Underserved Communities at Greater Risk for Non-adherence to Diabetes Medication

Evernorth Geographic Social Determinants Index (EGSDI) identifies opportunities for proactive patient and community engagement for individuals diagnosed with type 2 diabetes.

Diabetes is an epidemic affecting more than 37 million individuals in the United States. Approximately 90 to 95% of these individuals have type 2 diabetes, which means their body cannot properly control the amount of glucose in their blood. This chronic disease has the potential for a wide range of complications — including death and disability from heart attack, stroke and kidney failure, as well as blindness and amputations from damage to nerve and blood vessels.

Management of type 2 diabetes can be difficult. Many individuals need to be prescribed antidiabetic medication as a first line of treatment to help lower blood sugar levels.

Diabetes does not affect all people equally. Early research has indicated that individuals who had Covid-19 are at higher risk, and there has long been a higher prevalence of the disease among some racial and ethnic groups than others. In addition, diabetes is typically more common in communities with lower employment and wealth, and less access to healthy food, higher education and health care. These disparities in social determinants of health make preventing and managing type 2 diabetes more challenging.


Adult Type 1 and Type 2 Diabetes Diagnosis Rate by Ethnic Population (%)

A new analysis by Evernorth Research Institute shows that individuals with type 2 diabetes who live in areas with high social determinants of health are more likely to visit an emergency department for care, and less likely to be adherent to their medication, than those who live in communities with less of these determinants.

The Research Institute analyzed the pharmacy and medical claims analysis of approximately 4 million U.S. adults and identified those individuals with type 2 diabetes who were prescribed oral antidiabetic medication. The study revealed that individuals who live in areas with very high social need had more ED visits compared to those living in areas of low social need.

Diabetes-Related ED Visits by People Diagnosed with Type 2 Diabetes, Based on Assessment of Local Social Needs (Total Visits)

The study reported roughly 1,200 Diabetes-related ED visits (where diabetes was the primary reason for the visit) for every 100,000 people with type 2 diabetes who live in areas with very high social need — compared to approximately 800 visits among those living in areas of low social need. When the data is adjusted for key covariates (i.e., factors that could impact health outcomes, such as demographics and disease severity), there were 52% more diabetes-related ED visits in areas with very high social need.

ED Visits by People Diagnosed with Type 2 Diabetes, Based on Assessment of Local Social Needs (Total Visits)

In addition, areas with very high social need experienced…

  • 30% more ED visits overall (all cause visits)
  • 26% more all cause ED visits with higher complexity/intensity
  • 37% more all cause ED visits with moderate complexity/intensity
  • 34% more avoidable all cause ED visits

…compared to areas of low social need (based on data adjusted for key covariates).

An analysis of oral antidiabetic medication adherence indicates a 64.9% average adherence for those residing in areas with very high levels of negative social determinants of health, compared to 73.7% average adherence for those in areas with low levels.

Diabetes Medication Adherence Rate for People Diagnosed with Type 2 Diabetes, Based on Assessment of Local Social Needs (%)

This means that people with diabetes who live in areas with very high social need have up to a 12% lower likelihood of taking their medication as prescribed compared to those living in areas with fewer social needs.

Patient and community engagement may help improve diabetes management and prevent harmful complications

This analysis suggests that people with diabetes who live in the most underserved areas are more likely to suffer disparities in diabetes outcomes, as shown by higher rates of ED visits. They also have a decreased likelihood of proper management of their diabetes, indicated by lower adherence to their medication.

These findings highlight the need for plan sponsors to support members who live in underserved communities with specialized programs that help people address both their health and social needs. These programs can offer additional diabetes support resources such as patient monitoring and medication reminder programs, referrals to community education initiatives and copay assistance programs, and access to coaches and care professionals who understand the impacts of social determinants.

Local providers often ask about potential social barriers when seeing patients diagnosed with type 2 diabetes who are not adhering to their medication. Collaborating with local health systems can also help identify social determinants affecting these patients. Plan sponsors can support these efforts by notifying providers of any community resources and plan programs that can help address recognized social hurdles.

Regardless of where they live, it can be difficult for patients diagnosed with type 2 diabetes to admit how social challenges affect their ability to take care of themselves. By normalizing conversations about social needs, providers, community organizations and health plans can help individuals feel more comfortable discussing any problems they have regarding their medication use and diabetes management in general.

These actions can enable people to better prevent and manage diabetes, reduce unnecessary ED services, and help people enjoy a healthier life.

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Evernorth Research Institute
Evernorth Research Institute is a catalyst for change: generating the industry-leading thinking that will redefine health care as we know it. Combining Evernorth’s unmatched data and analytics with the expertise of our partners, we unlock pivotal insights that incite action and guide meaningful progress in health care.
Evernorth Geographic Social Determinants Index
The Evernorth Geographic Social Determinants Index (EGSDI) is designed to better understand the potential health challenges an individual may experience in the area where they live. It incorporates census data with 22 social determinant measures across six categories (economic, education, food access, health coverage, infrastructure, and language) to determine a geographic-based score that quantifies the potential impact of social determinants of a particular area. Higher EGSDI scores indicate areas with greater likelihood of being underserved.

This analysis was a retrospective, cohort study examining integrated pharmacy and medical data from January 1, 2018 to December 31, 2020 for approximately 4 million commercially insured customers whose pharmacy benefits were managed by Express Scripts, Inc. Patients diagnosed with type 2 diabetes mellitus (T2DM) aged 18 to 63 who filled at least two 30-day adjusted prescription medications for oral antidiabetic agents (non-injectable and non-insulin medications) between January 1, 2019 and December 31, 2019 were included in the analysis. Their diagnosis was within 365 days prior to the first oral antidiabetic drug claim. Adherence to oral antidiabetic medications was the proportion of patients with percent of days covered (PDC) >80% during their measurement period. Emergency department visits were identified as “diabetes-related” with a primary diagnosis of T2DM; “all cause” visits have a secondary diagnosis of T2DM.