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© 2024 Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ. http://creativecommons.org/licenses/by-nc/4.0/ This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ . Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License.

Abstract

Introduction

Diabetes disparities exist based on socioeconomic status, race, and ethnicity. The aim of this study is to compare two cohorts with diabetes from California and Florida to better elucidate how health outcomes are stratified within underserved communities according to state location, race, and ethnicity.

Research design and methods

Two cohorts were recruited for comparison from 20 Federally Qualified Health Centers as part of a larger ECHO Diabetes program. Participant-level data included surveys and HbA1c collection. Center-level data included Healthcare Effectiveness Data and Information Set metrics. Demographic characteristics were summarized overall and stratified by state (frequencies, percentages, means (95% CIs)). Generalized linear mixed models were used to compute and compare model-estimated rates and means.

Results

Participant-level cohort: 582 adults with diabetes were recruited (33.0% type 1 diabetes (T1D), 67.0% type 2 diabetes (T2D)). Mean age was 51.1 years (95% CI 49.5, 52.6); 80.7% publicly insured or uninsured; 43.7% non-Hispanic white (NHW), 31.6% Hispanic, 7.9% non-Hispanic black (NHB) and 16.8% other. Center-level cohort: 32 796 adults with diabetes were represented (3.4% with T1D, 96.6% with T2D; 72.7% publicly insured or uninsured). Florida had higher rates of uninsured (p<0.0001), lower continuous glucose monitor (CGM) use (18.3% Florida; 35.9% California, p<0.0001), and pump use (10.2% Florida; 26.5% California, p<0.0001), and higher proportions of people with T1D/T2D>9% HbA1c (p<0.001). Risk was stratified within states with NHB participants having higher HbA1c (mean 9.5 (95% CI 8.9, 10.0) compared with NHW with a mean of 8.4 (95% CI 7.8, 9.0), p=0.0058), lower pump use (p=0.0426) and CGM use (p=0.0192). People who prefer to speak English were more likely to use a CGM (p=0.0386).

Conclusions

Characteristics of medically underserved communities with diabetes vary by state and by race and ethnicity. Florida’s lack of Medicaid expansion could be a factor in worsened risks for vulnerable communities with diabetes.

Details

Title
Not all healthcare inequities in diabetes are equal: a comparison of two medically underserved cohorts
Author
Walker, Ashby F 1   VIAFID ORCID Logo  ; Haller, Michael J 2   VIAFID ORCID Logo  ; Addala, Ananta 3   VIAFID ORCID Logo  ; Filipp, Stephanie L 4 ; Lal, Rayhan 5 ; Gurka, Matthew J 6 ; Figg, Lauren E 7 ; Hechavarria, Melanie 4   VIAFID ORCID Logo  ; Zaharieva, Dessi P 7   VIAFID ORCID Logo  ; Malden, Keilecia G 4 ; Hood, Korey K 3 ; Westen, Sarah C 8 ; Wong, Jessie J 3 ; Donahoo, William T 9 ; Basina, Marina 10 ; Bernier, Angelina V 4 ; Duncan, Paul 11 ; Maahs, David M 3 

 University of Florida Diabetes Institute, Gainesville, Florida, USA; Department of Health Services Research, Management and Policy, University of Florida, Gainesville, Florida, USA 
 University of Florida Diabetes Institute, Gainesville, Florida, USA; Department of Pediatrics, University of Florida, Gainesville, Florida, USA 
 Stanford Diabetes Research Center, Stanford, California, USA; Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA 
 Department of Pediatrics, University of Florida, Gainesville, Florida, USA 
 Division of Endocrinology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA 
 Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia, USA 
 Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA 
 Department of Clinical and Health Psychology, University of Florida, Gainesville, Florida, USA 
 University of Florida Diabetes Institute, Gainesville, Florida, USA; Division of Endocrinology, Diabetes, & Metabolism, College of Medicine, University of Florida, Gainesville, Florida, USA; Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, Florida, USA 
10  Stanford Diabetes Research Center, Stanford, California, USA; Division of Endocrinology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA 
11  Department of Health Services Research, Management and Policy, University of Florida, Gainesville, Florida, USA 
First page
e004229
Section
Epidemiology/Health services research
Publication year
2024
Publication date
2024
Publisher
BMJ Publishing Group LTD
e-ISSN
20524897
Source type
Scholarly Journal
Language of publication
English
ProQuest document ID
3101394674
Copyright
© 2024 Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ. http://creativecommons.org/licenses/by-nc/4.0/ This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ . Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License.