Assessing Neighborhood Deprivation Reveals Rural-Urban Disparities in CGM Access Among Children With Type 1 Diabetes Free

Successful self-management of type 1 diabetes requires careful blood glucose monitoring. Improvements in continuous glucose monitors (CGMs) technology have led to their adoption in care guidelines as a recommendation for everyone with type 1 diabetes (T1D) and resulted in dramatic changes in insurance coverage for CGMs (1). Despite these changes, gaps in glucose monitoring remain a significant barrier to optimal diabetes care. Previous work has demonstrated barriers to CGM use among those of lower socioeconomic status, minoritized groups, and rural dwellers (2,3). Despite implications for improving care, the interaction between these factors has not been explored. We hypothesized that incorporating both rurality and local deprivation into a single measure could refine our understanding of how these interacting factors contribute to disparities in CGM access.

We analyzed clinical encounter–based data for children who completed at least one clinic visit with a pediatric endocrine provider between 1 January 2016 and 31 December 2023 with a provider-assigned ICD-10 code (E10) at an urban tertiary care hospital with clinics in western/southwestern Missouri and eastern/central Kansas. The home address at each encounter was used to assign a rural-urban commuting area (RUCA) code and neighborhood deprivation index (NDI) value (4). Rurality was defined according to the Health Resources and Services Administration definition, while deprivation was assigned relative to the sample median (5). CGM use was defined as at least one CGM reading within <30 days of the encounter.

A total of 4,161 patients completed 46,970 eligible encounters. CGM data were available for 43.4% of encounters and thus met the primary outcome for CGM use. Mean age of the study cohort was 13.4 years and HbA_1c 8.3% (70 mmol/mol). Those living in rural areas accounted for approximately one-quarter (25.3% [11,901]) of all encounters, with 9,252 of encounters completed by individuals in high-deprivation rural areas (19.7% of all encounters). Encounters with those from high-deprivation urban areas comprised 30.3% of the sample (14,219), and 44.3% (20,850) occurred with those from low-deprivation urban areas. Those in low-deprivation areas were more often White compared with those living in corresponding high-deprivation areas (82.0% vs. 63.6% urban, respectively, and 91.8% vs. 85.6% rural). Encounters among those from low-deprivation areas were primarily covered by private insurance (urban, 77.9%, and rural, 60.7%), while those from high-deprivation areas had more publicly insured visits (urban, 50.4%; rural, 51.1%).

To evaluate our hypothesis, we first examined the percentage of clinical encounters with CGM use compared between those from urban and those from rural areas (Fig. 1A). CGM uptake differed modestly in 2016 (urban, 6.8%; rural, 4.6%), but by 2018 this gap had opened to 6.6% (urban, 23.4%, and rural, 16.8%) before narrowing again by 2021 (66.6% vs. 65.8%, respectively). Stratifying by neighborhood deprivation (Fig. 1B) revealed larger and persistent differences in CGM use. Despite smaller disparities in 2016, by 2019 50% of those in the least deprived geographic areas had clinical encounters with CGM use, while those living in the most deprived quartile met this threshold 2 years later. By 2022/2023, CGM use availability remained largely stable within and across each group, with those in the highest deprivation areas completing 15.7% fewer visits with CGM data (quartile [Q]1, 79.3%, and Q4, 63.6%). Stratification by the composite geographic measure (Fig. 1C) showed children and adolescents from urban high-deprivation areas with the lowest rates of CGM use across each study year. Disparities in CGM use were also seen between individuals from urban low-deprivation areas and those from rural areas in every year, despite plateauing rates of uptake among youth from urban low-deprivation areas in the final 2 study years.

These data demonstrate marked disparities in CGM uptake between youth from low-deprivation urban areas and those from all other geographic areas including urban high-deprivation areas and rural low- and high-deprivation areas. Further, these findings highlight how relying on simple rural-urban comparisons can mask clinically actionable findings. Finally, plateauing CGM use across all youth highlights the need to examine and develop interventions to address barriers to CGM use broadly among all youth with T1D.

These data underscore the importance of the effect that our understanding of social barriers to care experienced by urban-dwelling patients has on perceptions of care for all youth with T1D. While barriers to transportation, high-speed internet, and work flexibility may be shared among those in high-deprivation rural and urban areas, other factors—including pharmacy access, work-specific challenges, and limited primary care access—likely require tailored interventions to address the needs of rural youth with T1D. Going forward investigators should work to further refine definitions and analytic methods for evaluation of these disparities while also evaluating the root causes of barriers to care to enable development of tailored interventions for both youth living in urban areas and youth living in rural areas.