Abstract
IMPORTANCE: Atherosclerotic cardiovascular disease is the leading cause of death among adults with type 2 diabetes in the US. Endocrinology and cardiology care may improve outcomes for these patients, but access to this care is limited for many patients by practitioner shortages in rural areas and other barriers. OBJECTIVE: To assess associations of geographic and sociodemographic factors with endocrinology and cardiology care receipt among adults with type 2 diabetes and atherosclerotic cardiovascular disease before and after widespread telemedicine uptake. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used electronic medical record and public geographic and infrastructure data at a large health system spanning urban and rural counties in Pennsylvania. Participants were adults with type 2 diabetes and atherosclerotic cardiovascular disease who received primary care from January 2018 to June 2022. EXPOSURES: Patient-level geographic measures, including distance to clinic, public transit, and cellular data access, and sociodemographic factors, including age, gender, race, and neighborhood socioeconomic status. MAIN OUTCOMES AND MEASURES: The primary outcome was at least 1 outpatient visit with endocrinology or cardiology. Geospatial analysis assessed patient-level geographic factors using zip code centroids, and separate multivariable logistic regression models evaluated associations between variables and endocrinology and cardiology care receipt. Analyses were stratified by period before (January 1, 2018, to March 15, 2020) and after (March 16, 2020, to June 30, 2022) COVID-19 pandemic-related telemedicine uptake; mixed-effects models tested for differences between periods. RESULTS: Of 9546 adults (mean [SD] age, 68.5 [10.0] years; 5854 male [61%]; 82 Asian [1%]; 930 Black [10%]; 8451 White [89%]; 7877 urban [83%]), 1747 received endocrinology care and 5578 received cardiology care. In the pretelemedicine period, distance to endocrinology clinic (adjusted odds ratio [aOR] per 10 miles, 0.74; 95% CI, 0.64-0.84) and older age (aOR per 10 years, 0.70; 95% CI, 0.66-0.75) were associated with lower odds of receiving endocrinology care. In the posttelemedicine period, the aOR for distance to clinic increased, but that for older age decreased. Black patients were less likely than White patients to receive cardiology care in the pretelemedicine period (aOR, 0.71; 95% CI, 0.60-0.82), and this association persisted in the posttelemedicine period. CONCLUSIONS AND RELEVANCE: In this cohort study of adults with type 2 diabetes and atherosclerotic cardiovascular disease, geographic and sociodemographic factors were associated with receipt of endocrinology and cardiology care. Widespread availability of telemedicine may enhance equitable access to endocrinology care for patients facing geographic barriers, but disparities in use of specialty care by age and race persisted in the posttelemedicine period.