Addressing Disparities in Pediatric Diabetes Treatment In Philadelphia
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From higher rates of diabetic ketoacidosis to lower utilization of life-saving diabetes technology like continuous glucose monitors (CGMs), children of color disproportionately face disparities in pediatric diabetes treatment.
“The data on the risk of mortality in Black children with diabetes range from three times to nine times that of white children,” Terri H. Lipman, PhD, CRNP, FAAN, pediatric nurse practitioner in the Division of Diabetes and Endocrinology at the Children’s Hospital of Philadelphia (CHOP), said at the ‘Systemic Racism and Disparities in Pediatric Diabetes Management’ symposium at the American Diabetes Association’s 81st Scientific Sessions.
Non-Hispanic Black children have higher HbA1c levels, more emergency department visits, hospitalizations and are less likely to be treated with insulin pumps or continuous glucose monitors (CGMs). Although pump therapy has resulted in a reduction in severe hypoglycemia and a sustained reduction in hemoglobin A1c, white children were significantly more likely than Black children to use insulin pumps.
Poverty also exacerbates health disparities. Philadelphia, where Lipman conducts her research, has the highest poverty rate of the largest ten U.S. cities. In 2019, Philadelphia’s Black and Latinx residents were among the poorest. Lipman says that poverty can impact a family’s ability to afford insulin, blood glucose checks and standard insulin pumps.
To address racial disparities at the Children’s Hospital in Philadelphia, Lipman has focused her research efforts on the social determinants that impact diabetes care access for children of color.
“A few years ago, we did focus groups with white and Black families. One of the questions that we asked is where do you obtain your most trusted diabetes information,” Lipman says.
When white families were asked, their responses included nurse practitioners or a physician in the diabetes center. For Black families, strangers were reported as giving more trusted diabetes information, Lipman shares.
“Historically, there has been injustice in health care. Medical mistrust—lack of trust or a suspicion in health care that is rooted in a patients’ negative past experiences—comes from a history of untrustworthy care to populations of color. So it’s not surprising that populations of color would be more trusting of information that comes from community members who share a life experience or similar living experience,” Lipman says.
Lipman stresses that part of ameliorating trust with communities of color can be achieved through a community health worker (CHW) initiative and weaving that framework into the fabric of diabetes care for children with diabetes.
Lipman conducted a study to examine the integration of CHW into the care of children with poorly managed diabetes. The preliminary data showed that families working with CHWs had significantly improved HbA1c at six months. “What is most interesting is that our CHWs do not provide diabetes education or diabetes care,” Lipman says. The CHWs focused solely on social determinants of health.
CHWs receive specialized training that focuses on social determinants, such as, improving medication access, reducing food and housing insecurity and advancing health literacy, improving the outcomes of children with type 1 diabetes or who are at risk for having type 1.
CHWs have a strong understanding of the community they serve, and can bridge the gap between medical and community services to support families in managing their child’s type 1 diabetes. Research has shown that CHWs reduced hospitalizations and total hospital days.
Addressing systemic racism and disparities in pediatric diabetes management requires more than a CHW framework. According to Lipman, a paradigm shift requires examining internal biases and efforts. “Are we prepared to examine our own biases? What can we do to change social inequities? And what resources must we provide to support diabetes technology provision and sustainability for under resourced children,” Lipman questions.
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