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Diabetes Digest


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Health inequality and diabetes: Practical consequences for the clinician

Daniel Flanagan
As clinicians, we assume that the causes of healthcare inequality happen before the individual reaches specialist care and that, at this point, the care delivered is the same for all. However, this interesting paper suggests that this may not be the full story.

The COVID-19 pandemic has sharply highlighted the health inequality within our society. We have seen a disease that targets particular groups because of social circumstances and then leads to a more severe disease course in those same groups. It feels unfair because it is unfair.

This information is not new. For many years we have studied the causes and consequences of health inequality but have had mixed results in addressing the problem. We assume that the differences happen before the individual reaches specialist care and that, at this point, the care delivered is the same for all. As diabetes specialists, we may feel that working to reduce health inequality involves lobbying for improved social care or access to primary health resources. However, this interesting paper by Walker and colleagues suggests that this may not be the full story.

The authors examined disparities in a specific area of diabetes care: the use of advanced technology in the management of type 1 diabetes. Although the paper describes two populations within the USA, a country with much sharper contrasts in healthcare delivery than the UK, the lessons can nonetheless be used to improve care within this country.

Two groups of people with type 1 diabetes were asked to join the study: one group in Florida and the other in California. People were invited if they had been admitted to hospital with diabetic ketoacidosis or if they had an HbA1c >75 mmol/mol (9.0%) and had not attended two or more of their specialist appointments within the previous year. Participants attended focus groups and were asked a series of targeted questions to explore the barriers to using technology to improve diabetes care. The obvious financial barriers, such as lack of health insurance, were identified. Some less obvious factors, however, were revealed, such as the perceived negative attitude of the diabetes team to use of technology. California participants described similar experiences to those from Florida, noting that “endocrinologists are more like the judges…and the visits I’m on trial”. Certainly in the UK, lack of attendance at previous appointments would be a strong factor against the use of pump therapy. These data would suggest a more complicated picture.

This paper once more shows that those at the highest need are the least likely to receive diabetes healthcare. This is true all of the way through the health system. It may be harder to provide care for some social groups, and so we may have to think of different ways to engage and deliver care. The first step is to recognise that this is the case and then think about innovative ways of delivering care. It would be interesting and helpful to see units presenting audit data of technology use across socioeconomic groups within their service.

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