For years, medicine has been plagued with inequities, especially regarding access to care and outcomes.
For sure, there have been historical exploitations of some segments of the public, from Nazi experimentation to the infamous Tuskegee syphilis study of Black Americans. The outrage that those exposures generated affirms the underlying benevolence of our medical community and the expectation of the global community that we will do the best we can for everyone, with all available resources.
Optimal performance, however, often defies good intent and maximum effort — witness the weekly scores for my favorite teams. So do our specialty board scores, which rarely achieve maximum, and most other measures of medical care that display how far below our aspirations we currently stand. And thus, poorer outcomes among Black Americans with diabetes persist, resulting in end-organ sequelae, poor glycemic control, and need for hospitalization.
Access to Technology and Health Equity
The availability of technology remains an important element of health equity. In all demographic groups, those with insulin pumps have achieved lower A1c values than those who received multiple injections.
A recent assessment in The Journal of Clinical Endocrinology & Metabolism suggests that access to the sophisticated insulin pump technology and continuous glucose monitoring (CGM) devices is lacking in Black and other minority populations.
The study group, all identified as employees of a company that manufactures insulin pumps and CGM, explored Medicare data to determine demographic and medical characteristics of beneficiaries who had obtained these advanced technology products for care of their type 1 diabetes. Using Medicare data had the advantage of making the eligibility for advanced technology independent of socioeconomics. The investigators extracted data from a Limited Data Set 5% sample, which enabled them to follow trends in device usage from 2017 to 2019. As these instruments became an accepted part of diabetes management, the authors identified increased usage among all groups of patients over time.
Black Patients Prescribed Fewer Devices
The study found that Black patients were prescribed these devices less often than White patients. Moreover, technology users were more likely to be female.
Because the racial gradients were identifiable, the authors attempted to assess why that might be. The researchers used insurance data to determine other patient characteristics, including age, sex, current reason for Medicare eligibility, dual Medicare/Medicaid eligibility, and visits to an endocrinologist.
Black patients were far more likely to be receiving Medicare due to end-stage renal disease or disability than their White counterparts and to be dual-eligible for Medicaid. Among Black patients who obtained advanced technology, the presence of ongoing renal care seemed to enhance their likelihood of being offered either a pump or a CGM device. Advanced technology users are more likely to have an endocrinologist among their providers.
Why the Inequities? It’s Complicated
The study includes an outstanding discussion of considerations we clinicians must sort through as we decide what to offer individual patients. Without firm criteria or a checklist that prompts the electronic health record to flash “CONTINUOUS SUBCUTANEOUS INSULIN INFUSION” in a unique nudge color on our screens, we rely on more personal criteria. This may be based on evidence of efficacy or a desire to remedy specific problems such as repetitive hypoglycemia or discordant data from the A1c values and accumulated blood glucose data.
We also have our own varying levels of comfort with technology. Some of us will get the latest iPhone as soon as it comes out whereas some of us still have flip-phones. The technology has been available long enough for each of us to have our own experience as prescribers, ranging from favorable transformations of patients with labile glucoses at one extreme to being legal defendants at another.
Our practice settings may differ considerably. As the sole endocrinologist at a safety-net hospital, I was more dependent on the device companies for patient support than an endocrinologist at a large institution with a dedicated team assigned to run an in-house pump program.
This study did not include primary physician participation or an identifiable physician of prime responsibility, which is assured in a dialysis or transplant program but highly unpredictable when referrals to the endocrinologist originate at a public clinic or at hospital discharge.
One strength of this analysis is that it relied on data from a single insurer with known benefits. But the office reality is generally very different, with a mixture of payers that have different criteria for approving payment for advanced diabetic technology. For example, the patient may be required to send 3 months of four-times-daily glucose testing data before the insurance company will pay for a device. Some patients are more motivated to do this than others. Missed appointments, unregulated diet, or last known address at a homeless shelter all can be deemed inadequate reliability.
While the decisions are made by patient characteristics, including previous encounters, there is uneven racial distribution among the social determinants of health. Race is an accessible measurement, but it is the instability that drives the clinician’s decision, at least in the safety-net settings.
However, this article also referenced other studies showing lower device use among high-income Black Americans compared with lower-income White patients, so race cannot simply be dismissed as a surrogate of other demographics.
From the Medicare data, our scorecard suggests that some patients with type 1 diabetes are not getting access to technology that would enhance their lifestyle if not their longevity. The most remediable starting point may be to develop guidelines defining which patients benefit the most from the technology and which ones make this intervention hazardous.
Our Bible states, “Each man did that which was right in his own eyes” (Judges 21:25). Evidence-based expectations seems a good way to correct this, as difficult as collecting and sorting the evidence may be.