Rural/Urban Disparities in Utilization of Diabetes Self-Management Training to the Fee-for-Service Medicare Population


Diabetes self-management training (DSMT) is the process of providing patients with the management skills necessary for diabetes self-care in order to improve quality of life, clinical outcomes, and health status. It has been shown to improve patient knowledge, ability to self-treat, and health outcomes, as well as reduce the odds of hospitalization and emergency department visits in a cost-effective manner for Medicare beneficiaries. Despite the recommendation of DSMT for all patients newly diagnosed with diabetes, there is a low utilization rate.

We extracted the 2012-2016 Medicare provider data and used Healthcare Common Procedure Coding System codes to determine the number of hours of DSMT services provided, the number of healthcare providers administering the service, and the number of beneficiaries served by each provider. Provider services and beneficiaries were then aggregated at the county level. Rural-Urban Continuum Codes were used to assign counties to rural versus urban designations.

Findings of our analysis suggest a disparity in the availability of DSMT services between urban and rural counties. Services appear to be predominantly clustered around urban centers, especially in the North and Northeast. Of particular interest may be the areas where DSMT services are sparse, specifically the western half of the continental U.S.

While rural utilization rates of DSMT services were higher than urban rates, rural beneficiaries typically utilized fewer units of service than those in urban counties. Finally, there is geographic evidence that DSMT services may not be utilized in areas with the greatest diabetes prevalence. Subsequently, the lower utilization of DSMT services may lead to a clinical outcome disparity between rural and urban patients. Expansion of DSMT programs into areas a significant distance from urban programs may help address this disparity and improve diabetes outcomes in rural populations.

Rural and Underserved Health Research Center
Christian Rhudy, Aric Schadler, Jeffery Talbert