David Klonoff: 0:03

Welcome to Diabetes Technology Report, co-hosted by endocrinologist David Klonoff from UCSF and David Kerr from Sutter Health. Welcome to Diabetes Technology Report. This is the first Diabetes Technology Podcast on this topic. I'm David Klonoff. I'm an endocrinologist at Sutter Health and UCSF. We have a special guest today, Osagie Ebiskozian, and my co-host, David Kerr, will introduce him.

David Kerr: 0:35

Thank you, david. I'm David Kerr. I'm speaking to you from Santa Barbara, california. I'm also a senior investigator with Sutter Health. I am so pleased to welcome Osagie today. I've known him for a number of years. He and I have actually co-authored a recent manuscript looking at the digital divide. But, osagie, for our listeners, how did you get into diabetes and how did you end up with the Type 1 Diabetes Exchange being its supreme leader?

Osagie Ebekozien: 1:07

you end up with the Type 1 Diabetes Exchange being its supreme leader. Well, thank you. I appreciate the pleasure and real honor to be joining both of you today, and I'm a fan of the podcast, I should say. I got a chance to listen to Anpita's episode and Bob Gabay's episode and I hope that I'll be able to share some of my own reflections as well today. So you know, I'm based here in Boston and I've been in Boston now for the past 15 years or so.

Osagie Ebekozien: 1:31

I trained as a primary care physician and been practicing as a family care physician caring for people with diabetes, and then in 2012, I got an opportunity to get involved in community-based diabetes care at a federal qualified health center in Boston. You know, one of the early projects then were funded by Kresge Foundation to really think about how do we create a wellness program for people living with type 2 diabetes, and particularly it was for African-American women in type 2 diabetes living in public housing units in Boston. So that's really where my interest in population health diabetes care really started from. So I started to transition from seeing patients in clinic to really start thinking about the broader population and how can we make an impact there. So did that work 2012,. A lot of insights into health equity, population health, really thinking more holistic about what happens outside of the clinic. And then went on to work for the city of Boston really playing a role, serving as head of population health, thinking about type 2 diabetes, obesity and all of those insights.

Osagie Ebekozien: 2:46

And then in 2017, 2018 was where I got the opportunity to get involved with 2-1-D Exchange. 2-1-d Exchange back then in 2017 was thinking a lot more around the population health space for type 1 diabetes and I've had all that experience with type 2 diabetes, working in the primary care center, working at Boston Medical Center, working for the city's public health department, and I had the chance to be able to get involved and really start to help the organization think about how do you bring that same lens of population health in a type 1 space. So I find myself really, really lucky to be where I am now and my role as the Chief Med Corps Officer of 2-1-D Exchange. I am overseeing our work with 62 type 1 diabetes centers in 22 states and 10 type 2 diabetes centers across five states as well. So we're doing a lot of work and I'm more than happy to speak about it. But I think one key thing is the power of collaboration, which is some of the things that have been the thread in the last 15 years of my career in diabetes.

David Kerr: 3:55

So, just in a simple couple of sentences what's the state of play for type 1 diabetes in the United States now? What's working well and what's missing? What do we still need to do?

Osagie Ebekozien: 4:08

I love that question. You know there's a very popular 2-1-D exchange paper in 2019 that my colleagues Nicole Foster, kelly Miller from the JIP Center put out. In the show that outcomes A1C outcomes were getting worse from 2010, 2012 to 2019. And that paper was sort of like a landmark paper and a shock for the diabetes system and folks were like wow, like I can't believe in the last eight years with all of this great insight, all of the new technology we already had CGMs then, we already had pumps then that those outcomes were getting worse. Now we had a paper, a follow-up paper, similar methodology, similar pattern, where we looked at new kinds of data and this is data from the clinics now that are engaged in collaboration, in data sharing and a whole population, not just people that were involved with clinical research prior to the exchange model. And the new paper shows that outcomes are getting better. We also published that in the same journal, like we did in the last time DTT, so that paper was in 2023.

Osagie Ebekozien: 5:18

Last year we showed that outcomes were getting better for more than 40,000 patients with type 1 diabetes. So similar kind of trend curve but more importantly, mini-1c outcomes going down, decay rates going down, severe hypoglycemia going down. So that's what we're excited about. So we're excited that outcomes are getting better.

Osagie Ebekozien: 5:39

The state of type 1 diabetes is improving and the recent 2-1D exchange data is showing that type 1 diabetes is improving and the recent 2-1D exchange data is showing that type 1 diabetes is improving. However, there's still more room for us to go, and when we compare our outcomes with that of some of our friends across the pond and I'm looking at David on the screen, I'm looking at our friends in England, mpda I'm looking at our friends in Germany, I'm looking at our friends in Australia Even though outcomes in the US, with 2-1-D exchange and other networks, are showing that things are getting better, we still see that there's room for us to even drive that improvement further. So the state of type 1 diabetes is improving, but we still have some routes to go and we're excited to go along that journey as well.

David Klonoff: 6:28

Osagie, what do you think are some areas where we could improve care for the population of folks with type 1?

Osagie Ebekozien: 6:35

One big piece is equity, and I think about equity very broadly. You know, one of the things that we can do better in the US, as compared to some of our other counterparts across the pond, is who has access to some of these exciting and innovative technologies and therapies. Let's pick CGMs, for example, or sensor-augmented pumps, or hybrid closed-loop systems. We've shown and we've published extensively that in all of those systems we're seeing huge gaps, not just by race or ethnicity, but also by insurance, and we're seeing how insurance is really driving some of these equity gaps. And that's where we need to think about how do we have a more holistic approach to access to these technologies. How do we work with Medicare, medicaid to ensure that people with diabetes on public insurance have very similar access, and we're not dealing with under insurance or dealing with the challenges of co-pays or the education or some of that that comes to the technology access. So that's one key piece I think we can do better as a society, as a system, is think about how do we close gaps in who has access to some of the great tools we have now.

Osagie Ebekozien: 8:01

The second protein is we need to think about how do we move away from competition across our health systems to collaboration, across our health systems to collaboration. And when you think about the work that is happening in a very innovative space, it needs to go beyond just individual unique institutions or even individual unique roles. You know we're blessed with a lot of great talent, but when you bring all that talent together, when you bring all of those resources together, when you bring the great insights that is happening at Sutter Health to what's happening at UCSF, to Mount Sinai, to Ready, you combine all of that, there's a broader power, there's a bigger input which we can harness from all of that collaboration. So I think we can do that better. I think we can be better in sharing insights across health systems. I think we can be better in promoting collaboration as opposed to competition for commercial market share. So those two things are top of mind.

Osagie Ebekozien: 9:10

First is close equity gaps. Make things more available. That makes technology more accessible. Promote collaboration and cooperation and communication, because so that best practices happening across the country get spread and people can adapt those really quickly and not have to reinvent the wheel across.

David Klonoff: 9:30

All of our different systems can adapt those really quickly and not have to reinvent the wheel across all of our different systems. Those are two good points. What's been your success when you talk to payers about closing these gaps?

Osagie Ebekozien: 9:42

The first piece is they go from a state of sometimes denial then move on to oh, maybe there are some of those gaps. Let's look at our data to a place of this is exactly what we can do to address that. So I'll give an example we worked with some of our partners in the Ohio Medicaid offices and also in Texas Medicaid offices really looking at how do we close gaps for access to CGM for people in public insurance, and our role was really to be able to share some of this data that I referenced on. Look at CGM outcomes, look at CGM access first for people in public insurance in that state, compare that to people in private insurance and you see that huge gap. And then start having conversations with them on. They have a role to play. And the next question becomes well, what can they do differently?

Osagie Ebekozien: 10:41

And one of the things we're being very critical in alighting and amplifying is you can look at your policies, your internal policies, your internal procedures, and think about how some of the boarding, the administrative boarding, how some of the requirements of, well, you need to have glucose checks or you need to have evidence of DKA or you need to have severe hypoglycemia or any of some of the other administrative criteria.

Osagie Ebekozien: 11:13

A lot of those things now get in the way of that access. So our work we're talking with a lot of the public, you know Medicaid offices it's really to amplify the role of each of those policies and the role of some of the administrative burden. It's beyond just this Medicaid coverage for CGM or for insulin pumps or for AID systems. It's what else do you have to do to get that in the hands of people that need it and what paperwork or hoops do they have to run through? How do you reduce a lot of that? And that's where we start to see the magic happen and we're really excited that we've had receptive ears over the years to work with partners on the ground to push some of these conversations forward.

David Kerr: 12:02

So, osange, we are presenting some data at the American Diabetes, where we looked at the proportion of people with type 1 using hybrid closed-loop systems. Have you got a figure for what it is at the T1D exchange at the moment and where you think it should be in, say, two years?

Osagie Ebekozien: 12:24

Yeah, so at the moment it's somewhere ranging from 25 to 35% for what we're seeing in the data. My prediction is in the next two, three years we should get closer to 60, 70%, and I think that's going to happen very naturally too, with even a lot of industry partners. You know, onboarding newer patients with type 1 diabetes on the AID system at diagnosis. I think that's one of the premise of this system. So in my personal opinion it's that we should start newly diagnosed with AIDs and get that to the hands of people. Then I also feel that, as some of the patients with type 1 or sensor-augmented pumps rolling over or renewing their plants, all of that transition to moving them from the prior legacy systems to the newer systems, I think all of that naturally to happen. And then I think there's a lot of room for us to think about some of the local system barriers and local system policies and practices as it relates to who gets to be on AID and who doesn't, so avoid bias in how that's being recommended or prescribed. So I feel very bullish.

David Klonoff: 13:43

I have one last question for you, Since you are the chief medical officer at T1D Exchange. What are your plans and what are the goals of this organization at the current time?

Osagie Ebekozien: 13:55

We are very, very focused on improving outcomes and less focused on improving outcomes. Now we're expanding the number of centers we're working with and we're expanding the impact of that. So our first big piece is really driving continue to drive improvement in outcomes and expand on that. The second piece is we're in the type 2 space with the intent of learning from what's also happening for people with type 2 diabetes how that can be applied to improve lives for type 1 diabetes as well. So we see a synergistic relationship between type 1 and type 2, and we want to make sure we're able to tap into both worlds to really amplify that. And then the third piece is we're committed to reducing gaps in care and we're working extensively with many partners to close equity gaps with insurance, race and ethnicity and language, and those are some of the key things that keeps us going in the morning.

David Klonoff: 14:57

Osagie, thank you very much for joining us today on Diabetes Technology Report. On behalf of my co-host, dr David Kerr, I would like to thank you and invite the listeners to attend our next Diabetes Technology Report. This podcast is available on Spotify, at the Apple Store and at the Diabetes Technology Society website. So until our next podcast. Goodbye everybody.

David Kerr: 15:24

Thank you very much.