Racial, Ethnic Inequities Persist in Diabetes Care
Significant differences in the use of insulin pump and/or CGM technology were noted based on demographic and socioeconomic factors
Although the use of diabetes technology has increased across all racial and ethnic groups, inequities persist, according to research published in the Journal of Endocrinology & Metabolism.1
In the United States, race and ethnicity have been associated with inequities in diabetes treatment and outcomes. Non-Hispanic Black and Hispanic indi- viduals with type 1 diabetes (T1D) have higher hemoglobin A1c (HbA1c), higher rates of severe hypoglycemia and dia- betic ketoacidosis, and are more likely to visit emergency departments and hospitals than individuals with T1D who identify as non-Hispanic White.
Researchers used a version of Optum’s deidentified Clinformatics Data Mart to select Medicare Advantage beneficiaries with T1D between January 1, 2017, and December 31, 2020. Beneficiaries were assessed annually for the presence of T1D and use of diabetes technology. Evaluated outcomes included use of insulin pumps, of a continuous glucose monitor (CGM), of either an insulin pump or a CGM, and of an insulin pump and a CGM. End points were assessed by race and ethnicity in each of the 4 annual cohorts.
A total of 34,649 unique beneficiaries were included in the analysis; 55.2% appeared in only 1 cohort, 18.6% appeared in 2, 12% appeared in 3, and 14.3% appeared in all 4 cohorts. The study population was 70% White, 12% Black, 8% Hispanic, and 2% Asian.
Investigators found that overall, use of an insulin pump, a CGM, both insulin pump and CGM, and either insulin pump or CGM increased during the 4-year study period; CGM use increased from 3.8% to 35.2%, and insulin pump use increased from 19.7% to 25.1% during the same time. The use of either technology “more than doubled” (21.3% to 44.9%), and the use of both technol- ogies increased 6-fold during the study period, from 2.25% to 15.4%.
When evaluating the data by racial and ethnic group, investigators found that the prevalence of each outcome did increase; however, “within each annual cohort and outcome, there were significant differences between racial/ethnic groups,” with gaps in prevalence between White individuals and individuals of other races and ethnicities remaining “generally increase[ing] or remaining stable” between 2017 and 2020.
When evaluating data from the 2020 cohort, there were significant differ- ences noted in the use of insulin pump and/or CGM technology based on demographic and socioeconomic factors. Those who utilized the technology tended to be younger, to have attended at least some college, have an annual income of $60,000 or higher, and to be a homeowner (P <.001 for all). A visit to an endocrinology health care provider “was also associated with significantly higher rates of technology use,” and those who used both an insulin pump and a CGM were twice as likely to have seen an endocrinologist within the cohort year compared with those who did not (66.6% vs 33.4%).
“Prior studies have documented numerous potential reasons for the inequities shown here, including language barriers, access to quality health care, and implicit bias,” the researchers noted.“ Recent qualitative studies have directly asked patients with T1D about barriers to technology use, and most commonly found problems at the pro- vider level, as opposed to the patient or system level.” These problems, they added, include poor communication, a lack of shared decision-making about treatments between patients and providers, and provider unwillingness to prescribe technology to patients who “did not already have optimal control of their diabetes.”
According to the researchers, the “persistent inequities” in diabetes technology access found in the current study have implications “not only for patients and providers, but also for health care systems and policymakers” and require multiple policy changes to improve equitable access.
The study had a number of limitations, including the possibility for misclassification, the smaller portion of Hispanic and Asian beneficiaries in the study population, and the inability to assign beneficiaries to more than 1 race. For further information on limitations, please see the full study.
“Health equity has emerged as a priority among policymakers, professional organizations, and health systems. While increases in rates of diabetes technology use within White, Black, Hispanic, and Asian Medicare Advantage beneficiaries are encouraging, between-group inequities...persist through 2020 and cannot be explained by markers of socioeconomic status,” the researchers concluded.
References
1. Kommareddi M, Wherry K, Vigersky RA. Racial/ethnic inequities in use of diabetes technologies among Medicare Advantage beneficiaries with type 1 diabetes. J Clin Endocrinol Metab. Published online January 30, 2023. doi:10.1210/clinem/dgad046
