Addressing Disparities in Diabetes Technology Access: Provider Bias, Barriers, and Solutions, Pt. 1
In part 1 of this interview, Estelle Everett, MD, explores the impact of provider bias and clinic barriers on access to diabetes technology. She shares how improving access to tools like continuous glucose monitors can transform patient outcomes, and offers strategies for ensuring equitable care for all patients with type 1 diabetes.
Consultant360: In the review, you mention that stigma and provider bias and can limit equitable access to diabetes technologies. First, what are the clinical consequences of delayed access, or no access at all, to these technologies?
Estelle Everett, MD: That's a great question. So I think prolonged access to diabetes technology really prolongs the time in many cases that patients are living with poor diabetes control. And we know poor diabetes control leads to more diabetes complications down the line. And so, for example, California Medicaid a few years ago changed their policy to eliminate that long list of requirements and more patients were able to access continuous glucose monitoring (CGM). And so we recently submitted a study from publication that evaluated the impact of this policy and we saw a 68% increase in CGM use. And of note, we found that the patients who wouldn't have qualified under the previous policy have the biggest improvements in their blood sugars.
And so I think this shows that if we improve access, the patients who may be more vulnerable to the poor complications of diabetes can get better and really it can impact their long -term health.
C360: Do you have recommendations for accountability measures to help reduce provider bias in clinical decision-making, particularly in the context of recommending CGMs and insulin pumps?
Dr Everett: I think providers are often well-intentioned in terms of offering technology to those who they perceive will appropriately use technology or benefit from them. But the issue is that we all have subconscious biases and there's evidence that providers are actually not very good at predicting who will be successful or benefit from technology. I collaborated on the study that published last year that shows that providers had lower rates of discussions about diabetes technology or particular groups and lower rates of prescribing.
A good place to start would be to set up a standardized approach that ensures that discussions about diabetes technology occur with all patients with type 1 diabetes. It doesn't mean that all patients should or would even want to be on technology but I think this approach will ensure that all patients are aware that that is a management option for them and then something that they consider they can that is something that they can consider if it aligns with their personal preferences, lifestyle, or treatment goals. So essentially this approach would ensure that every patient has the opportunity to make informed decisions about their care.
C360: You note that clinic infrastructure can be a barrier to the use of diabetes technology. What types of infrastructure improvements—such as digital integration systems, patient support programs, or telehealth—are most critical for increasing adoption of CGMs and insulin pumps?
Dr Everett: So there are many things in the clinic infrastructure that can be a barrier to diabetes technology use. For example, providers may not have enough time or knowledge to appropriately discuss the pros and cons of technology, or they may not have the support staff to appropriately educate their patients or train them to start technology. And then we know that prescribing technology sometimes has a lot of red tape in terms of authorizations or other paperwork that could be very time consuming.
After technology is initiated, providers also have to incorporate device downloads and reporting into their clinic workflow. So prescribing diabetes devices really adds a layer of complexity to endocrinologist's already busy schedule. And so that may be enough to dissuade providers from prescribing technology. So I think it's essential to provide clinicians with a supportive environment that allows and allows, along with the necessary resources and staff to help them effectively integrate technology into their practice. And this should also include resources to ensure that their patients are educated and properly supported through the whole process of starting technology and then using technology as they manage their diabetes.
Reference:
Kanbour S, Everett E. Addressing disparities in technology use among patients with type 1 diabetes. Curr Opin Endocrinol Diabetes Obes. 2024;31(1):14-21. doi:10.1097/MED.0000000000000840