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“In the past two years, we’ve all been faced with multiple challenges from the COVID-19 pandemic to rising health inequities,” explains Osagie Ebekozien, MD, MPH, CPHQ Executive Vice President, Chief Medical Officer at T1D Exchange.
The difference in healthcare provided to certain populations of people with type 1 diabetes (T1D) has become impossible to ignore. Race, ethnicity, and type of insurance are some of the most obvious contributing factors.
Identifying these health inequities led to the Health Equity Advancement Lab (HEAL) creation in April 2021. The first goal of the HEAL program was to identify the factors that negatively impact the healthcare provided to certain racial and ethnic groups with T1D.
In less than two years, HEAL has identified that people of certain racial and ethnic groups 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 next step is to develop potential solutions that positively impact these disparities with the goal of providing equal care to all people with T1D.
Understanding the problem—then testing potential solutions
“Every day, we’re constantly thinking about all the strategies and ways we can address this issue. We have documented a lot of work,” explains Ebekozien.
For example, Ebekozien explains that HEAL has developed tools to track and measure factors like implicit provider bias—when providers unknowingly treat certain patients differently than others.
“We’ve also introduced a new benchmarking tool called the Quality Improvement Quota,” adds Ebekozien. The Quality Improvement Quota allows all clinic providers participating in the Quality Improvement Collaborative (T1DX-QI) to look at their own data and then test out potential solutions.
“We need to understand the problem in order to test out practical solutions,” reminds Ebekozien. “I’m optimistic that we can address health equity in type 1 diabetes.”
Health inequity is an active problem in the United States
Despite the many advancements we’ve seen in technology, insulin, and other medications for people with diabetes, there is a significant issue in who is offered or has access to these advanced care and management tools.
“We have real-world evidence which confirms that health inequity still persists in the U.S.,” explains Nudrat Noor, PhD, Associated Director of Population Health at T1D Exchange.
“When we look at race-ethnicity groups, we see that black and Hispanic people with T1D have more adverse outcomes compared to the white population. We see that people on public insurance—those on Medicaid or Medicare—are less likely to have well-managed diabetes.”
Research identifying these factors includes:
- Differences in A1c levels based on race and ethnicity
- Insulin pump use based on race and ethnicity
- CGM use based on race and ethnicity
- Improving provider bias and prescribing habits with targeted interventions
- Improving access to CGMs for high-risk patients
Noor emphasizes that deeply investigating these health inequities from all sides (structural, economic, individual) is critical in order to reduce health inequities in diabetes care.
Managing the Quality Improvement Portal
“In my role as a product owner for the Quality Improvement Portal, I’m working with engineers to look at data with health equity filters,” explains Ann Mungmode, MPH, Project Manager of the T1DX-QI at T1D Exchange.
By comparing data based on factors including race and ethnicity, gender, zip code, and type of health insurance, Mungmode and other team members can identify whether disparities in healthcare exist.
“If we look at the data and we’re able to determine if there is a disparity, then we can do something about it,” says Mungmode. “What action can we take? What small tests of change can we try in our clinical flow to address some of those factors and hopefully reduce the gap?”
These potential strategies and tested solutions have already proven effective in clinical settings.
Two examples of this strategic and impactful work include:
- 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 increase CGM prescription rates in underserved populations substantially.
- 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.
The HEAL program continues to publish research that has successfully identified factors influencing gaps in care provided to certain patient populations—and the efficacy of potential solutions.
Providing equal healthcare starts at home
How can a person with T1D focus on blood sugar management if they’re also struggling to afford food, transportation to work or to a doctor’s appointment, and stable housing?
These social determinants of health (SDOH) play a significant role in a person’s ability to manage T1D on any given day. Including measurements to identify and address these concerns is an important part of T1DX-QI and HEAL.
“In my role as director of clinical partnerships, I am adding new measures and interventions that include improving and addressing resources for patients,” explains Nicole Rioles, Director of Clinical Partnerships at T1D Exchange.
“That includes access to transportation, housing, food.”
With limited time during a doctor’s appointment, these critical issues affecting a person’s daily health could go unnoticed. By first identifying these SDOHs during patient care, providers can ensure every patient with T1D has access to the basics of health and wellness.
Change is a persistent step-by-step process
With 2023 just around the corner, we look forward to next year’s progress in identifying and developing effective solutions to impact health inequity—striving to improve the lives of people with T1D across the country.
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Investigating Factors that Worsen Diabetes Care in the U.S.
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