Racial Disparities in Access and Use of Diabetes Technology Among Adult Patients With Type 1 Diabetes in a U.S. Academic Medical Center

Sarah Kanbour, Marissa Jones, Mohammed S Abusamaan, Caitlin Nass, Estelle Everett, Risa M Wolf, Aniket Sidhaye, Nestoras Mathioudakis, Sarah Kanbour, Marissa Jones, Mohammed S Abusamaan, Caitlin Nass, Estelle Everett, Risa M Wolf, Aniket Sidhaye, Nestoras Mathioudakis

Abstract

Objective: Recent studies highlight racial disparities in insulin pump (PUMP) and continuous glucose monitor (CGM) use in children and adolescents with type 1 diabetes (T1D). This study explored racial disparities in diabetes technology among adult patients with T1D.

Research design and methods: This was a retrospective clinic-based cohort study of adult patients with T1D seen consecutively from April 2013 to January 2020. Race was categorized into non-Black (reference group) and Black. The primary outcomes were baseline and prevalent technology use, rates of diabetes technology discussions (CGMdiscn, PUMPdiscn), and prescribing (CGMrx, PUMPrx). Multivariable logistic regression analysis evaluated the association of technology discussions and prescribing with race, adjusting for social determinants of health and diabetes outcomes.

Results: Among 1,258 adults with T1D, baseline technology use was significantly lower for Black compared with non-Black patients (7.9% vs. 30.3% for CGM; 18.7% vs. 49.6% for PUMP), as was prevalent use (43.6% vs. 72.1% for CGM; 30.7% vs. 64.2% for PUMP). Black patients had adjusted odds ratios (aORs) of 0.51 (95% CI 0.29, 0.90) for CGMdiscn and 0.61 (95% CI 0.41, 0.93) for CGMrx. Black patients had aORs of 0.74 (95% CI 0.44, 1.25) for PUMPdiscn and 0.40 (95% CI, 0.22, 0.70) for PUMPrx. Neighborhood context, insurance, marital and employment status, and number of clinic visits were also associated with the outcomes.

Conclusions: Significant racial disparities were observed in discussions, prescribing, and use of diabetes technology. Further research is needed to identify the causes behind these disparities and develop and evaluate strategies to reduce them.

Conflict of interest statement

Duality of Interest. No potential conflicts of interest relevant to this article were reported.

© 2022 by the American Diabetes Association.

Figures

Graphical abstract
Graphical abstract
Figure 1
Figure 1
Comparison of diabetes technology outcomes among Black vs. non-Black patients. A: CGM outcomes by race. B: PUMP outcomes by race. *P < 0.05; ***P < 0.001.
Figure 2
Figure 2
Association of patient characteristics and CGMdiscn in CGM-naive cohort (n = 893) (A) and CGMrx in the CGMdiscn cohort (n = 793) (B). Data displayed represent point estimates and 95% CIs derived from multivariable regression.
Figure 3
Figure 3
Association of patient characteristics and PUMPdiscn in the PUMP-naive cohort (n = 623) (A) and PUMPrx in the PUMPdiscn cohort (n = 481) (B). Data displayed represent point estimates and 95% CIs derived from multivariable regression.

References

    1. Beck RW, Bergenstal RM, Laffel LM, Pickup JC. Advances in technology for management of type 1 diabetes. Lancet 2019;394:1265–1273
    1. American Diabetes Association . Standards of Medical Care in Diabetes–2022 abridged for primary care providers. Clin Diabetes 2022;40:10–38
    1. Hill-Briggs F, Adler NE, Berkowitz SA, et al. . Social determinants of health and diabetes: a scientific review. Diabetes Care 2020;44:258–279
    1. Addala A, Auzanneau M, Miller K, et al. . A decade of disparities in diabetes technology use and HbA1c in pediatric type 1 diabetes: a transatlantic comparison. Diabetes Care 2021;44:133–140
    1. Lipman TH, Willi SM, Lai CW, Smith JA, Patil O, Hawkes CP. Insulin pump use in children with type 1 diabetes: over a decade of disparities. J Pediatr Nurs 2020;55:110–115
    1. Lipman TH, Hawkes CP. Racial and socioeconomic disparities in pediatric type 1 diabetes: time for a paradigm shift in approach. Diabetes Care 2021;44:14–16
    1. Rodriguez-Gutierrez R, Herrin J, Lipska KJ, Montori VM, Shah ND, McCoy RG. Racial and ethnic differences in 30-day hospital readmissions among US adults with diabetes. JAMA Netw Open 2019;2:e1913249.
    1. Lado JJ, Lipman TH. Racial and ethnic disparities in the incidence, treatment, and outcomes of youth with type 1 diabetes. Endocrinol Metab Clin North Am 2016;45:453–461
    1. Saydah S, Imperatore G, Cheng Y, Geiss LS, Albright A. Disparities in diabetes deaths among children and adolescents—United States, 2000–2014. MMWR Morb Mortal Wkly Rep 2017;66:502–505
    1. Lai CW, Lipman TH, Willi SM, Hawkes CP. Racial and ethnic disparities in rates of continuous glucose monitor initiation and continued use in children with type 1 diabetes. Diabetes Care 2021;44:255–257
    1. Agarwal S, Kanapka LG, Raymond JK, et al. . Racial-ethnic inequity in young adults with type 1 diabetes. J Clin Endocrinol Metab 2020;105:e2960–e2969
    1. Fantasia KL, Wirunsawanya K, Lee C, Rizo I. Racial disparities in diabetes technology use and outcomes in type 1 diabetes in a safety-net hospital. J Diabetes Sci Technol 2021;15:1010–1017
    1. Ju Z, Piarulli A, Bielick L, Marschall S, Brouillard E, Steenkamp D. Advanced diabetes technology remains underutilized in underserved populations: early hybrid closed-loop system experience at an academic safety net hospital. Diabetes Technol Ther 2022;24:143–147
    1. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research Electronic Data Capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009;42:377–381
    1. Harris PA, Taylor R, Minor BL, et al. .; REDCap Consortium . The REDCap consortium: building an international community of software platform partners. J Biomed Inform 2019;95:103208.
    1. Kind AJH, Buckingham WR. Making neighborhood-disadvantage metrics accessible—the Neighborhood Atlas. N Engl J Med 2018;378:2456–2458
    1. Aleppo G, Ruedy KJ, Riddlesworth TD, et al. .; REPLACE-BG Study Group . REPLACE-BG: a randomized trial comparing continuous glucose monitoring with and without routine blood glucose monitoring in adults with well-controlled type 1 diabetes. Diabetes Care 2017;40:538–545
    1. Mayer-Davis EJ, Beyer J, Bell RA, et al. .; SEARCH for Diabetes in Youth Study Group . Diabetes in African American youth: prevalence, incidence, and clinical characteristics: the SEARCH for Diabetes in Youth Study. Diabetes Care 2009;32(Suppl. 2):S112–S122
    1. Willi SM, Miller KM, DiMeglio LA, et al. .; T1D Exchange Clinic Network . Racial-ethnic disparities in management and outcomes among children with type 1 diabetes. Pediatrics 2015;135:424–434
    1. Lin MH, Connor CG, Ruedy KJ, et al. .; Pediatric Diabetes Consortium . Race, socioeconomic status, and treatment center are associated with insulin pump therapy in youth in the first year following diagnosis of type 1 diabetes. Diabetes Technol Ther 2013;15:929–934
    1. Miller KM, Beck RW, Foster NC, Maahs DM. HbA1c levels in type 1 diabetes from early childhood to older adults: a deeper dive into the influence of technology and socioeconomic status on HbA1c in the T1D Exchange Clinic Registry findings. Diabetes Technol Ther 2020;22:645–650
    1. Messer LH, Tanenbaum ML, Cook PF, et al. . Cost, hassle, and on-body experience: barriers to diabetes device use in adolescents and potential intervention targets. Diabetes Technol Ther 2020;22:760–767
    1. Anderson JE, Gavin JR, Kruger DF. Current eligibility requirements for CGM coverage are harmful, costly, and unjustified. Diabetes Technol Ther 2020;22:169–173
    1. American Diabetes Association . Standards of Medical Care in Diabetes—2019 abridged for primary care providers. Clin Diabetes 2019;37:11–34
    1. Ziegler R, Heidtmann B, Hilgard D, Hofer S, Rosenbauer J; DPV-Wiss-Initiative . Frequency of SMBG correlates with HbA1c and acute complications in children and adolescents with type 1 diabetes. Pediatr Diabetes 2011;12:11–17
    1. Fredette ME, Zonfrillo MR, Park S, Quintos JB, Gruppuso PA, Topor LS. Self-reported insulin pump prescribing practices in pediatric type 1 diabetes. Pediatr Diabetes 2021;22:758–765
    1. Valenzuela JM, La Greca AM, Hsin O, Taylor C, Delamater AM. Prescribed regimen intensity in diverse youth with type 1 diabetes: role of family and provider perceptions. Pediatr Diabetes 2011;12:696–703
    1. American Diabetes Association . Standards of Medical Care in Diabetes—2013. Diabetes Care 2013;36(Suppl. 1):S11–S66
    1. Tanenbaum ML, Adams RN, Hanes SJ, et al. . Optimal use of diabetes devices: clinician perspectives on barriers and adherence to device use. J Diabetes Sci Technol 2017;11:484–492
    1. Lawton J, Kimbell B, Rankin D, et al. .; CLOuD Consortium . Health professionals’ views about who would benefit from using a closed-loop system: a qualitative study. Diabet Med 2020;37:1030–1037
    1. Agarwal S, Crespo-Ramos G, Long JA, Miller VA. “I didn’t really have a choice”: qualitative analysis of racial-ethnic disparities in diabetes technology use among young adults with type 1 diabetes. Diabetes Technol Ther 2021;23:616–622
    1. Mencher SR, Weinzimer SA, Nally LM, Van Name M, Nunez-Smith M, Sadler LS. Technology utilization in Black adolescents with type 1 diabetes: exploring the decision-making process. Diabetes Technol Ther 2022;24:249–257
    1. Addala A, Hanes S, Naranjo D, Maahs DM, Hood KK. Provider implicit bias impacts pediatric type 1 diabetes technology recommendations in the United States: findings from the Gatekeeper Study. J Diabetes Sci Technol 2021;15:1027–1033
    1. Evans MK, Graves JL Jr, Shim RS, Tishkoff SA, Williams WW. Race in medicine—genetic variation, social categories, and paths to health equity. N Engl J Med 2021;385:e45.
    1. Ducat L, Philipson LH, Anderson BJ. The mental health comorbidities of diabetes. JAMA 2014;312:691–692
    1. Adler NE, Stead WW. Patients in context—EHR capture of social and behavioral determinants of health. N Engl J Med 2015;372:698–701
    1. Takeshita J, Wang S, Loren AW, et al. . Association of racial/ethnic and gender concordance between patients and physicians with patient experience ratings. JAMA Netw Open 2020;3:e2024583.

Source: PubMed

Sponsorit ja yhteistyökumppanit

Sairaudet

Huumeiden interventiot

3
Tilaa