Racial Inequity in Diabetes Technology Use Among Medicare Beneficiaries

From 2017 to 2019, White Medicare beneficiaries were more likely to use a continuous glucose monitor or insulin pump than Black beneficiaries. Overall, the use of diabetes technology has increased; however, the gap has increased over the three years.

Vigersky and colleagues collected research from the Type 1 Diabetes Exchange Registry in the Medicare Limited Data Set. They found that HbA1c levels are affected by age, race-ethnicity, and socioeconomic status and that insulin pump and continuous glucose monitoring (CGM) is influenced by racial-ethnic inequity. As a result, the American Diabetes Association (ADA) has sponsored a scientific review of the Social Determinants of Health (SDOH). The SDOH’s include education/income/occupation, neighborhood/physical environment, food environment, healthcare, and social context. And to promote the health of patients with diabetes “no matter their race, income, zip code, age, education or gender,” the ADA published a Health Equity Bill of Rights.

The study population was Medicare FFS enrollees with type 1 diabetes between January 1st, 2017, and December 31st, 2019. First, inclusion criteria included the requirement to have at least one inpatient/emergency department visit or two outpatient claims with a diagnosis of type 1 or type 2 diabetes. Secondly, continuous enrollment in Medicare FFS parts A & B was required. Lastly, the study population was enrollees with type 1 diabetes identified with at least one inpatient or outpatient claim diagnosed with type 1 diabetes.

Enrollees that met the enrollment and diagnostic criteria were divided into those using pump therapy and those not using pump therapy. In addition, the race-ethnicity identification was classified as White, Black, Other, Asian, Hispanic, North American Native, and Unknown. Additional baseline characteristics collected included age, sex, current Medicare eligibility, and dual Medicare/Medicaid eligibility.

The comparisons made during the study were: (1) prevalence of technology use (either CGM, insulin pump, or both) from 2017 to 2019, (2) CGM or pump use vs. no technology use in 2019, and (3) any technology use versus none in 2019.

In each year of the three years, White beneficiaries were over three-quarters of the total study population. For each coverage year, the difference in the prevalence of pumps, CGM, or any technology used in race-ethnicity groups was significant (P < 0.001). For example, in 2019, only 4.6% of Black used pumps compared to 18.2% of White beneficiaries. Regarding CGM use, 11.8% of Black and 10.2% of Other beneficiaries used the technology, compared to 24.9% of White beneficiaries. Overall, the prevalence of technology use increased from 12.7% to 19.4% and 28% over the three years. However, 14% of Black and 12.1% of Other beneficiaries used any technology, compared to 31.9% of White beneficiaries.

Researchers mentioned numerous factors contributing to the lower technology adoption of some racial-ethnic groups in the US. Some of the barriers mentioned in the article include government-subsidized/no insurance, lower-income, cultural barriers, lack of health literacy, limited access to health care resources, poor patient-provider relationships, information technology usability issues, Age > 10, English not the primary language of the parent, parent’s perception of a higher cost of treatment, physician perception of poorer child and family competence and implicit provider/physician bias.

The strengths of this study included a national database, the large number of Medicare-eligible subjects with type 1 diabetes, and similar insurance benefits for all subjects. 

Study limitations included that the Medicare FFS 5% sample may not represent the general population of people with type 1 diabetes. In addition, the database relies on people self-reporting their race-ethnicity using poorly defined categories. And the data set did not provide a way of knowing if the prescribed technology was being correctly used.

Researchers concluded that an important public health goal is to reduce health inequity in the US. Although the use of diabetes technology has increased across all racial-ethnic groups between 2017 and 2019, the gap between White, Black, and Other beneficiaries in the use of insulin pump adoption grew between 2017 and 2019. To improve the quality of diabetes care, it is essential to address all of the social determinants of health affecting health, including race-ethnicity. Vigersky stated that “In addition, unconscious bias training is important not only for the health care provider but everyone on the team who is involved in the care of people with diabetes.”

Practice Pearls:

• It is essential to be aware of the social determinants of health regarding diabetes care for people with type 1 diabetes.
• Diabetes technology use has increased across all groups; however, the gap among racial-ethnicity groups has also increased.
• Unconscious bias training can improve the disparities in diabetes technology use.

 

Reference for “Racial inequity in diabetes technology use among Medicare beneficiaries”:

Wherry, Kael, et al. “Inequity in Adoption of Advanced Diabetes Technologies Among Medicare Fee-for-Service Beneficiaries.” OUP Academic, Oxford University Press, 15 Dec. 2021, https://academic.oup.com/jcem/advance-article/doi/10.1210/clinem/dgab869/6458828?login=true.

Azeezat Rasaki, PharmD. Candidate, Florida A&M University, College of Pharmacy