Barriers to Technology Use and Endocrinology Care for Underserved Communities With Type 1 Diabetes

Abstract

Disparities in type 1 diabetes related to use of technologies like continuous glucose monitors (CGMs) and utilization of diabetes care are pronounced based on socioeconomic status (SES), race, and ethnicity. However, systematic reports of perspectives from patients in vulnerable communities regarding barriers are limited. RESEARCH DESIGN AND METHODSTo better understand barriers, focus groups were conducted in Florida and California with adults $18 years old with type 1 diabetes with selection criteria including hospitalization for diabetic ketoacidosis, HbA 1c >9%, and/or receiving care at a Federally Qualified Health Center. Sixteen focus groups were conducted in English or Spanish with 86 adults (mean age 42 ± 16.2 years). Transcript themes and pre-focus group demographic survey data were analyzed. In order of frequency, barriers to diabetes technology and endocrinology care included: 1) provider level (negative provider encounters); 2) system level (financial coverage); and 3) individual level (preferences). RESULTSOver 50% of participants had not seen an endocrinologist in the past year or were only seen once including during hospital visits. In Florida, there was less technology use overall (38% used CGMs in FL and 63% in CA; 43% used pumps in FL and 69% in CA) and significant differences in pump use by SES (P 5 0.02 in FL; P 5 0.08 in CA) and race/ethnicity (P 5 0.01 in FL; P 5 0.80 in CA). In California, there were significant differences in CGM use by race/ethnicity (P 5 0.05 in CA; P 5 0.56 in FL) and education level (P 5 0.02 in CA; P 5 0.90 in FL). CONCLUSIONSThese findings provide novel insights into the experiences of vulnerable communities and demonstrate the need for multilevel interventions aimed at offsetting disparities in diabetes.Health outcomes in type 1 diabetes in the U.S. are profoundly shaped by socioeconomic status (SES), race, and ethnicity from childhood and throughout the life span. People living with type 1 diabetes from low SES households face elevated risks for suboptimal glycemic control, diabetic ketoacidosis (DKA), disease

Solutions to Address Inequity in Diabetes Technology Use in Type 1 Diabetes: Results from Multidisciplinary Stakeholder Co-creation Workshops

“… 15 In another study of 86 adults with type 1 diabetes at federally qualified health centers, similar provider interactions and system-level issues prevented use of technology. 19 These findings are consistent with studies that found physicians unconsciously and preferentially prescribed diabetes technology for youth and adult patients with type 1 diabetes who exhibited higher health literacy, SES, and lower HbA1c values. 1 , 12 , 38 , 39 …”

Overcoming Barriers to Diabetes Technology in Youth with Type 1 Diabetes and Public Insurance: Cases and Call to Action

“…SDOH are essential intervention targets to achieve equity in diabetes care [ 12 ]. Financial cost is a major obstacle to diabetes technology use [ 23 ]. In the US, youths of lower SES on public insurance are unlikely to afford CGM and insulin pumps without insurance coverage.…”

Understanding the needs of people aging with type 1 diabetes: a user-focused research study with prototype diabetes advance directive and setting the stage for future research

“…Additionally, not all healthcare providers are trained to use the data from these devices, such as when a patient presents to primary care, urgent care, or emergency department for non-diabetes focused care needs [ 29 ]. There can be a mismatch in expectations of care [ 30 ] on both sides, depending on whether patients have access to these technologies or not [ 31 ], and whether healthcare providers are aware of the extent of these technologies’ role in their patients’ diabetes management. Further exploration should consider not only the hardware technologies themselves but also tangible recorded datasets and information that provide a comprehensive view of diabetes management and may also serve to leverage the patient’s credibility from the perspective of a care provider who is hesitant to interact with, or rely on data from, their patients’ diabetes tools.…”