Addressing the inequities that exist in diabetes care relies on each and every one of us in the diabetes space. On this episode of The Huddle, we spoke with Dr. Osagie Ebekozien, Chief Medical Officer at the T1D Exchange and award-winning researcher. Dr. Ebekozien talked about T1D Exchange’s Health Equity Advancement Lab (HEAL) and it's work in advancing health equity for underserved populations. He also outlines actionable steps, no matter how big or small, that DCES across the country can take to advance this work in their practices. Please note, this podcast was originally recorded in 2023, and host Sacha Uelmen has since moved on from ADCES to pursue another professional opportunity. Learn more about T1D Exchange here: T1D Exchange Homepage - T1D Exchange and learn more about the Health Equity Advancement Lab specifically here: HEAL - T1D Exchange Stay up to date on diabetes advocacy initiatives here: Diabetes Advocacy (adces.org) Dive deeper into health equity research at the links below: Addressing type 1 diabetes health inequities in the United States: Approaches from the T1D Exchange QI Collaborative Achieving Equity in Diabetes Research: Borrowing From the Field of Quality Improvement Using a Practical Framework and Improvement Tools Equitable Post-COVID-19 Care: A Practical Framework to Integrate Health Equity in Diabetes Management
Addressing the inequities that exist in diabetes care relies on each and every one of us in the diabetes space. On this episode of The Huddle, we spoke with Dr. Osagie Ebekozien, Chief Medical Officer at the T1D Exchange and award-winning researcher. Dr. Ebekozien talked about T1D Exchange’s Health Equity Advancement Lab (HEAL) and it's work in advancing health equity for underserved populations. He also outlines actionable steps, no matter how big or small, that DCES across the country can take to advance this work in their practices.
Please note, this podcast was originally recorded in 2023, and host Sacha Uelmen has since moved on from ADCES to pursue another professional opportunity.
Learn more about T1D Exchange here: T1D Exchange Homepage - T1D Exchange and learn more about the Health Equity Advancement Lab specifically here: HEAL - T1D Exchange
Stay up to date on diabetes advocacy initiatives here: Diabetes Advocacy (adces.org)
Dive deeper into health equity research at the links below:
Sacha Uelmen
Hello and welcome to ADCES’ podcast, The Huddle: Conversations with the diabetes care team. In each episode, we speak with guests from across the diabetes care space to bring you perspectives, issues and updates that elevate your role, inform your practice and ignite your passion. I'm Sacha Uelmen, Director of Diabetes Education and Prevention Programs at the Association of Diabetes Care and Education Specialists.
Today, we're joined by Dr. Ebekozien, Chief Medical Officer at the T1D Exchange. In his role, Dr. Ebekozien directs the Diabetes Learning Health Network of 55 U.S. endocrinology centers. He also serves as an adjunct professor of population health at the University of Mississippi Medical Center, where he teaches graduate-level population health and quality improvement courses. Dr. Ebekozien has many years of experience and research focused on diabetes health equity, quality improvement, and population health science to improve real-world outcomes. Dr. Ebekozien is here today to share how you as a DCES can advance health equity in your practice and beyond. So thank you, Dr. Ebekozien. Welcome to The Huddle.
Dr. Ebekozien
Thank you so much, Sacha. I'm excited to be here. I'm a big fan of The Huddle. So it's a great honor to get a chance to share a few things from my experiences. So thank you for having me.
Sacha
Can you tell our audience a little bit more about yourself and why this topic is so important to you?
Dr. Ebekozien
I tell people that I feel diabetes is a calling for me. You know, my journey in diabetes started more than 15 years ago. First, it's a very personal mission. I have immediate family members living with type 1 diabetes, type 2 diabetes. They were diagnosed with gestational diabetes. So it's sort of the whole gamut. You know, I trained as a physician, primary care physician. I've had to also care for many people in my practice with diabetes as well. So there's also sort of the physician perspective to this work. I've had the privilege of working in different spaces where I've interacted with people that have experienced a lot of inequities in diabetes broadly. So, a little over 10 years ago, I worked for a community health center in Boston, where I was focused on really trying to improve outcomes for African American women living in public housing units with type 2 diabetes. Went on to work for the city of Boston and the work around quality improvement, accreditation and large-scale population, which also focused on efforts around improving outcomes for people with type 2 diabetes amongst others. And now my current role at T1D Exchange, focus on improving outcomes for people living with type 1 diabetes and we’ve since expanded efforts to really improve outcomes of people with type 2 diabetes. You know, one of the things that makes this topic very critical and crucial is in more than 15 years of this work and being involved in the diabetes space, one thing is very glaring, that for us to actually truly improve the health of the population, we need to very intentionally tackle issues of equity and issues of disparities. So for me, there's no way for us to truly improve quality, truly improve outcomes without addressing equity.
Sacha
I couldn't agree with you more. And you work along with the HEAL program, the Health Equity Advancement Lab. Can you tell us a little bit more about that?
Dr. Ebekozien
So the HEAL group really came up from this idea of: we need to promote and expand best practices wherever we can find them. The goal with HEAL of how do we actually advance health-equity using best practices from other spaces. So if there's a promising practice in asthma care or in hypertension or in obesity, can we take that and bring that into the work we're doing to improve outcomes in diabetes? So we started this work, we brought a lot of stakeholders from industry, from the payor space, the insurance providers, and also people living with diabetes themselves. And our goal really was, we want to learn what's happening within your space. And we want to be able to bring best practices outside of those spaces to think about, how can we amplify what's working well? You know, I think that's one of the things I'm most excited about the work we're doing with HEAL, which is an approach that I feel, it's very tangible to the DCES group as we think about: what can you do related to addressing equity. I think one of the first things I always tell folks is “let's think about opportunities to, you know, look at best practices, not having to reinvent the wheel.” And if there's a best practice, how do we amplify and scale that in your local practice, in your local clinic, in your local setting? That's what HEAL is all about. HEAL is about amplifying and promoting best practices and approaches.
Sacha
That's great. As you know, many of our audience are working in clinics and health centers across the country, from community health workers and medical assistants to nurses and NPs, pharmacists, dietitians. How would you guide this diverse group of professionals to make an impact in their practice setting today?
Dr. Ebekozien
Everyone has a very strong role to play. And that's why I really like that question. We all, and everyone listening to this Huddle now, you have a role to play. At the T1D Exchange, we've published extensively on our approaches to addressing equity. And I'll sort of articulate that very briefly. We have six main, sort of broad things we think that can make a difference. And is making a difference, we also have data to show that these outcomes actually improving and impacting equity and reducing some of the equity gaps. So the first piece is data and what's the role of data. Data not just to describe the problem. I think we already know there are inequities. We already know there are disparities. We already know there are gaps. But, one of the things that we could do better is, what else is contributing to some of those gaps? We know a few things around like insurance. We know some place around some of the structural racism, but are there other things we can quantify contributing to this gap? And that's one of the things that I think that our colleagues across the country can start to do. Have you looked at your internal system, your internal clinic data, not just to identify gaps, but to also look at what are some promising practices for people with diabetes that might be of, you know, the minoritized community in terms of being publicly insured, African American or Hispanic, or any of the other minoritized groups? We looked at the data to see those that are doing optimally well, those that are doing better than others, what's unique in terms of how they're approaching care? What's unique in terms of access? What's unique in terms of technology? And how can we take what we learn from the ones that are doing really good, how do we take that and amplify that into our routine practice? So, the power of data, the power of using data, and if you are caring for someone in your practice, there's some data you're generating, some data you have access to, and you can start there. I'm like, “what's my data telling me, and how can I use that?” We're using data to really sort of strengthen that.
Now, the second sort of approach we've taken to this issue is really amplifying your role as a gatekeeper, or amplifying your role as someone that has power and authority in making recommendations. You know, the DCES all across the country are key stakeholders in really sort of helping make referrals and making recommendations on who should get a certain technology or who should not or how we even educate the people that come into our clinic doors regarding certain technology. So we've done a lot of work to really show the role of implicit bias, implicit bias as a caregiver, implicit bias as a member of the care team. And I think that's the second broad sort of approach is: think about your practice, think about your work, think about the process at which you recommend technology and how do you make those recommendations? You know, are there any things intentionally or not intentionally that might be creating some bias in that work there? And you're welcome to read more about some of our findings and our studies and some practical approaches we think you can use to reduce user’s bias.
And then the third piece is, there's a very strong role in quality improvement science. We believe in the power of testing small changes. So you can think about, yes, this is the problem. Yes, these are potential contributors. What can you do about that? And there's something you can do today, tomorrow. You can test a small change. You can test a small change on how you do a referral, you can test a small change on how that referral is expanded. You can test a change on many issues. And when you bring out that quality improvement science, what we call the plan, do study at cycle, any of the other models that you might be comfortable with, you can use those models to try something in clinic. If it works, you expand it. If it doesn't work, that's okay. You can go back and try something different. And you can read more as well on our website on other ways you can do this as some of the things we've been successful in doing as it relates to that.
And then what's the role of learning from others, benchmarking, you know, and that's sort of like our fourth approach. It's thinking about your colleagues across the country. So you have a friend in Ohio, you have another diabetes educator, a DCES in Arizona, DCES in Phoenix, or in New York. And can you share best practices with them? Can you share insights into, this is what's happening in my clinic as it relates to this group? This is what I've done. Can I learn from you? What are you doing differently? And the beauty of benchmarking, you can do that on a small scale. You can do that on a large scale. You can do that in the regional space. You know, that's why I really sort of appreciate platforms like The Huddle because now we're learning from others. We're getting from others and, you know, hopefully some of the insights that we're sharing can also sort of support those. And in the rest of our paper, we had to collect all our approaches, including our work in HEAL, which I talked about earlier. But the other piece I will wrap up with is the importance of ensuring that we have people most impacted on the table. We need the ideas, we need the recommendations, we need to co-produce solutions with them. So it's not just about you having the knowledge and expertise but it's also about their own experiences, their lived experiences, how they've navigated the process, how they've navigated your system. Gather those insights from them and learn about whatever is unique or different and use that, all of those insights in thinking about the changes you can make to your local practice or local clinic.
Sacha
These are all things that our programs really should be incorporating into their work. They're required to do a CQI project every year, so this is right in their expertise. And a lot of them do use the PDSA model. And I think what really rang strong was you're talking about the technology bias, and they might not feel like they have a strong impact. But if they even can look at the data and really do small things to push and move that needle a little bit further to make sure people are getting equitable access to that technology. What about the people in our audience who do have an official role or voice in decision making? What are some things that they can do today to make an impact?
Dr. Ebekozien
The beauty of this is if you have some spare of influence with five people or with 10 people or with 20 people, that begins to sort of help in the overall conversation. And that's the beauty of starting small. One of the main sort of ideas that we found to be successful, it's the old concept around shared decision making. And shared decision making involves you and the person in front of you, you and the patient you're caring for, you and the family member of the child you're caring for. And the beauty of that is we have that conversation with the patient and these are the options. These are the things to consider. These are the things I want you to think about, and I want you to be involved in making this decision together. So it's not just my recommendation and that's it. You have a voice and I want to partner with you.
And then the next piece is there's always a role to sort of test something small and then think about how you bring the data to the key decision maker. So if you start a project in your local clinic and yes, you only have influence on your clinic that happens on Tuesday afternoons or on Monday evenings or whenever that's happening. But you've noticed that while there are some certain processes or procedures that can be changed, can be amplified. That's a space to where you can start small, gather the results, see what impact or difference you're making, and then share that with decision makers on, “look, I tried this with just 20 patients, with just 10 patients, and this is what I found, and I think that perhaps we can look at this.” And then the last sort of comment on this is to think about what are certain policies within your institution or processes? They might not always be fully documented policies. Some of them might be sort of informal processes, like “this is how we do business here.” So for example, in the course of the work we do, one of the sites we worked with, they had a policy where they wouldn't offer technology to people with A1C greater than 9%. And they had a rationale and a justification for that. Now, everyone sort of like that sort of like the known. But you as a DCES has the power to like, sort of bring that up at a meeting or bring that up at, you know, a staff meeting or a ground round like, oh, you know, wait a minute, let's think about this policy. Let's think about this practice and let's sort of think about how this policy or practice might contribute to the inequities we're maybe seeing in our data. And can we, are we open to sort of testing and trying out a change or stopping this policy or practice, you know, for a week, for two weeks and see if it makes a difference. Right. So you have a voice to identify those potential practices that might be leading to inequities. You have a voice to test new change, but more importantly, you have a voice to help encourage patients to be a self -advocate and to be involved in that shared decision -making towards this broad goal. It's going to take a village.
Sacha
Yeah. I think it's asking sometimes people are going to be stepping a little out of their comfort zone. Asking questions can be uncomfortable, but I think you're spot on is that sometimes we just assume these things. What are some final thoughts you want to share? This is so many useful pearls of wisdom here, and I think our members can really take action today, it sounds like. There's a lot of things you've mentioned that they can do. What are some final thoughts you want to share?
Dr. Ebekozien
There's a role for advocacy, and there's a role for us to also use a voice to speak to members of the legislature in our state. So, speak to council members, speak to hospital leadership. I feel that our work needs to also move beyond just what's happening in the clinic and the practices there. One of the things that we're also encouraging is, use your voice as an individual, use your voice as a member of the community to also advocate for these broad policy changes. So I do think it's important for us to think about this issue from multiple lenses. You know, there's what we can do as individuals. There's what we can do as a clinic or as a health institution, but there's also things we can do as a society and you have a role to play in all of those traits. So I encourage our members to sort of think about those different lenses, those different spaces.
And then finally, action. Do something today, do something tomorrow. I think a lot of these conversations, sometimes I feel intimidated on where to start. But I tell people, just start somewhere, just start maybe the next piece I just decided to do is, well, my action step would be, I'm going to look into my data to identify their inequities or identify their good performers or identify their best practices within my data that can support things to be amplified. So that might be where you might start from. Or you might decide that, well, my action step is I'm going to reach out to my colleagues in other parts of the city or other parts of the state to benchmark my performance with them and see what I can learn from there. So it's come up with something tangible of all the potential ideas and take one action. Take a baby step tomorrow, take a baby step on Tuesday, next week, Thursday, and then amplify it from there. And I think once we get started and have that momentum, over time, we sort of see some of the difference. So there’s hope, there's optimism, but there's a lot more work we have to do. And it's going to take all of us as a village to move this needle forward.
Sacha
Absolutely. I think of our programs out there and thinking of their CQI projects and what they can do to make a difference and close those gaps. I think they can do it one patient at a time, but they can also, you know, we're always encouraging them to look at their data and compare their data of who they're seeing to even their local data to see, are we seeing the population we should be serving that are impacted by diabetes? And then how do you close that gap? I know that was something we always saw when I was working in DSMES, is there was a gap between who had diabetes in my community, but who we were serving wasn't always that same mix. And so it was always an effort to say, how do we make this match a little bit better? We should be seeing more people in certain populations because of the diabetes impact. And so they can, they even have that in their power to do it a global way. And then I know we're going to have some notes in the show notes here for some resources from T1D Exchange and then ADCES advocacy. I'm sure your organization does like ours, makes it real easy to advocate for certain things as they come up. So you can just sign off on a letter or oftentimes you can send your own letter, but use one as a guide that we've provided.
Dr. Ebekozien
I love that Sacha. And I think we need to do more of that. We need to be, continue to be united as a voice and we can move the needle and we are moving the needle and I think collectively we can do more to really change the face of diabetes in the country.
Sacha
Absolutely. Any additional thoughts before we close?
Dr. Ebekozien
No, I just thank you again to you and the team and I'm grateful for the platform and the opportunity to be able to share. And as always, I encourage folks, let's come together, let's work towards a united front and let's continue to move this conversation forward.
Outro
Thank you for listening to this episode of The Huddle. Make sure to download the resources discussed on today's episode. You can find them linked in the show notes at adces.org/perspectives/the-huddle-podcast. And remember being an ADCES member gets you access to many resources, education and networking opportunities. Learn about the many benefits of ADCES membership at adces.org.
The information in this podcast is for informational purposes only and may not be appropriate or applicable for your individual circumstances. This podcast does not provide medical or professional advice and is not a substitute for consultation with a healthcare professional. Please consult your healthcare professional for any medical questions.