Diabetes Complication Risk Larger in US Small Towns

TOPLINE:

People with diabetes who live in small towns in the United States experience higher rates of complications than those living in cities and remote areas.

METHODOLOGY:

• Retrospective cohort study using the OptumLabs Data Warehouse used a deidentified data set of US commercial and Medicare Advantage beneficiaries including 2,901,563 adults with diabetes between 2012 and 2021.
• Overall, 2.6% lived in remote areas (population < 2500), 14.1% in small towns (2500-50,000), and 83.3% in cities (> 50,000).
• Multivariable analysis adjusted for age, sex, health plan type, index year, diabetes type, baseline comorbidities, and medication use.

TAKEAWAY:

• Relative to people living in cities, people in remote areas had significantly greater risks for myocardial infarction (hazard ratio, 1.06) and revascularization (1.04) but lower risks for hypoglycemia (0.90) and stroke (0.91).
• Compared with cities, people living in small towns had significantly more hyperglycemia (1.06), hypoglycemia (1.15), end-stage kidney disease (1.04), myocardial infarction (1.10), heart failure (1.05), amputation (1.05), other lower-extremity complications (1.02), and revascularization (1.05), but a lower risk for stroke (0.95).
• Compared with small towns, people living in remote areas had lower risks for hyperglycemia (0.85), hypoglycemia (0.92), and heart failure (0.94).
• No geographic differences were found for retinopathy or atrial fibrillation/flutter.
• The results didn’t differ significantly when the 2.5% overall with type 1 diabetes were removed from the dataset.

IN PRACTICE:

“While more research is needed to better understand the underlying causes of disparate diabetes outcomes along the rural-urban continuum, this study establishes the foundational differences to guide improvement efforts and helps to identify complications with the greatest disparities to which policy interventions may be targeted.”

SOURCE:

The study was conducted by Kyle Steiger, MD, Internal Medicine Residency, Mayo Clinic, Rochester, Minnesota, and colleagues, and published in Diabetes Care.

LIMITATIONS:

Claims data were from a single national health insurance provider that administers multiple private and Medicare Advantage health plans with disproportionate representation of urban populations and without people who have Medicaid or traditional Medicare fee-for-service or who are without insurance (and would be expected to have higher complication rates). There were no data on race/ethnicity. Potential for residual confounding.

DISCLOSURES:

This study was funded by the National Institute of Diabetes and Digestive and Kidney Diseases. Steiger had no disclosures.

Miriam E. Tucker is a freelance journalist based in the Washington DC area. She is a regular contributor to Medscape, with other work appearing in the Washington Post, NPR’s Shots blog, and Diabetes Forecast magazine. She is on X (formerly known as Twitter) @MiriamETucker.