Racial disparities in diabetes technology use widen among Medicare beneficiaries
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White Medicare beneficiaries were more likely to use an insulin pump or continuous glucose monitor than Black beneficiaries from 2017 to 2019, with the gap increasing over the 3-year period, according to study data.
In an analysis of data on technology use among Medicare beneficiaries with type 1 diabetes published in the Journal of Clinical Endocrinology and Metabolism, insulin pump and CGM use increased overall from 2017 to 2019, but greater gains were seen among white adults compared with Black adults and those of other ethnicities.
“The causes of health disparities in diabetes are complex and multifactorial,” Robert Vigersky, MD, chief medical officer at Medtronic Diabetes and professor of medicine at Uniformed Services University of the Health Sciences, told Healio. “Previous studies in non-Medicare beneficiaries point to socioeconomic status as the key driver of unequal adoption of diabetes technology, but this study shows many other contributing factors, such as unconscious bias among health care providers who may feel that non-whites are unable to use these technologies. Other important factors are cultural barriers, low health literacy and limited access to health care, particularly to endocrinologists.”
Vigersky and colleagues collected data from the Medicare Limited Data Set of Medicare fee-for-service (FFS) enrollees with type 1 diabetes from January 1, 2017, to December 31, 2019. Enrollees with at least one inpatient or emergency department visit, at least one inpatient or outpatient claim with a diagnosis of type 1 diabetes and continuous enrollment in Medicare FFS parts A and B were included. The study cohort was divided according to use of insulin pump therapy. Race and ethnicity were based on self-reports collected by the Social Security Administration or Railroad Retirement Board. The “other” ethnic group included Asian, Hispanic and North American Native adults, as well as those whose ethnicity was reported as unknown. Age, sex, reason for Medicare eligibility, dual Medicare/Medicaid eligibility and visits to an endocrinologist were collected from the Master Beneficiary Summary File.
Increasing disparities in technology use
More than 75% of participants were white in each of the 3 years of the study. For the full study cohort, use of an insulin pump, CGM and any technology increased each year. There were significant differences in device use by race. In 2019, 18.2% of white beneficiaries used pumps compared with 4.6% of Black beneficiaries, and 24.9% of white adults used CGM compared with 11.8% of Black adults. The use of any technology in 2019 was observed in 31.9% of white vs. 14% of Black beneficiaries.
While all racial-ethnic groups had increases in technology use during the study period, the increase was more pronounced for white adults. From 2018 to 2019, white beneficiaries had a 10.8% increase in CGM use vs. a 7.5% increase for Black beneficiaries and a 5.4% increase for beneficiaries of other ethnicities.
In 2019, Black and other ethnicity beneficiaries were more likely to have Medicare FFS coverage due to disability or end-stage renal disease compared with white beneficiaries (P < .001). Of those using pump therapy, 47.7% of Black adults and 33.3% of those from the other ethnicities were dual eligible for Medicare and Medicaid compared with 12.6% of white beneficiaries. For those not using a pump, 50.5% of Black participants and 62.3% of other ethnicity beneficiaries were dual eligible compared with 24.8% of white adults.
Of those who used CGM, 49.3% of Black beneficiaries and 48% of other beneficiaries were dual eligible for Medicare and Medicaid compared with 16.8% of white beneficiaries. Visits to an endocrinologist were similar by racial-ethnic group for CGM users; however, for non-CGM users, 26.9% of Black adults and 28.5% of those in other ethnic groups visited an endocrinologist compared with 33.5% of white adults (P < .001).
Combatting technology use disparities
Of the full study cohort, 3,868 used diabetes-related technology, and 9,928 reported no technology use. Among those using any diabetes-related technology, 57% of white adults used a pump compared with 33.1% of Black adults and 30.3% of adults from the other ethnicities.
Vigersky said health care professionals must take several steps to close the racial disparities observed in the study.
“All health care providers should engage in informed and shared decision-making using the [Association of Diabetes Care and Education Specialists]-promulgated framework of ‘identify, configure and collaborate,’ which recognizes that while choices will evolve over time, providing a person with diabetes with tools that match their care plan as well as assessing and addressing barriers to following that care plan will pay long-term dividends in overall health,” Vigersky said. “In addition, unconscious bias training is important not only for the health care provider, but everyone on the team who is involved in care of people with diabetes.”
For more information:
Robert Vigersky, MD, can be reached at robert.a.vigersky@medtronic.com.
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