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Patel PM, Thomas D, Liu Z, Aldrich-Renner S, Clemons M, Patel BV. Systematic review of disparities in continuous glucose monitoring and insulin pump utilization in the United States: Key themes and evidentiary gaps. Diabetes Obes Metab 2024; 26:4293-4301. [PMID: 39010293 DOI: 10.1111/dom.15774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 06/14/2024] [Accepted: 06/23/2024] [Indexed: 07/17/2024]
Abstract
AIM This study aims to provide a comprehensive overview of real-world evidence pertaining to disparities in the utilization of continuous glucose monitors (CGMs)/insulin pumps to highlight potential evidentiary gaps and discern emerging themes from the literature. MATERIALS AND METHODS A systematic review of published manuscripts and abstracts was conducted from: MEDLINE, EMBASE, Nursing and Allied Health, Web of Science and CINHAL. Attributes related to patients, outcomes, interventions (CGMs/pumps/both) and study type were captured. In addition, factors associated with disparities in device utilization were examined. RESULTS Thirty-six studies were included in the final analysis; the studies predominantly focused on people living with type 1 diabetes. Only two studies included individuals with type 2 diabetes. Almost two-thirds of the studies reported outcomes associated with disparities (e.g. glycated haemoglobin, diabetic ketoacidosis, resource utilization). Most studies highlighted disparities across race, ethnicity and insurance type. Evidentiary gaps were identified, particularly in the evidence for people with type 2 diabetes, the continuation of CGM/pump use and limited studies addressing disparities among Native Americans/American Indians. CONCLUSION This study reveals critical disparities in diabetes technology use across race, ethnicity and insurance type, particularly among people with type 1 diabetes. Evidentiary gaps assessing disparities in diabetes technology use persist, particularly concerning people with type 2 diabetes, Native American/American Indian and LGBTQ+ populations, and in outcomes related to continuation of use. Social and digital determinants of health, such as income, transportation, residential location and technological literacy, are crucial to achieving equitable access. Future research should focus on the patient journey to identify opportunities for equitable access to diabetes technology as its use grows.
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Affiliation(s)
- Pranav M Patel
- University of Toledo College of Pharmacy and Pharmaceutical Sciences, Toledo, Ohio, USA
| | - Divya Thomas
- University of Toledo College of Pharmacy and Pharmaceutical Sciences, Toledo, Ohio, USA
| | - Zhixi Liu
- University of Toledo College of Pharmacy and Pharmaceutical Sciences, Toledo, Ohio, USA
| | - Sarah Aldrich-Renner
- University of Toledo General Internal Medicine Clinic and College of Pharmacy and Pharmaceutical Sciences, Toledo, Ohio, USA
| | - Marilee Clemons
- University of Toledo General Internal Medicine Clinic and College of Pharmacy and Pharmaceutical Sciences, Toledo, Ohio, USA
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2
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Mensah P, Valdez K, Gyawali A, Snell-Bergeon J. Social and Structural Determinants of Cardiovascular Complications of Diabetes. Curr Diab Rep 2024; 24:147-157. [PMID: 38696042 DOI: 10.1007/s11892-024-01541-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2024] [Indexed: 06/22/2024]
Abstract
PURPOSE OF REVIEW Cardiovascular disease (CVD) is the leading cause of mortality in people who have diabetes. Racial and ethnic minorities with diabetes have suboptimal management of cardiovascular risk factors, leading to higher mortality. Social and structural determinants of health are external factors that influence an individual's ability to choose positive health behaviors. In this review, we will discuss cardiovascular complications in people who have diabetes and their relationship to social determinants of health (SDOH). RECENT FINDINGS Recent innovations in diabetes treatment, including new devices and medications, have improved care and survival. However, disparities in the availability of these treatments to racial and ethnic minorities may contribute to continued inequities in CVD outcomes. Racial/ethnic disparities in CVD relate to inequities in economic opportunity, education and health literacy, neighborhoods and social cohesion, and health care access and quality driven by structural racism.
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Affiliation(s)
- Portia Mensah
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Mail Stop F547, Aurora, CO, 80045, USA
- Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kelly Valdez
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Mail Stop F547, Aurora, CO, 80045, USA
- Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Ankita Gyawali
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Mail Stop F547, Aurora, CO, 80045, USA
| | - Janet Snell-Bergeon
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Mail Stop F547, Aurora, CO, 80045, USA.
- Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
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3
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Ni K, Tampe CA, Sol K, Cervantes L, Pereira RI. Continuous Glucose Monitor: Reclaiming Type 2 Diabetes Self-efficacy and Mitigating Disparities. J Endocr Soc 2024; 8:bvae125. [PMID: 38974988 PMCID: PMC11223994 DOI: 10.1210/jendso/bvae125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Indexed: 07/09/2024] Open
Abstract
Context The rise in continuous glucose monitor (CGM) use has been characterized by widening disparities between the least and most socially marginalized. Given access barriers, there is limited CGM patient experience information that is inclusive of those with type 2 diabetes mellitus from socially marginalized backgrounds. Objective To understand the CGM usage experience in the primary care setting across a US Medicaid population with type 2 diabetes at federally qualified health centers. Methods This qualitative study used semi-structured phone interviews with 28 English- or Spanish-speaking participants prescribed the CGM who were enrolled in a US Medicaid program that subsidized CGMs. Audio recordings of interviews were transcribed and analyzed by reflective thematic analysis. Results Twenty-eight participants (75% female, median age 56 years with interquartile-range 48-60 years) were interviewed. Participants were from different racial/ethnic backgrounds: 21% non-Hispanic White, 57% Hispanic, and 18% non-Hispanic Black. Participants primarily spoke English (68%) or Spanish (32%), and 53% reported 9 or fewer years of formal education. We identified 6 major themes: initial expectations and overcoming initiation barriers, convenience and ease promote daily use, increased knowledge leads to improved self-management, collaboration with provider and clinical team, improved self-reported outcomes, and barriers and burdens are generally tolerated. Conclusion CGM use was experienced as easy to understand and viewed as a tool for diabetes self-efficacy. Expanded CGM access for socially marginalized patients with type 2 diabetes can enhance diabetes self-management to help mitigate diabetes outcome disparities.
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Affiliation(s)
- Kevin Ni
- Medicine Service-Endocrinology, Denver Health, Denver, CO 80204, USA
- Department of Medicine, University of Colorado, Aurora, CO 80045, USA
| | - Carolyn A Tampe
- Medicine Service-Endocrinology, Denver Health, Denver, CO 80204, USA
| | - Kayce Sol
- Medicine Service-Endocrinology, Denver Health, Denver, CO 80204, USA
| | - Lilia Cervantes
- Department of Medicine, University of Colorado, Aurora, CO 80045, USA
| | - Rocio I Pereira
- Medicine Service-Endocrinology, Denver Health, Denver, CO 80204, USA
- Department of Medicine, University of Colorado, Aurora, CO 80045, USA
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Lacy ME, Lee KE, Atac O, Heier K, Fowlkes J, Kucharska-Newton A, Moga DC. Patterns and Trends in Continuous Glucose Monitoring Utilization Among Commercially Insured Individuals With Type 1 Diabetes: 2010-2013 to 2016-2019. Clin Diabetes 2024; 42:388-397. [PMID: 39015169 PMCID: PMC11247039 DOI: 10.2337/cd23-0051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/18/2024]
Abstract
Prior studies suggest that only ∼30% of patients with type 1 diabetes use continuous glucose monitoring (CGM), but most studies to date focused on children and young adults seen by endocrinologists or in academic centers. This study examined national trends in CGM utilization among commercially insured children and adults with type 1 diabetes. Overall, CGM utilization was 20.12% in 2010-2013 and 49.78% in 2016-2019, reflecting a 2.5-fold increase in utilization within a period of <10 years. Identifying populations with low CGM use is a necessary first step in developing targeted interventions to increase CGM uptake.
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Affiliation(s)
- Mary E. Lacy
- College of Public Health, University of Kentucky, Lexington, KY
| | | | - Omer Atac
- College of Public Health, University of Kentucky, Lexington, KY
- Department of Public Health, International School of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Kory Heier
- College of Public Health, University of Kentucky, Lexington, KY
| | - John Fowlkes
- College of Medicine, University of Kentucky, Lexington, KY
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Stallings DE, Higgins KJ. The use of multiple daily injections versus insulin pump therapy for HgbA1c reduction in patients with insulin-dependent type 2 diabetes. J Am Assoc Nurse Pract 2023; 35:615-619. [PMID: 37219563 DOI: 10.1097/jxx.0000000000000890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 04/20/2023] [Indexed: 05/24/2023]
Abstract
BACKGROUND More than 35 million Americans live with type 2 diabetes (T2D), resulting in the need for newer strategies and technologies to manage the disease. Insulin pump therapy (IPT) has historically been reserved for type 1 diabetes, although emerging data demonstrates improved glucose outcomes for patients with T2D using IPT. PURPOSE To measure the change in HgbA1c in patients with T2D after changing therapy from multiple daily injections (MDI) to continuous subcutaneous insulin infusion through IPT. METHODOLOGY A retrospective comparison study was conducted by reviewing the electronic medical record of patients with T2D, older than 18 years, who had been on multiple daily insulin injections for at least 1 year, followed by IPT for at least 1 year. RESULTS One hundred seventy-one patients met the inclusion criteria. There was a statistically significant reduction in mean HgbA1c from 9.6% to 7.6%. CONCLUSION Insulin pump therapy may result in lower HgbA1c levels for T2D not at goal on MDI. IMPLICATIONS Patients on multiple daily insulin injections who are not at goal should be considered for IPT.
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Affiliation(s)
| | - Karen J Higgins
- School of Nursing, Old Dominion University, Virginia Beach, Virginia
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Kommareddi M, Wherry K, Vigersky RA. Racial/Ethnic Inequities in Use of Diabetes Technologies Among Medicare Advantage Beneficiaries With Type 1 Diabetes. J Clin Endocrinol Metab 2023; 108:e388-e395. [PMID: 36715293 DOI: 10.1210/clinem/dgad046] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 01/11/2023] [Accepted: 01/24/2023] [Indexed: 01/31/2023]
Abstract
CONTEXT Racial/ethnic inequities have been observed in diabetes care. OBJECTIVE To measure changes in prevalence of continuous glucose monitoring (CGM) and insulin pump therapy among Medicare Advantage beneficiaries with type 1 diabetes by race/ethnicity and to determine the impact of socioeconomic factors on racial/ethnic inequities. DESIGN The prevalence of CGM and pump use was assessed by race/ethnicity for Medicare Advantage beneficiaries annually from 2017 through 2020. Models predicting technology use by year, race/ethnicity, age, sex, endocrinology visits, and measures of socioeconomic status were fit. SETTING Community. PATIENTS OR OTHER PARTICIPANTS Beneficiaries with type 1 diabetes and 2 or more claims with a diabetes diagnosis in the coverage year. INTERVENTION(S) Insulin pump or CGM therapy. MAIN OUTCOME MEASURE(S) Use of diabetes technology by racial/ethnic group. RESULTS Technology use increased from 2017 through 2020 in all racial/ethnic groups. The absolute difference in use between White and Black beneficiaries from 2017 to 2020 remained stable for insulin pumps (10.7% to 10.8%) and increased for CGM (2.6% to 11.1%). The differences in pump use from 2017 to 2020 narrowed between White and Hispanic beneficiaries (12.3% to 11.4%) and White and Asian beneficiaries (9.7% to 6.6%), whereas the opposite occurred for CGM use (3.0% to 15.5% for White vs Hispanic beneficiaries; 1.5% to 8.0% for White vs Asian beneficiaries). Racial/ethnic inequities persisted (P < .0001) after adjusting for other characteristics. CONCLUSIONS Differences in diabetes technology use between racial/ethnic groups often persisted from 2017 through 2020 and could not be explained by demographics, socioeconomic status, or endocrinology visits.
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Affiliation(s)
| | - Kael Wherry
- Medtronic Diabetes, Northridge, CA 91325, USA
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Ni K, Tampe CA, Sol K, Richardson DB, Pereira RI. Effect of CGM Access Expansion on Uptake Among Patients on Medicaid With Diabetes. Diabetes Care 2023; 46:391-398. [PMID: 36480729 PMCID: PMC9887615 DOI: 10.2337/dc22-1287] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 11/07/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Current studies on continuous glucose monitor (CGM) uptake are revealing for significant barriers and inequities for CGM use among patients from socially underprivileged communities. This study explores the effect of full subsidies regardless of diabetes type on CGM uptake and HbA1c outcomes in a U.S. adult patient population on Medicaid. RESEARCH DESIGN AND METHODS This retrospective cohort study examined 3,036 adults with diabetes enrolled in a U.S. Medicaid program that fully subsidized CGM. CGM uptake and adherence were assessed by CGM prescription and dispense data, including more than one fill and adherence by medication possession ratio (MPR). Multivariate logistic regression evaluated predictors of CGM uptake. Pre- and post-CGM use HbA1c were compared. RESULTS CGM were very well received by both individuals with type 1 diabetes and individuals with type 2 diabetes with similar high fill adherence levels (mean MPR 0.78 vs. 0.72; P = 0.06). No significant difference in CGM uptake outcomes were noted among major racial/ethnic groups. CGM use was associated with improved HbA1c among those with type 2 diabetes (-1.2% [13.1 mmol/mol]; P < 0.001) that was comparable between major racial/ethnic groups and those with higher fill adherence achieved greater HbA1c reduction (-1.4% [15.3 mmol/mol]; P < 0.001) compared with those with lower adherence (-1.0% [10.9 mmol/mol]; P < 0.001). CONCLUSIONS CGM uptake disparities can largely be overcome by eliminating CGM cost barriers. CGM use was associated with improved HbA1c across all major racial/ethnic groups, highlighting broad CGM appeal, utilization, and effectiveness across an underprivileged patient population.
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Affiliation(s)
- Kevin Ni
- Medicine Service–Endocrinology, Denver Health, Denver, CO
- Department of Medicine, University of Colorado, Aurora, CO
| | | | - Kayce Sol
- Medicine Service–Endocrinology, Denver Health, Denver, CO
| | | | - Rocio I. Pereira
- Medicine Service–Endocrinology, Denver Health, Denver, CO
- Department of Medicine, University of Colorado, Aurora, CO
- Corresponding author: Rocio I. Pereira,
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Kushniruk A, Katz N, Mirchi T, Green CR. Usability and Teachability of Continuous Glucose Monitoring Devices in Older Adults and Diabetes Educators: Task Analysis and Ease-of-Use Survey. JMIR Hum Factors 2022; 9:e42057. [PMID: 36347498 PMCID: PMC9801269 DOI: 10.2196/42057] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 10/18/2022] [Accepted: 11/08/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Continuous glucose monitoring (CGM) devices continuously sense and relay glucose concentration data from the interstitial fluid to a mobile phone or receiver. Older adults benefit from this continuous monitoring of glucose levels. Proper deployment of the sensing wire is facilitated by a specialized applicator. OBJECTIVE Our aim was to assess a new seventh-generation (G7) CGM device (Dexcom, Inc) for use by adults 65 years of age or older and certified diabetes care and education specialists (CDCESs). Ease of use related to intradermal insertion and mobile app setup will be assessed and compared to the fifth- and sixth-generation systems. METHODS Formal task analysis was conducted to enumerate the number and complexity of tasks associated with CGM deployment. We recruited 10 older adults with no prior CGM experience and 10 CDCESs to assess ease of use through hands-on insertion and initiation of a G7 system followed by a survey and, for older adults, a system usability scale survey. RESULTS About half as many tasks are needed to deploy G7 compared to G6. Older adults and CDCESs reported overall high usability of the G7 CGM device. CDCESs noted G7's easier setup compared to previous generations. The system usability scale score for the CGM system was 92.8, which reflects excellent usability. CONCLUSIONS For CDCESs and for older adults using the G7 CGM system, cognitive burden is relatively low and reduced compared to previous CGM systems. Easing of this burden and simplification of the glucose monitoring aspect of proper diabetes management will likely contribute to improved outcomes in this population.
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Affiliation(s)
| | - Noam Katz
- Dexcom, Inc, San Diego, CA, United States
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Forlenza GP, Carlson AL, Galindo RJ, Kruger DF, Levy CJ, McGill JB, Umpierrez G, Aleppo G. Real-World Evidence Supporting Tandem Control-IQ Hybrid Closed-Loop Success in the Medicare and Medicaid Type 1 and Type 2 Diabetes Populations. Diabetes Technol Ther 2022; 24:814-823. [PMID: 35763323 PMCID: PMC9618372 DOI: 10.1089/dia.2022.0206] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Background: The Tandem Control-IQ (CIQ) system has demonstrated significant glycemic improvements in large randomized controlled and real-world trials. Use of this system is lower in people with type 1 diabetes (T1D) government-sponsored insurance and those with type 2 diabetes (T2D). This analysis aimed to evaluate the performance of CIQ in these groups. Methods and Materials: A retrospective analysis of CIQ users was performed. Users age ≥6 years with a t:slim X2 Pump and >30 days of continuous glucose monitoring (CGM) data pre-CIQ and >30 days post-CIQ technology initiation were included. Results: A total of 4243 Medicare and 1332 Medicaid CIQ users were analyzed among whom 5075 had T1D and 500 had T2D. After starting CIQ, the Medicare beneficiaries group saw significant improvement in time in target range 70-180 mg/dL (TIR; 64% vs. 74%; P < 0.0001), glucose management index (GMI; 7.3% vs. 7.0%; P < 0.0001), and the percentage of users meeting American Diabetes Association (ADA) CGM Glucometrics Guidelines (12.8% vs. 26.3%; P < 0.0001). The Medicaid group also saw significant improvement in TIR (46% vs. 60%; P < 0.0001), GMI (7.9% vs. 7.5%; P < 0.0001), and percentage meeting ADA guidelines (5.7% vs. 13.4%; P < 0.0001). Patients with T2D and either insurance saw significant glycemic improvements. Conclusions: The CIQ system was effective in the Medicare and Medicaid groups in improving glycemic control. The T2D subgroup also demonstrated improved glycemic control with CIQ use. Glucometrics achieved in this analysis are comparable with those seen in previous randomized controlled clinical trials with the CIQ system.
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Affiliation(s)
- Gregory P. Forlenza
- Barbara Davis Center, Division of Pediatric Endocrinology, Department of Pediatrics, University of Colorado Denver, Denver, Colorado, USA
| | - Anders L. Carlson
- International Diabetes Center, HealthPartners Institute, Minneapolis, Minnesota, USA
| | - Rodolfo J. Galindo
- Division of Endocrinology, Metabolism, and Lipids, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Davida F. Kruger
- Division of Endocrinology, Diabetes, Bone and Mineral, Henry Ford Health System, Detroit, Michigan, USA
| | - Carol J. Levy
- Division of Endocrinology, Diabetes, and Metabolism, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Janet B. McGill
- Division of Endocrinology, Metabolism and Lipid Research, Washington University in St. Louis, School of Medicine, St. Louis, Missouri, USA
| | - Guillermo Umpierrez
- Division of Endocrinology, Metabolism Emory University School of Medicine, Atlanta, Georgia, USA
| | - Grazia Aleppo
- Division of Endocrinology, Metabolism and Molecular Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Address correspondence to: Grazia Aleppo, MD, FACE, FACP, Division of Endocrinology, Metabolism and Molecular Medicine, Feinberg School of Medicine, Northwestern University, 645 N. Michigan Avenue, Suite 530, Chicago, IL 60611, USA
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Brown SA. On the Path toward Expanding Treatment Options for Diabetes. N Engl J Med 2022; 387:935-936. [PMID: 36069876 DOI: 10.1056/nejme2209840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Sue A Brown
- From the Division of Endocrinology, Center for Diabetes Technology, University of Virginia, Charlottesville
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