Extra support may alleviate widespread disparities in diabetes technology adoption

Diabetes technology uptake continues to be low among people with type 1 diabetes from underrepresented groups, and providers should not overlook patients who may struggle with diabetes management, according to a speaker.

“Health care providers may be inadvertently creating disparities in technology usage, so we have a responsibility to change that and to pay special attention about who we are recommending for devices and who we are ultimately supporting,” Shivani Agarwal, MD, MPH, an assistant professor of medicine at Albert Einstein College of Medicine and director of the Supporting Emerging Adults with Diabetes program at Montefiore Health System in New York, told Healio. “Patients who have social needs and other challenges may need extra support to start and use diabetes technology effectively; however, these patients may benefit the most from using these technologies, even if not perfectly.”

Low uptake among Black, Hispanic adults

Growing data highlight racial-ethnic disparities in insulin pump and continuous glucose monitor use in people with type 1 diabetes, and studies show socioeconomic status, health care or diabetes-specific factors are not the main drivers of differences in technology use, Agarwal said during a virtual presentation at the Association of Diabetes Care & Education Specialists Annual Conference.

In a study published in Diabetes Technology & Therapeutics in March, Agarwal and colleagues recruited a diverse sample of 300 young adults aged 18 to 28 years with type 1 diabetes from six diabetes centers in the U.S., enrolling equal numbers of white, Black and Hispanic participants (52% publicly insured). Researchers used logistic regression to examine to what extent socioeconomic status, demographics, health care factors and diabetes self-management explained insulin pump and CGM use by race.

The researchers observed large disparities in insulin pump and CGM use: 61% and 53% for white participants, 49% and 58% for Hispanic participants, and 20% and 31% for Black participants, respectively.

“What we found, dishearteningly, was that pump and CGM use were different between white and Black participants,” Agarwal said during the presentation. “When we tried to look at factors that may explain these disparities ... self-management, clinic attendance, pediatric vs. adults care settings, socioeconomic variables, we thought these factors would explain these disparities. What we found was the opposite.”

Unmeasured variables

In a follow-up study, also published in Diabetes Technology & Therapeutics, Agarwal and colleagues conducted interviews with participants to assess interactions with providers about technology.

“What we found was potentially exacerbating factors [behind] these technology disparities,” Agarwal said. “Patients said there was no shared decision-making with providers. It was an on/off switch; the provider said you had to have this technology or you were not ‘allowed’ to have this technology. The other thing young adults told us loud and clear was there was no room to discuss their preferences. Not having that space to have that conversation was getting in the way of accepting a new therapy, and clearly, if you think about it, could widen disparities in outcomes.”

What was promising, Agarwal said, was young adults also talked about alleviating factors that influenced technology uptake. When providers were optimistic about patient outcomes, used tools tailored to individual outcomes or when patients clearly understood the benefits of technology, they were more likely to initiate it, she said.

“These are all things that could contribute to people saying ‘yes’ to technology, even if they were nervous or reticent to accept it prior,” Agarwal said. “This showed us that there are modifiable factors that we can do something about in our conversations with our patients.”

Agarwal said young adults need support throughout the technology journey, and peers and family must be involved in the process. It is also important to remember that barriers to access will still remain after insurance coverage for diabetes devices expands.

“We are doubling down on the hope that technology will diminish some of these disparities in outcomes that we see, but insurance coverage is not enough,” she said.

Providers, too, may be “very well meaning,” yet inadvertently perpetuate inequities in device access by avoiding initiating pump or CGM therapy with a patient who, for example, might struggle to manage blood glucose, Agarwal said.

“Patients do not need to learn how to carb count before being put on a hybrid closed-loop insulin pump or CGM,” Agarwal told Healio. “They do not need to have in-target blood glucose levels to initiate technologies. It is a myth.

“There are probably a lot of solutions. I would pick at least one and commit to it,” Agarwal said. “This is hard work, but it is important work, and if we all take a crack at this, we can do something about the inequities.”

Reference:

Agarwal S, et al. Diabetes Technol Thera. 2021;doi:10.1089/dia.2020.0338.

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