Socioeconomic disparities in access to intensive insulin regimens for adults with type 1 diabetes: a qualitative study of patient and healthcare professional perspectives

Opportunities to overcome underutilization of enhanced insulin delivery technologies in people with type 2 diabetes: a narrative review

Use of innovative technologies such as continuous glucose monitoring (CGM) and insulin delivery systems have been shown to be safe and effective in helping patients with diabetes achieve significantly improved glycemic outcomes compared to their previous therapies. However, these technologies are underutilized in many primary care practices. This narrative review discusses some of the clinical and economic benefits of tubeless insulin delivery devices and discusses how this technology can overcome the main obstacles inherent to use of conventional insulin delivery devices.

Bridging gaps in health? A qualitative study about bridge-building and social inequity in Danish healthcare

Attendance to health appointments may pose challenges to patients, especially when living in socially disadvantaged situations, with a fragile network. Inequality in health is increasingly highlighted in Denmark. To enhance social equity in health, a non-governmental organization introduced bridge-building, where healthcare students volunteer to accompany persons in socially vulnerable situations to health appointments.The purpose of the study was to explore what bridge-building entails and which gaps bridge-building attempts to span, in a welfare state, based on equal rights to healthcare.The study is based on an ethnographic fieldwork among the stakeholders in bridge-building, using interviews and participant observation in the form of "walking fieldwork".Informants emphasized safe-making and wayfinding as important components in bridge-building, with bridge-builders acting as as-if-relatives. Bridge-building navigates in borderlands, the in-between spaces with fluid and contested borders, encompassing public, civic society, and family spheres. All informants emphasized that bridge-building covers a need in contemporary Danish healthcare.Bridge-building entails a double temporality, a here-and-now intervention where persons in vulnerable situations get social support to make it to health appointments, and a future investment in future health professionals' understanding of vulnerability in lives and barriers to health access; insights that may be valuable in their future job positions.

Bridging Inequity Gaps in Healthcare Systems While Educating Future Healthcare Professionals-The Social Health Bridge-Building Programme

Social inequity in healthcare persists even in countries with universal healthcare. The Social Health Bridge-Building Programme aims to reduce healthcare inequities. This paper provides a detailed description of the programme. The Template for Intervention Description and Replication (TIDieR) was used to structure the description. The programme theory was outlined using elements from the British Medical Research Council's framework, including identifying barriers to healthcare, synthesising evidence, describing the theoretical framework, creating a logic model, and engaging stakeholders. In the Social Health Bridge-Building Programme, student volunteers accompany individuals to healthcare appointments and provide social support before, during, and after the visit. The programme is rooted in a recovery-oriented approach, emphasising personal resources and hope. The programme finds support in constructs within the health literacy framework. Student volunteers serve as health literacy mediators, supporting individuals in navigating the healthcare system while gaining knowledge and skills. This equips students for their forthcoming roles as healthcare professionals, and potentially empowers them to develop and implement egalitarian initiatives within the healthcare system, including initiatives that promote organisational health literacy responsiveness. The Social Health Bridge-Building Programme is a promising initiative that aims to improve equity in healthcare by addressing individual, social, and systemic barriers to healthcare. The programme's description will guide forthcoming evaluations of its impact.

Social disparities in the use of ART treatment: a national register-based cross-sectional study among women in Denmark

STUDY QUESTION

How are educational level, labor market attachment and income associated with receiving a first ART treatment in either the public or private healthcare sector among women in Denmark?

SUMMARY ANSWER

Higher educational level and income as well as labor market attachment were associated with higher probability of initiating ART treatment at public and private fertility clinics among women in Denmark.

WHAT IS KNOWN ALREADY

Infertility is common in populations worldwide, and the approach to this issue differs between societies and healthcare systems. In the public Danish healthcare system, ART treatment is free of charge, and the direct cost for patients is therefore low. In the private healthcare sector in Denmark, ART treatment is self-financed. There is limited knowledge about the association between socioeconomic factors and seeking ART treatment, although previous studies have indicated that higher socioeconomic status is associated with seeking ART treatment.

STUDY DESIGN, SIZE, DURATION

Women undergoing ART treatment during 1994-2016 registered in the Danish IVF register were individually linked with data from sociodemographic population registers using the Danish Personal Identification number. The study population consisted of 69 018 women treated with ART and 670 713 age-matched comparison women from the background population with no previous history of ART treatment.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The women included in the analyses were aged 18-45 years. The associations between attained educational level, labor market attachment and income and receiving a first ART treatment attempt were investigated for women either initiating treatment in the public sector or in the private sector, respectively. Information on age and origin was included as potential confounders, and odds ratios (ORs) were estimated in logistic regression models. In addition, analyses were stratified by age group to investigate potential differences across the age span.

MAIN RESULTS AND THE ROLE OF CHANCE

Adjusted results showed increased odds of receiving a first ART treatment in either the public or private sector among women with a higher educational level. Furthermore, women in employment were more likely to receive a first ART treatment in the public or private sector compared to women outside the workforce. The odds of receiving a first ART treatment increased with increasing income level. Surprisingly, income level had a greater impact on the odds of receiving a first ART treatment in the public sector than in the private sector. Women in the highest income group had 10 times higher odds of receiving a first ART treatment in the public sector (OR: 10.53 95% CI: 10.13, 10.95) compared to women in the lowest income group. Sub-analyses in different age groups showed significant associations between ART treatment and income level and labor market attachment in all age groups.

LIMITATIONS, REASONS FOR CAUTION

Our study does not include non-ART treatments, as the national IVF register did not register these types of fertility treatments before 2007.

WIDER IMPLICATIONS OF THE FINDINGS

In Denmark, there is equal access to medically assisted reproduction treatment in the publicly funded healthcare system, and since there is no social inequality in the prevalence of infertility, social inequality in the use of ART treatment would not be expected as such. However, our results show that social inequality is found for a first ART treatment attempt across publicly and privately funded ART treatment across the socioeconomic indicators, educational level, labor market attachment and income.

STUDY FUNDING/COMPETING INTEREST(S)

The funding for the establishment of the Danish National ART-Couple II Cohort (DANAC II Cohort) was obtained from the Rosa Ebba Hansen Foundation. The authors have no conflict of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Mental Fatigue, Activities of Daily Living, Sick Leave and Functional Status among Patients with Long COVID: A Cross-Sectional Study

Studies suggest that persistent symptoms after COVID-19 (long COVID) influence functioning and activities of daily living (ADL). However, it is still uncertain how and to what extent. This study aimed to describe patient-reported mental fatigue, ADL problems, ADL ability, sick leave and functional status among patients with long COVID. In this cross-sectional study, 448 patients, ≥18 years old and referred to occupational therapy at a Danish Post-COVID-19 Clinic, were included. Mental fatigue was measured by the Mental Fatigue Scale, ADL problems and ability were measured by the Canadian Occupational Performance Measure, sick leave was self-reported and functional status was evaluated by the Post-COVID-19 Functional Status Scale. Mean age was 46.8 years, 73% of the patients were female, and 75% suffered from moderate to severe mental fatigue. The majority reported difficulties performing productive and leisure activities. The median performance and satisfaction scores were 4.8 and 3, respectively. In total, 56% of the patients were on sick leave, and 94% were referred to rehabilitation. A decrease in functional status was found between pre-COVID-19 and assessment. Conclusively, the patients were highly affected in their everyday life and had distinct rehabilitation needs. Future research is needed to address causalities and rehabilitation for this patient group.

Barriers and Facilitators in Access to Diabetes, Hypertension, and Dyslipidemia Medicines: A Scoping Review

Objective: Identify barriers and facilitators in access to medicines for diabetes, hypertension, and dyslipidemia, considering patient, health provider, and health system perspectives.

Methods: Scoping review based on Joanna Briggs methodology. The search considered PubMed, Cochrane Library, CINAHL, Academic Search Ultimate, Web of Science, SciELO Citation Index, and grey literature. Two researchers conducted screening and eligibility phases. Data were thematically analyzed.

Results: The review included 219 documents. Diabetes was the most studied condition; most of the evidence comes from patients and the United States. Affordability and availability of medicines were the most reported dimension and specific barrier respectively, both cross-cutting concerns. Among high- and middle-income countries, identified barriers were cost of medicines, accompaniment by professionals, long distances to facilities, and cultural aspects; cost of transportation emerges in low-income settings. Facilitators reported were financial accessibility, trained health workers, medicines closer to communities, and patients’ education.

Conclusion: Barriers and facilitators are determined by socioeconomic and cultural conditions, highlighting the role of health systems in regulatory and policy context (assuring financial coverage and free medicines); providers’ role bringing medicines closer; and patients’ health education and disease management.

Implicit Racial-Ethnic and Insurance-Mediated Bias to Recommending Diabetes Technology: Insights from T1D Exchange Multicenter Pediatric and Adult Diabetes Provider Cohort

Background: Despite documented benefits of diabetes technology in managing type 1 diabetes, inequities persist in the use of these devices. Provider bias may be a driver of inequities, but the evidence is limited. Therefore, we aimed to examine the role of race/ethnicity and insurance-mediated provider implicit bias in recommending diabetes technology. Method: We recruited 109 adult and pediatric diabetes providers across 7 U.S. endocrinology centers to complete an implicit bias assessment composed of a clinical vignette and ranking exercise. Providers were randomized to receive clinical vignettes with differing insurance and patient names as proxy for Racial-Ethnic identity. Bias was identified if providers: (1) recommended more technology for patients with an English name (Racial-Ethnic bias) or private insurance (insurance bias), or (2) Race/Ethnicity or insurance was ranked high (Racial-Ethnic and insurance bias, respectively) in recommending diabetes technology. Provider characteristics were analyzed using descriptive statistics and multivariate logistic regression. Result: Insurance-mediated implicit bias was common in our cohort (n = 66, 61%). Providers who were identified to have insurance-mediated bias had greater years in practice (5.3 ± 5.3 years vs. 9.3 ± 9 years, P = 0.006). Racial-Ethnic-mediated implicit bias was also observed in our study (n = 37, 34%). Compared with those without Racial-Ethnic bias, providers with Racial-Ethnic bias were more likely to state that they could recognize their own implicit bias (89% vs. 61%, P = 0.001). Conclusion: Provider implicit bias to recommend diabetes technology was observed based on insurance and Race/Ethnicity in our pediatric and adult diabetes provider cohort. These data raise the need to address provider implicit bias in diabetes care.

Helpful or harmful? The impact of the ketogenic diet on eating disorder outcomes in type 1 diabetes mellitus

INTRODUCTION

Eating disorders (EDs) are common complications in people with type 1 diabetes (PwT1D), given the rigid focus on food and insulin dose adjustment. Dietary recommendations for T1D match those for the general population, yet many fail to achieve target HbA1c. Evidence suggests that lower carbohydrate meals and thus reduced insulin requirements may decrease inconsistencies in insulin absorption, maintain euglycemia and weight. Dietary restriction is a recognized risk factor for ED development, and Ketogenic Diets (KD) involve restriction of common family-based foods, thus impacting social normality and microbiome diversity. We reviewed the current literature on PwT1D following a KD to understand effects on ED risks.

AREAS COVERED

Published data from MEDLINE, Embase, and PsycINFO were used. Search terms included: type 1 diabetes mellitus; or insulin dependent diabetes or T1D AND EDs or anorexia or bulimia or disordered eating AND low-carbohydrate diet or carbohydrate restricted diet or low carb diet or ketogenic diet.

EXPERT OPINION

Research into the effects of KDs on ED outcomes in PwT1D are limited, given the concerns over risks of diabetic ketoacidosis, hypoglycemia, and dyslipidemia. Longer term studies on the participants' experience and motivations of adhering or admonishing the diet are needed.

Development of an Insulin Pen is a Patient-Centric Multidisciplinary Undertaking: A Commentary

The goal of human-centered insulin pen design is to relieve the treatment burden of a chronic condition and help affected individuals to feel free of disease. The patient as well as their entire ecosystem should be considered. At Novo Nordisk A/S, we believe that embedding human-centered design at the heart of our development processes is best achieved with multidisciplinary experts in-house to work alongside product development teams and, importantly, the end user. Novo Nordisk introduced the first commercially available insulin pen in 1985 and has continued to develop reusable/durable and prefilled insulin pens to meet different patient needs, through to the latest NovoPen 6 and NovoPen Echo Plus with SMART technology. Human-centered design is essential for delivering meaningful and practical solutions for individuals with diabetes.

Qualitative Research Methods in Chronic Disease: Introduction and Opportunities to Promote Health Equity

Public health research that addresses chronic disease has historically underutilized and undervalued qualitative methods. This has limited the field's ability to advance (a) a more in-depth understanding of the factors and processes that shape health behaviors, (b) contextualized explanations of interventions' impacts (e.g., why and how something did or did not work for recipients and systems), and (c) opportunities for building and testing theories. We introduce frameworks and methodological approaches common to qualitative research, discuss how and when to apply them in order to advance health equity, and highlight relevant strengths and challenges. We provide an overview of data collection, sampling, and analysis for qualitative research, and we describe research questions that can be addressed by applying qualitative methods across the continuum of chronic disease research. Finally, we offer recommendations to promote the strategic application of rigorous qualitative methods, with an emphasis on priority areas to enhance health equity across the evidence generation continuum.

Socioeconomic disparities in asthma health care utilization, exacerbations, and mortality: A systematic review and meta-analysis

BACKGROUND

Prior studies investigating the effect of socioeconomic status (SES) on asthma health care outcomes have been heterogeneous in the populations studied and methodologies used.

OBJECTIVE

We sought to systematically synthesize evidence investigating the impact of SES on asthma health care utilization, exacerbations, and mortality.

METHODS

We searched Embase, Medline, and Web of Science for studies reporting differences in primary care attendance, exacerbations, emergency department attendance, hospitalization, ventilation/intubation, readmission, and asthma mortality by SES. Study quality was assessed using the Newcastle Ottawa Scale, and meta-analyses were conducted using random-effects models. We conducted several prespecified subgroup analyses, including by health care system (insurance based vs universal government funded) and time period (before vs after 2010).

RESULTS

A total of 61 studies, comprising 1,145,704 patients, were included. Lower SES was consistently associated with increased secondary health care utilization including emergency department attendance (odds ratio [OR], 1.61; 95% confidence interval [CI], 1.40-1.84), hospitalization (OR, 1.63; 95% CI, 1.34-1.99), and readmission (OR, 1.31; 95% CI, 1.19-1.44). Substantial associations were also found between SES and ventilation/intubation (OR, 1.76; 95% CI, 1.13-2.73), although there was no association with primary care attendances (OR, 0.79; 95% CI, 0.51-1.24). We found evidence of borderline significance for increased exacerbations (OR, 1.18; 95% CI, 0.98-1.42) and mortality (OR, 1.12; 95% CI, 0.92-1.37) among more deprived groups. There was no convincing evidence that disparities were associated with country-level health care funding models or that disparities have narrowed over time.

CONCLUSIONS

Patients with a lower SES have substantially increased secondary care health care utilization. We found evidence suggestive of increased exacerbations and mortality risk, although CIs were wide. These disparities have been consistently reported worldwide, including within countries offering universally funded health care systems. Systematic review registration: CRD42020173544.

Barriers to Technology Use and Endocrinology Care for Underserved Communities With Type 1 Diabetes

OBJECTIVE

Disparities in type 1 diabetes related to use of technologies like continuous glucose monitors (CGMs) and utilization of diabetes care are pronounced based on socioeconomic status (SES), race, and ethnicity. However, systematic reports of perspectives from patients in vulnerable communities regarding barriers are limited.

RESEARCH DESIGN AND METHODS

To better understand barriers, focus groups were conducted in Florida and California with adults ≥18 years old with type 1 diabetes with selection criteria including hospitalization for diabetic ketoacidosis, HbA_1c >9%, and/or receiving care at a Federally Qualified Health Center. Sixteen focus groups were conducted in English or Spanish with 86 adults (mean age 42 ± 16.2 years). Transcript themes and pre-focus group demographic survey data were analyzed. In order of frequency, barriers to diabetes technology and endocrinology care included 1) provider level (negative provider encounters), 2) system level (financial coverage), and 3) individual level (preferences).

RESULTS

Over 50% of participants had not seen an endocrinologist in the past year or were only seen once including during hospital visits. In Florida, there was less technology use overall (38% used CGMs in FL and 63% in CA; 43% used pumps in FL and 69% in CA) and significant differences in pump use by SES (P = 0.02 in FL; P = 0.08 in CA) and race/ethnicity (P = 0.01 in FL; P = 0.80 in CA). In California, there were significant differences in CGM use by race/ethnicity (P = 0.05 in CA; P = 0.56 in FL) and education level (P = 0.02 in CA; P = 0.90 in FL).

CONCLUSIONS

These findings provide novel insights into the experiences of vulnerable communities and demonstrate the need for multilevel interventions aimed at offsetting disparities in diabetes.

Marked improvements in glycaemic outcomes following insulin pump therapy initiation in people with type 1 diabetes: a nationwide observational study in Scotland

AIMS/HYPOTHESIS

Our aim was to assess the use of continuous subcutaneous insulin infusion (CSII) in people with type 1 diabetes in Scotland and its association with glycaemic control, as measured by HbA_1c levels, frequency of diabetic ketoacidosis (DKA) and severe hospitalised hypoglycaemia (SHH), overall and stratified by baseline HbA_1c.

METHODS

We included 4684 individuals with type 1 diabetes from the national Scottish register, who commenced CSII between 2004 and 2019. We presented crude within-person differences from baseline HbA_1c over time since initiation, crude DKA and SHH event-rates pre-/post-CSII exposure. We then used mixed models to assess the significance of CSII exposure, taking into account: (1) the diffuse nature of the intervention (i.e. structured education often precedes initiation); (2) repeated within-person measurements; and (3) background time-trends occurring pre-intervention.

RESULTS

HbA_1c decreased after CSII initiation, with a median within-person change of -5.5 mmol/mol (IQR -12.0, 0.0) (-0.5% [IQR -1.1, 0.0]). Within-person changes were most substantial in those with the highest baseline HbA_1c, with median -21.0 mmol/mol (-30.0, -11.0) (-1.9% [-2.7, -1.0]) change in those with a baseline >84 mmol/mol (9.8%) within a year of exposure, that was sustained: -19.0 mmol/mol (-27.6, -6.5) (-1.7% [-2.5, -0.6]) at ≥5 years. Statistical significance and magnitude of change were supported by the mixed models results. The crude DKA event-rate was significantly lower in post-CSII person-time compared with pre-CSII person-time: 49.6 events (95% CI 46.3, 53.1) per 1000 person-years vs 67.9 (64.1, 71.9); rate ratio from Bayesian mixed models adjusting for pre-exposure trend: 0.61 (95% credible interval [CrI] 0.47, 0.77; posterior probability of reduction pp = 1.00). The crude overall SHH event-rate in post-CSII vs pre-CSII person-time was also lower: 17.8 events (95% CI 15.8, 19.9) per 1000 person-years post-exposure vs 25.8 (23.5, 28.3) pre-exposure; rate ratio from Bayesian mixed models adjusting for pre-exposure trend: 0.67 (95% CrI 0.45, 1.01; pp = 0.97).

CONCLUSIONS/INTERPRETATION

CSII therapy was associated with marked falls in HbA_1c especially in those with high baseline HbA_1c. CSII was independently associated with reduced DKA and SHH rates. CSII appears to be an effective option for intensive insulin therapy in people with diabetes for improving suboptimal glycaemic control.

Disparities in Utilization and Outcomes With Continuous Subcutaneous Insulin Infusion in Young Adults With Type 1 Diabetes

OBJECTIVE

To evaluate which factors determine utilization patterns and outcomes of continuous subcutaneous insulin infusion (CSII) in young adults with type 1 diabetes.

METHODS

Utilizing the Optum deidentified electronic health record data set between 2008 to 2018 to perform a retrospective cohort study, we identified 2104 subjects with type 1 diabetes aged 18 to 30 years. We evaluated the effect of race on determining CSII utilization, HbA1c (%), and hospital admission for diabetic ketoacidosis (DKA). Crude and adjusted estimates were computed using logistic regression and linear mixed models.

RESULTS

There was low CSII utilization among individuals who were Black, Hispanic, male, and those with governmental insurance. These groups also demonstrated higher HbA1c levels. Subjects who were Black, Hispanic, and those with governmental insurance had higher odds of DKA. Even when commercially insured, Black and Hispanic subjects demonstrated higher HbA1c levels, and Black individuals had higher odds of DKA.

CONCLUSION

In a large electronic health record database in the U.S., there was low CSII utilization overall, particularly in Black and Hispanic minorities, despite CSII showing superior HbA1c control without an increase in DKA events.