| Description |
- Background: Neighborhood socioeconomic deprivation is a known contributor to health inequities, though its impact on the care of people with diabetes is not well characterized. Understanding the contribution of systemic forces that drive disparate outcomes is important to promote equity and improve quality incentive design. We sought to assess the association of neighborhood deprivation with indicators of comprehensive diabetes care in a large, nationally representative sample.
Methods: We conducted a retrospective cohort study of a national sample of Medicare Advantage enrollees with diabetes from 2015-2020. The primary exposure was neighborhood socioeconomic deprivation, measured by the Area Deprivation Index. The primary outcome was performance on the 6 indicators of Comprehensive Diabetes Care (CDC) from the Healthcare Effectiveness and Data Information Set, including hemoglobin A1c (HbA1c) testing, control (<8%), and poor control (>9%); blood pressure control (<140/90 mmHg); yearly eye exam receipt; and medical attention for nephropathy. We first adjusted for individual characteristics (age, sex, race/ethnicity, individual poverty, reason for Medicare eligibility), followed by regional characteristics (rurality, primary care providers per capita). We additionally stratified estimates by race/ethnicity to assess differing effects across groups. All estimates were modeled to reflect the undesirable outcome (i.e. a higher risk ratio (RR) reflects worse performance on the quality indicator).
Results: A total 827,227 enrollments were included across the 5-year study period. Adjusted for patient characteristics, high neighborhood deprivation was associated with uncontrolled HbA1c (RR 1.07, 95% CI 1.05-1.09) and not receiving a recommended eye exam (RR 1.05, 95% CI 1.02-1.07). Further adjustment for regional characteristics afforded minimal changes to the estimates; high deprivation was again associated with uncontrolled HbA1c (RR 1.06, 95% CI 1.04-1.08), though no longer with eye exam receipt. Stratification by race/ethnicity demonstrated distinct trends in the association between neighborhood deprivation and CDC outcomes. Among White and Asian patients, high deprivation was associated with worse HbA1c control (RR 1.09, 95% CI 1.06-1.12 and RR 1.20, 95% CI 1.09-1.32, respectively). Among Black and Hispanic patients, we observed no significant relationship between neighborhood deprivation and HbA1c control, though these groups experienced significantly worse performance across all levels of deprivation.
Conclusions: We present the first study to examine the relationship between neighborhood deprivation and multiple indicators of comprehensive diabetes care at the national level. An increased risk of poor glycemic control was observed for patients from areas of high neighborhood deprivation, which was independent from patient factors (including individual socioeconomic status). This relationship was most significant for White and Asian patients; Black and Hispanic patients experienced worse control overall, with less respect to neighborhood status. Furthermore, disparities in eye exams were accounted for by controlling for access to healthcare resources. These disparities were observed despite universal insurance coverage among our sample, underscoring the need for improved access to comprehensive diabetes care and environments which support effective disease management. Neighborhood factors, and their intersection with racial and ethnic disparities, are important considerations for policies and programs to address inequities in diabetes care.
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