Racial Disparities in Use of Diabetes Technology Widen among Medicare Enrollees

The gap between Black and White Medicare beneficiaries in use of diabetes technology widened significantly between 2017 and 2019 according to results of a new study. 

The research, which looked specifically at prevalence of insulin pump therapy and continuous glucose monitoring (CGM), found that while use of both technologies increased among White and ethnic populations over the 3 years, insulin pump use among Black beneficiaries, already low at 3.9% in 2017, increased less than 1% to 4.6% in 2019. Among White beneficiaries, 2017 insulin pump use was 14% and increased substantially to 18.2% in 2019.

“The causes of health disparities in diabetes are complex and multifactorial,” said senior author Robert Vigersky, MD, chief medical officer at Medtronic Diabetes and professor of medicine at Uniformed Services University of the Health Sciences, in a news release from the Endocrine Society. “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 people of color are unable to use these technologies.

"Other important factors are cultural barriers, low health literacy and limited access to health care, particularly to endocrinologists.” The findings were published December 15, 2021, in the Endocrine Society's official publication, the Journal of Clinical Endocrinology & Metabolism.

Using the Medicare Limited Data Set of Medicare fee-for-service (FFS) enrollees, Vigersky and colleagues collected data on individuals with type 1 diabetes (T1D) between January 1, 2017, to December 31, 2019. Enrollees included had at least 1 inpatient or emergency department visit, at least 1 in- or outpatient claim with a T1D diagnosis, and continuous enrollment in Medicare FFS parts A and B. Using data from coverage year 2019, technology users and nonusers were compared by race-ethnicity, sex, average age, Medicare eligibility criteria, and visit to an endocrinologist.

Race and ethnicity were self-reported and “other” ethnic groups included Asian, Hispanic, and North American Native adults, as well as those who reported ethnicity as unknown.

Of the full study cohort, 3,868 used diabetes-related technology, and 9,928 reported no technology use.

Results

Vigersky et al report that in each of the study’s 3 years, >75% of participants were White. Across the study cohort an increase was seen each year in use of an insulin pump, CGM, and any technology, however, significant differences emerged in device use by race, according to study authors.

Coverage Year 2019

Use of insulin pumps: Whites 18.2%, Blacks 4.6%

Use of CGM: Whites 24.9%, Blacks 11.8%

Use of any diabetes technology: Whites 31.9%, Black 14%

During the year 2018-2019, while use of technology increased across racial and ethnic groups, investigators saw a particularly pronounced rise in use for White adults: CGM use rose by 10.8% for this group while for Blacks and beneficiaries of other ethnicities the increase was 7.5% and 5.4% respectively.

When the researchers analyzed visits to an endocrinologist over the 3-year study period by device use, they found similar rates across racial and ethnic groups for enrollees who used CGM. For non-CGM users, however, 33.5% of White adults had a follow-up with an endocrinologist compared with 26.9% of Black adults and 28.5% of those in the other ethnic groups.

Vigersky, who is also a past president of the Endocrine Society, said, “We need to address the social determinants of health, including race and ethnicity, before all aspects of diabetes care become more equitable.”

Reference: Wherry K, Zhu C, Vigersky RA. Inequity in adoption of advanced diabetes technologies among medicare fee-for-service beneficiaries. J Clin Endocrinol Metab. Published online December 15, 2021.