Provider Implicit Bias Impacts Pediatric Type 1 Diabetes Technology Recommendations in the United States: Findings from The Gatekeeper Study

Abstract

Background: Diabetes technology use is associated with favorable type 1 diabetes (T1D) outcomes. American youth with public insurance, a proxy for low socioeconomic status, use less diabetes technology than those with private insurance. We aimed to evaluate the role of insurance-mediated provider implicit bias, defined as the systematic discrimination of youth with public insurance, on diabetes technology recommendations for youth with T1D in the United States.

Methods: Multi-disciplinary pediatric diabetes providers completed a bias assessment comprised of a clinical vignette and ranking exercises (n = 39). Provider bias was defined as providers: (1) recommending more technology for those on private insurance versus public insurance or (2) ranking insurance in the top 2 of 7 reasons to offer technology. Bias and provider characteristics were analyzed with descriptive statistics, group comparisons, and multivariate logistic regression.

Results: The majority of providers [44.1 ± 10.0 years old, 83% female, 79% non-Hispanic white, 49% physician, 12.2 ± 10.0 practice-years] demonstrated bias (n = 33/39, 84.6%). Compared to the group without bias, the group with bias had practiced longer (13.4±10.4 years vs 5.7 ± 3.6 years, P = .003) but otherwise had similar characteristics including age (44.4 ± 10.2 vs 42.6 ± 10.1, p = 0.701). In the logistic regression, practice-years remained significant (OR = 1.47, 95% CI [1.02,2.13]; P = .007) when age, sex, race/ethnicity, provider role, percent public insurance served, and workplace location were included.

Conclusions: Provider bias to recommend technology based on insurance was common in our cohort and increased with years in practice. There are likely many reasons for this finding, including healthcare system drivers, yet as gatekeepers to diabetes technology, providers may be contributing to inequities in pediatric T1D in the United States.

Keywords: diabetes technology; health disparities; implicit bias; insurance; minority health; pediatric type 1 diabetes.

Conflict of interest statement

Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr. Maahs has had research support from the NIH, JDRF, NSF, and the Helmsley Charitable Trust and his institution has had research support from Medtronic Diabetes, Dexcom, Insulet, Bigfoot Biomedical, Tandem, and Roche. Dr. Maahs has also consulted for Abbott, the Helmsley Charitable Trust, Sanofi, Novo Nordisk, Eli Lilly, Medtronic, and Insulet. Dr. Hood has received consulting fees from Lifescan Diabetes Institute and MedIQ and an investigator-initiated grant from Dexcom, Inc. Otherwise, no potential conflicts of interest relevant to this article were reported by the authors.

Figures

Figure 1.

Patient factors ranked in order of importance for providers to recommend insulin pump or CGM. Legend: Figure 1a presents patient factors considered in order of importance for recommending insulin pumps. Figure 1b presents patient factors considered in order of importance for recommending CGM. 1 denotes the most important patient factor and 7 denotes the least important. The median is denoted by the white dot and the black bar indicated the first through third quartiles. Abbreviations: CGM, continuous glucose monitoring; HbA1c, Hemoglobin A1c; SMBG, Self-monitoring Blood Glucose checks per day.