Economics Not Cause of Racial Disparity in Kids' Diabetes Care

Jenni Laidman

February 17, 2015

Socioeconomic status plays no role in the sharp racial disparities found in the treatment of pediatric type 1 diabetes and in the outcomes of that treatment, a new study published online February 16 in Pediatrics reveals.

Previous research has documented a racial divide in the number of African Americans put on insulin pumps and in the generally poorer levels of glycemic control found in blacks. But some theorized that socioeconomic differences accounted for much of the disparity.

Now Steven M Willi, MD, from the Diabetes Center for Children's Hospital of Philadelphia, Pennsylvania, and colleagues have used the Type 1 Diabetes Exchange Clinic Network registry data on 10,704 children visiting 60 pediatric endocrinology practices in 31 states to look at racial disparities in diabetes care among children and to examine the role of parental education and income in the racial divide.

Dr Willi and colleagues found that higher income did little to equalize insulin pump use for African Americans. Use of an insulin pump is associated with tighter glycemic control than multiple daily injections of a fixed insulin dose, the two methods of insulin delivery compared in the study.

The study confirmed lower use of insulin pumps for black and Hispanic children across the board (26% and 39%, respectively, compared with 61% for white children, adjusted for gender, age, diabetes duration, and socioeconomic status [P < .001]).

It also showed higher levels of HbA1c among black children (9.6%) compared with white children (8.4%) and Hispanic children (8.7%). Black children were also more likely to experience diabetic ketoacidosis and severe hypoglycemic events in the previous year than members of either other ethnic group in this study.

In an accompanying commentary, Stuart A Chalew, MD, from Children's Hospital, New Orleans, Louisiana, noted that HbA1c levels in African Americans were higher than in white or Hispanic children, no matter the method of diabetes control employed.

"Let's say the pump is the best and everyone should be on the pump. When you slice up their data and look at African American kids on pumps vs white kids on pumps, the African American kids are still higher [for HbA1c levels]," he said.

Pump use lowered HbA1c levels, but not as much in blacks as it did in white or Hispanic children. "They're higher by the same percentage no matter what method of diabetes control they use. We in the diabetes community are failing.

"Despite all the innovations with continuous glucose monitoring and all sorts of fancy ways to give insulin, kids are not doing well. Most kids are not getting to the targets. And African American kids are doing the worst," Dr Chalew told Medscape Medical News.

Are Some Preconceived Notions Affecting Prescribing?

The study showed that while 73% of white children from homes with incomes of $100,000 or more used an insulin pump, only 45% of black children from homes in the highest-income group used a pump (P < .001). In fact, white children from homes earning less than $50,000 were just as likely to use an insulin pump as black children from the wealthiest homes, with 45% of each group using a pump.

And white children without private insurance were more than twice as likely to use an insulin pump as black children without private insurance. Even when black children had private insurance, white children without it were still more likely to use an insulin pump (47% of white children lacking private insurance vs 36% of black children with private insurance; P = .006.).

And education made little difference in closing the racial divide. When a white child's parents were college educated, 68% of the children used an insulin pump, while only 34% of the children of college-educated black parents used a pump (P < .001).

"This breaks down some of the explanations for the disparities in our prescribing practices. It may uncover that there's some bias, some preconceived notions that are influencing physician prescribing practices," Dr. Willi told Medscape Medical News.

"It's not necessarily prescriber bias. There could also be issues of trust or communication that may underlie this disparity. I focus on providers because I am one.

"My hope from this paper is to demonstrate we should really maintain an open mind about how and when we prescribe, and we should develop programs that are culturally sensitive and that help patients have an opportunity to succeed."

New Approaches to Patient Monitoring May Be Needed

Dr Willi said the elevated HbA1c levels in black children suggest that there may be an independent component contributing to higher HbA1c, meaning HbA1c fails to accurately reflect mean blood glucose. This could be something genetic, for example.

"If there is a discrepancy between HbA1c and mean blood glucose, one would expect to find that more aggressive use of insulin would result in an increased incidence of hypoglycemia," he said, noting that African American children in this study were 2.5 times more likely to have experienced one or more severe hypoglycemic events in the past year compared with white children (P < .001) and 2.3 times more likely than Hispanic children (P < .001).

"Clarification of the impact of factors besides mean blood glucose as a cause of higher HbA1c is important because such factors may require new approaches to patient monitoring and innovative interventions for safe and effective prevention of complications," Dr Chalew writes.

Dr Willi reports no relevant financial relationships; disclosures for the coauthors are listed in the article. Dr Chalew reports no relevant financial relationships.

Pediatrics. Published online February 16, 2015. Abstract


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