Like real estate, the quality of diabetes care comes down to “location, location, location,” a large cohort study led by a team from Mayo Clinic, Rochester, Minnesota, has found.
Adults with diabetes who live in rural areas, as well as those who live in areas of socioeconomic disadvantage, were much less likely to achieve optimal diabetes care than people who live in urban areas and in less socioeconomically deprived areas. Outcomes were even worse among racial and ethnic minority groups, according to the researchers, whose findings appeared December 29 in JAMA Network Open.
“High costs of diabetes medications, testing supplies, and appointments, as well as difficulty receiving needed medical care for their diabetes all contribute to the gaps in diabetes care quality among people in deprived areas,” said Rozalina G. McCoy, MD, associate professor of medicine in Mayo Clinic’s Division of Community Internal Medicine, Geriatrics, and Palliative Care, and the principal investigator on the study. “As clinicians and health systems, we need to better understand the challenges our patients face every day and work with them to help them overcome them.”
‘We’re never going to get control of this diabetes animal if we’re just throwing drugs at it.’
Alan Reisinger III, MD, associate medical director for MDVIP, a Boca Raton, Florida-based operator of a network of physicians providing preventive care and personalized primary care, called the new study “well-done and necessary.”
Reisinger, who is spearheading an effort to teach physicians how to prevent diabetes, strokes, and heart attacks, added that more patient education is needed starting in primary school to prevent diabetes.
“We’re never going to get control of this diabetes animal if we’re just throwing drugs at it,” Reisinger told Medscape Medical News. “In the typical primary care practice, where you have 8 to 10 minutes to spend with a patient, there just simply isn’t the time for the type of health coaching that would be the most effective to manage a diabetic or pre-diabetic patient.”
The study examined medical records of 31,934 patients with diabetes between 18 and 75 years of age cared for in 75 primary care practices across Minnesota, Iowa, and Wisconsin.
McCoy and her colleagues used data from the US Census American Community Survey to calculate area-level deprivation (ADI) for the US Census block groups where patients live and their zip codes to determine if the area is rural or urban. ADI is a measure of socioeconomic deprivation that reflects the income, employment, housing, and education levels of people living in a particular geographic region.
To assess the quality of care in rural and urban settings, as well as different levels of socioeconomic deprivation, the researchers used the “D5” — a composite measure of comprehensive diabetes treatment. Achieving the D5 requires that the patient achieves control of blood sugar, blood pressure, and lipids; takes aspirin if they have ischemic heart disease; and does not use tobacco.
Forty-one percent of patients (n=13,138) achieved the optimal D5 level, the researchers reported. They were more likely to be older, female, White, and to live in more urban areas in relative economic comfort. However, Co-author Shaheen Kurani, PhD, said, “We found that patients living in more deprived and rural areas were significantly less likely to attain high-quality diabetes care compared with those living in less deprived and urban areas.”
Among the Results:
Patients living in rural zip codes were 16% less likely to meet the composite D5 metric than those in urban areas, while those living in highly rural areas were 19% less likely to achieve all D5 metric components. Patients from these rural and highly rural areas were also less likely than urban dwellers to attain lipid control. Tobacco use and blood pressure control were not associated with rural residence.
Patients who lived in the most deprived 20% of census block groups were 28% less likely to meet the composite D5 metric than those living in the least deprived quintile. Residents of more deprived areas also were significantly less likely to meet glycemic control and to not use tobacco.
Minority patients with diabetes were less likely than White patients to meet goals for glycemic, lipid, and blood pressure control.
Older patients were more likely to achieve the D5 composite measure, blood sugar control, lipid control, and no tobacco use. Men were less likely than women to achieve the D5 composite measure and the individual components, with the exception of lipid control, which was not associated with sex.
Telemedicine has the potential of helping these patients, McCoy said, but not for patients without access to broadband internet service, “which is frequently a barrier in highly rural areas, and without established medical care.”
She also stressed the importance of identifying and addressing the barriers to diabetes care that people living in socioeconomically deprived areas face. The results provide “a framework for evaluating diabetes care quality and equity through the lens of geographic disparities, yielding rapidly actionable information for health systems, policymakers, and payers to drive innovation and improvement in underserved areas,” she said.
One critic said the Mayo study might be unsurprising to primary care clinicians in underserved areas of the country.
Alan Blum, MD, director of the Center for the Study of Tobacco and Society, Department of Family Medicine at the University of Alabama School of Medicine, Tuscaloosa, added that most rural primary care physicians are already knowledgeable about the issues that the Mayo study addressed “with vast amounts of data about rural-urban health disparities.”
“In my experience, rural family physicians know their patients as well as, if not better than, their urban counterparts,” he said. “They live in the same towns as their patients, where they regularly bump into them outside of the healthcare setting.”
McCoy reported grant funding from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), which supported the study, as well as consulting to Emmi on developing patient education materials on prediabetes and diabetes. The other sources in the story reported no relevant financial conflicts of interest.
Howard Wolinsky is a medical writer in Chicago, Illinois.