Racial Disparities in Diabetes Technology Adoption and Their Association with HbA1c and Diabetic Ketoacidosis

Figures & data

Table 1 Descriptive Characteristics of Barbara Davis Study Participants with Type 1 Diabetes, Mean ± Std or % (n)

	Overall N= 5539	Pediatric N= 1468	Adults N= 4071
Age, years	28.7 ± 15.0	15.3 ±1.7	33.5 ± 14.7^b
Age group
12–17	(1468) 26.5
18–24	(1659) 30.0
24–39	(1250) 22.6
≥ 40	(1162) 21.0
Sex, female (%[n])	50.3 (2788)	47.2 (693)	51.5 (2095)^a
Race/ethnicity (%[n])
White	71.2 (3945)	61.6 (904)	74.7 (3041)^b,†
Black	2.9 (161)	3.3 (49)	2.8 (112)
Hispanic	13.0 (719)	18.7 (275)	10.9 (444)
Other	12.9 (7154)	16.4 (240)	11.6 (474)
Diabetes Duration, years	14.4 ± 11.8	6.1 ± 3.4	17.5 ± 12.3^b
Health Insurance (%[n])
Private	67.4 (3733)	59.0 (866)	70.4 (2867)^b,†
Military	2.8 (156)	3.8 (56)	2.5 (100)
Medicaid	28.2 (1564)	35.8 (526)	25.5 (1038)
Other	0.5 (27)	0.27 (4)	0.56 (23)
None	1.1 (59)	1.1 (16)	1.1 (43)
Technology use (%[n])
CSII	67.7 (3750)	74.3 (1090)	65.3 (2660)^b
CGM	70.6 (3910)	83.9 (1231)	65.8 (2679)^b
AID use	44.1 (2444)	49.9 (730)	23.8 (738)^b
Any technology use	84.1 (4659)	88.6 (1301)	82.5 (3358)^b
HbA1c (%)	8.2 ± 1.9	8.7 ± 1.9	8.1 ± 1.9^b
DKA in the past year (%[number of patients])	4.2 (213)	5.4 (78)	3.7 (135)^a
Number of DKA events in the past year
No events	95.9 (4920)	94.6 (1368)	96.3 (3552)
1 event	3.0 (156)	3.7 (54)	2.8 (102)
2 events	0.7 (37)	1.0 (54)	0.6 (22)
3 or more events	0.39 (20)	0.6 (9)	0.3 (11)

Notes: ^ap<0.01 ^bp<0.0001. ^†p-value <0.05 for global differences between groups.

Table 2 Descriptive Characteristics of Barbara Davis Study Participants with Type 1 Diabetes, Stratified by Race/Ethnicity, Mean ± Std or % (n)

	White (n, 3945)	Black (n= 161)	Hispanic (n, 719)	Other (n, 714)
Age, years	30.3 ± 16	24.6 ± 12^a	22.9 ± 10^a	26.4 ± 14.1^a
Sex, female	49.5 (1953)	46.5 (75)	54.4 (391)	51.8 (369)
Diabetes duration, years	15.6 ± 3	11.7 ± 10	10.4 ± 8	12.8 ± 11.1
Health insurance
Private	79.2 (2957)	40.4 (65)	37.6 (270)	61.8 (441)^a,†
Military	2.0 (109)	0.6 (1)	2.1 (15)	4.3 (109)
Medicaid	21.0 (827)	57.8 (93)	57.7 (415)	32.1 (229)
Other	0.5 (20)	0.6 (1)	0.3 (2)	0.6 (4)
None	0.8 (32)	0.6 (1)	2.4 (17)	0.8 (32)
Technology use
CSII	72.5 (2861)	41.0 (66)	49.1 (353)	65.8 (470)^a,†
CGM	73.2 (2886)	52.2 (84)	59.0 (424)	72.3 (516)
AID use	47.8 (11,886)	24.2 (39)	32.0 (230)	40.5 (289)^a,†
Any technology use	87.4 (3448)	60.9 (98)	70.9 (510)	84.5 (603)
HbA1c	8.0 ± 1.7	9.5 ± 2.4	9.2 ± 2.2	8.3 ± 1.9
DKA in the past year	3.1 (114)	7.4 (11)	8.4 (56)	4.8 (32)^a,†
Number of DKA events in the past year
1 event	2.5 (91)	4.7 (7)	5.4 (36)	3.3 (22)^a,†
2 events	0.4 (15)	2.0 (3)	2.0 (13)	0.9 (6)
3 or more events	0.2 (8)	0.7 (1)	1.5 (7)	0.6 (4)

Notes: ^ap<0.0001. ^†p-value <0.05 for global differences between groups.

Table 3 Descriptive Characteristics of the Participants, Stratified by Race and Age Group, Mean ± Std or % (n)

	White	Black	Hispanic	Other Races
Pediatric Population
Age, years	15.3 ± 1.7	15.2 ± 1.7	15.4 ± 1.6	15.2 (1.7)
Sex, female	45.5 (411)	59.2 (29)	50.6 (139)	47.5 (114)
Diabetes duration, years	6.2 ± 3.4	5.8 ± 3.5	5.6 ± 1.6^a	6.0 ± 3.6
Health insurance
Private	72.2 (653)	28.6 (14)	25.1 (69)	54.2 (130)^c,†
Military	3.9 (35)	0.0 (0)	2.2 (6)	6.3 (15)
Medicaid	22.7 (205)	71.4 (35)	70.1 (194)	38.3 (92)
Other	0.2 (2)	0.0 (0)	0.7 (2)	0.0 (0)
None	1.0 (9)	0.0 (0)	1.3 (3)	1.3 (3)
Technology use
CSII	82.1 (742)	67.4 (33)	44.0 (121)	25.8 (62)^c,†
CGM	89.6 (810)	46.9 (23)	69.8 (192)	85.8 (206)
AID use	56.6 (512)	20.4 (10)	35.3 (97)	46.3 (111)^c,†
Any technology use	93.5 (845)	55.1 (27)	77.5 (213)	90.0 (216)
HbA1c	8.3 ± 1.7^c	10.6 ± 2.5^c	9.6 ± 2.2^a	8.7 ± 1.8
DKA in the past year	3.9 (35)	10.6 (5)	8.9 (24)	6.0 (14)^a
DKA frequency in the past year
1 event	3.1 (28)	6.4 (3)	5.5 (15)	3.4 (8)
2 events	0.6 (5)	2.1 (1)	1.9 (5)	1.7 (4)
3 or more events	0.2 (2)	2.1 (1)	1.5 (4)	0.9 (2)
Adult Population
Age, years	34.7 ± 15.1	28.7 ± 12.7^c	27.5 ± 10.1^c	32.1 ± 14.3^b
Sex, female	50.7 (1542)	41.1 (46)	56.8 (252)	53.9 (255)^a,†
Diabetes duration, years	18.4 ± 12.8	14.3 ± 10.5^b	13.3 ± 8.4^c	16.2 ± 11.8^b
Health insurance
Private	75.8 (2304)	45.5 (51)	45.3 (201)	65.6 (311)^c,†
Military	2.4 (74)	0.9 (1)	2.0 (9)	3.4 (16)
Medicaid	20.5 (622)	51.8 (58)	49.8 (221)	28.9 (137)
Other	0.6 (18)	0.9 (1)	0.0 (0)	0.8 (4)
None	0.8 (23)	0.9 (1)	2.9 (13)	1.3 (6)
Technology use
CSII	69.7 (2119)	44.6 (50)	44.8 (199)	61.6 (292)^c,†
CGM	68.3 (2076)	54.5 (61)	52.3 (232)	65.4 (310)
AID use	45.2 (1374)	25.9 (29)	30.0 (133)	37.6 (178)^c,†
Any technology use	85.6 (2603)	63.4 (71)	66.9 (297)	81.7 (387)
HbA1c	7.9 ± 1.7	9.6 ± 2.3^c	8.9 ± 2.2^c	8.1 ± 1.9^a
DKA in the past year	2.3 (79)	5.9 (6)	8.1 (32)	4.2 (18)^c,†
Number of DKA events in the past year
1 event	2.3 (63)	4.0 (4)	5.3 (21)	3.2 (14)
2 events	0.4 (10)	2.0 (2)	2.0 (8)	0.5 (2)
3 or more events	0.2 (6)	0.0 (0)	0.8 (3)	0.5 (2)

Notes: ^ap<0.01 ^bp<0.001 ^cp<0.0001. ^†p-value <0.05 for global differences between groups. Bold and italicized font within the table used to delineate study population subgroups (strata).

Table 4 Multivariable Adjusted Relationship of Race/Ethnicity with Technology Use in Type 1 Diabetes, Stratified by Age Group

	Any Technology Use OR (95% CI)	CSII OR (95% CI)	CGM OR (95% CI)	AID OR (95% CI)
Pediatric Population
Race
White	Ref	Ref	Ref	Ref
Black	0.11 (0.06–0.22)	0.13 (0.07–0.26)	0.13 (0.07–0.24)	0.22 (0.11–0.46)
Hispanic	0.37 (0.24–0.57)	0.40 (0.29–0.56)	0.37 (0.26–0.54)	0.51 (0.37–0.70)
Other	0.71 (0.42–1.19)	0.68 (0.48–0.98)	0.77 (0.49–1.19)	0.69 (0.51–0.93)
Age, per five year increase	0.53 (0.31–0.92)	0.47 (0.31–0.70)	0.42 (0.26–0.68)	0.74 (0.53–1.03)
Sex, female vs male	1.54 (1.07–2.20)	1.30 (1.00–1.69)	1.24 (0.91–1.68)	1.29 (1.04–1.60)
Diabetes duration	1.12 (1.06–1.19)	1.16 (1.11–1.21)	1.06 (1.01–1.11)	1.14 (1.10–1.18)
Insurance
Private	Ref	Ref	Ref	Ref
None	0.35 (0.09–1.39)	0.19 (0.07–0.55)	0.40 (0.12–1.35)	0.46 (0.15–1.38)
Medicaid	0.32 (0.22–0.48)	0.41 (0.31–0.54)	0.40 (0.29–0.56)	0.64 (0.50–0.82)
Military	1.01 (0.30–3.40)	1.45 (0.63–3.32)	1.06 (0.40–2.77)	1.00 (0.57–1.76)
Other	0.25 (0.02–2.56)	0.27 (0.04–2.10)	0.47 (0.05–4.73)	0.33 (0.03–3.37)
Adult Population
Race
White	Ref	Ref	Ref	Ref
Black	0.27 (0.17–0.42)	0.34 (0.23–0.51)	0.53 (0.34–0.84)	0.42 (0.26–0.66)
Hispanic	0.35 (0.27–0.45)	0.34 (0.27–0.43)	0.53 (0.42–0.67)	0.56 (0.45–0.72)
Other	0.76 (0.58–1.00)	0.68 (0.55–0.84)	0.90 (0.72–1.13)	0.73 (0.59–0.90)
Age, per five year increase	0.94 (0.90–0.97)	0.87 (0.84–0.90)	1.03 (1.00–1.06)	0.91 (0.88–0.94)
Sex, female vs male	1.41 (1.18–1.68)	1.46 (1.27–1.68)	1.18 (1.02–1.36)	1.11 (0.97–1.27)
Diabetes duration	1.01 (1.01–1.02)	1.02 (1.02–1.03)	1.00 (0.99–1.01)	1.02 (1.01–1.03)
Insurance
Private	Ref	Ref	Ref	Ref
None	0.41 (0.21–0.82)	0.37 (0.19–0.71)	0.57 (0.29–1.11)	0.28 (0.12–0.64)
Medicaid	0.38 (0.31–0.46)	0.49 (0.41–0.57)	0.41 (0.35–0.49)	0.45 (0.38–0.54)
Military	0.96 (0.50–1.83)	1.01 (0.63–1.62)	0.74 (0.46–1.20)	1.02 (0.67–1.56)
Other	2.31 (0.51–10.45)	1.90 (0.68–5.32)	0.84 (0.34–2.06)	1.13 (0.48–2.65)

Notes: Analyses also adjusted for the number of visits with the provider in the past year. Bold, italicized font within the table used to delineate study population subgroups (strata).

Abbreviations: CSII, continuous subcutaneous insulin infusion CGM, continuous glucose monitoring AID, automated insulin delivery.

Table 5 Race Stratified Multivariable Adjusted Factors Associated with Technology Use in the Pediatric Population

	White OR (95% CI)	Black OR (95% CI)	Hispanic OR (95% CI)	Other OR (95% CI)
Any Technology Use (CSII or CGM)
Age, per five year increase	0.42 (0.18–0.98)	0.66 (0.09–4.86)	0.45 (0.18–1.23)	1.81 (0.50–6.54)
Sex, female vs male	1.48 (0.83–2.64)	0.99 (0.26–3.74)	1.93 (1.05–3.55)	1.31 (0.54–3.17)
Diabetes duration	1.19 (1.08–1.31)	0.86 (0.69–1.07)	1.09 (0.98–1.20)	1.21 (1.03–1.42)
Private/Military/Other vs Medicaid/None	3.19 (1.82–5.57)	5.45 (1.02–29.00)	3.92 (1.65–9.29)	1.98 (0.82–4.77)
CSII
Age, per five year increase	0.37 (0.21–0.65)	0.26 (0.03–2.64)	0.35 (0.15–0.81)	1.55 (0.63–3.79)
Sex, female vs male	1.18 (0.82–1.69)	1.11 (0.24–5.18)	1.98 (1.17–3.37)	0.96 (0.52–1.76)
Diabetes duration	1.16 (1.09–1.23)	0.89 (0.70–1.15)	1.23 (1.12–1.34)	1.17 (1.06–1.30)
Private/Military/Other vs Medicaid/None	2.73 (1.87–3.98)	12.20 (1.95–76.92)	2.39 (1.31–4.38)	2.07 (1.12–3.83)
CGM
Age, per five-year increase	0.33 (0.16–0.67)	0.95 (0.12–7.49)	0.36 (0.15–0.91)	1.00 (0.33–2.98)
Sex, female vs male	1.14 (0.73–1.80)	1.73 (0.44–6.80)	1.57 (0.90–2.74)	0.89 (0.42–1.87)
Diabetes duration	1.09 (1.02–1.17)	0.79 (0.61–1.03)	1.02 (0.93–1.11)	1.12 (0.99–1.26)
Private/Military/Other vs Medicaid/None	2.07 (1.30–3.31)	7.06 (1.16–42.95)	4.00 (1.89–8.47)	2.02 (0.95–4.29)
AID
Age, per five year increase	0.77 (0.51–1.17)	0.15 (0.01–2.40)	0.52 (0.23–1.19)	1.15 (0.53–2.54)
Sex, female vs male	1.13 (0.86–1.49)	0.47 (0.07–3.01)	2.75 (1.60–4.73)	0.98 (0.58–1.65)
Diabetes duration	1.15 (1.10–1.20)	1.03 (0.80–1.32)	1.13 (1.04–1.23)	1.12 (1.04–1.22)
Private/Military/Other vs Medicaid/None	1.43 (1.04–1.96)	13.44 (1.91–94.59)	1.71 (0.96–3.05)	1.71 (0.99–2.94)

Notes: Analyses also adjusted for the number of visits with the provider in the past year. Bold font within the table used to delineate population subgroups (race/ethnicity) or subgroup analyses of technology type.

Abbreviations: CSII, continuous subcutaneous insulin infusion CGM, continuous glucose monitoring AID, automated insulin delivery.

Table 6 Race/Ethnicity Stratified Multivariable Adjusted Factors Associated with Technology Use in the Adult Population

	White OR (95% CI)	Black OR (95% CI)	Hispanic OR (95% CI)	Other OR (95% CI)
Any Technology Use (CSII or CGM)
Age, per 5 year increase	0.93 (0.89–0.97)	0.99 (0.76–1.30)	0.94 (0.83–1.07)	0.91 (0.82–1.02)
Sex, female vs male	1.45 (1.17–1.80)	1.24 (0.50–3.06)	1.58 (1.02–2.45)	0.89 (0.52–1.53)
Diabetes duration	1.01 (1.00–1.02)	1.04 (0.98–1.11)	1.03 (1.00–1.07)	1.04 (1.01–1.07)
Private/Military/Other vs Medicaid/None	2.06 (1.60–2.64)	2.93 (1.19–7.24)	3.80 (2.36–6.12)	5.08 (2.94–8.79)
CSII
Age, per 5 year increase	0.87 (0.84–0.90)	0.82 (0.65–1.04)	0.90 (0.80–1.02)	0.77 (0.70–0.85)
Sex, female vs male	1.46 (1.24–1.72)	1.36 (0.56–3.33)	1.49 (0.99–2.24)	1.44 (0.96–2.18)
Diabetes duration	1.02 (1.01–1.02)	1.07 (1.01–1.13)	1.04 (1.01–1.07)	1.07 (1.04–1.09)
Private/Military/Other vs Medicaid/None	1.61 (1.33–1.96)	5.09 (2.06–12.55)	3.68 (2.40–5.62)	3.03 (1.94–4.72)
CGM
Age, per 5 year increase	1.03 (0.99–1.07)	1.06 (0.82–1.38)	1.03 (0.90–1.17)	1.03 (0.93–1.14)
Sex, female vs male	1.13 (0.95–1.34)	2.39 (0.96–5.94)	1.38 (0.90–2.11)	1.01 (0.66–1.56)
Diabetes duration	1.00 (0.99–1.01)	1.03 (0.97–1.10)	1.02 (0.99–1.05)	1.00 (0.98–1.03)
Private/Military/Other vs Medicaid/None	2.15 (1.75–2.64)	2.24 (0.93–5.40)	3.07 (1.94–4.86)	2.92 (1.83–4.64)
AID
Age, per 5 year increase	0.92 (0.88–0.95)	0.91 (0.71–1.16)	0.88 (0.76–1.01)	0.80 (0.71–0.90)
Sex, female vs male	1.03 (0.88–1.20)	1.71 (0.64–4.59)	1.46–0.94–2.27)	1.39 (0.91–2.12)
Diabetes duration	1.02 (1.01–1.03)	1.07 (1.00–1.14)	1.03 (1.00–1.07)	1.06 (1.03–1.08)
Private/Military/Other vs Medicaid/None	1.84 (1.52–2.24)	4.57 (1.67–12.55)	3.32 (2.08–5.30)	4.33 (2.58–7.26)

Notes: Analyses also adjusted for the number of visits with the provider in the past year. Bold font within the table used to delineate population subgroups (race/ethnicity) or subgroup analyses of technology type.

Abbreviations: CSII, continuous subcutaneous insulin infusion CGM, continuous glucose monitoring AID, automated insulin delivery.

Figure 1 Mean multivariable adjusted HbA1c by race/ethnicity and technology use. Mean HbA1c by race/ethnicity and diabetes technology use: 1) pediatric population; 2) adult population. Mean HbA1c by race/ethnicity and CGM use: 3) pediatric population; 4) adult population. Mean HbA1c by race/ethnicity and CSII use: 5) pediatric population; 6) adult population. Analyses adjusted for age, diabetes duration, and number of provider visits over the past year. *p<0.05, **p<0.01, ***P<0.001, ****p<0.0001 for differences by any technology (panels 1 and 2), CGM (panels 3 and 4) or CSII use (panels 5 and g).^ap<0.05, ^cp<0.001, ^dp<0.0001 for differences by race.

Abbreviations: B, non-Hispanic Black; H, Hispanic O, Other races; NHW, non-Hispanic White; CGM, continuous glucose monitoring; CSII, continuous subcutaneous insulin infusion.

Figure 2 Mean multivariable adjusted HbA1c by race/ethnicity and Automated Insulin Delivery Systems (AID) use in the pediatric and adult patient populations at the Barbara Davis Center. Analyses adjusted for age, diabetes duration, and number of provider visits over the past year. *p<0.05, **p<0.01, ***p<0.001 for differences by AID use. ^ap<0.05, ^bp<0.01, ^cp<0.001, ^dp<0.0001 for differences by race.

Table 7 Multivariable Adjusted Association of Technology Use with Diabetic Ketoacidosis in the Past Year

	Base Model OR (95% CI)	Base Model + Health Insurance OR (95% CI)	Any Technology Use OR (95% CI)	CSII Use OR (95% CI)	CGM Use OR (95% CI)	AID Use OR (95% CI)
Race
White	Ref	Ref	Ref	Ref	Ref	Ref
Black	2.23 (1.17–4.23)	1.55 (0.80–3.00)	1.55 (0.80--3.01)	1.41 (0.72–2.75)	1.50 (0.77–2.91)	1.51 (0.78–2.93)
Hispanic	2.42 (1.73–3.93)	1.67 (1.17–2.39)	1.67 (1.16–2.40)	1.55 (1.08–2.24)	1.63 (1.13–2.34)	1.64 (1.15–2.36)
Other	1.43 (0.96–2.15)	1.28 (0.85–1.93)	1.28 (0.85–1.93)	1.25 (0.83–1.88)	1.27 (0.85–1.92)	1.27 (0.84–1.91)
Age group, pediatric vs adult	0.90 (0.65–1.24)	0.85 (0.62–1.17)	0.85 (0.61–1.17)	0.88 (0.64–1.22)	0.86 (0.62–1.20)	0.86 (0.62–1.18)
Sex, female	1.18 (0.89–1.56)	1.16 (0.88–1.54)	1.16 (0.88–1.54)	1.19 (0.89–1.57)	1.17 (0.88–1.55)	1.17 (0.88–1.55)
Diabetes duration	0.96 (0.95–0.98)	0.97 (0.95–0.98)	0.97 (0.95–0.98)	0.97 (0.95–0.98)	0.97 (0.95–0.98)	0.97 (0.95–0.98)
Private/Military/Other vs Medicaid/None		0.39 (0.29–0.52)	0.39 (0.29–0.53)	0.41 (0.30–0.56)	0.40 (0.29–0.54)	0.39 (0.53–0.29)
Technology use			0.99 (0.67–1.47)	0.73 (0.54–0.99)	0.85 (0.61–1.18)	0.89 (0.66–1.20)
Age group by race interaction			P, 0.86 for joint test	P, 0.90 for joint test	P, 0.87 for joint test	P, 0.87 for joint test

Notes: Analyses also adjusted for the number of visits with the provider in the past year. Bold font within the table used to delineate subgroup analyses of technology type. The interaction tests between race and age group for each of the full models are presented in the bottom of the table below the solid black bar.

Abbreviations: CSII, continuous subcutaneous insulin infusion CGM, continuous glucose monitoring AID, automated insulin delivery.