Relationships Between Socioeconomic Status, Insurance Coverage for Diabetes Technology and Adverse Health in Patients With Type 1 Diabetes

Abstract

Introduction: Insulin pumps and continuous glucose monitors (CGM) have many benefits in the management of type 1 diabetes. Unfortunately disparities in technology access occur in groups with increased risk for adverse effects (eg, low socioeconomic status [SES], public insurance). Research Design & Methods: Using 2015 to 2016 data from 4,895 participants from the T1D Exchange Registry, a structural equation model (SEM) was fit to explore the hypothesized direct and indirect relationships between SES, insurance features, access to diabetes technology, and adverse clinical outcomes (diabetic ketoacidosis, hypoglycemia). SEM was estimated using the maximum likelihood method and standardized path coefficients are presented. Results: Higher SES and more generous insurance coverage were directly associated with CGM use (β = 1.52, SE = 0.12, P < .0001 and β = 1.21, SE = 0.14, P < .0001, respectively). Though SES displayed a small inverse association with pump use (β = -0.11, SE = 0.04, P = .0097), more generous insurance coverage displayed a stronger direct association with pump use (β = 0.88, SE = 0.10, P < .0001). CGM use and pump use were both directly associated with fewer adverse outcomes (β = -0.23, SE = 0.06, P = .0002 and β = -0.15, SE = 0.04, P = .0002, respectively). Both SES and insurance coverage demonstrated significant indirect effects on adverse outcomes that operated through access to diabetes technology (β = -0.33, SE = 0.09, P = .0002 and β = -0.40, SE = 0.09, P < .0001, respectively). Conclusions: The association between SES and insurance coverage and adverse outcomes was primarily mediated through diabetes technology use, suggesting that disparities in diabetes outcomes have the potential to be mitigated by addressing the upstream disparities in technology use.

Implementing an integrated psychology, social services, and pediatric diabetes clinic.

“…We hope that innovations, such as holistic, integrated care, and tools, such as continuous glucose monitors and insulin pumps, will help to erase these disparities. At the time of this writing, there are inequitable policies and prerequisites to obtain these supportive technologies that have been shown to improve A1c results and decrease adverse health outcomes (Everett & Wisk, 2022).…”

Narrowing the Divide: The Role of Telehealth in Type 1 Diabetes Care for Marginalized Communities

“…Remote care for T1D hinges on the ability to access patient-generated health data from continuous glucose monitoring (CGM) devices and insulin pumps, but disparities in use of such therapeutic technology persist. 16 -20,24 -26 Health insurance plans must universally cover CGM and insulin pump devices—now recommended as treatment options for people of all ages 82,83 —as a first step. Government policies are needed in parallel to expand broadband Internet access—no longer a luxury but now a strong determinant of outcomes in both health 84 and education 85 —which would enable remote data-sharing as well as synchronous telehealth interactions.…”

“…15 Disparities in access to therapeutic technology and health outcomes based on income and race/ethnicity are well-documented for people with T1D. [16][17][18][19][20][21][22][23][24][25][26] In addition, T1D care is well-suited to telehealth due to its reliance on patient-generated health data and behavioral health coaching; for this reason, telehealth was employed for T1D management even prior to the COVID-19 pandemic.…”

Socio‐economic disparities in hospital care among Dutch patients with diabetes mellitus

“…30 Regarding adults, recent studies from the USA have reported lower CSII and CGM use in patients of all ages with lower SES or less generous insurance. 13,14,31 In New Zealand lower SES was also associated with lower CSII use in patients of all ages. 12 Moreover, a study from the United Kingdom evaluated the use of diabetes technology in adults and found less frequent use in participants from the most deprived neighbourhoods.…”