Disparities in Diabetes Technology Use Among Military Dependents with Type 1 Diabetes within an Equal Access Healthcare System

Presentation Number: MON 575
Date of Presentation: April 3rd, 2017

Rachael Paz*, Traci Carter, Daniel Brooks and Karen Vogt
Walter Reed National Military Medical Center, Bethesda, MD

Abstract

Background: Disparities in the care of type 1 diabetes, manifested as differences in glycemic control, are well established. These differences persist even in the US military healthcare system (MHS) despite equal access to and full coverage of healthcare for all military service members and their families. There has been an increase in the available technology for the management of type 1 diabetes, and some studies have reported significantly better glycemic control with the use of technology. We sought to determine if within the MHS, disparities may also exist in the use of diabetes technology (insulin pumps and continuous glucose monitors [CGM]), and if glycemic control differs in those using diabetes technologies from those who are not.

Methods: We performed a retrospective chart review of patients aged 2-19 years with type 1 diabetes whose parent was a military service member seen in our National Capital Area military pediatric endocrinology clinics between January 2006 and August 2016. Exclusion criteria included diabetes duration <1 year, insulin dosage <0.5 units/kg/day, and underlying conditions necessitating a higher hemoglobin A1c (HbA1c) goal. We excluded those on NPH insulin from the analysis due to small numbers.

Results: A total of 405 patients met criteria. The median age was 16 years (IQR 12-18), median diabetes duration 6 years (IQR 4-9), and median HbA1c 8.7% (IQR 7.9-9.7). 46.2% were female, 68.1% white, and 53.8% children of military Officers (versus Enlisted). 49.1% were treated with an insulin pump, 20.2% used a CGM, and 16.5% had both a pump and a CGM. Insulin pumps were used more often by those of white race (OR 2.7, 95% CI: 1.8-4.2) and Officer’s children (OR 2.3, 95% CI: 1.6-3.5). CGM was also used more often by those of white race (OR 2.0, 95% CI: 1.1-3.6) and Officer’s children (OR 1.9, 95% CI: 1.1-3.1). Patients using an insulin pump were more likely to have a CGM (OR 6.5, 95% CI: 3.5-11.8): 34% of those using an insulin pump had a CGM compared to 7% on multiple daily injections (MDI) (p<0.001). Those on a pump had a lower median HbA1c than those on MDI (8.4% versus 9.1%, p<0.001). Those who used CGM also had a lower median HbA1c than those who did not (8.1% versus 8.9%, p<0.001). Diabetes-related hospitalizations did not differ whether a pump or MDI was used (30.2% versus 30.6%, NS). Only 19.5% of those with CGM had a history of hospitalization versus 33.1% of those without a CGM (p=0.016).

Conclusion: Our results show that disparities in the utilization of currently available diabetes technology do exist and could be contributing to differences in glycemic control between certain patient populations. These findings highlight the need to identify root causes of these disparities and to determine processes to eliminate disparities ensuring all of our patients have the greatest opportunity to optimize their health.

 

Nothing to Disclose: RP, TC, DB, KV