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Federally qualified health centers (FQHCs) represent the largest system of safety-net primary care clinics serving medically underserved populations in the United States, providing care for over 30 million patients nationwide. While continuous glucose monitoring (CGM) technology has transformed diabetes management and demonstrated significant benefits for both type 1 and type 2 diabetes patients, its adoption in safety-net settings remains poorly understood.¹

A study published in JAMA Network Open reveals concerning disparities in access to CGM technology among patients with diabetes receiving care at these centers. The research, which represents one of the largest analyses of CGM prescribing patterns in FQHCs to date, comes at a critical time when diabetes technology is rapidly advancing but questions about equitable access persist.¹

The research team, led by Amisha Wallia, MD, MSCI, of Northwestern University, analyzed electronic health record data from over 36,000 patients with diabetes receiving care at 275 FQHC clinic sites nationwide between 2014-2021. Their findings paint a stark picture of the challenges facing vulnerable populations in accessing modern diabetes care technologies.¹

"Despite CGM's potential to improve diabetes care and outcomes, this technology remains underutilized,鈥� particularly in primary care settings where the majority of type 2 diabetes treatment is provided, the researchers noted. This gap in technology access is particularly concerning given that approximately two-thirds of FQHC patients are members of racial or ethnic minority groups with incomes below the federal poverty level, populations already at higher risk for diabetes-related complications.¹

Striking disparities in access

The analysis included 1,168 patients with type 1 diabetes and 35,216 patients with type 2 diabetes. The study population exhibited poor glycemic control overall, with approximately half of type 1 diabetes patients and almost one-third of type 2 diabetes patients having HbA1c values above 9.0%.¹

Only 11% of patients with type 1 diabetes and a mere 1% of those with type 2 diabetes received CGM prescriptions during the study period. These rates were significantly lower than those reported in other healthcare settings. Racial and ethnic disparities were prominent. Hispanic patients with type 1 diabetes had 70% lower odds of receiving a CGM prescription compared to non-Hispanic White patients, while Black patients had 39% lower odds. Similar disparities were observed among type 2 diabetes patients, with Hispanic patients having 57% lower odds and Black patients having 24% lower odds of receiving CGM prescriptions.¹

Insurance coverage emerged as a major determinant of CGM access. Uninsured patients had 58% lower odds of receiving CGM prescriptions compared to those with private insurance. This finding is particularly concerning given that approximately 41% of type 2 diabetes patients and 31% of type 1 diabetes patients in the study were uninsured.¹

For type 2 diabetes patients, poor glycemic control (HbA1c >9.0%) was associated with three times higher odds of receiving CGM prescriptions compared to those with HbA1c 鈮�7.0%. Additionally, patients with more diabetes complications were more likely to receive CGM prescriptions. While CGM prescriptions increased over time, particularly after 2018, the overall rates remained very low throughout the study period. The researchers observed this trend despite mounting evidence showing CGM's benefits for both type 1 and type 2 diabetes management.¹

Limitations and strengths

While the study provides important insights into CGM prescribing patterns, several limitations should be noted. 

• The researchers could not verify long-term CGM use through pharmacy claims data
• The study lacked information about telehealth visits during the COVID-19 pandemic period when care delivery patterns changed significantly. 
• Additionally, the researchers were unable to analyze state-specific trends in CGM prescribing that may have impacted their findings.¹

However, the study's major strength lies in its analysis of data from a large, national network of FQHCs spanning 275 clinic sites across 19 states, providing a comprehensive view of CGM access in safety-net settings serving medically underserved populations. Furthermore, the extensive study period from 2014 to 2021 allowed researchers to observe important temporal trends in CGM prescribing patterns.¹

Where to from here? 

The findings highlight critical gaps in implementing CGM clinical practice guidelines in safety-net settings. "Our findings highlight the importance of expanding efforts to promote diabetes health equity in this setting," the researchers emphasized.¹

The researchers outline several potential solutions to address the disparities identified in CGM access. Policy changes in Medicaid coverage emerge as a critical priority, given that Medicaid is the primary payer in FQHCs. However, the researchers emphasize that Medicaid reforms alone will not be sufficient, as additional strategies will be needed to address the large proportion of uninsured patients. They point to promising initiatives, such as a Colorado Medicaid program that provided full subsidies for CGM devices, while noting that financial barriers continue to significantly impact CGM access. The team also calls for further research to better understand the barriers to CGM use among FQHC clinicians and their patients, suggesting that a multi-faceted approach combining policy changes, enhanced provider support, and targeted interventions may be necessary to improve access to diabetes technology in these safety-net settings.

Urgent attention is needed to address these disparities and improve access to diabetes technology in safety-net settings, particularly given the potential benefits of CGM for improving diabetes outcomes in these vulnerable populations.

Published: December 27, 2024