992-P: Pediatric Diabetes Providers Are Poorly Adherent to the ADA Treatment Guidelines for New-Onset Type 2 Diabetes (T2D)

Since 2018, the ADA Standards of Medical Care has provided evidence-based treatment guidelines for clinically suspected youth-onset T2D. We hypothesized adherence of pediatric diabetes providers to these guidelines was poor. We conducted a retrospective chart review of new onset T2D youth seen for initial consultation at our multidisciplinary tertiary care pediatric diabetes clinic. Between 7/20 and 6/2020, 90 youth completed initial visits: mean initial HbA1c 9.7% (6.5-14%) , mean age of 14.5 (range 9-19) , 57% female, 85% English-speaking, 60% Black, 10% Non-Hispanic White, and 27% Hispanic. Forty-one had an initial HbA1c <8.5% without acidosis, with 34 of these 41 (83%) started on metformin, in accordance with ADA guidelines. Four of the 41 (10%) patients were started on insulin therapy; these 4 had higher HbA1c than those started on metformin alone (8.1% vs. 6.7%, p = 0.0003) . In contrast, 49 of the 90 patients presented with an initial HbA1c ≥8.5% without acidosis. Of these 49, 6 (12%) were started on metformin and basal insulin, in accordance with ADA guidelines; however, the basal insulin was dosed at a mean of 0.27 unit/kg (0.20-0.45) rather than the recommended 0.5 unit/kg. Metformin with basal + prandial insulin was started in 23 (47%) . Sixteen of 49 (33%) were started on basal (0.20 unit/kg) + prandial insulin without metformin. Notably, in patients with HbA1c ≥8.5%, initial treatment choice did not differ by age, HbA1c, or race/ethnicity. Overall, providers exhibited greater fidelity to ADA treatment recommendations in those with HbA1c < 8.5% (83% adherence) than those with HbA1c ≥ 8.5% (12%) . In 80% of patients with a HbA1c ≥ 8.5, providers appeared to default to typical T1D treatment with an initial basal dose of 0.2 unit/kg and inclusion of prandial insulin. These findings demonstrate poor adherence to youth-onset T2D guidelines. A quality improvement project is underway to reduce practice variance and optimize the care of youth with newly diagnosed T2D.