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Despite so many advancements in diabetes technology and medications over the past 30 years, the care a person receives can still vary dramatically based on their race and ethnicity.
“We are still very far from where we should be in caring for people with diabetes,” said Osagie Ebekozien, MD, MPH, CPHQ Executive Vice President, Chief Medical Officer at T1D Exchange.
“In part because the issues of health equity, including structural and systemic racism, are so ingrained into our system.”
The ongoing COVID-19 pandemic shone a bright light on the drastic differences in the healthcare provided to people with and without diabetes. In diabetes, health inequity proves to be a dangerously pervasive problem in both pediatric and adult settings across the United States.
T1D Exchange’s work in researching health inequity throughout the pandemic led to the creation of the Health Equity Advancement Lab (HEAL). HEAL will continue the critical work to understand and change the care provided to people of color with diabetes.
Does your race & ethnicity affect the healthcare you receive?
Created in April 2021, HEAL has been working to identify and change the unequal care people of color with type 1 diabetes (T1D) receive. In 2022, HEAL launched a pilot program focused on people living with type 2 diabetes.
Some of this work so far has found that people of non-white populations are:
- Less likely to be prescribed a continuous glucose monitor (CGM)
- Less likely to be prescribed an insulin pump
- Less likely to receive education regarding newer diabetes technology
- Less likely to have access to CGM and insulin pump technology
- Less likely to be prescribed newer types of insulin and glucagon medications
- More likely to develop complications including neuropathy, retinopathy, and nephropathy
- More likely to be frequently hospitalized for severe hypoglycemia
- More likely to be frequently hospitalized for diabetic ketoacidosis (DKA)
- More likely to be hospitalized due to COVID-19
- More likely to die from COVID-19
The first step was determining what health inequity looks like. The next step is working to change it.
How the HEAL program works
The HEAL program operates within T1D Exchange’s Quality Improvement Collaborative (T1DX-QI) with its own advisory committee. Comprised of 20 clinical healthcare professionals that work with clinics across the country, the HEAL program uses a multi-pronged approach to address the many system factors contributing to health inequity in T1D care.
“We see biases in a number of places in healthcare, and so when we see the stark inequities in technology use, especially in black and Hispanic T1D patients when compared with white T1D patients, it’s definitely a factor worth examining,” explained Ann Mungmode, MPH, CPHQ, Quality Improvement Program Manager at T1D Exchange.
“There are multiple strategies because inequities can occur due to individual or interpersonal reasons, institutional practices and systems, and structural elements that exist in society,” explained Mungmode.
While the list of areas to tackle may seem overwhelming, the HEAL program is already making a direct impact on the lives of people with T1D.
Delivering real-world change for equal healthcare
By combining clinical health outcomes (including A1c levels, complications, etc.) with real-world data, the HEAL program has begun addressing health inequity through a variety of avenues. Truly improving the care certain racial and ethnic groups receive requires change across many different levels in the healthcare system—starting with every healthcare provider’s potential bias and prejudice.
HEAL’s first pilot project focused on health inequities specifically related to diabetes technology use among Non-Hispanic Black and Hispanic people with T1D as compared to Non-Hispanic White people.
Since its inception, the T1D Exchange Diabetes Technology Equity Project has:
- Provided custom bias training for more than 200 providers to identify, prevent, and change prejudice in healthcare
- Completed a pre-pilot proof of concept, which has:
- Increased rates of CGM access from 50% to 82% of patients ages 2+ at one diabetes clinic
- Reduced disparity in CGM access for Non-Hispanic Whites and Non-Hispanic Blacks from 18% to 6%
- Reduced CGM disparity by 3% for Hispanics compared to Non-Hispanic Whites, averaged over six clinics
- Published a manuscript article on T1D Exchange Equity project in the Journal of Diabetes
T1D Exchange is an innovative leader in addressing diabetes health equity and has delivered real world results using quality improvement principles to address health inequities in T1D.
As we approach the last quarter of 2022, HEAL sets its sights on the continued work of delivering equal care to all people with type 1 and type 2 diabetes.
Some of HEAL’s published research in 2022
The following are a handful of studies produced by the HEAL program in 2022.
Differences in A1c levels based on race and ethnicity
A1c levels among 36,390 children and adults with T1D were followed from 2016 to 2021:
- Non-Hispanic White: Decrease from 8.5% in 2016 to 8.2% in 2021
- Hispanic: Remained stable from 9.0% in 2016 to 8.9% in 2021
- Asian: Remained stable at 8.4% in both 2016 and 2021
- Non-Hispanic Black: Increased from 9.6% in 2016 to 9.9% in 2021
Insulin pump use based on race and ethnicity
HEAL determined the following differences in pump use based on race and ethnicity:
- Non-Hispanic White: 45% use inulin pumps
- Non-Hispanic Black: 17% use insulin pumps
- Hispanic: 26% use insulin pumps
CGM use based on race and ethnicity
HEAL determined the follow differences in CGM use based on race and ethnicity:
- Non-Hispanic White: 58% use CGMs
- Non-Hispanic Black: 49% use CGMs
- Hispanic: 48% use CGMs
Improving provider bias and prescribing habits with targeted interventions
HEAL developed targeted interventions in clinical settings to address provider biases that influence who receives prescriptions for CGM technology. These interventions included CGM equity awareness, staff training, and workflow efficiency to substantially increase CGM prescription rates in underserved populations.
Improving access to CGMs for high-risk patients
HEAL defined the existing process—with feedback from patients, caregivers, and staff—to better understand and identify disparities in CGM prescribing and insurance coverage for publicly insured patients. This patient group also faces a higher risk of developing diabetes-related complications and difficulty reaching blood glucose targets. Interventions included increasing provider awareness of CGM insurance coverage and prescribing habits, reducing disparities in CGM coverage for publicly insured patients, and providing access to CGM devices during clinic visits.
CGM prescriptions and provider’s bias based on a patient’s insurance coverage
HEAL determined that a patient’s insurance provider was a significant factor in whether or not they recommended and prescribed CGM technology. Insurance coverage also proves to play a significant role in a patient’s A1c and other diabetes-related health outcomes.
Providers prescribing habits based on a patient’s name
HEAL determined that a significant percentage of providers held an implicit bias when prescribing diabetes technology. Patients with English-sounding names received recommendations and prescriptions for diabetes technology more frequently than patients with ethnic-sounding names.
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How a Person’s Race & Ethnicity Affect their T1D Care
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