July/August 2024

July/August 2024 Issue

Diabetes: Improving Diabetes Care in Small Towns and Rural Locations
By Lindsey Getz
Today’s Geriatric Medicine
Vol. 17 No. 4 P. 28

Diabetes complications such as end-stage kidney disease, heart failure, and heart attacks are extremely serious but also potentially preventable with proper diabetes management. However, where a patient lives might influence their likelihood of developing (or avoiding) these complications in the first place. According to a study by researchers at the University of Maryland School of Medicine, those who live in small towns experience a significantly higher risk of eight major classes of complications related to diabetes compared with those who live in well-populated suburbs and cities.

The study, which was published in the journal Diabetes Care, analyzed health insurance data from nearly three million adults with diabetes across the United States over the period of 10 years. Researchers found that those living in small towns (population size of 2,500 to 50,000 people) were 10% more likely to experience a heart attack, 5% more likely to be hospitalized for heart failure, and roughly 4% more likely to have end-stage kidney disease compared with those living in larger towns and cities.

“We know that access to primary care is a major issue,” says study corresponding author Rozalina McCoy, MD, an associate professor of medicine at University of Maryland School of Medicine and director of the Precision Medicine and Population Health Program at the University of Maryland Institute for Health Computing. “Diabetes management can be very complicated, with many new medications available. These can have benefits that help reduce complications, but patients first need to access a health care specialist in order to be prescribed these options.”

Those in smaller towns might not be accessing care as regularly—or at all.

An interesting finding, McCoy says, was that people living in remote areas had lower risks of being diagnosed with certain diabetes complications. For instance, they were 15% less likely to be treated in the emergency department or hospital for dangerously high blood sugar levels and 6% less likely to be hospitalized for heart failure compared with those living in small towns.

But because the study analyzed data pertaining to patients who used health care services for their conditions, information about those complications would not be captured for people who hadn’t accessed services

“It’s likely that there are patients in remote areas that aren’t even able to make it to the hospital, so their data was never included,” McCoy says. “While our study separated remote or ‘rural’ areas from ‘small towns,’ much of the currently available research groups these two locations together. I think it’s important to look at these two groups separately since there are even greater barriers to access to care in remote areas.”

In addition to potentially lacking access to medical care, another issue in rural areas might be the lack of opportunities for exercise and healthful diets, McCoy suggests.

“We know that engaging in physical activity and eating a healthy and nutritious diet are important when it comes to preventing diabetes complications,” she continues. “But there could be fewer options for both in rural and remote areas. People living in rural areas, for instance, might have to go into town to grocery shop or lack sidewalks and parks for physical activity.”

Improving Access to Care
Finding ways to improve access to medical care and provide people with more education about a healthful lifestyle is no simple feat. But McCoy says it’s important in order to begin to see improvements in diabetes management.

Telehealth, she explains, is one piece of the puzzle but not a singular solution. After all, using technology requires having access to it in the first place. Some rural areas may have broadband connectivity issues that remain a barrier, McCoy explains.

She also refers to another recent study she was involved in, led by Margaret F. Zupa, MD, at the University of Pittsburgh, which found that for patients with type 2 diabetes treated with complicated insulin regimen, telehealth alone had inferior outcomes to those who used in-person or mixed care.

“Patients not requiring multiple daily injections of insulin did OK with telehealth, but those with more complicated regimens needed more care that just isn’t easily replicated during a telehealth visit,” McCoy says. “Same for patients who had elevated hemoglobin A1c and needed more intensive care. Having an in-person visit is important—there are labs that need to be done, care that needs to be coordinated, education to potentially be delivered. It’s also important for a patient to be seen for a physical exam to be done, like to allow the clinician to check the patient’s feet, ensuring that there are no foot complications.”

However, McCoy says, in the interim period between in-person visits, telehealth can help provide important education and opportunities to identify gaps in care and opportunities to support patients.

Engaging the Community
According to McCoy, another potential solution to improving diabetes care involves thinking about the wide range of professionals already in the community who could help meet patients’ needs. It doesn’t always have to be a doctor, she adds. “Home visits from a nurse, community health worker, or paramedic who can perform an exam, speak with patients about potential problems or barriers they are experiencing, and identify and address challenges provide that real-time, personal, but often unavailable physical component,” she says. “They can also facilitate visits with health care professionals in the clinic as needed as well; for example, they can bring an iPad with cellular connection and help patients do a telehealth visit with them right there to help.”

The concept of mobile clinics for mammograms and other preventive services are becoming more popular for rural areas, and McCoy says this can be replicated with diabetes care. Further, she says, other professionals in the community—such as dietitians in grocery stores and pharmacists in pharmacies—can also play a role in helping improve diabetes management.

“I think to bring better care to rural communities, we need to think about how we can engage all members of the community and the health care team,” she adds. “There’s only so much that any one of us can do. But as we consider the greater community, we can all work together to make sure that our patients can receive the support, education, resources, and health care they need to be well.”

One Small Change at a Time
McCoy admits that access to care in small towns and rural areas is a multifaceted issue. But there are ways to start instigating change. “This is a big issue, but if we start looking at how every small step that we take can make a difference, it becomes more feasible. We can think about community-based providers who might be able to help us bridge the gap for patients who do not have easy access to medical care,” she says. “We need to think creatively about how we can bring care to rural communities. It doesn’t have to be one big undertaking. There are a lot of small things that we can be doing that can add up.”

Geriatricians and other health care providers working with older adults can get more involved in solving these problems by helping identify what barriers might stand in the way of their patients’ diabetes management, McCoy adds. “Asking patients about the barriers that they experience in their lives—such as physical access to care, access to healthy food, and a space for safe physical activity—is a great start,” she suggests. “Providers can create a checklist. Even if they’re able to address one item, that’s making progress.”

Going forward, McCoy hopes to identify whether there are regions or clinics that are doing disproportionately well in delivering care to small towns and rural areas so that she can learn from their approaches. Working with a grant from the American Diabetes Association, she’ll look more closely at primary care in rural areas and how it affects outcomes.

“I’ve been surprised by how little is known about diabetes in rural areas on a national level,” she concludes. “I’m hoping that we can complete more work to better understand the drivers of these gaps in care and start implementing better systems. It’s an area I’m very passionate about because by working together and working creatively, we can make a difference in improving our patients’ lives.”

— Lindsey Getz is an award-winning freelance writer in Royersford, Pennsylvania.