Study Highlights Racial Disparities in T1D Pediatric Population

Regardless of insurance status, racial disparities in technology use and diabetes outcomes persist in children with type 1 diabetes (T1D), according to study results published in Pediatric Diabetes.

T1D is the third most common pediatric chronic disease in the United States and annual incidence of the condition has increased in the past 20 years. “While T1D disproportionally affects non-Hispanic White (NHW) vs non-Hispanic Black (NHB) children…between 2002 and 2015 the risk of T1D rose sharply in NHB children; with a 40% increase in incidence, compared to less than 15% in NHW children,” authors wrote.

As researchers point out, significant advances in T1D therapeutics and technologies over recent years may have exacerbated racial disparities. Previous reports have found racial disparities in insulin pump use among children with T1D, which may play a role in clinical outcomes in this population. Insulin pumps are widely used to ensure optimal glycemic control in patients with T1D and, when used correctly, can significantly reduce the incidence of disease complications.

In the current study, researchers analyzed electronic health records of all children presenting to the Diabetes Center at Children’s Hospital of Philadelphia from October 2018 to December 2019. All children were under the age of 18 and had a diabetes duration of 2 years or more. At this center, all children are assigned to a clinical care team including a nurse practitioner, certified diabetes educator, nutritionist, social worker and physician.

Investigators stratified appointment attendance, treatment modalities, and clinical outcomes according to race and insurance status of 1331 children. Median (interquartile range [IR]) age was 14.2 (11.5-16.3) years and children had a median T1D duration of 5.8 (3.8-9) years. A total of 1026 (77%) of children were NHW, 198 (15%) were NHB, and 107 (8%) were Hispanic. In addition, government insurance, which was used as a proxy for low socioeconomic status, was used by 358 (27%) of children. Of this cohort, 60% were NHB, 53% were Hispanic and 18% were NHW children. No significant differences in age, sex, or duration of diabetes by race or type of incurrence were found in the overall sample.

Analyses revealed:

• More NHB children were hospitalized over the study period, followed by Hispanic and NHW children (18%, 10%, and 3%, respectively)
• The odds ratio for hospitalization was 7.7 (95% CI, 4.6-12.8) times higher in NHB than NHW children and 4 (95% CI, 2-8.4) times higher in Hispanic than NHW children
• NHW children were treated with insulin pumps (72%) more than twice as frequently as NHB (34%) and 1.3 times more often than Hispanic (47%) children (P < .001 for both)
• Far fewer children (44%) with government insurance were treated with insulin pumps and, in those with government insurance, NHW children used this technology more than twice as often as NHB (57% vs 28%, P < .001) and 1.6 times more often than Hispanic children (37%, P = .006)
• The odds of not using an insulin pump were 4.9 (95% CI, 3.5-6.8) times higher in NHB and 3 (95% CI, 2-4.5) times higher in Hispanic than in NHW children, a pattern seen both in government and commercially insured children
• There were no racial disparities with regard to the number of appointments attended

Overall, NHB children had higher glycated hemoglobin (HbA1C), more emergency department visits and hospitalizations, and were less likely to be treated with insulin pumps or continuous glucose monitors than NHW children (P <.001 for all).

“In our center, higher HbA1c levels were seen in NHB children with government and commercial insurance. Although it has been shown that NHB patients with T1D have slightly higher HbA1c levels than NHW patients with similar average glucose readings, the magnitude of increase observed in our NHB children far exceeds this physiological difference,” researchers wrote. “This racial disparity is further evident from the observation that NHW children with government insurance have lower HbA1c levels than NHB children with commercial insurance.”

Implicit racial/ethnic bias among some health care professionals may account for some disparities in the treatment and outcomes of minority patients documented in the study. A previous study found a family’s perception of medical costs and healthcare providers’ perception of family competence were both associated with prescribed treatment regimens, authors explained.

The incomplete assessment of socioeconomic status and the retrospective nature of the study mark limitations. However, researchers hope the single-center study will encourage other centers to review their own data in relation to disparities and consider strategies to address any identified.

“Remedying the deep-rooted healthcare disparities in this country will require a concerted effort on several fronts,” researchers concluded. For example, developing standardized protocols related to diabetes treatments may result in more equitable prescribing practices for diabetes technology. Strategies aimed at addressing social determinants of health could also be implemented, such as the addition of community health workers to the multidisciplinary team. Additional programs targeting the development of a more diverse clinical workforce may improve clinician-patient relationships.

“Disparities in healthcare cannot be eliminated without a societal effort to address structural racism…The unique role of pediatric healthcare providers, as child advocates, demands that we take a leadership role in the study and alleviation of racial disparities.”

Reference

Lipman TH, Smith JA, Patil O, Willi SM, and Hawkes CP. Racial disparities in treatment and outcomes of children with type 1 diabetes. Pediatr Diabetes. Published online October 8, 2020. doi:10.1111/pedi.13139