Study: Racial-Ethnic Disparities in T1D Technology Use Worsened From 2017 to 2019

Between 2017 and 2019, the gap in diabetic technology adoption between Black and White Medicare beneficiaries grew, despite the overall upward trend in any technology use during that period, according to research published in the Endocrine Society’s Journal of Clinical Endocrinology & Metabolism.

For example, the analysis found that in 2019 approximately a quarter of White beneficiaries were using continuous glucose monitors (CGMs), compared with 12% of Black beneficiaries, and that gap has grown since 2017.

Previous research has revealed significant disparities in insulin pump and CGM use among individuals with type 1 diabetes (T1D) based on age, race, and socioeconomic status (SES), researchers explained. However, even after adjusting for multiple factors, it was found that Black individuals—who had significantly higher glycated hemoglobin (A1C) and worse disease severity—were still less likely than their White counterparts to use insulin pumps.

“Because race is culturally not biologically defined, and definitions of race-ethnicity are inconsistent, the search for the causes of health inequity has turned to other factors for which race-ethnicity has often served as a proxy, such as SES and health care access,” authors wrote. “Health care access, affordability and quality are highly correlated with race-ethnicity, SES and geographic location in the U.S.”

The benefits of both CGM and insulin pump use for those with T1D have been documented.

To elucidate the differences in diabetes-related technology adoption by race-ethnicity, researchers assessed data from US Medicare fee-for-service (FFS) beneficiaries with T1D and compared characteristics between CGM and pump users vs nonusers.

“Importantly, the FFS population provides a group of people with T1D who have the same insurance benefit, thus removing one of the most important factors associated with access to therapy,” they noted.

Changes to Medicare coverage of CGM were also implemented in 2017, and investigators utilized data recorded between January 2017 and December 2019 in the Medicare Limited Data Set 5% sample to conduct their analyses. Race-ethnicity data were based on self-reported data collected via the Social Security Administration or Railroad Retirement Board; additional information was gleaned from the Master Beneficiary Summary File.

The majority of beneficiaries documented during the study window were White, while in coverage-year (CY) 2019, “the percentage of White beneficiaries was more than 5 times higher (79%, n = 10,911) than that of Black beneficiaries (13.8%, n = 1093) and 4 times higher than that of Black plus Other beneficiaries (20.9%; 1903 + 982 = 2885)” researchers said.

They found that between CY 2017 and CY 2019, overall pump prevalence increased from 11.8% to 13.3% to 15.3%, but each year data showed significant differences between race-ethnicity groups with regard to pumps, CGM, or use of any technology. Black and other patients also tended to be younger on average in this cohort.

Additional analyses revealed:

• Prevalence of insulin pump use was less than 5% for Black and other beneficiaries yet increased from 14% to 18% among White beneficiaries.
• In CY 2019, 57% of White patients used a pump compared with 33.1% of Black and 30.3% of other patients (P < .001).
• Black patients were more likely than White patients to be eligible due to disability/end-stage renal disease or to be Medicare/Medicaid eligible (both P < .001), whether using technology or not.
• Significant race-ethnicity differences (P < .001) existed between technology users and nonusers for all evaluated factors except visiting an endocrinologist.

“This study highlights the complexity of the causes of health disparities in diabetes,” said Robert Vigersky, MD, chief medical officer of Medtronic Diabetes. “Previous studies in non-Medicare beneficiaries point to [SES] as the key driver of unequal adoption of diabetes technology, but our study shows many other contributing factors,” he noted, such as unconscious bias among health care providers, cultural barriers, low health literacy, and limited access to health care.

The role of these potentially contributing factors is bolstered by research that has found Black children with private insurance were less likely to be prescribed insulin pumps than White children without private insurance, researchers explained. An additional study also showed “lower rates of insulin pump use were associated with identifying as a racial-ethnic minority and having government insurance, even though government-sponsored health plans cover insulin pump therapy.”

Because standard guidelines do not exist when it comes to selecting patients for diabetes technology use, some providers may rely on individual criteria that are not evidence-based to identify good candidates. These can include a certain number of daily glucose tests or a minimum number of annual patient visits.

A lack of minority recruitment to T1D clinical trials could also serve as a barrier to advanced technology prescription.

The data set used in this current analysis may not be generalizable to the wider T1D population, authors cautioned, marking a limitation to the study. There was also no way to verify beneficiaries correctly used the technology, and the database relied on self-reported race-ethnicity using sometimes poorly defined categories, researchers said.

“In the case of diabetes, improving the quality of diabetes care among underserved minorities could contribute to reducing complication rates, thereby decreasing morbidity and mortality, as well as lowering health care costs” in the United States, they said.

“Yet the numerous factors that contribute to health care inequity also rule out simple solutions. A concerted effort to address all of the [social determinants of health] affecting health, including race-ethnicity, will be required before diabetes care becomes more equitable,” authors concluded.

Medtronic Diabetes helped fund the study and all authors are employees of Medtronic.

Reference

Wherry K, Zhu C, Vigersky RA. Inequity in adoption of advanced diabetes technologies among medicare fee-for-service beneficiaries. J Clin Endocrinol Metab. Published online December 15, 2021.