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.

Barriers to Uptake of Insulin Technologies and Novel Solutions

“…For example, the likelihood of a provider recommending diabetes technology has been suggested to be influenced by insurance status, with this bias becoming more prevalent as practice years increased (but not age). 103 Commissariat’s study considers if the disparity is not solely from medical provider bias, but also that PwD from lower SES backgrounds face greater financial constraints and therefore may limit utilization of technologies, given the significant burden of cost with these devices. Those with high SES backgrounds may have more disposable income for diabetes supplies and to enroll in private insurance.…”

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

“…Multiple studies in populations with type 1 diabetes have highlighted the role of the health care provider as the “gateway” to diabetes technology. 15 , 18 , 19 Some studies suggest that overt or unconscious bias may be occurring and manifesting itself as lack of shared decision making and microaggressive language during medical encounters. 18 , 33 , 42 Unconscious bias may degrade the patient–provider relationship and trust necessary for patients to accept new treatments, such that patients may be rejecting diabetes technology when offered.…”

“… 15 , 18 , 19 Some studies suggest that overt or unconscious bias may be occurring and manifesting itself as lack of shared decision making and microaggressive language during medical encounters. 18 , 33 , 42 Unconscious bias may degrade the patient–provider relationship and trust necessary for patients to accept new treatments, such that patients may be rejecting diabetes technology when offered. 43–45 In our prior published study with patients, provider behaviors that instilled confidence in new technology use included optimism, tailoring of information, and clinical expertise.…”

“… 44 Patients were mainly recruited for the prototyping phase given our and other previously published studies on patient-perceived facilitators and barriers. 15 , 16 , 18 , 19 , 41 …”

“…Underserved populations have unique health care experiences and social needs that may be limiting diabetes technology use. Challenges from social determinants of health, 1 , 20–28 low social support, 29–32 structural racism, 33–36 and inequities in health care delivery 1 , 11 , 12 , 15 , 17 , 18 , 37 can contribute to fractured care, lost opportunities for building rapport with providers, and inability to follow traditional diabetes care guidelines.…”