Universal Type 1 Diabetes Screening in Pediatrics

Background:

Type 1 diabetes (T1D) is the most common form of diabetes in children and adolescents, affecting approximately 1 in 300 young people in the United States. The disease results from autoimmune destruction of pancreatic β-cells and often progresses silently over months to years before clinical symptoms emerge. Although first-degree relatives have a substantially higher risk of developing T1D, most children diagnosed with T1D do not have a family history of the disease. The presence of multiple islet autoantibodies is associated with an almost certain lifetime risk of insulin-requiring diabetes, and early identification before symptom onset can significantly reduce rates of life-threatening diabetic ketoacidosis (DKA), support structured monitoring, and potentially allow for disease-modifying interventions.

Despite clear benefits, early detection through autoantibody screening is not routinely implemented in U.S. pediatric primary care. Currently, screening largely occurs in research settings, and little is known about how best to integrate universal T1D screening into busy community pediatric practices. Key concerns include workflow burden, clinician capacity, limited availability of pediatric endocrinologists, parent understanding and acceptability, and other structural barriers such as insurance coverage. Emerging recommendations from leading professional organizations worldwide, including the International Society for Pediatric and Adolescent Diabetes and the American Diabetes Association, highlight the potential of population-based screening; however, practical strategies for real-world implementation remain underdeveloped.

This study is designed to generate practice-informed evidence on how universal T1D islet autoantibody screening can be feasibly, acceptably, and appropriately integrated into routine pediatric well-child visits. Guided by implementation science, the study evaluates a set of implementation strategies that includes clinician education, clinician ordering reminders, and facilitation.

Observational Study Model:

This is an observational implementation study. The research team does not assign or deliver any clinical interventions. T1D screening orders and blood draws occur as part of routine care at clinician discretion, and the study observes electronic health record (EHR) outcomes and collects surveys/interviews.

The research team will offer a set of implementation strategies to all participating clinics to enable routine screening adoption. These are clinic-wide activities and are not research 'interventions' assigned to participants, and clinical decisions remain at clinician discretion. These supports will not be randomly assigned.

Study Objectives:

• Assess feasibility, acceptability, and appropriateness of integrating population-based islet autoantibody screening for T1D into pediatric primary care. Preliminary implementation strategy effectiveness will also be examined by tracking the proportion of eligible individuals for which clinicians order screening (penetration), proportion of eligible individuals who complete screening (reach), and proportion of eligible individuals with ICD-10 codes documented for early-stage T1D (unspecified stage, E10.A0; Stage 1, E10.A1; Stage 2, E10.A2; clinical documentation).
• Understand perspectives of multiple constituent groups, including parents, clinicians, other care team members, pediatric endocrinologists, and national and regional experts on implementing population-based T1D screening as part of standard pediatric preventive care.

Findings from this study will inform future scale-up efforts and support the development of implementation strategies for integrating universal T1D screening across U.S. pediatric care settings.

Inclusion criteria

Children

• Clinics will be encouraged to select screening ages or visits that align with international consensus statements for screening during early childhood, mid-childhood, and preadolescence and routine U.S. well-child visit schedules, and that minimize workflow disruption and maximize screening completion, such as visits that already include blood draws for other routine tests (e.g., lead screening at age 2). Children who have visits at their clinic's selected ages will be eligible to have their data extracted from the electronic health record (EHR)

Parents/Caregivers - All parents or legal guardians (hereafter, parents) who attended the well-child visit, who are eligible to have their child's EHR data extracted, and who are over age 18, will be eligible to complete the post-visit survey and interview.

Clinicians and Other Care Team Members

• All pediatric primary care clinicians (i.e., physician [MD, DO], nurse practitioner, physician assistant) at participating clinics will be eligible to complete an interview.
• All other care team members, including nurses, medical assistants, phlebotomists, and front desk staff at participating clinics will be eligible to complete an interview.

Exclusion criteria

• Parents who have opted-out of survey recruitment at their clinic will not be eligible for the survey/interview.