Disparities in Diabetes Care: Differences Between Rural and Urban Patients Within a Large Health System

Article Figures & Data

Table 1.

Characteristics of the Study Population of Patients With Type 2 Diabetes

Characteristic	Total (N = 45,279)	Location		P Value
Characteristic	Total (N = 45,279)	Rural (n = 24,637)	Urban (n = 20,642)	P Value
Age, mean (SD), y	65.7 (14.0)	65.8 (13.9)	65.6 (13.9)	.20^{^a}
Female, No. (%)	20,735 (45.8)	11,433 (46.4)	9,302 (45.1)	.004^{^b}
Race, No. (%)				<.001^{^b}
White	41,887 (92.5)	23,195 (94.2)	18,692 (90.6)
Non-White	3,369 (7.5)	1,427 (5.8)	1,942 (9.4)
ACG risk score, mean (SD)^{^c}	1.1 (0.96)	1.1 (0.96)	1.1 (0.97)	.91^{^a}
Insurance, No. (%)				<.001^{^b}
Commercial	12,034 (26.6)	6,119 (24.9)	5,915 (28.7)
Medicaid	3,470 (7.7)	1,961 (8.0)	1,509 (7.3)
Medicare	28,069 (62.1)	15,533 (63.2)	12,536 (60.8)
Other	1,616 (3.6)	965 (3.9)	651 (3.2)
Missing	90 (0.2)	59 (0.2)	31 (0.2)
Number of outpatient visits, mean (SD)	3.5 (4.39)	3.2 (4.04)	3.9 (4.75)	<.001^{^a}
Visits, No. (%)
Diabetes education	7,844 (17.3)	4,325 (17.6)	3,519 (17.0)	.16^{^b}
Nutrition	2,449 (5.4)	1,350 (5.5)	1,099 (5.3)	.47^{^b}
Endocrinology	3,257 (7.2)	1,347 (5.5)	1,928 (9.3)	<.001^{^b}
Primary care clinician type, No. (%)				<.001^{^b}
Advanced practice provider	8,170 (18.0)	6,289 (25.5)	1,881 (9.1)
Physician	36,356 (80.3)	18,192 (73.8)	18,164 (88.0)
Resident or fellow	743 (1.6)	152 (0.6)	591 (2.9)
Other	10 (<0.1)	4 (<0.1)	6 (<0.1)

Table 2.

Patients’ Attainment of the D5 Metric and Its Component Goals

D5 Metric	Total, No. (%) (N = 45,279)	Location		P Value^{^a}
D5 Metric	Total, No. (%) (N = 45,279)	Rural, No. (%) (n = 24,637)	Urban, No. (%) (n = 20,642)	P Value^{^a}
Component goals met
Antiplatelet medication use as indicated	44,740 (98.8)	24,337 (98.8)	20,403 (98.8)	.56
Blood pressure <140/90 mm Hg	34,299 (75.8)	18,553 (75.3)	15,746 (76.3)	.02
A_1c level <8.0%	31,364 (69.3)	16,924 (68.7)	14,440 (70.0)	.004
LDL cholesterol level at goal or statin prescribed	38,576 (85.2)	20,722 (84.1)	17,854 (86.5)	<.001
No tobacco use	37,754 (83.4)	20,316 (82.5)	17,438 (84.5)	<.001
All 5 goals met	18,752 (41.4)	9,842 (39.9)	8,910 (43.2)	<.001

A_1c = glycated hemoglobin; D5 = diabetes 5-item composite metric; LDL = low-density lipoprotein.
↵a From Kruskal-Wallis analysis.

Table 3.

Multivariate Model of Characteristics Associated With Meeting the D5 Metric

Characteristic	Adjusted Odds Ratio (95% CI)^{^a}	P Value
Rural vs urban	0.93 (0.88-0.97)	.003
Female vs male	1.08 (1.03-1.12)	.001
Increasing age, per 10 years	1.22 (1.10-1.02)	<.001
ACG risk score <1 vs ≥1	1.19 (1.13-1.25)	<.001
Diabetes education visit vs none	0.92 (0.87-0.97)	.004
Nutrition visit vs none	1.06 (0.97-1.16)	.17
Endocrinology visit vs none	0.80 (0.73-0.86)	<.001
Increasing outpatient visits, per 1 visit	1.03 (1.03-1.04)	<.001
Insurance
Commercial (reference group)	1.00	…
Medicaid	0.58 (0.53-0.63)	<.001
Medicare	1.17 (1.10-1.24)	<.001
Other	0.97 (0.87-1.09)	.63
Non-White vs White	0.83 (0.77-0.90)	<.001
APP vs physician^{^b}	0.94 (0.87-1.02)	.12

ACG = adjusted clinical group; APP = advanced practice provider; D5 = diabetes 5-item composite metric.
Notes: Results of the generalized linear mixed model. D5 is a set of 5 treatment goals for diabetes developed by the Minnesota Community Measurement to represent the gold standard for managing diabetes.
↵a An odds ratio greater than 1 indicates that the first characteristic listed is associated with higher odds of meeting the D5 metric. All characteristics shown have been adjusted for in the same model as fixed effects; site and primary care clinician type were random effects in the model.
↵b Physician includes residents and fellows.