Inequity in Adoption of Advanced Diabetes Technologies Among Medicare Fee-for-service Beneficiaries

Health inequities are differences in health status or in the distribution of health resources between different population groups, arising from the social conditions in which people are born, grow, live, work and age. Health inequities are unfair and could be reduced by the right mix of government policies. People born in low-income neighborhoods may have limited access to safe housing, clean water, nutritious food, education, and medical treatment, all influencing health. Health disparity occurs locally, nationally, and globally, affecting all countries. Compared to their White counterparts, people in various racial and ethnic minority groups have greater rates of poor health and illness for various health issues, including diabetes, hypertension, obesity, asthma, heart disease, cancer, and premature delivery.

Diabetes-related problems are more prevalent among racial and ethnic minority groups. Decades of studies have shown that diabetes disproportionately affects racial and ethnic minority and low-income adult groups in the United States, with generally persistent patterns found in their greater risk of diabetes, rates of diabetic complications, and death. Age, race-ethnicity, and socioeconomic status all affected glycated hemoglobin (HbA1c) levels, and racial-ethnic disparities influenced insulin pump and continuous glucose monitoring (CGM) use across all age categories, according to data from the Type 1 Diabetes (T1D) Exchange registry.

In a new study published in The Journal of Clinical Endocrinology & Metabolism, researchers at Medtronic Diabetes, Kael Wherry, Cyrus Zhu, and Dr. Robert Vigersky investigated the prevalence of insulin pump and CGM utilization among many Medicare beneficiaries with type 1 diabetes (T1D) by race-ethnicity. The proportion of technology utilization (pump, CGM) was assessed by race-ethnicity for Medicare fee-for-service participants in covering years (CY) 2017-2019. Using CY2019 data, technology users were compared to nonusers based on race-ethnicity, gender, average age, Medicare eligibility requirements, and endocrinologist visits. The authors main findings were that insulin pump and CGM use were lower among Black adults with type 1 diabetes in the U.S. compared with their white peers according to study data.

In the current study, white beneficiaries made up more than three-quarters of the entire study population in each of the three years. In the coverage year 2019, the percent of white beneficiaries was more than five times that of black beneficiaries. During the three years, the total use of pumps, CGM, and or both technologies increased. Overall, pump use prevalence improved from 11.8% to 13.3% to 15.3% between CY2017 and CY2019; however, in CY2019, 18.2% of White beneficiaries utilized pumps compared to only 4.6% of black beneficiaries. The incidence of the pump, CGM, and or both technology usage increased more for white beneficiaries than for black or other beneficiaries, particularly for CGM use. When only CY2019 data were analyzed, insulin pump vs. no-pump groups was separated by race-ethnicity. Females made up a larger proportion of pump users than nonusers across all racial and ethnicity categories. When compared to white beneficiaries, Black and Other beneficiaries were much more likely to receive Medicare FFS coverage due to disability or end-stage renal disease. Among pump users of all races and ethnicities, at least one visit to an endocrinologist was more prevalent than among nonusers. Females made up a larger proportion of CGM users than nonusers.

The authors found that diabetes-related technology was used by fewer individuals with T1D of all races and ethnicities in CY2019. However, the racial discrepancy among beneficiaries utilizing any diabetes-related device was stark: 57% of white patients used a pump, compared to 33.1 % of black and 30.3% of other patients. Whether they utilized technology or not, black patients were much more likely than white patients to be qualified for Medicare due to disability or end-stage renal illness, or to be dual eligible.

In conclusion, the current study demonstrated substantial race-ethnicity disparities in T1D management using technology. Between 2017 and 2019, the disparity in diabetes technology uptake between black and white beneficiaries increased. The pace of innovation in diabetes technology is accelerating with currently higher standards of care in type 1 diabetes, therefore understanding and eliminating disparities in use of these important new diabetes technologies is crucial to overcoming and disrupting the cycle of inequity in long-term outcomes for minority type 1 diabetes populations. Future studies should perhaps address preferences for black patients, health care provider implicit bias, mistrust of medical systems and patient-provider relationships to assess whether these factors contribute to advanced diabetes technologies use disparities.