Sourik Beltrán, BA; Daniel J. Arenas, PhD; Itzel J. López-Hinojosa; Elizabeth L. Tung, MD, MS; Peter F. Cronholm, MD, MSCE
Corresponding Author: Sourik Beltrán, BA; University of Pennsylvania.
Contact Email: Sourik.Beltran@pennmedicine.upenn.edu
Section: Brief Report
Publication Date: September 2021
INTRODUCTION: Evidence suggests that clinicians may view or label patients as nonadherent in a biased manner. Therefore, we performed a retrospective cohort analysis exploring associations between patient demographics and zip code-level income with ICD-10 diagnoses for nonadherence among Type 2 Diabetes Mellitus (T2DM) patients, comparing primary and specialty care settings.
METHODS: Participants were identified from five primary care and four endocrinology sites in the University of Pennsylvania Health System between January 1, 2015 and January 1, 2019. Demographics, hemoglobin A1c (HbA1c), and ICD-10 codes for T2DM and nonadherence were extracted from the electronic health record and analyzed in October, 2019. Log-binomial regression models were used to estimate patients' risk of nonadherence labeling by race, insurance, and zip code-level median household income, controlling for patient characteristics and HbA1c as a proxy for diabetes self-management. Results were compared between primary and specialty care sites.
RESULTS: 6,072 patients ages 18 – 70 were included in this study. Black race, Medicare, and Medicaid were associated with increased nonadherence labeling while controlling for patient characteristics [(ARR=2.48, 95%CI: 2.01, 3.04), (ARR=1.82, 95%CI: 1.50, 2.18), (ARR=1.61, 95%CI: 1.32, 1.93), respectively]. The results remained significant upon adjustment with zip code-level income and showed no differences between primary and specialty sites. Lower income zip codes showed a significant association with increased rates of nonadherence labeling.
CONCLUSIONS: Black race, non-private insurance, and lower income zip codes were associated with disproportionately high rates of nonadherence labeling in both primary and specialty management of T2DM, possibly suggestive of racial or class bias.