Rural–Urban Differences in Use of Diabetes Self-Management Education and Support in Arkansas, 2015–2019

OBJECTIVE Previous studies have identified limited access to diabetes self-management education and support (DSMES) programs in many U.S. communities. This retrospective cohort study examines rural–urban differences in DSMES use among individuals newly diagnosed with type 2 diabetes using the Arkansas All-Payer Claims Database from 2015 to 2019. RESEARCH DESIGN AND METHODS A cohort of 42,875 individuals covered by commercial or Medicare/Medicare Advantage insurance was identified. Generalized estimating equations, based on multivariable logistic regression, were used to assess the association between rural residence and DSMES use, accounting for clustering at the county level. The model adjusted for demographic characteristics, insurance type, diabetes complication severity score, and county-level factors, including primary care shortages, median household income, and density of DSMES-recognized programs per 10,000 individuals with diabetes. RESULTS DSMES use was lower in rural compared with urban areas (3.4% vs. 6.2%; P < 0.01). However, after adjusting for county-level factors, rural–urban differences were not statistically significant (odds ratio [OR] 0.83; 95% CI 0.47–1.47; P = 0.52). Individuals in the lowest quartile of household income had lower odds of DSMES use (OR 0.65; 95% CI 0.46–0.91; P = 0.01). Those in counties with a higher density of DSMES programs had higher odds of DSMES use (quartile 2: OR 1.75; 95% CI 1.22–2.50; P < 0.01; quartile 3: OR 1.53; 95% CI 1.10–2.12; P = 0.01; quartile 4: OR 1.40; 95% CI 1.04–1.90; P = 0.03). CONCLUSIONS Findings suggest that structural factors, including income and program availability, explain many of the rural–urban differences in DSMES use. Geographic context should be considered in efforts to improve access to diabetes education.