The COVID-19 pandemic and the Black Lives Matter movement have put a spotlight on extreme inequities across the U.S. health care system and the patient outcomes it produces. Many chronic conditions play into this, but diabetes is one of the most prominent. African Americans are 60% more likely to be diagnosed with diabetes than their white counterparts – and they are much, much more likely to have severe complications such as end-stage renal disease (3.5x) or lower limb amputation (2.3x).
Latinos are also at a much higher risk of developing type 2 diabetes, with a 50% lifetime risk and higher rates of complications such as kidney failure and vision loss. Further, with the unfolding pandemic African Americans and Latinos are facing a new virulent health risk that is compounded by those they already had, and both are rooted in inequality and poverty.
African Americans and Latinos are three times more likely to become infected with the novel coronavirus, due to higher rates of exposure in public-facing jobs that cannot be missed, crowding in living situations and reliance on public transportation. Once infected, they are also nearly twice as likely to die from a COVID-19 infection as whites. Diabetes is one of a handful of chronic conditions that are often poorly managed in Black and Latino patients that can contribute to more severe COVID-19 complications and a higher risk of death.
After the recent conclusion of the American Diabetes Association (ADA) Scientific Sessions, virtual diabetes management company Onduo LLC – a company now owned exclusively by Verily Life Sciences, which is the med-tech business of Mountain View, Calif.-based Google parent Alphabet Inc. – held an event with the ADA and diabetes researchers to discuss how technology can help to bridge that gap to empower more diabetes patients.
“When you talk about managing your diabetes and behavior change, I want people living with diabetes to understand and know that they're not alone and they can manage this. What I did was not out of the ordinary, as a person living with type 2 diabetes,” said ADA CEO Tracey Brown. “I think that there's a combination of things that have to occur. We're going to continue to use the voices of the millions of people to advocate for what is needed for people living with diabetes, access and just overall health equity.”
“Breaking down a lot of the barriers that lead to this inequity from access, from the income, from where you live from a food perspective – all of these things have to be broken down,” she continued. “Personally, given the pervasiveness of type 2 diabetes, if we can solve it for people living with diabetes, I think we will solve it for a large swath of other chronic diseases that face Americans.”
Brown joined the ADA in June 2018 as its first African American CEO, as well as the first to personally have type 2 diabetes.
The COVID-19 pandemic has forced a rapid transition to telehealth, which could enhance health care provider access for diabetes. In May, the Centers for Medicare and Medicaid Services (CMS) modified its payment and coverage rules to enable remote patient training for diabetes self-management.
Medicare also has reduced the burden for patients to get access to continuous glucose monitoring (CGMs). Patients can get CGMs and related testing supplies directly without meeting with a physician in person. In addition, CMS will no longer enforce the coverage policy that requires patients to perform fingersticks four times or more daily alongside CGM use. Medicare covers CGMs for type 1 diabetes patients, as well as type 2 patients who use insulin intensively.
“The American Diabetes Association, particularly during COVID, has worked very hard to get permission for an exclusion or emergency waiver to bypass the need to have the patient have four checks of their blood glucose. This is a big deal,” said Brown. “When you can bypass that, your ability to prescribe and have more people using CGM becomes very real.”
Sidelining fingersticks, educating doctors
Another panelist, Richard Bergenstal who is the executive director of the International Diabetes Center at Park Nicollet, noted that data presented at ADA by Irl Hirsch showed that regardless of the number of fingerstick tests conducted in conjunction with CGM use, patients still received a benefit from using it. “I'm hoping this data is going to empower the advocates to say keep this exception in place and no need to limit people's access to CGM by some artificial barrier,” he said.
Bergenstal cited another study of 2,500 patients who started on CGM and saw hospital admissions decline by 33%, as well as major reductions in acute diabetes events. That makes CGM use imperative in diabetes both from a patient outcome as well as from the perspective of cost-savings, he suggested.
David Price, vice president of medical affairs at San Diego-based CGM maker Dexcom Inc. followed up by arguing for the ADA guidelines to be updated to recommend CGM use in conjunction with insulin across the board for type 2 patients, rather than for just insulin-intensive patients.
ADA’s Brown noted her own moving personal story of being able to use a CGM to transition from insulin use to four oral medications – and most recently to only one oral drug that she expects to also be able to dispense with eventually.
Another top priority is educating primary care doctors, who are the ones routinely managing type 2 diabetes patients rather than endocrinologists. But they are largely unfamiliar with CGMs and how to employ the data they generate to adjust lifestyle and treatment. ADA has certified diabetes educators who are intended to work with these physicians to improve their technology use and access.
“Most type 2 diabetes patients are still seen in primary care,” noted Bergenstal. “We're in a large, multi-specialty clinic with several thousand primary care doctors and when they were introduced to CGM, they loved the idea. They had no idea that an A1c of 8.2 can just be a crazy pattern that's actually addressable when you actually know what the picture looks like as opposed to a number. They like it but they're not quite organized in a way to handle it.”
“A big focus has to be: how do you get that data seamlessly into primary care’s hands. In many cases, it will be through an intermediate, it would be through a diabetes educator to prepare the data and look at it and put it in front of the primary care doctor,” Bergenstal continued. “Other primary care doctors are ready; if it showed up instantly in their electronic medical record when they opened the file, they'd be happy to act on it. So, we’ve got a little bit of work to do to move from amazing data that can work in clinical trials to a workflow in primary care where it's an efficient and effective use”