Disclosures: Addala reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
May 25, 2021
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Disparities growing in pediatric diabetes technology use, HbA1c in US

Disclosures: Addala reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
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Socioeconomic disparities in diabetes technology use and HbA1c widened among children in the United States in 2016-2018 compared with 2010-2012, according to a study published in Diabetes Care.

Researchers evaluated socioeconomic disparities in diabetes technology use and HbA1c among youths in the U.S. and Germany. Although disparities were observed in both countries in 2010-2012, disparities worsened in the U.S. in 2016-2018 and were more pronounced than the ones observed among German children.

Socioeconomic disparities in CGM use in the US widened from 2010-2012 to 2016-2018. Data were derived from Addala A, et al. Diabetes Care. 2021;doi:10.2337/dc20-0257.

“The take-home message from this work is a call to action to prioritize equitable access to diabetes care in America,” Ananta Addala, DO, MPH, an instructor in the division of pediatric endocrine and diabetes at Stanford University, told Healio. “In this study, we report that disparities in the use of diabetes technology and HbA1c by socioeconomic status have worsened over the last decade for the poorest youth in America. We found that diabetes technology use was the primary factor in this worsening of HbA1c seen in America.”

Ananta Addala

Addala and colleagues analyzed data from 16,457 youths in the U.S. with type 1 diabetes who had data registered with the Type 1 Diabetes Exchange and 39,836 German children with diabetes included in the Diabetes Prospective Follow-up. All participants had data available from either the period of 2010-2012 or 2016-2018. Insurance type, education level and annual income were used to categorize participants into socioeconomic status quintile groups. The first quintile included those with the lowest socioeconomic status, and the fifth quintile included participants with the highest socioeconomic status.

Disparities widen in US diabetes technology use

Both insulin pump use and continuous glucose monitor use increased in the U.S. and Germany from 2010-2012 to 2016-2018. Among German children, insulin pump use increased from 53.8% in the lowest quintile to 57% in the fourth quintile before dropping to 49.1% in the highest quintile from 2010-2012 (P = .002). A similar pattern was observed in 2016-2018. In the U.S., the prevalence of insulin pump use was 28.6% in the lowest quintile and 70.3% in the highest quintile from 2010-2012 (P < .001). In the 2016-2018 period, 36.5% of youths in the lowest quintile used an insulin pump and 75.8% in the highest quintile used one (P < .001).

In Germany, CGM use was 5.7% in the lowest quintile and 3.8% in the highest quintile from 2010-2012 (P = .004). In 2016-2018, the lowest quintile had a CGM use prevalence of 48.5%, and 57.1% in the highest quintile used a CGM (P < .001). In the U.S., 2.9% in the lowest quintile and 11% in the highest used a CGM from 2010-2012 (P < .001). The gap increased in 2016-2018, with 15% in the first quintile using a CGM vs. 52.3% in the fifth quintile (P < .001).

Larger HbA1c disparities in the US than Germany

In Germany, the lowest quintile had a mean HbA1c of 8% in 2010-2012 and the highest quintile had a mean HbA1c of 7.6% (P < .001). In 2016-2018, the mean HbA1c decreased to 7.8% in the lowest quintile and 7.5% in the highest quintile (P < .001).

In the U.S., the mean HbA1c was 9% for the lowest quintile and 7.8% for the highest from 2010-2012 (P < .001). In 2016-2018, the gap increased, with the lowest quintile having a mean HbA1c of 9.3% and the lowest a mean HbA1c of 8% (P < .001).

For German youths, the association between socioeconomic status and HbA1c did not significantly change between the two time periods, whereas socioeconomic disparities among U.S. children changed significantly. Although HbA1c increased across all socioeconomic quintiles in the U.S., there were larger increases in the lower quintiles between the two time periods (P = .0005). The increase in HbA1c was no longer significant after adjusting for insulin pump and CGM use.

“We anticipated that disparities by socioeconomic status would be present in both America and Germany, but we were surprised and sobered by the fact that disparities have in fact worsened in the last decade in America,” Addala said. “We found it interesting that the relationship between diabetes technology and socioeconomic status was not present in German youth.”

Addala said the findings reveal how increased access to diabetes technology could be one step in reducing disparities for youths in the U.S.

“Prioritizing equitable access to diabetes technology for all youth appears to be a clear strategy to, at minimum, reverse the trend of worsening diabetes outcomes,” Addala said. “It will be important to note that increasing access to diabetes technology is one step in addressing disparities, but should not be the only one. There is a growing body of literature that suggests factors that are not directly related to diabetes, such as systemic racism or provider bias, are important to address for equitable diabetes outcomes.”

Addala said future studies are needed to examine the drivers of disparities in pediatric diabetes technology use to improve outcomes.

For more information:

Ananta Addala, DO, MPH, can be reached at addala@stanford.edu; Twitter: @DrAAddala