A Decade of Disparities in Diabetes Technology Use and HbA1c in Pediatric Type 1 Diabetes: A Transatlantic Comparison
Open accessAbstract
OBJECTIVE: As diabetes technology use in youth increases worldwide, inequalities in access may exacerbate disparities in hemoglobin A1c (HbA1c). We hypothesized that an increasing gap in diabetes technology use by socioeconomic status (SES) would be associated with increased HbA1c disparities. RESEARCH DESIGN AND METHODS: Participants aged <18 years with diabetes duration ≥1 year in the Type 1 Diabetes Exchange (T1DX, U.S., n = 16,457) and Diabetes Prospective Follow-up (DPV, Germany, n = 39,836) registries were categorized into lowest (Q1) to highest (Q5) SES quintiles. Multiple regression analyses compared the relationship of SES quintiles with diabetes technology use and HbA1c from 2010–2012 to 2016–2018. RESULTS: HbA1c was higher in participants with lower SES (in 2010–2012 and 2016–2018, respectively: 8.0% and 7.8% in Q1 and 7.6% and 7.5% in Q5 for DPV; 9.0% and 9.3% in Q1 and 7.8% and 8.0% in Q5 for T1DX). For DPV, the association between SES and HbA1c did not change between the two time periods, whereas for T1DX, disparities in HbA1c by SES increased significantly (P < 0.001). After adjusting for technology use, results for DPV did not change, whereas the increase in T1DX was no longer significant. CONCLUSIONS: Although causal conclusions cannot be drawn, diabetes technology use is lowest and HbA1c is highest in those of the lowest SES quintile in the T1DX, and this difference for HbA1c broadened in the past decade. Associations of SES with technology use and HbA1c were weaker in the DPV registry.
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Inequitable use of diabetes technologies contributes at least in part to worse diabetes outcomes for socially disadvantaged groups with T1D.
“Inequitable use of diabetes technologies contributes at least in part to worse diabetes outcomes for socially disadvantaged groups with T1D (e.g., racial or ethnic minority or lower socioeconomic status [SES]).”
From Social disadvantage and technology use among adults with type 1 diabetes in Quebec: A cross‐sectional study using data from the Canadian <scp>T1D</scp> ( <scp>BETTER</scp> ) Registry (2025) · cites this paper as [23]
The Conclusions report that technology use was lowest and HbA1c highest among youth in the lowest SES quintile in the U.S. But they explicitly say causal conclusions cannot be drawn, so the paper does not establish that inequitable technology use contributes to worse outcomes. The Introduction also reports lower technology use and higher HbA1c among pediatric patients of minority status, without establishing that causal link. (LLM, conf=0.89)
Experimental — accuracy not yet measuredDisparities in diabetes technology use persist despite the availability of insurance or public funding.
“Although financial costs are a major barrier to accessing diabetes technologies, disparities persist despite the availability of insurance or public funding.”
Previous studies have demonstrated associations between income, insurance status and Race on use of diabetes technologies.
“Although previous studies have demonstrated associations between income, insurance status and Race on use of diabetes technologies, 21 , 23 , 24 we are not aware of any previous studies applying an intersectional approach.”
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References 39 · Cited by 283
Research works printed but not linked: 30
- [1]DeSalvo DJ, Miller KM, Hermann JM,.; T1D Exchange and DPV Registries. Continuous glucose monitoring and glycemic control among youth with type 1 diabetes: international comparison from the T1D Exchange and DPV Initiative. Pediatr Diabetes 2018; 19: 1271– 1275 29923262 PMC6175652
- [2]Foster NC, Beck RW, Miller KM,. State of type 1 diabetes management and outcomes from the T1D Exchange in 2016-2018. Diabetes Technol Ther 2019; 21: 66– 72 30657336 PMC7061293
- [3]Miller KM, Hermann J, Foster N,.; T1D Exchange and DPV Registries. Longitudinal changes in continuous glucose monitoring use among individuals with type 1 diabetes: international comparison in the German and Austrian DPV and U.S. T1D Exchange registries. Diabetes Care 2020; 43: e1– e2 31672703 PMC7881298
- [4]American Diabetes Association. 13. Children and adolescents: Standards of Medical Care in Diabetes—2019. Diabetes Care 2019; 42(Suppl. 1): S148– S164 30559239
- [6]Sherr JL, Tauschmann M, Battelino T,. ISPAD clinical practice consensus guidelines 2018: diabetes technologies. Pediatr Diabetes 2018; 19(Suppl. 27): 302– 325 30039513
- [9]Prahalad P, Addala A, Scheinker D, Hood KK, Maahs DM. CGM initiation soon after type 1 diabetes diagnosis results in sustained CGM use and wear time. Diabetes Care 2020; 43: e3– e4 31558548 PMC7011198
- [10]Prahalad P, Addala A, Buckingham BA, Wilson DM, Maahs DM. Sustained continuous glucose monitor use in low-income youth with type 1 diabetes following insurance coverage supports expansion of continuous glucose monitor coverage for all. Diabetes Technol Ther 2018; 20: 632– 634 30020810 PMC6421989
- [11]Miller KM, Beck RW, Foster NC, Maahs DM. HbA1c levels in type 1 diabetes from early childhood to older adults: a deeper dive into the influence of technology and socioeconomic status on HbA1c in the T1D Exchange clinic registry findings. Diabetes Technol Ther 2020; 22: 645– 650 31905008 PMC7640747
- [12]Walker J, Colhoun H, Livingstone S,.; Scottish Diabetes Research Network Epidemiology Group. Type 2 diabetes, socioeconomic status and life expectancy in Scotland (2012-2014): a population-based observational study. Diabetologia 2018; 61: 108– 116 29075822 PMC6448945
- [13]Knighton AJ, Savitz L, Belnap T, Stephenson B, VanDerslice J. Introduction of an area deprivation index measuring patient socioeconomic status in an integrated health system: implications for population health. EGEMS (Wash DC) 2016; 4: 1238 27683670 PMC5019337
- [14]Govan L, Maietti E, Torsney B,.; Scottish Diabetes Research Network Epidemiology Group. The effect of deprivation and HbA1c on admission to hospital for diabetic ketoacidosis in type 1 diabetes. Diabetologia 2012; 55: 2356– 2360 22733482 PMC4209851
- [15]Mair C, Wulaningsih W, Jeyam A,.; Scottish Diabetes Research Network (SDRN) Epidemiology Group. Glycaemic control trends in people with type 1 diabetes in Scotland 2004-2016. Diabetologia 2019; 62: 1375– 1384 31104095 PMC6647722
- [16]Auzanneau M, Lanzinger S, Bohn B,.; DPV Initiative. Area deprivation and regional disparities in treatment and outcome quality of 29,284 pediatric patients with type 1 diabetes in Germany: a cross-sectional multicenter DPV analysis. Diabetes Care 2018; 41: 2517– 2525 30327359
- [19]Weisman A, Bai JW, Cardinez M, Kramer CK, Perkins BA. Effect of artificial pancreas systems on glycaemic control in patients with type 1 diabetes: a systematic review and meta-analysis of outpatient randomised controlled trials. Lancet Diabetes Endocrinol 2017; 5: 501– 512 28533136
- [21]Bohn B, Karges B, Vogel C,.; DPV Initiative. 20 years of pediatric benchmarking in Germany and Austria: age-dependent analysis of longitudinal follow-up in 63,967 children and adolescents with type 1 diabetes. PLoS One 2016; 11: e0160971 27532627 PMC4988648
- [22]de Onis M, Onyango AW, Borghi E, Siyam A, Nishida C, Siekmann J. Development of a WHO growth reference for school-aged children and adolescents. Bull World Health Organ 2007; 85: 660– 667 18026621 PMC2636412
- [23]Rosenbauer J, Dost A, Karges B,.; DPV Initiative and the German BMBF Competence Network Diabetes Mellitus. Improved metabolic control in children and adolescents with type 1 diabetes: a trend analysis using prospective multicenter data from Germany and Austria. Diabetes Care 2012; 35: 80– 86 22074726 PMC3241332
- [24]Maahs DM, Hermann JM, DuBose SN,.; DPV Initiative; T1D Exchange Clinic Network. Contrasting the clinical care and outcomes of 2,622 children with type 1 diabetes less than 6 years of age in the United States T1D Exchange and German/Austrian DPV registries. Diabetologia 2014; 57: 1578– 1585 24893863
- [25]Noble M, Wright G, Smith G, Dibben C. Measuring multiple deprivation at the small-area level. Environ Plan A 2006; 38: 169– 185
- [26]Schederecker F, Kurz C, Fairburn J, Maier W. Do alternative weighting approaches for an Index of Multiple Deprivation change the association with mortality? A sensitivity analysis from Germany. BMJ Open 2019; 9: e028553 PMC6719755 31455703
- [27]Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Smedley BD, Stith AY, Nelson AR, Eds. Washington, DC, National Academies Press, 2003 25032386
- [29]Cheng TL, Goodman E; Committee on Pediatric Research. Race, ethnicity, and socioeconomic status in research on child health. Pediatrics 2015; 135: e225– e237 25548336 PMC9923597
- [30]Zimmerman FJ, Anderson NW. Trends in health equity in the United States by race/ethnicity, sex, and income, 1993-2017 [published correction appears in JAMA Netw Open 2019;2:e199357]. JAMA Netw Open 2019; 2: e196386 31251377 PMC6604079
- [32]Messer LH. Why expectations will determine the future of artificial pancreas. Diabetes Technol Ther 2018; 20: S265– S268 29916739
- [33]Nielsen NF, Gaulke A, Eriksen TM, Svensson J, Skipper N. Socioeconomic inequality in metabolic control among children with type 1 diabetes: a nationwide longitudinal study of 4,079 Danish children. Diabetes Care 2019; 42: 1398– 1405 31123155
- [34]Valenzuela JM, La Greca AM, Hsin O, Taylor C, Delamater AM. Prescribed regimen intensity in diverse youth with type 1 diabetes: role of family and provider perceptions. Pediatr Diabetes 2011; 12: 696– 703 21457425
- [35]Hernandez I, Good CB, Shrank WH, Gellad WF. Trends in Medicaid prices, market share, and spending on long-acting insulins, 2006-2018. JAMA 2019; 321: 1627– 1629 30907933 PMC6487544
- [37]Papanicolas I, Woskie LR, Jha AK. Health care spending in the United States and other high-income countries. JAMA 2018; 319: 1024– 1039 29536101
- [38]Mackenbach JP, Valverde JR, Artnik B,. Trends in health inequalities in 27 European countries. Proc Natl Acad Sci U S A 2018; 115: 6440– 6445 29866829 PMC6016814
- [39]Maier W. Indices of multiple deprivation for the analysis of regional health disparities in Germany: experiences from epidemiology and healthcare research [published correction appears in Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2017;60:1455–1456]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2017; 60: 1403– 1412 [in German] 29119206
- Authors
- Addala, A., Auzanneau, M., Miller, K., Maier, W., Foster, N., Kapellen, T., Walker, A., Rosenbauer, J., Maahs, D. M., & Holl, R. W.
- Affiliations
- Stanford Medicine (US)
- Universität Ulm (DE)
- Jaeb Center for Health Research (US)
- Helmholtz Munich (DE)
- Leipzig University (DE)
- University of Florida Health (US)
- Deutsches Diabetes-Zentrum e.V. (DE)
- Corresponding author
- Addala, Ananta
- ORCID
- Venue
- Diabetes Care
- Publisher
- American Diabetes Association
- Published
- 2020-09-16
- Volume
- 44
- Issue
- 1
- Pages
- 133-140
- ISSN
- 0149-5992 (ISSN-L)
- 1935-5548
- PMC
- PMC8162452
- OpenAlex
- W3087184545
- Cited by
- 283
- References
- 39
- Citations by year
- 2026: 29 · 2025: 42 · 2024: 51 · 2023: 60 · 2022: 52 · 2021: 43 · 2020: 6
- FWCI
- 30.36
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Diabetes Care (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Site cant be reached (submittedVersion, other-oa)
- PuSH - Publication Server of Helmholtz Zentrum München (submittedVersion)
- Funders
- Leona M. and Harry B. Helmsley Charitable Trust
- German Center for Diabetes Research (82DZD14A02)
- German Diabetes Association
- European Foundation for the Study of Diabetes
- Topics
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Education
- Life Sciences › Biochemistry, Genetics and Molecular Biology › Genetics › Diabetes and associated disorders
- Keywords
- type 1 diabetes in children, diabetes technology use, socioeconomic disparities, HbA1c, glycemic control, diabetes technology access, transatlantic comparison, diabetes registry, health disparities
- MeSH terms
- Adolescent, Child, Diabetes Mellitus, Type 1, Germany, Glycated Hemoglobin, Humans, Prospective Studies, Registries, Technology
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