Racial Disparities in Access and Use of Diabetes Technology Among Adult Patients With Type 1 Diabetes in a U.S. Academic Medical Center

Abstract

OBJECTIVE Recent studies highlight racial disparities in insulin pump (PUMP) and continuous glucose monitor (CGM) use in children and adolescents with type 1 diabetes (T1D). This study explored racial disparities in diabetes technology among adult patients with T1D. RESEARCH DESIGN AND METHODS This was a retrospective clinic-based cohort study of adult patients with T1D seen consecutively from April 2013 to January 2020. Race was categorized into non-Black (reference group) and Black. The primary outcomes were baseline and prevalent technology use, rates of diabetes technology discussions (CGMdiscn, PUMPdiscn), and prescribing (CGMrx, PUMPrx). Multivariable logistic regression analysis evaluated the association of technology discussions and prescribing with race, adjusting for social determinants of health and diabetes outcomes. RESULTS Among 1,528 adults with T1D, baseline technology use was significantly lower for Black compared with non-Black patients (7.9% vs. 30.3% for CGM; 18.7% vs. 49.6% for PUMP), as was prevalent use (43.6% vs. 72.1% for CGM; 30.7% vs. 64.2% for PUMP). Black patients had adjusted odds ratios (aORs) of 0.51 (95% CI 0.29, 0.90) for CGMdiscn and 0.61 (95% CI 0.41, 0.93) for CGMrx. Black patients had aORs of 0.74 (95% CI 0.44, 1.25) for PUMPdiscn and 0.40 (95% CI, 0.22, 0.70) for PUMPrx. Neighborhood context, insurance, marital and employment status, and number of clinic visits were also associated with the outcomes. CONCLUSIONS Significant racial disparities were observed in discussions, prescribing, and use of diabetes technology. Further research is needed to identify the causes behind these disparities and develop and evaluate strategies to reduce them.

The role of real‐time continuous glucose monitoring in diabetes management and how it should link to integrated personalized diabetes management

“…Despite the implementation of nationally and internationally agreed recommendations, it has been recognized that there are health care inequalities with regards to access and this includes access to all diabetes technologies. People with T1D from lower socio‐economic demographic and ethnic minority groups are less likely to access rtCGM and insulin pump systems 38,39 . Ongoing efforts to bridge these inequalities are being prioritized 40 …”

Continuous glucose monitors and virtual care in high-risk, racial and ethnic minority populations: Toward promoting health equity

“…Only one new study has been published since the most recent review in this area (2022) ( 17 ). Kanbaour et al., 2023 conducted a retrospective clinic-based cohort study of 1,258 adults with T1D who received care between 2013-2020 ( 28 ). The authors report that, relative to non-Black adults, Black adults were less likely to use CGM at baseline and were less likely to initiate CGM over the study period.…”

“…Of relevance to CGM use, a few studies document provider implicit bias to recommend diabetes technology based on insurance ( 32 , 33 ) and race or ethnicity ( 33 ). Relatedly, a recent clinic-based retrospective study demonstrated that, relative to non-Black adults, Black adults with T1D were less likely to discuss CGMs with their providers and be prescribed a CGM than non-Black adults (see Table 1 ) ( 28 ). It is plausible that providers may eliminate CGM as an option for members of marginalized groups based on biases, stereotypes, and generalizations regarding factors such as health literacy, socioeconomic status, and social contexts affecting their ability to take on new treatment regimens; however, this is an area requiring further study.…”

Addressing disparities in technology use among patients with type 1 diabetes: a review

“…Patients have reported that providers have ‘discouraged and blocked’ the use of technology due to ‘glycemic control’ concerns or perceptions of a ‘device being too complex for the patient’, even against their wishes [27 ▪▪ ]. There have also been reports of receiving infrequent discussions and incomplete information about the benefits of technologies [25,28 ▪ ]. Given that patients heavily rely on providers for knowledge and these recommendations regarding technology use [19 ▪▪ ], any limitations in these discussions could exacerbate disparities among these groups.…”