Rural type 2 diabetes patients have higher A1c levels, while urban counterparts have higher health care costs, study finds

Type 2 diabetes is a large and growing health concern for millions of Americans. This preventable condition is responsible for billions of dollars in health care costs and carries the risk of a wide range of complications. To better understand what factors affect diabetes-related health care costs, a research team at the Texas A&M University School of Public Health recently studied commercially insured adults with type 2 diabetes in Texas.

The study, published in the journal PLOS ONE, was led by Regents and Distinguished Professor Marcia Ory as part of the Texas A&M Rural Moonshot Initiative sponsored by Blue Cross and Blue Shield of Texas (BCBSTX).

The researchers documented hemoglobin A1c, a measure of average blood glucose levels over the past three months that is often used to guide diabetes management, as well as the presence of comorbidities and diabetes-related complications as clinical factors. The study also included diabetes-related costs for each subject along with their age, sex and county of residence.

Previous research has found that socioeconomic status may be associated with higher A1c values. Additionally, because rural populations often have lower incomes, geographic factors may play a part in variances in A1c.

The researchers analyzed commercial claims for 2018 and 2019 from a large commercial insurer in Texas. They focused on adults between the ages of 18 and 64 diagnosed with type 2 diabetes who had A1c readings between 4 and 14 percent. The American Diabetes Association recommends adults with type 2 diabetes aim for an A1c level of less than 7 percent as this typically indicates blood glucose control.

Analysis of the data found a median A1c value of 7 percent and median diabetes-related costs of $120 per quarter. Subjects who had diabetes-related complications were often older and had higher A1c values, more comorbidities and greater diabetes-related costs. The researchers also found that men had higher A1c values than women and those living in rural areas had higher A1c levels than urban dwellers.

Further analysis showed that higher costs were associated with higher comorbidity scores and higher A1c values. Additionally, subjects with diabetes-related complications had greater costs than those without complications. However, although rural subjects had higher A1c levels, people living in urban areas had higher diabetes-related costs.

These findings reinforce that sociodemographic, clinical and geographic factors are all associated with higher A1c values, especially for people living in rural areas. This could be due in part to limited access to health care, though further study is needed. There is also need for further study into variations in health care costs, possible effects of health insurance stability on diabetes-related costs and health care use, and to what degree higher costs of health care services in urban areas influence diabetes-related care costs .

“The findings of this study highlight the value of helping patients with type 2 diabetes properly manage A1c levels and avoid complications. Additionally, it is vital that clinicians and public health officials consider the social determinants of health that are found in rural areas and other underserved regions such as lower income and limited health care access,” Ory said.  “Creating diabetes management programs that include these factors could help reduce disparities in A1c values and potentially decrease possible future complications and higher health care costs.”

“As the only health insurer in all 254 counties of Texas, we applaud Dr. Ory and her team’s work to examine the health risks posed by type 2 diabetes and its associated cost factors,” said Dr. Mark Chassay, BCBSTX chief medical officer. “The findings in the Texas A&M University School of Public Health study underscores our recognition of the impact that social and economic factors have on health and wellness. That is the primary reason why we realigned our community investments strategy into strategic pillars that more directly target social determinants of health. Our focus on optimal health outcomes includes helping to close gaps in diabetes care.”