Skip to main content
  • More from ADA
    • Diabetes
    • Diabetes Care
    • Diabetes Spectrum
    • ADA Standards of Medical Care
    • ADA Standards of Medical Care, Abridged
    • ADA Scientific Sessions Abstracts
    • BMJ Open Diabetes Research & Care
  • Subscribe
  • Log in
  • My Cart
  • Follow ada on Twitter
  • RSS
  • Visit ada on Facebook
Clinical Diabetes

Advanced Search

Main menu

  • Home
  • Current
    • Current Issue
    • Online Ahead of Print
    • ADA Standards of Medical Care
    • ADA Standards of Medical Care, Abridged
  • Browse
    • Issue Archive
    • Saved Searches
    • COVID-19 Article Collection
    • Quality Improvement Sucess Stories
    • ADA Standards of Medical Care
    • ADA Standards of Medical Care, Abridged
    • Clinical Compendia
  • Info
    • About the Journal
    • About the Editors
    • ADA Journal Policies
    • Instructions for Authors
  • Advertising
  • Reprints/Reuse
  • Subscriptions
    • Individual Subscriptions
    • Institutional Subscriptions and Site Licenses
    • Access Institutional Usage Reports
    • Purchase Single Issues
  • Alerts
    • E­mail Alerts
    • RSS Feeds
  • Podcasts
    • Diabetes Core Update
    • Special Podcast Series: Therapeutic Inertia
    • Special Podcast Series: Influenza Podcasts
    • Special Podcast Series: SGLT2 Inhibitors
    • Special Podcast Series: COVID-19
  • Submit
    • Submit a Manuscript
    • Submit Cover Art
    • Instructions for Authors
    • ADA Journal Policies
  • More from ADA
    • Diabetes
    • Diabetes Care
    • Diabetes Spectrum
    • ADA Standards of Medical Care
    • ADA Standards of Medical Care, Abridged
    • ADA Scientific Sessions Abstracts
    • BMJ Open Diabetes Research & Care

User menu

  • Subscribe
  • Log in
  • My Cart

Search

  • Advanced search
Clinical Diabetes
  • Home
  • Current
    • Current Issue
    • Online Ahead of Print
    • ADA Standards of Medical Care
    • ADA Standards of Medical Care, Abridged
  • Browse
    • Issue Archive
    • Saved Searches
    • COVID-19 Article Collection
    • Quality Improvement Sucess Stories
    • ADA Standards of Medical Care
    • ADA Standards of Medical Care, Abridged
    • Clinical Compendia
  • Info
    • About the Journal
    • About the Editors
    • ADA Journal Policies
    • Instructions for Authors
  • Advertising
  • Reprints/Reuse
  • Subscriptions
    • Individual Subscriptions
    • Institutional Subscriptions and Site Licenses
    • Access Institutional Usage Reports
    • Purchase Single Issues
  • Alerts
    • E­mail Alerts
    • RSS Feeds
  • Podcasts
    • Diabetes Core Update
    • Special Podcast Series: Therapeutic Inertia
    • Special Podcast Series: Influenza Podcasts
    • Special Podcast Series: SGLT2 Inhibitors
    • Special Podcast Series: COVID-19
  • Submit
    • Submit a Manuscript
    • Submit Cover Art
    • Instructions for Authors
    • ADA Journal Policies
Feature Articles

Primary Care Providers in California and Florida Report Low Confidence in Providing Type 1 Diabetes Care

  1. Rayhan A. Lal1–,3,
  2. Nicolas Cuttriss1,
  3. Michael J. Haller4–,6,
  4. Katarina Yabut1,
  5. Claudia Anez-Zabala6,
  6. Korey K. Hood1,3,
  7. Eleni Sheehan7,
  8. Marina Basina2,3,
  9. Angelina Bernier6,
  10. Linda G. Baer1,
  11. Stephanie L. Filipp8,
  12. C. Jason Wang3,9,
  13. Marissa A. Town1,3,
  14. Matthew J. Gurka8,
  15. David M. Maahs1,3 and
  16. Ashby F. Walker5,10
  1. 1Department of Pediatrics, Division of Endocrinology, Stanford University School of Medicine, Stanford, CA
  2. 2Department of Medicine, Division of Endocrinology, Stanford University School of Medicine, Stanford, CA
  3. 3Stanford Diabetes Research Center, Stanford, CA
  4. 4Department of Health Services Research, Management and Policy, University of Florida, Gainesville, FL
  5. 5University of Florida Diabetes Institute, Gainesville, FL
  6. 6Division of Endocrinology, Department of Pediatrics, University of Florida, Gainesville, FL
  7. 7Division of Endocrinology, Department of Medicine, University of Florida, Gainesville, FL
  8. 8Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, FL
  9. 9Center for Policy, Outcomes and Prevention, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
  10. 10Department of Health Service Research, Management, and Policy, University of Florida, Gainesville, FL
  1. Corresponding author: Rayhan A. Lal, inforay{at}stanford.edu
Clinical Diabetes 2020 Apr; 38(2): 159-165. https://doi.org/10.2337/cd19-0060
PreviousNext
  • Article
  • Figures & Tables
  • Suppl Material
  • Info & Metrics
  • PDF
Loading

Abstract

People with type 1 diabetes may receive a significant portion of their care from primary care providers (PCPs). To understand the involvement of PCPs in delivering type 1 diabetes care, we performed surveys in California and Florida, two of the most populous and diverse states in the United States. PCPs fill insulin prescriptions but report low confidence in providing type 1 diabetes care and difficulty accessing specialty referrals to endocrinologists.

In the United States, at least 1.25 million people live with type 1 diabetes, and more than 40,000 new diagnoses are made annually (1). Data from the T1D Exchange, a U.S. clinic registry established in 2010 and including more than 25,000 people with type 1 diabetes of all ages (2), suggest that 79% of adults and 83% of children with type 1 diabetes seen at diabetes centers in the United States do not meet A1C targets (3). Eighty-two percent of T1D Exchange participants are Caucasian, and all have access to health care at major diabetes centers. The challenges of clinical care are even greater for socioeconomically disadvantaged individuals, and limited access to resources and subspecialty care is associated with poor glycemic control (4–9). In the long term, these individuals are at disproportionately increased risk for developing microvascular and cardiovascular disease as a result of chronic hyperglycemia (10,11).

Compounding these difficulties is a shortage of clinical endocrinologists in the United States (12–14). A study of geographic access to endocrinologists in America found that the overall population-to-endocrinologist ratio within 20 miles was 75,573:1 (39,492:1 for people ≤18 years of age, 29,887:1 for those aged 18–64 years, and 6,194:1 for those ≥65 years of age), although these ratios varied widely from location to location (15). With 0.55% of the United States population effected by type 1 diabetes (16), this amounts to 416 patients with type 1 diabetes for every endocrinologist, if endocrinologists were distributed uniformly throughout the country and all saw patients with diabetes. Unfortunately, these assumptions are not reality. To see every person with type 1 diabetes four times annually would require every endocrinologist see seven patients per working day, and this volume does not include the multitude of people with type 2 diabetes or other endocrine conditions. Further, during the transition from pediatric endocrinology to adult care, many are lost to follow-up. In the Canadian universal health care system, 40% of patients with type 1 diabetes were found to have dropped out of adult medical care (17). Young adults transferring to adult endocrinology may seek care from a local primary care provider (PCP) or disconnect from the health care system entirely. We must therefore conclude that many people with type 1 diabetes do not see an endocrinologist. PCPs frequently are required to take on the responsibilities of type 1 diabetes management traditionally performed by endocrinologists.

Most studies examining type 1 diabetes health outcomes use data from endocrinology clinics. However, because of the aforementioned barriers to access and utilization of specialty services, primary care clinics play a central role in the management of patients, particularly among those affected by health disparities (18). To improve health care delivery, we must understand the unique challenges PCPs face in providing care to patients with type 1 diabetes.

Research Design and Methods

Sampling

To better understand barriers for individuals with type 1 diabetes in primary care settings, we administered a cross-sectional survey to PCPs in California and Florida. Convenience sampling was used to recruit participants from a diverse range of clinical settings. Given challenges related to obtaining high response rates from PCPs, the Dillman method (19) was used for subsequent follow-up. Publicly available statewide provider directories were used to mail 400 printed surveys with postage-paid return envelopes provided, as well as a website where the survey could be completed online instead. Family medicine departments and other primary care locations were identified from online directories for each state. Department chairs were telephoned and asked to participate and to disseminate a REDCap (Research Electronic Data Capture) online survey Internet link to their faculty distribution lists. REDCap is a secure web-based application designed to support data capture for research studies. After completing the survey online or mailing in a completed paper survey, respondents received via e-mail a link to a website where they could redeem a $25 Starbucks gift card.

The survey (see Supplementary Materials) included inquiries regarding the provider’s title, roles, responsibilities, practice type, size of practice, insurance accepted, patient demographics, number of patients with diabetes, and clinical practice patterns with regard to diabetes. The survey also assessed existing protocols for type 1 diabetes care delivery and confidence in type 1 diabetes care management and allowed providers to identify common barriers they encounter in the care of patients with type 1 diabetes.

The Stanford University and University of Florida institutional review boards approved the research protocol.

Data Capture and Statistical Methods

This cross-sectional survey was administered between April and December 2018. Data were collected directly via a REDCap online survey or on paper; paper survey responses were returned via mail and manually entered into the REDCap database by trained research coordinators. Data were monitored for errors throughout the study period. Data management and analyses were conducted using SAS, version 9.4 (SAS Institute, Cary, NC).

Descriptive statistics were computed for basic provider and practice demographic information, practice management and standards of care, challenges, and confidence in managing patients with type 1 diabetes. A paired t test was used to compare the difference in distance (miles) between adult and pediatric endocrinologists among those responding to both pediatric and adult care questions. To further evaluate confidence in managing patients with type 1 diabetes, these questions were stratified by years in practice. Cochran-Mantel-Haenszel tests of nonzero correlation were used to determine whether confidence varied across strata by years in practice.

Results

In total, 123 completed surveys were returned, including 68 (55.3%) from California and 55 (44.7%) from Florida. Demographics of respondents are presented in Table 1. Surveys were completed by PCPs in a multitude of settings, including solo practice (20.2%), multispecialty groups (35.3%), single-specialty groups (22.7%), hospital systems (10.9%), and other settings (10.9%). These practices saw private, public, self-pay, and uninsured patients. Self-pay may reflect revenue from uninsured, from those with insurance who pay a balance, or from those whose insurance is not accepted. The mean distance to the closest pediatric endocrinology practice (42.8 ± 57.4 miles) was greater than the distance to an adult endocrinologist (23.8 ± 30.8 miles); among those responding to both pediatric and adult questions, the average distance to a pediatric endocrinologist was 22.4 miles greater than to an adult endocrinologist (P <0.0001). Among 123 responders, 12 had incomplete responses regarding the number of patients with type 1 diabetes in their practice. Of the remaining 111 who answers that question, 109 (98%) reported that their practice saw patients with type 1 diabetes.

View this table:
  • View inline
  • View popup
TABLE 1

Provider/Practice Demographics (N = 123)

PCPs were questioned regarding practice habits and standards of care for the treatment of type 1 diabetes. Pediatric and adult practice management responses are reflected in Figure 1. For the pediatric population, 58% of PCPs reported referring children to endocrinologists for diabetes care, and only 45% reported checking A1C for children with type 1 diabetes during clinic visits. For the adult population, 30% of PCPs referred patients to endocrinologists, and 65% reported checking A1C.

FIGURE 1
  • Download figure
  • Open in new tab
  • Download powerpoint
FIGURE 1

Practice management responses from PCPs seeing children and adults with type 1 diabetes. DKA, diabetic ketoacidosis; HbA1c, glycated hemoglobin; T1D, type 1 diabetes.

Inquiries regarding insulin prescribing habits, challenges with referrals, and the need for resources are presented in Table 2. A majority of PCPs (73%) reported filling an insulin prescription for a patient with type 1 diabetes in the past year. Fewer than half of respondents (43%) reported experiencing no problems with referrals to endocrinology. The majority of respondents indicated that patients may prefer receiving care from a PCP because of its convenience. PCPs desired clinical resources including type 1 diabetes educational materials, information about diabetes technology, and behavioral health services.

View this table:
  • View inline
  • View popup
TABLE 2

Challenges, Patient Care Preferences, and Needed Resources (N = 123)

A final set of survey questions was designed to assess PCP confidence with type 1 diabetes management (Table 3). Many respondents (58%) reported feeling “not at all confident” or only “somewhat confident” with management of type 1 diabetes in the primary care setting. Even fewer reported confidence with diabetes technology, including insulin pumps (17% said they were “moderately” or “extremely” confident) and continuous glucose monitoring (CGM) systems (28% said they were “moderately” or “extremely” confident). Despite this lack of confidence, >76% stated they prescribed insulin for patients with type 1 diabetes. Furthermore, there is a statistically significant difference in the distribution of confidence in management of patients with type 1 diabetes being treated with insulin pumps when stratified by years in practice. Among those with the least clinical experience, 77% were not at all confident managing these patients. Overall, few were extremely confident, regardless of years in practice.

View this table:
  • View inline
  • View popup
TABLE 3

Confidence in Managing Patients With Type 1 Diabetes in Primary Care Settings (N = 123)

Discussion

Many people with type 1 diabetes do not consistently receive care from an endocrinologist. PCPs are delivering type 1 diabetes care and regularly filling insulin prescriptions despite a lack of confidence in providing services, especially related to diabetes technologies such as CGM systems and insulin pumps. These survey responses, from PCPs in a range of clinical settings, demonstrate gaps in the delivery of standard care and concurrently reveal the crucial role PCPs play in type 1 diabetes management.

Efforts to improve outcomes in type 1 diabetes must include targeted interventions in primary care settings (Figure 2) (20). Protocols for type 1 diabetes care in primary care settings need improvement, including more consistent A1C monitoring, the provision of basic type 1 diabetes education, and screening for comorbidities. Most importantly, PCPs seeing patients with type 1 diabetes desire additional resources to learn about and provide the best care.

FIGURE 2
  • Download figure
  • Open in new tab
  • Download powerpoint
FIGURE 2

Barriers to providing type 1 diabetes care in primary care settings. T1D, type 1 diabetes.

There are not enough endocrinologists to provide routine follow-up care to all patients with diabetes. Given this growing mismatch between supply and demand, the health care delivery system is in need of interventions that rapidly multiply provider efficacy. Programs such as Project ECHO (Extension for Community Healthcare Outcomes) can amplify specialty knowledge by linking primary care community practices (“spokes”) to multidisciplinary specialists (“hub”) via tele-education, using the hub-and-spoke model (21–23). Whereas traditional telemedicine connects patients with a specialist for a one-to-one visit, Project ECHO amplifies specialty knowledge by building and leveraging local capacity (Figure 3).

FIGURE 3
  • Download figure
  • Open in new tab
  • Download powerpoint
FIGURE 3

Project ECHO is not traditional telemedicine and leverages tele-mentoring to interact with groups of providers to amplify knowledge and the effect of the specialist. Reprinted with permission from Project ECHO/ECHO Institute.

The data presented here summarize PCP-identified education needs and will help target future programs. It is our hope that providing training and resources to PCPs will lead to improved diabetes care and reduce rampant inequities in health care delivery.

Article Information

Funding

The Leona M. and Harry B. Helmsley Charitable Trust provided funding for this research.

Duality of Interest

R.A.L. has consulted for GlySens Incorporated and Abbott Diabetes Care. He receives research support from the National Institute of Diabetes and Digestive and Kidney Diseases (1K12DK122550) and the Stanford Maternal Child Health Research Institute. M.J.H. receives research support from the National Institutes of Health (NIH), JDRF, the Helmsley Charitable Trust, the McJunkin Family Foundation, the Schultze Foundation, and the Diabetes Action Research and Education Foundation and is an advisory board member of SAb Biotherapeutics. K.K.H. has received research funding from Dexcom for an investigator-initiated study and consultant fees from LifeScan Diabetes Institute and Roche. A.B. has received support from The McJunkin Family Foundation. M.A.T. has received speaker fees from Insulet. D.M.M. has received research support from the NIH (P30 DK116074), JDRF, National Science Foundation, and Helmsley Charitable Trust. His institution has had research support from Bigfoot Biomedical, Dexcom, Insulet, Medtronic, Roche, and Tandem. He has consulted for Abbott, Eli Lilly, the Helmsley Charitable Trust, Insulet, Novo Nordisk, and Sanofi. No other potential conflicts of interest relevant to this article were reported.

Author Contributions

R.A.L. wrote the manuscript. N.C., M.J.H., K.K.H., E.S., M.B., A.B., L.G.B., C.J.W., M.A.T., and D.M.M. reviewed/edited the manuscript. K.Y. and C.A.-Z. collected data and reviewed/edited the manuscript. S.L.F. performed data analysis, created tables, and reviewed/edited the manuscript. M.J.G. performed data analysis and reviewed/edited the manuscript. A.F.W. oversaw the study and reviewed/edited the manuscript. A.F.W. is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Prior Presentation

Portions of this study were presented in abstract form at the 79th Scientific Sessions of the American Diabetes Association in San Francisco, CA, 7–11 June 2019.

Footnotes

  • This article contains supplementary materials online at https://clinical.diabetesjournals.org/lookup/suppl/doi:10.2337/cd19-0060/-/DC1.

  • © 2020 by the American Diabetes Association
https://www.diabetesjournals.org/content/license

Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. More information is available at https://www.diabetesjournals.org/content/license.

References

  1. 1.↵
    1. Selvin E,
    2. Parrinello CM,
    3. Daya N,
    4. Bergenstal RM
    . Trends in insulin use and diabetes control in the U.S.: 1988–1994 and 1999–2012. Diabetes Care 2016;39:e33–e35
    OpenUrlFREE Full Text
  2. 2.↵
    1. Beck RW,
    2. Tamborlane WV,
    3. Bergenstal RM,
    4. Miller KM,
    5. DuBose SN,
    6. Hall CA; T1D Exchange Clinic Network
    . The T1D Exchange clinic registry. J Clin Endocrinol Metab 2012;97:4383–4389
    OpenUrlCrossRefPubMedWeb of Science
  3. 3.↵
    1. Foster NC,
    2. Beck RW,
    3. Miller KM, et al
    . State of type 1 diabetes management and outcomes from the T1D Exchange in 2016–2018. Diabetes Technol Ther 2019;21:66–72
    OpenUrlPubMed
  4. 4.↵
    1. Gallegos-Macias AR,
    2. Macias SR,
    3. Kaufman E,
    4. Skipper B,
    5. Kalishman N
    . Relationship between glycemic control, ethnicity and socioeconomic status in Hispanic and white non-Hispanic youths with type 1 diabetes mellitus. Pediatr Diabetes 2003;4:19–23
    OpenUrlCrossRefPubMed
  5. 5.
    1. Hassan K,
    2. Loar R,
    3. Anderson BJ,
    4. Heptulla RA
    . The role of socioeconomic status, depression, quality of life, and glycemic control in type 1 diabetes mellitus. J Pediatr 2006;149:526–531
    OpenUrlCrossRefPubMedWeb of Science
  6. 6.
    1. Secrest AM,
    2. Costacou T,
    3. Gutelius B,
    4. Miller RG,
    5. Songer TJ,
    6. Orchard TJ
    . Associations between socioeconomic status and major complications in type 1 diabetes: the Pittsburgh Epidemiology of Diabetes Complication (EDC) Study. Ann Epidemiol 2011;21:374–381
    OpenUrlCrossRefPubMed
  7. 7.
    1. Berhan YT,
    2. Eliasson M,
    3. Möllsten A,
    4. Waernbaum I,
    5. Dahlquist G; Swedish Childhood Diabetes Study Group 2013
    . Impact of parental socioeconomic status on excess mortality in a population-based cohort of subjects with childhood-onset type 1 diabetes. Diabetes Care 2015;38:827–832
    OpenUrlAbstract/FREE Full Text
  8. 8.
    1. Walker AF,
    2. Schatz DA,
    3. Johnson C,
    4. Silverstein JH,
    5. Rohrs HJ
    . Disparities in social support systems for youths with type 1 diabetes. Clin Diabetes 2015;33:62–69
    OpenUrlAbstract/FREE Full Text
  9. 9.↵
    1. Andrade LF,
    2. Rapp T,
    3. Sevilla-Dedieu C
    . Exploring the determinants of endocrinologist visits by patients with diabetes. Eur J Health Econ 2016;17:1173–1184
    OpenUrl
  10. 10.↵
    1. Diabetes Control and Complications Trial Research Group;
    2. Nathan DM,
    3. Genuth S,
    4. Lachin J, et al
    . The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993;329:977–986
    OpenUrlCrossRefPubMedWeb of Science
  11. 11.↵
    1. Diabetes Control and Complications Trial (DCCT)/Epidemiology of Diabetes Interventions and Complications (EDIC) Study Research Group
    . Intensive diabetes treatment and cardiovascular outcomes in type 1 diabetes: the DCCT/EDIC study 30-year follow-up. Diabetes Care 2016;39:686–693
    OpenUrlAbstract/FREE Full Text
  12. 12.↵
    1. Rizza RA,
    2. Vigersky RA,
    3. Rodbard HW, et al
    . A model to determine workforce needs for endocrinologists in the United States until 2020. Diabetes Care 2003;26:1545–1552
    OpenUrlAbstract/FREE Full Text
  13. 13.
    1. Vigersky RA,
    2. Fish L,
    3. Hogan P, et al
    . The clinical endocrinology workforce: current status and future projections of supply and demand. J Clin Endocrinol Metab 2014;99:3112–3121
    OpenUrlCrossRefPubMed
  14. 14.↵
    1. Stewart AF
    . The United States endocrinology workforce: a supply-demand mismatch. J Clin Endocrinol Metab 2008;93:1164–1166
    OpenUrlCrossRefPubMed
  15. 15.↵
    1. Lu H,
    2. Holt JB,
    3. Cheng YJ,
    4. Zhang X,
    5. Onufrak S,
    6. Croft JB
    . Population-based geographic access to endocrinologists in the United States, 2012. BMC Health Serv Res 2015;15:541
    OpenUrlCrossRefPubMed
  16. 16.↵
    1. Centers for Disease Control and Prevention
    . National Diabetes Statistics Report, 2017. Atlanta, GA, U.S. Department of Health and Human Services, 2017
  17. 17.↵
    1. Van Walleghem N,
    2. Macdonald CA,
    3. Dean HJ
    . Evaluation of a systems navigator model for transition from pediatric to adult care for young adults with type 1 diabetes. Diabetes Care 2008;31:1529–1530
    OpenUrlAbstract/FREE Full Text
  18. 18.↵
    1. Ferrer RL
    . Pursuing equity: contact with primary care and specialist clinicians by demographics, insurance, and health status. Ann Fam Med 2007;5:492–502
    OpenUrlAbstract/FREE Full Text
  19. 19.↵
    1. Hoddinott SN,
    2. Bass MJ
    . The Dillman Total Design survey method. Can Fam Physician 1986;32:2366–2368
    OpenUrlPubMedWeb of Science
  20. 20.↵
    1. Malkani S,
    2. Keitz SA,
    3. Harlan DM
    . Redesigning diabetes care: defining the role of endocrinologists among alternative providers. Curr Diab Rep 2016;16:121
    OpenUrl
  21. 21.↵
    1. Arora S,
    2. Thornton K,
    3. Murata G, et al
    . Outcomes of treatment for hepatitis C virus infection by primary care providers. N Engl J Med 2011;364:2199–2207
    OpenUrlCrossRefPubMedWeb of Science
  22. 22.
    1. Bouchonville MF,
    2. Paul MM,
    3. Billings J,
    4. Kirk JB,
    5. Arora S
    . Taking telemedicine to the next level in diabetes population management: a review of the Endo ECHO model. Curr Diab Rep 2016;16:96
    OpenUrl
  23. 23.↵
    1. Zhou C,
    2. Crawford A,
    3. Serhal E,
    4. Kurdyak P,
    5. Sockalingam S
    . The impact of Project ECHO on participant and patient outcomes: a systematic review. Acad Med 2016;91:1439–1461
    OpenUrl
PreviousNext
Back to top
Clinical Diabetes: 38 (2)

In this Issue

April 2020, 38(2)
  • Table of Contents
  • Table of Contents (PDF)
  • About the Cover
  • Index by Author
  • Masthead (PDF)
Sign up to receive current issue alerts
View Selected Citations (0)
Print
Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Email Article

Thank you for your interest in spreading the word about Clinical Diabetes.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Primary Care Providers in California and Florida Report Low Confidence in Providing Type 1 Diabetes Care
(Your Name) has forwarded a page to you from Clinical Diabetes
(Your Name) thought you would like to see this page from the Clinical Diabetes web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Primary Care Providers in California and Florida Report Low Confidence in Providing Type 1 Diabetes Care
Rayhan A. Lal, Nicolas Cuttriss, Michael J. Haller, Katarina Yabut, Claudia Anez-Zabala, Korey K. Hood, Eleni Sheehan, Marina Basina, Angelina Bernier, Linda G. Baer, Stephanie L. Filipp, C. Jason Wang, Marissa A. Town, Matthew J. Gurka, David M. Maahs, Ashby F. Walker
Clinical Diabetes Apr 2020, 38 (2) 159-165; DOI: 10.2337/cd19-0060

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Add to Selected Citations
Share

Primary Care Providers in California and Florida Report Low Confidence in Providing Type 1 Diabetes Care
Rayhan A. Lal, Nicolas Cuttriss, Michael J. Haller, Katarina Yabut, Claudia Anez-Zabala, Korey K. Hood, Eleni Sheehan, Marina Basina, Angelina Bernier, Linda G. Baer, Stephanie L. Filipp, C. Jason Wang, Marissa A. Town, Matthew J. Gurka, David M. Maahs, Ashby F. Walker
Clinical Diabetes Apr 2020, 38 (2) 159-165; DOI: 10.2337/cd19-0060
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • Abstract
    • Research Design and Methods
    • Results
    • Discussion
    • Article Information
    • Footnotes
    • References
  • Figures & Tables
  • Suppl Material
  • Info & Metrics
  • PDF

Related Articles

Cited By...

More in this TOC Section

  • “I’ve Had an Alarm Set for 3:00 a.m. for Decades”: The Impact of Type 1 Diabetes on Sleep
  • Investigating and Comparing the Effect of Teach-Back and Multimedia Teaching Methods on Self-Care in Patients With Diabetic Foot Ulcers
  • Prognostic Factors of Fatal and Nonfatal Cardiovascular Events in Patients With Type 2 Diabetes: The Role of Renal Function Biomarkers
Show more Feature Articles

Similar Articles

Navigate

  • Current Issue
  • Papers in Press
  • Abridged Standards of Care
  • Archives
  • Submit
  • Subscribe
  • Email Alerts
  • RSS Feeds

More Information

  • About the Journal
  • Instructions for Authors
  • Journal Policies
  • Reprints and Permissions
  • Advertising
  • Privacy Policy: ADA Journals
  • Copyright Notice/Public Access Policy
  • Contact Us

Other ADA Resources

  • Diabetes
  • Diabetes Care
  • Diabetes Spectrum
  • Scientific Sessions Abstracts
  • Standards of Medical Care in Diabetes
  • BMJ Open - Diabetes Research & Care
  • Professional Books
  • Diabetes Forecast

 

  • DiabetesJournals.org
  • Diabetes Core Update
  • ADA's DiabetesPro
  • ADA Member Directory
  • Diabetes.org

© 2021 by the American Diabetes Association. Clinical Diabetes Print ISSN: 0891-8929, Online ISSN: 1945-4953.