How low socioeconomic status influences disparities in diabetes care

A variety of sociodemographic characteristics feed into the disparities found in pediatric diabetes care. At the 81st virtual Scientific Sessions for the American Diabetes Association, Ananta Addala, DO, MPH, pediatric endocrinologist and physician scientist at Stanford University in Palo Alto, California, addressed the role that socioeconomic status has in those disparities.

Addala noted that previous research has shown that minority patients often receive a lower quality of health care than their peers. Reasons for the differences in care include environmental factors and discriminations. Clinical judgement about appropriateness of care as well as patient preference have also been considered as contributing to the difference in care quality, but have long been noted as not contributing to disparities, but Addala believes that both do. With diabetes management, one of the major places that disparities are seen is when it comes to access to diabetes technology such as insulin pumps and continuous glucose monitors. Diabetes technology has been shown to improve hemoglobin A1c levels, especially in pediatric cases. Children with low family incomes as well as public or no insurance have higher hemoglobin A1c levels, which indicates lower access to diabetes technology.

She then discusses the results of a study that compared insulin pump use and continuous glucose monitoring by socioeconomic status in 2 cohorts: 1 in the United States and Germany, at 2 different points in time, 2010-2012 and 2016-2018. The German cohort was selected because it represented a similar economy to the United States. In both cohorts, the investigators found increasing use of insulin pumps between the 2 time periods. However, the US cohort showed that far fewer patients in the lowest socioeconomic group used pumps than those in the highest economic group whereas in the German cohort there was negligible differences noted across socioeconomic groups. Continuous glucose monitoring saw significant increases in use for both cohorts, but as with insulin pumps, the US cohort showed significant disparities in use across socioeconomic status. In Germany, there was very little difference across them. Consequently, hemoglobin A1c levels are significantly higher in the lowest socioeconomic status level in the United States. Children at the lowest socioeconomic status level in Germany also had higher hemoglobin A1c levels than their more well-off peers, but the difference was much less significant.

Insurance can drive these disparities Addala noted. She discussed a recent commentary that showed the variability of the requirements for a child in a Medicaid program to get continuous glucose monitoring. Some states like Ohio and Wisconsin offer no specific requirements for the technology. Others like Utah and New York will only cover the technology for patients with type 1 diabetes who are also doing self-managed blood glucose testing via finger sticks at least 4 times a day. One final driver of disparities is the biases that some providers may have towards patients with a lower socioeconomic status. A meta-analysis found that providers often tended to have less empathy for patients who were from low socioeconomic groups.

Reference

1. Addala A. The state of disparities in pediatric diabetes care: the role of socioeconomic status. American Diabetes Association Scientific Sessions 2021; June 26, 2021; virtual. Accessed June 26, 2021.