Fighting disparities in diabetes care
Many factors, including ethnicity, location and socioeconomic status, contribute to disparities in diabetes care and it is important that these are addressed to improve clinical outcomes and quality of life for all. Some innovative approaches to tackling these disparities were discussed at the recent Advanced Technologies & Treatments for Diabetes (ATTD) conference. Dr Susan Aldridge reports.
Professor Partha Kar, National Specialty Advisor in Diabetes with NHS England, looked at how disparities in diabetes care are being tackled in the UK, where there has been a lot of progress in rolling out technology – 80% of people with type 1 diabetes now have flash monitoring or continuous glucose monitoring (CGM), and CGM is also offered in 98% of type 1 diabetes pregnancies.
Meanwhile, the most recent National Paediatric Diabetic Audit (NPDA) for type 1 diabetes showed the best HbA1c data since records began. “This looks amazing, but the big thing about overarching data in a system is that it doesn’t show the underlying problem,” said Professor Kar. “Looking at real-time CGM in 2019, for instance, we see that a Black child had half the chance of having it compared with a White child. There is nothing different between the two – same hospital, same system – but the colour of their skin.”
The NPDA shows that Black children and those from deprived backgrounds have higher HbA1c levels. This is not because Black people are poor. “The richest Black child has worse data than the poorest White child, so it’s not just deprivation,” continued Professor Kar. This may be controversial, but he thinks that healthcare staff may sometimes be biased in the way they treat people with diabetes. “We are all part of society, even when we put on a uniform,” he said. “Sexism, racism, and homophobia do exist among staff and that’s the reality we face.”
Professor Kar and colleagues have collected data from as many hospitals as possible to look at CGM usage by ethnicity and deprivation, as in the example cited above. Looking at flash data across the UK, with the help of Abbott Diabetes Care, does show that disparities have decreased in many places over the last few years. And there are many other ‘levelling up’ projects that are trying different things – for instance, in Leicester, Blackpool and Worcestershire, there are tailored satellite clinics to improve access, while in the North East region there is ‘poverty proofing’ training for healthcare professionals.
Meanwhile, diabetes is a key clinical area in the NHS CORE20PLUS5 Programme, which is designed to help support integrated care to drive targeted action in healthcare inequalities improvement among children and young people. “So you start by looking at the data and admitting there is a problem and then use your data to drive change,” Professor Kar concluded. “I firmly believe that if we challenge our own biases, change can be done.”
Tackling disparity in India
“Where you live should not determine whether you live or whether you die, but this is the harsh reality of the world we live in,” said Jazz Sethi, who lives with type 1 diabetes and is the founder and director of the Diabesties Foundation. “Disparity and deprivation exist everywhere – it’s just their intensity that differs. India is a country of extremes. We have a proportion of the population that can afford the best technology and the best treatment, but there is also an India where access to insulin is a privilege and technology is a luxury.”
She introduced the concept of Jugaad, which is about making the most of what you already have and not waiting for policy or politics to improve patient care. “What we do at the Diabesties Foundation in India [with Diabetes India] is to change the way people look at type 1 diabetes and also change the way people live with it.” To this end, they have set up various activities, such as one-to-one counselling, peer support meet-ups, awareness drives, access projects and mental health support. For instance, Back to Basics sessions allow discussion of all aspects of type 1 diabetes with educators who live with the condition themselves.
“India is overburdened with diabetes,” she continued. “We have a population of 1.5 billion but few diabetologists and they can spare only 10 minutes per patient. We know that’s not enough, so we step in and become the ally, become the bridge between the healthcare professional and the person with diabetes. By offering them that platform, we can sit with them for one and a half hours and really get into the details – that’s the important thing.”
Over 1,000 of these tailored sessions have now been set up. Then there is peer support. Anyone living with a chronic condition knows how important this is, which is why the Diabesties Foundation exists. Finally, there is the access project, which is about distributing insulin, but also leading the person on a journey with that free insulin including injection technology, dosing and carb counting.
Disparity exists everywhere and is often used as an excuse for not improving things. “You make change happen with whatever you’ve got,” said Jazz. “What we’ve realised is that we don’t need too much. We don’t need much money or policy. If you have a little care and concern, you can actually make someone’s life better. As Martin Luther King said, ‘Of all the forms of inequality, injustice in health is the most shocking and inhumane.’ So our effort, anywhere in the world, is to strive for a just and equitable health system that takes care of all with type 1 diabetes, making sure they thrive, not just survive.”
Technology against disparities in India
Dr V Mohan of Dr Mohan’s Diabetes Specialities Centre, Gopalapuram, India described how technology is being used to solve disparities in diabetes care in India. First, telediabetology can be developed as a model for healthcare in underserved rural areas. Most of India’s population live in rural areas, while most diabetologists practice in urban areas. In rural areas, there are 34.9 million people with diabetes who suffer problems of access, lack of specialised diabetes care, poverty and low literacy. Dr Mohan and colleagues based a new model of diabetes care, based in the village of Chunampet, on the 6A test (available, accessible, affordable, appropriate, acceptable, accountable). They set up a telediabetology van on land donated by the owner of the village, which is fitted with basic infrastructure for screening for complications, such as a retinal camera, ECG and biothesiometry, as well as all the equipment needed for telemedicine. People in the village were then employed to carry out simple checks and a follow-up clinic was built.
The project has reached 42 villages with the telediabetology van, raising awareness of diabetes in 200,000 people, screening 23,380 and finding 330 new cases. Together with 808 self-reported cases, there were 1,138 people screened for complications like retinopathy, neuropathy, nephropathy, peripheral arterial disease and coronary artery disease. The mean HbA1c of this group at baseline was 9.3% and it had fallen to 8.5% at follow-up, using the lowest cost generic drug (India is very good at producing generics).
Another example is the use of teleophthalmology in retinal screening. “We started making low-cost cameras in India for one-tenth of the price of a regular camera and we can now use these on a smart phone, so they can be sent anywhere, and we then introduced artificial intelligence (AI) into the system,” said Dr Mohan. Comparing results from a rural centre with no ophthalmologist with a face-to-face consultation in a clinic for a diabetic retinal screen, Dr Mohan said, “There is not much difference – you can almost match what you’re doing in a face-to-face appointment. We have shown that, at least for sight-threatening retinopathy, this is a good model. All you need is a good camera and a technician.”
Next, given that there is a need to be in constant touch with people with diabetes, Dr Mohan and colleagues produced a series of apps. The 3 Ds consists of DIA, an AI-based health assistant bot for the general public and people with diabetes to give out information – it deals with frequently asked questions, clinic location, booking appointments and allows chat with a live agent. Then there’s DIALA, a Diabetes Lifestyle Assistant App, which offers a diabetes shop, medical records, daily health tracker, lab results, prescription refills, notifications, articles, recipes and nutritional value of foods. And lastly DIANA, the Diabetes Novel Subgroup Assessment, which is a web-based advanced machine learning precision diabetes tool for doctors and scientists. This helps to classify newly diagnosed type 2 diabetes into subgroups to monitor response to treatment and risk of complications. There is also gamification for diabetes awareness and education. For instance, there is Sweet Hack, which is similar to the game Candy Crush, which has been tested in a rural setting and has achieved improvements in consumption of fruit and vegetables and medium to vigorous physical activity.
So the use of technology can help decrease disparities in diabetes care in developing countries like India. “If we come together and work together, we can use technology to bridge the gap,” Dr Mohan concluded. “Similar models could be used elsewhere, with modification.”
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Any opinions expressed in this article are the responsibility of the EASD e-Learning Programme Director, Dr Eleanor D Kennedy.