Researchers Look for Factors Underlying Disparities in Diabetes Care

Children with type 1 diabetes are not able to produce insulin on their own, which puts them at risk for long-term complications involving their eyes, nerves, circulation, kidneys, and heart. One way that they can prevent these problems is by using insulin pump therapy to help control the levels of sugar (glucose) in their blood. These systems can be programmed to imitate the body’s normal release of insulin and allow some children with diabetes to avoid daily insulin injections.

A study published in Pediatrics and written by Steven Willi, MD, director of the Diabetes Center for Children at The Children’s Hospital of Philadelphia, took a close look at health care practitioners’ prescribing practices for insulin pumps. The study team investigated potential racial and ethnic disparities in insulin treatment approaches and health outcomes among 10,704 participants from 2010 to 2012 in the T1D Exchange (T1DE) Clinic Registry. CHOP is the largest pediatric member of the T1DE, which includes 60 pediatric diabetes sites across 31 states.

“We had a sense that there were subtle differences in prescribing practices and that insulin pump therapy, in particular, was not being prescribed as often to children from ethnic minorities,” Dr. Willi said. “We recognized that there was controversy in the literature about whether these disparities exist, and if so, why. Since the T1DE is the largest collection of patients with type 1 diabetes in the U.S., we thought the data would allow us to examine those questions. We were quite surprised by the disparities that we uncovered.”

The study’s results showed that fewer black children were receiving insulin pump treatment than Hispanic or white children, regardless of socioeconomic status. White children were 3.6 times more likely to receive insulin pump therapy than black children, and 1.9 times more likely than Hispanics. The researchers also found that even in high-income families, black children were less likely to be on a pump, and they had much higher glucose levels, which suggest that black children tend to have poorer diabetes control.

“What I found quite remarkable is that you were more likely to have an insulin pump if your parents had a high school education and you were white than if your parents were educated at the level of a master’s degree and you were black,” Dr. Willi said. “I would not have predicted that finding, as previous studies have suggested that socioeconomic status was the primary determinant of insulin pump use.”

It raises the question, he continued, of how much prescribing practices are being influenced by personal bias. For example, if practitioners harbor preconceived notions about who may be more or less likely to respond to an insulin pump, then they may be more reluctant to introduce the treatment method as an option to patients.

To counteract this possible bias, diabetes teams should try to objectify the prescription of these devices, Dr. Willi said. Objective criteria, a checklist for example, could be used to identify patients who might benefit from insulin pump therapy. It also is important, he said, for practitioners to recognize that previous research has shown that patients of all backgrounds can successfully undergo training to use an insulin pump.

“We would like for this to serve as a wake-up call for diabetes practices to open their minds to the idea that insulin pumps can be safely prescribed and that we shouldn’t allow our biases to determine who is a ‘good’ pump candidate,” Dr. Willi said.

The study team concluded that further research is needed to identify the barriers to optimal diabetes management in all racial, ethnic, and socioeconomic status groups and to determine the reasons why practitioners may not prescribe insulin pumps as frequently in certain minority children with type 1 diabetes. The research team also has a study underway that aims to explain some of the health outcomes disparities that have been found among ethnic groups. They will explore how glycated hemoglobin (HbA1c) may be influenced by genetics, as some research has suggested that HbA1c may be lower in whites than blacks, even when they have the same blood sugar levels.

At CHOP, insulin pump prescribing practices have increased dramatically over the last decade, according to Dr. Willi, and insulin pump therapy classes are available to all patients interested in incorporating the technology into their diabetes care plan.