Structural
Structural determinants of diabetes technology use: a descriptive analysis Chloe Bennett* Chloe Bennett Rob Cavanaugh Louisa Smith
Continuous glucose monitors (CGM) have been shown to significantly improve diabetes control, yet CGM use differs by race/ethnicity. Evidence suggests systemic barriers affect CGM use.
This study assessed the relationship between two structural determinants and CGM use among a cohort of people with self-reported type 2 diabetes (T2D) enrolled in the NIH All of Us Research Program. CGM use was determined via procedural codes in electronic health records. Participants were surveyed on healthcare provider bias, rating how often healthcare providers treat them with less respect than others. Logistic regressions estimated associations between state-level acceptance of Medicaid expansion, defined as implementation prior to 2023, and participant-reported healthcare provider bias and CGM use. We also assessed effect modification by race/ethnicity.
Among the participants with self-reported T2D (N=17,507), 56% had hemoglobin A1c data. Of these, 4.5% (N=438) had any procedural codes relating to CGMs. 5.1% of White and 3.6% of Black participants had evidence of CGM use. CGM users were similar in age to non-users (mean years 65.4 and 64.8, respectively). 70% of CGM users lived in Medicaid expansion states vs. 64% of non-users. After adjusting for race/ethnicity, gender, and mean A1c, living in a state that adopted Medicaid expansion was associated with increased odds of CGM use (OR: 1.31; 95% CI 1.04, 1.67). Interaction analyses revealed that the association was strongest among Black participants (6.03; 2.93,12.42). Healthcare provider bias was not associated with CGM use (1.02; 0.79, 1.29) overall. However, both Black (0.68; 0.33, 1.39) and Hispanic (0.78; 0.32, 1.89) people who reported not always feeling respected by a healthcare provider were less likely to ever use CGMs.
These findings highlight the importance of considering the effect of federal and state-level policy changes on reducing racial disparities in diabetes technology access and use.