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The use of insulin pumps and continuous glucose monitors (CGMs) increased in recent years among Medicare beneficiaries with type 1 diabetes, but so did disparities in usage between Black and white patients, researchers reported.

From 2017 to 2019, the prevalence of insulin pump use increased among whites from 14% to 18%, but increased from just 3.8% to 4.6% among Black patients (P<0.001 for the difference), reported Robert Vigersky, MD, and colleagues from Medtronic Diabetes in Northridge, California.

Writing in the , the group's analysis of Medicare data found that CGMs caught on quickly after coverage changes were implemented in 2017, but seemingly caught on quicker for whites than Black individuals. Approximately 14% of white patients used a CGM in 2018, and that number jumped to nearly 25% in 2019. But for Black patients, the number increased from approximately 4% to only 12% during the same time (P<0.001).

"This study highlights the complexity of the causes of health disparities in diabetes," Vigersky said in a statement. "Previous studies in non-Medicare beneficiaries point to socioeconomic status as the key driver of unequal adoption of diabetes technology, but our study shows many other contributing factors."

"Other factors include unconscious bias among healthcare providers who may feel that people of color may not be able to use these technologies," he explained. "In addition, there are cultural barriers, low health literacy, and limited access to healthcare, particularly to endocrinologists."

Because of the lack of standardized clinical guidelines for selecting patients for diabetes-technology use, clinicians may instead rely on personal -- and possibly biased criteria -- toward choosing more compliant patients, including those with lower HbA1c levels, the researchers suggested.

"These selection criteria for insulin pump prescription may include a minimum number of daily blood glucose tests, a minimum number of annual patient visits, a certain HbA1c threshold, and a minimum duration of diabetes, none of which are evidence-based criteria," Vigersky's group wrote. "Consequently, patients from racial and ethnic minorities may be excluded from consideration by the bias of 'gate-keepers' to therapy access."

The researchers cited a however, that challenged conventional patient selection criteria. It found patients could in fact achieve excellent glycemic control with a hybrid closed-loop insulin delivery system despite not being dubbed "good candidates" for such technology, they said.

Another barrier to diabetes care technology is the lack of minority recruitment to clinical trials. The researchers went on to point out how more than 90% of clinical trial participants are white, "meaning that crucial data and experience for minority patients is lacking." They also added that discontinuation rates for minority patients are higher.

"Encouraging participation by minority patients in clinical trials may necessitate changes in regulatory requirements and industry practices," they suggested.

Vigersky's group analyzed data from a Medicare 5% sample. It included Medicare fee-for-service enrollees with type 1 diabetes. The number of individuals varied from 16,114 in 2017 to 13,796 in 2019. During these coverage years, nearly 80% of these beneficiaries were white and about 15% were Black.

When the researchers examined the 7% of Medicare beneficiaries of other races, which included Asian, Hispanic, and North American Native populations, they found similar trends. Insulin pump use remained at about 4% from 2017 to 2019 for these populations, and the use of CGMs only increased from approximately 5% in 2018 to about 10% in 2019.

Vigersky and colleagues noted some limitations to their study. Their analysis did not include the cost of diabetes-related technologies, which also remains a large barrier to insulin pump and CGM access. The Medicare database relied on self-reported race-ethnicity with "poorly defined categories," they said. In addition, their analysis didn't include any actual health outcomes, although these would presumably improve with the use of diabetes technologies, they explained.

Finally, their selection criteria excluded patients with current long-term use of oral hypoglycemic medications. "That exclusion may have removed some otherwise eligible type 1 diabetes beneficiaries who were also taking metformin, sodium glucose cotransporter 2 (SGLT2) inhibitors, or glucagon-like peptide 1 (GLP-1) agonists," they concluded.

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