Research shows rural children with type 1 diabetes less likely to use continuous glucose-monitoring devices

Type 1 diabetes is significantly more prevalent in rural areas than urban ones. Unfortunately, living in a rural area is known to be a barrier to accessing care, including new technologies, for adults with the disease. Despite the fact that 20% of Americans live in rural areas, little is known about how rural geography affects children, who are most commonly diagnosed with type 1 diabetes.

Daniel Tilden, M.D., MPH, assistant professor of endocrinology, diabetes and clinical pharmacology at the University of Kansas Medical Center, wanted to find out more. He conducted a study looking at the use of continuous glucose monitors (CGMs), wearable sensor-based devices that enable people to monitor their glucose (blood sugar) without having to prick their fingers, by rural children and adolescents living with type 1 diabetes. CGMs, which send glucose readings to the wearer’s smartphone or other device and can also send them directly to a health care provider, are becoming the standard of care for diabetes management.

“CGMs are super important for us to have the information we need to adequately treat people and adjust doses of insulin for people with type 1 diabetes,” said Tilden. “We know that outcomes are better.”

Type 1 diabetes, an incurable autoimmune condition, causes the body to destroy the insulin-producing cells in the pancreas. Without insulin, glucose cannot enter the cells to produce energy. When diabetes is not well controlled, glucose builds up in the blood and can cause complications that damage major organs in the body, causing disabilities and even threatening life.

In the study, which was published in Diabetes Care this spring, Tilden and his colleagues looked at electronic health records for more than 2,000 people younger than 18 years of age with type 1 diabetes from 2018 through 2021. Each patient was assigned a rural or urban category according to a Rural-Urban Commuting Area code based on their home address. These codes factor in the distance to resources such as clinics and hospitals. Patients were also assigned a neighborhood deprivation index (NPI) value, a composite score of 10 measures of socioeconomic status that cover factors such as median income, education levels and housing conditions.

Previous studies examining the use of CGMs by children relied on prescription records to identify use of these devices, but just because someone is prescribed a CGM does not mean that they use one; barriers such as cost can stand in the way. Tilden’s study instead identified use of these devices according to billing codes for the interpretation of CGM readings by the provider.

The results unearthed a sizeable disparity. Those living in rural areas were significantly less likely to use a CGM than those in urban areas, even after adjusting for sex, race or ethnicity and insurance type. Specifically, compared with youth living in urban areas, the use of CGMs was 31% lower for children and adolescents living in small rural towns, and 49% lower for those living in isolated rural towns. The gap between rural and urban patients persisted across the four years of the study, even as the use of CGMs increased for all patient types during this time. These results are also relevant to people with type 2 diabetes who require insulin, Tilden said.

The results also revealed that non-White patients, those who had public insurance and patients who lived in areas with a higher NPI all were less likely to use CGMs.

More research is needed to explore the reasons for these disparities, but Tilden said they likely are a function of such issues as cost, reduced internet access, which CGMs require to relay their data, and distance from clinics and Medicaid-contracted pharmacies. “A visit to the nurse in a clinic can be really helpful to troubleshoot and help with getting the sensor started,” said Tilden. “When you’re coming from 15 minutes away, it’s not that big of a deal to make an extra visit to the clinic. But when you're coming from an hour and a half or two hours away, that is a big deal.”

The next step is figuring out how to eliminate those disparities. “If we are going to say that CGMs are the standard of care, then how do we make sure of all the details are taken care of to get people set up with these devices, and how do we develop systems of care that serve everyone equally across the state, regardless of where they live?” Tilden said.

Tilden is currently seeking funding to design an intervention that uses telemedicine and partners with a network of 35 clinics across Kansas to deliver specialty care to diabetes patients in rural areas. Currently, he said, he knows of no practicing endocrinologists west of Hutchinson, which is close to the center of the state, making the delivery of such specialty care important.

“KU in particular is positioned to have a unique perspective,” said Tilden. “This is a large urban academic medical center, but we are in a state with a large portion of the population from rural areas, and there's a lot of expertise here to really dive into developing interventions for rural folks.”