address Healthy Eating, Active Living issues by providing grant support to Healthy Cities to set up and accept Cal Fresh and WIC benefits to enable community to obtain fresh fruits and vegetables at Farmer’s Markets.
Physical activity	15	Provide physical activity equipment to select schools based on demonstrated need and commitment to practice-based and environmental changes; introduce or expand physical activity programs	- We will enroll 15 community members participate in the program the first year. In the subsequent 2 years, we hope to educate 30 participants per year. Among those completing the program will have reduced their risk of Type II Diabetes by lowering their body weight by 5 to 7% and increase physical activity to 150 min/week.
Diabetes pathophysiology and treatment options	4	Provide education to primary care providers and community-based organizations regarding childhood obesity and diabetes prevention and/or management.	- CRMC’s diabetes medical home provides coordinated care for patients from a multi-disciplinary team consisting of a physician, nurse practitioner, nurse, case manager and outreach worker. Team members ensure that patients diagnosed diabetes receive appropriate and timely care, medications, and transportation to appointments. Intense case management is provided to patients facing hardships, including directly linking patients to community resources.
Healthy coping with psychosocial issues and concerns	4	Enhance identification of high risk populations by recognizing and treating depression, which can hinder a patient’s ability to take care of themselves	- Implement an educational program for adolescents to prepare them for independence - Develop type 2 diabetes screening protocols or referral process for screening for at risk behavioral health inpatients and outpatients based on clinical criteria.
Preventing, detecting, and treating acute and chronic complications	2	Increase screening for high risk factors in newly diagnosed patients with Type I diabetes	- Cleveland Clinic Children’s offers inpatient, outpatient and education services, including nutrition counseling focused on diabetes, its long term complications and disease management.
Medication usage	0	None.	None.
Monitoring and using patient-generated health data (PGHD)	0	None.	None.
Problem solving	0	None.	None.
Emergent categories
Prevention	42	Targeted outreach in the community related to diabetes awareness, prevention, and risk factors; may include partnership efforts (eg, with the American Diabetes Association or community organizations) and/or community health screenings	- “Remarkable You” community screening initiative in high African American populations - Implement a variety of chronic disease prevention education messaging using Vidant Medical Center’s social media, digital messaging, and Public Relations/Community relations - Develop and implement regional strategies for preventing and/or managing childhood obesity - Increase education and awareness of programs available at the community level through outreach to Community-Based (CBO) and FaithBased Organizations (FBO’s)
Education	20	Formal and informal education on treating and managing diabetes for patients and/or hospital staff; improving existing hospital education tools	- Provide subsidized chronic conditions care management education - Educate inpatient nursing on diabetes survival skills
Quality improvement	14	Improvement or expansion of existing services to address affordability, accessibility, quality of care, and successful transition into adult care	- Promote use of Doctors on Demand for low-cost e-visits and virtual care, including iCare for chronic care management and in -home and Eicu services for acute care
Self-management	6	Referral of patients to self-management programs, or education on self-management skills Improved patient outcomes, Reduced readmissions; reduced diabetes-related ER visits; improved medication compliance; improved health outcomes; consistent links to ongoing social services	- Partner with internal and/or external diabetes self-management programs for referral purposes for people with type 2 diabetes. Refer through the Community Health Network, RIDOH’s centralized referral system, individuals eligible and qualified for no-cost diabetes self-management programs and chronic disease self-management programs

Figure 1.

Children’s hospitals diabetes strategies by target demographic.

Eighty-five percent of children’s hospital interventions did not explicitly mention a focus on reducing health disparities. The most common level of intervention was at the individual level such as targeting health behaviors (35%). Nearly one-third (32%) of programs were focused on capacity building (eg, increasing communities’ capacities to increase access to food assistance and support partnerships that sustain and scale health promotion efforts), 23% at the community level (eg, environmental assessments in local schools to inform development of physical activity programs), and only 10% adopted upstream or structural approaches (eg, physical activity programs and policies). See Table 1 for examples of each type of strategy.

Discussion

It is critical to address the rising incidence of type 1 and type 2 diabetes among children⁴ and the long-term impacts of diabetes on morbidity and mortality across the life course. Children’s hospitals are foundational in preventing, diagnosing, and treating diabetes in formal provision of pediatric health care services and in the broader community through their community benefit requirements in exchange for tax exemption. Yet, the extent to which hospitals are employing evidence-based best practices to address the burden of diabetes or utilizing upstream approaches likely to impact health equity across the life course is unclear. Drawing on a national database of children’s hospitals in the U.S., we identified diabetes-focused strategies employed by children’s hospitals and categorized these strategies using the DSMES. We assessed the type of strategies hospitals employed, including whether the strategies were aligned with the DSMES, the population(s) of interest, the level of interventions, and determined whether the strategies explicitly addressed health disparities.

Importantly, the majority of strategies employed by hospitals were outside the DSMES framework. Of the 130 unique programs that children’s hospitals adopted, only 37% aligned with the evidence-based DSMES framework. Given that the DSMES is an evidence-based best-practice approach to address diabetes,¹⁰ the finding that hospitals are employing few strategies that fall within the DSMES is perplexing. The DSMES identifies 8 broad categories and hospitals reported strategies that addressed 2 of these categories: healthy eating (18% of strategies) and physical activity (12% of strategies). Findings suggest that children’s hospitals are not addressing the majority of DSMES priority areas. Despite prior research documenting the value of the DSMES for disease management, hypoglycemia outcomes, psychological health, and cardiometabolic health,^16
-19 results from this study bolster prior work documenting the underutilization of the DSMES, including in hospital-based community health programs.²⁰

We also found that children’s hospitals primarily employed individual-level, rather than structural-level, strategies which have important implications for health equity. A growing body of research has documented social determinants of health and structural inequities as root causes of diabetes disparities.¹⁴ By focusing primarily on individual-level approaches, children’s hospitals are overlooking key opportunities to implement structural-level strategies shown to reduce diabetes disparities. Given that a large body of research has documented diabetes disparities,¹³ it was surprising to see that most children’s hospital interventions did not explicitly focus on reducing health disparities. Prior research has underscored the prevalence of racial and ethnic diabetes disparities.²¹ Hospital interventions should focus on place-based diabetes disparities including poor housing conditions,²² neighborhood racial composition, and urban, racially-integrated, low income communities.^15,23 Collectively, this research provides strong grounds for hospitals to bring diabetes disparities to the forefront and to apply multi-level approaches to improve diabetes outcomes and improve health equity. In addition, hospitals can improve their implementation by establishing diabetes support groups that are moderated by a diabetes care and education specialist. Hospitals should employ telehealth delivery, and other alternative avenues to deliver DSMES to reduce barriers to care.

Limitations

Study findings should be considered in light of limitations. First, this study identified and categorized children’s hospital programs to address diabetes using the implementation strategies reported as part of formal community benefit reporting. Therefore, results only capture programs explicitly discussed in hospitals’ implementation strategies. It is possible that these reports do not fully capture the scope of programs or the distinct levels of intervention (eg, structural, community level) or all hospital-based diabetes programs. Relatedly, when coding whether hospitals employed strategies targeting health disparities, only implementation strategies that explicitly mentioned health disparities were coded as addressing health disparities. Although this coding approach was used to ensure reliability, it is possible that efforts with implications for health equity were undercounted if reports did not explicitly mention a health disparities focus.

Implications

This study is the first to draw on a national dataset of children’s hospital programs to systematically investigate the strategies children’s hospitals are employing to mitigate diabetes burden in U.S. communities. Furthermore, this study has identified important gaps (eg, preventing, detecting, and treating acute and chronic complications, medication usage) in diabetes-focused community health programs. Future research should extend this line of work by investigating whether the strategies children’s hospitals are employing vary by factors, such as region (eg, rural, urban), socioeconomic status (eg, neighborhood disadvantage), and neighborhood racial composition.

Findings have several implications for diabetes prevention and care. First, findings underscore the need for hospitals to draw on evidence-based approaches to inform effective interventions and mobilization of resources to prevent and care for those affected by diabetes.

Second, findings suggest that children’s hospitals have overlooked several evidence-based diabetes prevention and care efforts including preventing, detecting, and treating acute and chronic complications of diabetes.

Children’s hospitals should consider ways to address these important gaps. Third, children’s hospitals should consider that addressing the burden of diabetes requires a diverse range of strategies. Currently, children’s hospitals are primarily focusing on healthy eating and physical activity, which overlooks the broad range of efforts needed to effectively prevent and care for communities affected by diabetes. Fourth, hospitals are primarily focusing on individual-level approaches in diabetes prevention and care. By employing multi-level approaches (eg, structural, community, individual levels), hospitals can expand the reach of their programs to better mitigate the burden of diabetes. Finally, less than 15% of children’s hospitals are employing strategies focused on health disparities. Given that diabetes disproportionately affects specific racial and ethnic minoritized groups (eg, American Indians/Alaskan Natives, Black Americans, Mexican Americans, Puerto Ricans, and Filipinos)²⁴ and those living in areas of concentrated poverty,¹³ hospitals should increase efforts focused on mitigating racial, ethnic, socioeconomic, and place-based diabetes disparities.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Allyson S. Hughes

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Availability of Evidence-Based Diabetes Programs in U.S. Children’s Hospitals

Abstract

Keywords

Introduction

Methods

Data and Sample

Data Analysis

Results

Discussion

Limitations

Implications

Footnotes

Declaration of Conflicting Interests

Funding

ORCID iD

References