Most Medicare beneficiaries with diabetes do not use blood glucose monitoring or CGM
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The majority of Medicare beneficiaries with insulin-treated diabetes are either not prescribed continuous blood glucose monitoring or do not use the technology as directed, according to study data.
“Our finding of nonadherence or no glucose monitoring suggests that a large number of beneficiaries were frequently or always calculating their insulin dosages without glucose monitoring data, putting them at greater risk for severe hypoglycemia and its consequences,” Gary A. Puckrein, PhD, president and CEO of the National Minority Quality Forum, and colleagues wrote. “The American Diabetes Association has strongly emphasized the importance of blood glucose monitoring in making therapeutic adjustments in their standards of care. These results should raise serious concerns throughout the health care community about the safety of all beneficiaries with diabetes who are treated with insulin and/or other antihyperglycemic medications.”
Researchers conducted a retrospective analysis of data from 1,329,061 Medicare beneficiaries with diabetes in 2018 who had documented use of intensive insulin therapy through an insulin pump or multiple daily injections. The cohort was divided into four groups: adults who acquired real-time continuous glucose monitoring supplies, adults who fully acquired blood glucose monitoring supplies, those who partially acquired blood glucose monitoring supplies, and beneficiaries with no record of acquiring CGM or blood glucose monitoring supplies. Adults were considered to be adherent to insulin and glucose monitoring if they filled prescriptions for 80% or more of the days they were covered.
Of the study cohort, 35.42% were nonadherent to their prescribed blood glucose monitoring and 38.14% had no record of acquiring blood glucose monitoring or CGM supplies. There was a higher percentage of beneficiaries with no record of blood glucose monitoring or CGM acquisition among Black adults (46.1%) compared with Hispanic adults (36.9%) and white adults (36.7%; P < .0001 for both). The percentage of beneficiaries using CGM was higher among white adults (3.7%) compared with Black adults (1.6%) and Hispanic adults (1.3%; P < .0001 for both).
Of the cohort, 47.36% had two or more comorbidities. A higher proportion of Black adults (52.12%) and Hispanic adults (50.68%) had two or more comorbidities compared with white adults (46.27%). Black beneficiaries had a higher proportion of people with two comorbidities plus no record of glucose monitoring (25.6%) compared with white beneficiaries (18.3%) and Hispanic beneficiaries (19.2%; P < .0001 for both).
Hospitalizations did not vary across adherence groups or glucose monitoring method for adults with no comorbidities. Among those with two or more comorbidities, Black adults had a higher hospitalization incidence rate and higher hospitalization costs compared with white beneficiaries. The association was observed regardless of glucose monitoring method or adherence.
“Medicare beneficiaries with insulin-treated diabetes would benefit from concerted efforts to increase glucose monitoring adherence; blood glucose monitoring or real-time CGM,” the researchers wrote. “While poor adherence is likely influenced by many factors, we do know that structured diabetes self-management education is a potent enabler of adherence. It is imperative that Medicare take immediate steps to eliminate barriers to beneficiary access to diabetes self-management education and support and medical nutrition therapy services.”
Perspective
Back to TopOsagie Ebekozien, MD, MPH, CPHQ
Millions of people living with diabetes are Medicare beneficiaries. Real world data analysis of Medicare claims provides critical insights to the state of diabetes care in the U.S.
We congratulate Puckrein and colleagues on this study. The authors evaluated use of real-time continuous glucose monitoring devices, blood glucose monitoring adherence and association with race and ethnicity among a cohort of over 1.3 million persons. The study highlights widespread racial and ethnic inequities in access to blood glucose monitoring despite insurance coverage. The study also demonstrated increased hospitalization for people of color, irrespective of blood glucose monitoring adherence.
While this study is an impactful addition to the diabetes health equity literature, there are significant limitations. The data are 5 years old (2018) and do not reflect some more recent COVID-19 pandemic policy changes that might have impacted access to blood glucose monitoring options; furthermore, this study does not include data on intermittent scanned CGM.
Despite the limitations, this study aligns with similar findings from our T1D Exchange Quality Improvement Collaborative that access to insurance coverage is not enough to eliminate disparities. In our study, DeSalvo and colleagues found that non-Hispanic white patients on public insurance (like Medicare) in our cohort had higher CGM use as compared to non-Hispanic Black patients on private insurance. One of the contributors to inequities despite insurance coverage is provider bias in prescribing CGM as demonstrated in another T1D Exchange Quality Improvement Collaborative study by Odugbesan and colleagues. This study is another call to urgently address diabetes inequities with a multi-prong approach.
References:
DeSalvo DJ, et al. J Diabetes Sci Technol. 2021;doi:10.1177/19322968211049783.
Odugbesan O, et al. Diabetes Technol Ther. 2022;doi:10.1089/dia.2022.0042.
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