Skip to main content
  • More from ADA
    • Diabetes
    • Diabetes Care
    • Diabetes Spectrum
    • ADA Standards of Medical Care
    • ADA Standards of Medical Care, Abridged
    • ADA Scientific Sessions Abstracts
    • BMJ Open Diabetes Research & Care
  • Subscribe
  • Log in
  • Log out
  • My Cart
  • Follow ada on Twitter
  • RSS
  • Visit ada on Facebook
Clinical Diabetes

Advanced Search

Main menu

  • Home
  • Current
    • Current Issue
    • Online Ahead of Print
    • ADA Standards of Medical Care
    • ADA Standards of Medical Care, Abridged
  • Browse
    • Issue Archive
    • Saved Searches
    • COVID-19 Article Collection
    • Quality Improvement Sucess Stories
    • ADA Standards of Medical Care
    • ADA Standards of Medical Care, Abridged
  • Info
    • About the Journal
    • About the Editors
    • ADA Journal Policies
    • Instructions for Authors
  • Advertising
  • Reprints/Reuse
  • Subscriptions
    • Individual Subscriptions
    • Institutional Subscriptions and Site Licenses
    • Access Institutional Usage Reports
    • Purchase Single Issues
  • Alerts
    • E­mail Alerts
    • RSS Feeds
  • Podcasts
    • Diabetes Core Update
    • Special Podcast Series: Therapeutic Inertia
    • Special Podcast Series: Influenza Podcasts
    • Special Podcast Series: SGLT2 Inhibitors
    • Special Podcast Series: COVID-19
  • Submit
    • Submit a Manuscript
    • Submit Cover Art
    • Instructions for Authors
    • ADA Journal Policies
  • More from ADA
    • Diabetes
    • Diabetes Care
    • Diabetes Spectrum
    • ADA Standards of Medical Care
    • ADA Standards of Medical Care, Abridged
    • ADA Scientific Sessions Abstracts
    • BMJ Open Diabetes Research & Care

User menu

  • Subscribe
  • Log in
  • Log out
  • My Cart

Search

  • Advanced search
Clinical Diabetes
  • Home
  • Current
    • Current Issue
    • Online Ahead of Print
    • ADA Standards of Medical Care
    • ADA Standards of Medical Care, Abridged
  • Browse
    • Issue Archive
    • Saved Searches
    • COVID-19 Article Collection
    • Quality Improvement Sucess Stories
    • ADA Standards of Medical Care
    • ADA Standards of Medical Care, Abridged
  • Info
    • About the Journal
    • About the Editors
    • ADA Journal Policies
    • Instructions for Authors
  • Advertising
  • Reprints/Reuse
  • Subscriptions
    • Individual Subscriptions
    • Institutional Subscriptions and Site Licenses
    • Access Institutional Usage Reports
    • Purchase Single Issues
  • Alerts
    • E­mail Alerts
    • RSS Feeds
  • Podcasts
    • Diabetes Core Update
    • Special Podcast Series: Therapeutic Inertia
    • Special Podcast Series: Influenza Podcasts
    • Special Podcast Series: SGLT2 Inhibitors
    • Special Podcast Series: COVID-19
  • Submit
    • Submit a Manuscript
    • Submit Cover Art
    • Instructions for Authors
    • ADA Journal Policies
Commentary

Diabetes Technologies: We Are All in This Together

  1. Sean M. Oser and
  2. Tamara K. Oser
  1. Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO
  1. Corresponding author: Sean M. Oser, sean.oser{at}cuanschutz.edu
Clinical Diabetes 2020 Apr; 38(2): 188-189. https://doi.org/10.2337/cd19-0046
PreviousNext
  • Article
  • Figures & Tables
  • Info & Metrics
  • PDF
Loading

The United States faces a shortage of both primary care physicians (PCPs) and endocrinologists—the two groups of clinicians who provide the majority of care to people with diabetes (1–3). Patients treated with intensive insulin therapy, including all of those with type 1 diabetes and many with type 2 diabetes, face numerous daily self-management decisions. These decisions include factoring insulin dosing, glucose management, diet, activity, and other behavioral factors into their decision-making. These patients stand to gain from using the treatment and monitoring technologies that are rapidly advancing and accumulating evidence in support of their benefits. Despite this situation, the actual use of such technologies, including continuous glucose monitoring (CGM) and closed-loop artificial pancreas systems, remains relatively low (4,5).

One potential barrier to uptake of such advanced diabetes technologies is a hypothesized mismatch between geographical location of people with diabetes and available clinicians. Employing datasets from the U.S. Census Bureau (6) and the American Medical Association Health Workforce Mapper (7), as well as prevalence estimates from the American Diabetes Association and JDRF, we sought to compare the distribution of PCPs and endocrinologists across the United States to the distribution of people with diabetes. This endeavor was undertaken as a step toward understanding whether encouraging PCP management of advanced diabetes technologies might benefit people treated with intensive insulin therapy.

The distribution of people with diabetes approximates the distribution of the general population of the United States (8,9). The distribution of PCPs largely matches that distribution; of 3,143 U.S. counties, 3,017 (96.0%) have at least one PCP, and only 126 have no PCPs. The distribution of endocrinologists, on the other hand, is quite different; 777 counties (24.7%) have an endocrinologist, leaving 2,366 counties (75.3%) with none. Although every U.S. county borders at least one county with at least one PCP, the distribution of endocrinologists reveals many sizable gaps. These are depicted in Figure 1.

FIGURE 1
  • Download figure
  • Open in new tab
  • Download powerpoint
FIGURE 1

U.S. counties with A) at least one pediatric or adult endocrinologist or diabetologist and B) at least one PCP.

Although no person with diabetes is ever more than one county away from a PCP, the nearest endocrinologist can be hundreds of miles and many counties away. This situation contributes to a disparity in care. Current diabetes technologies such as insulin pumps (traditional or closed-loop systems) and CGM systems are associated with better diabetes management, including improving A1C resulting from reductions in both hyperglycemia and hypoglycemia (10) and are also generally managed by the geographically concentrated endocrinologists rather than by most of the more geographically dispersed PCPs. This not only adds strain to the relatively smaller endocrinology workforce; it also forces many patients to miss work, travel considerable distances, and/or incur considerable expense to gain access to such technologies or to forgo the opportunity to use them. Social determinants of health, including issues related to income, employment, and transportation, may leave many patients unable to access subspecialty care even if they wanted to try.

Advanced diabetes technologies such as CGM and closed-loop artificial pancreas systems are poised to improve outcomes and patient experiences even more, and in the hands of PCPs could reach many more patients than in the hands of endocrinologists alone. Research on CGM use is increasingly showing improved outcomes and better patient experience, but little of this research has been done with primary care populations. Additionally, research and development of closed-loop artificial pancreas systems have focused nearly exclusively on endocrinologist-treated populations thus far. Future research should evaluate whether and how such advanced diabetes technologies would and could be incorporated into diabetes management among broader and expanding delivery models and provider roles. This research should include primary care settings to help ease the strain on the endocrinology workforce and to help bring such technologies to the many locales in which endocrinologists are not available.

Additional efforts could include enlisting other health workforce colleagues to help do this work, as was made clear at a recent workshop cosponsored by JDRF and the Leona M. and Harry B. Helmsley Charitable Trust. At this event, where attendance and enthusiasm both overflowed the meeting room, certified diabetes educators, pharmacists, school nurses, social workers, representatives from professional organizations, industry representatives, and researchers all sat shoulder to shoulder with endocrinologists, family physicians, general internists, and pediatricians. The assembled group reviewed resources available to support clinicians caring for people with diabetes to identify resource gaps and discuss how we can work together to serve this population we all want to help.

Together, participants at the workshop envisioned a future landscape of diabetes care, perhaps 10 years from now, in which PCPs and endocrinologists alike comfortably prescribe automated, closed-loop artificial pancreas systems; diabetes educators and social workers are more accessible to all patients and can help support patient education and insurance approvals for advanced diabetes devices; psychologists are more frequently engaged to round out whole-person treatment of people living with diabetes and the behavioral health issues that often go hand-in-hand with having a chronic condition and using new technologies; and school nurses are recognized as important contributors to children’s diabetes care and can help to support students using advanced diabetes devices at school. As disparate as the workshop participants were, we held a unified belief and spoke in a single voice. Although our roles are different and there are striking differences in the distribution of our workforces, we share the common goal of providing the best available care to our patients, and we are all in this together.

Article Information

Duality of Interest

No potential conflicts of interest relevant to this article were reported.

Author Contributions

S.M.O. and T.K.O. conceived of the concept, conducted literature review, and wrote the text. S.M.O. performed data analysis and map creation. T.K.O. performed final editing. S.M.O. is the guarantor of this work and, as such, had full access to all data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Prior Presentation

Some of the data in this article was first presented as an abstract at the 46th North American Primary Care Research Group Annual Meeting in Chicago, IL, 9–13 November 2018.

  • © 2020 by the American Diabetes Association
https://www.diabetesjournals.org/content/license

Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. More information is available at https://www.diabetesjournals.org/content/license.

References

  1. 1.↵
    1. American Association of Medical Colleges
    . The complexities of physician supply and demand: projections from 2017 to 2032. Available from https://aamc-black.global.ssl.fastly.net/production/media/filer_public/31/13/3113ee5c-a038-4c16-89af-294a69826650/2019_update_-_the_complexities_of_physician_supply_and_demand_-_projections_from_2017-2032.pdf. Accessed 2 January 2020
  2. 2.
    1. Lu H,
    2. Holt JB,
    3. Cheng YJ,
    4. Zhang X,
    5. Onufrak S,
    6. Croft JB
    . Population-based geographic access to endocrinologists in the United States, 2012. BMC Health Serv Res 2015;15:541
    OpenUrlCrossRefPubMed
  3. 3.↵
    1. Sadhu AR,
    2. Healy AM,
    3. Patil SP,
    4. Cummings DM,
    5. Shubrook JH,
    6. Tanenberg RJ
    . The time is now: diabetes fellowships in the United States. Curr Diab Rep 2017;17:108
    OpenUrl
  4. 4.↵
    1. Foster NC,
    2. Beck RW,
    3. Miller KM, et al.
    State of type 1 diabetes management and outcomes from the T1D Exchange in 2016–2018. Diabetes Technol Ther 2019;21:66–72
    OpenUrlPubMed
  5. 5.↵
    1. Sikes KA,
    2. Weyman K
    . Diabetes and the use of insulin pumps. Endocrinology Advisor 17 September 2018. Available from https://www.endocrinologyadvisor.com/home/decision-support-in-medicine/endocrinology-metabolism/diabetes-and-the-use-of-insulin-pumps/article/595843. Accessed 2 January 2020
  6. 6.↵
    1. United States Census Bureau
    . Try out our new way to explore data. Available from www.census.gov/data.html. Accessed 2 January 2020
  7. 7.↵
    1. American Medical Association
    . Health workforce mapper. Available from www.ama-assn.org/about-us/health-workforce-mapper. Accessed 29 June 2018
  8. 8.↵
    1. Puett RC,
    2. Lamichhane AP,
    3. D Nichols M, et al.
    Neighborhood context and incidence of type 1 diabetes: the SEARCH for Diabetes in Youth study. Health Place 2012;18:911–916
    OpenUrlPubMed
  9. 9.↵
    1. Liese AD,
    2. Lawson A,
    3. Song HR, et al.
    Evaluating geographic variation in type 1 and type 2 diabetes mellitus incidence in youth in four US regions. Health Place 2010;16:547–556
    OpenUrlCrossRefPubMedWeb of Science
  10. 10.↵
    1. Chamberlain JJ,
    2. Doyle-Delgado K,
    3. Peterson L,
    4. Skolnik N
    . Diabetes technology: review of the 2019 American Diabetes Association Standards of Medical Care in Diabetes. Ann Intern Med. Epub ahead of print on 13 August 2019 (DOI: 10.7326/M19-1638
View Abstract
PreviousNext
Back to top
Clinical Diabetes: 38 (2)

In this Issue

April 2020, 38(2)
  • Table of Contents
  • Table of Contents (PDF)
  • About the Cover
  • Index by Author
  • Masthead (PDF)
Sign up to receive current issue alerts
View Selected Citations (0)
Print
Article Alerts
Sign In to Email Alerts with your Email Address
Email Article

Thank you for your interest in spreading the word about Clinical Diabetes.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Diabetes Technologies: We Are All in This Together
(Your Name) has forwarded a page to you from Clinical Diabetes
(Your Name) thought you would like to see this page from the Clinical Diabetes web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Diabetes Technologies: We Are All in This Together
Sean M. Oser, Tamara K. Oser
Clinical Diabetes Apr 2020, 38 (2) 188-189; DOI: 10.2337/cd19-0046

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Add to Selected Citations
Share

Diabetes Technologies: We Are All in This Together
Sean M. Oser, Tamara K. Oser
Clinical Diabetes Apr 2020, 38 (2) 188-189; DOI: 10.2337/cd19-0046
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • Article Information
    • References
  • Figures & Tables
  • Info & Metrics
  • PDF

Related Articles

Cited By...

More in this TOC Section

  • Reflection (With Some Coaching) on a Quality Improvement Initiative: Finding Our Collective Voice Along the Journey
  • Suggestions to Overcome Racial Inequities Among Health Care Professionals
  • Improving Transition to Insulin Through Clinical Conversations
Show more Commentary

Similar Articles

Navigate

  • Current Issue
  • Papers in Press
  • Abridged Standards of Care
  • Archives
  • Submit
  • Subscribe
  • Email Alerts
  • RSS Feeds

More Information

  • About the Journal
  • Instructions for Authors
  • Journal Policies
  • Reprints and Permissions
  • Advertising
  • Privacy Policy: ADA Journals
  • Copyright Notice/Public Access Policy
  • Contact Us

Other ADA Resources

  • Diabetes
  • Diabetes Care
  • Diabetes Spectrum
  • Scientific Sessions Abstracts
  • Standards of Medical Care in Diabetes
  • BMJ Open - Diabetes Research & Care
  • Professional Books
  • Diabetes Forecast

 

  • DiabetesJournals.org
  • Diabetes Core Update
  • ADA's DiabetesPro
  • ADA Member Directory
  • Diabetes.org

© 2021 by the American Diabetes Association. Clinical Diabetes Print ISSN: 0891-8929, Online ISSN: 1945-4953.