Discussion
This study investigated geographic disparities and temporal changes of non-gestational diabetes-related ED visit rates in Florida from 2016 to 2019. Although diabetes prevalence and healthcare access for individuals with diabetes vary across counties in Florida ( Ricci-Cabello et al., 2010 ; Barker et al., 2011 ; Lord, Roberson & Odoi, 2020 ), little is known about the geographic disparities of non-gestational diabetes-related ED visits and yet this information is critical for improving the health and quality of life of populations with diabetes. The findings of the current study help to fill this gap and are important for guiding healthcare planning targeted at reducing disparities in non-gestational diabetes-related ED visit rates in Florida. In addition, this study investigated sociodemographic, environmental, and lifestyle-related predictors of non-gestational diabetes-related ED visit rates. The results are useful for guiding evidence-based resource allocation aimed at guiding the implementation of control programs and reducing the burden of diabetes in Florida.

The observed high non-gestational diabetes-related ED visit rates in the northern and southcentral parts of Florida may be related to access to diabetes care in these rural communities. Since diabetes is an ambulatory-care sensitive condition, getting regular primary care could substantially reduce ED visit risks and improve quality of life ( Agency for Healthcare Research and Quality, 2001 ). However, access to primary care for diabetes could be limited due to the lack of health insurance coverage, which could result in higher diabetes-related ED visit rates. This is evidenced by the findings of this study because counties with high percentages of populations with no health insurance coverage had high diabetes-related ED visit rates. Additionally, a study by Khan et al. (2021) reported that northern Florida had lower diabetes self-management education (DSME) program participation rates than urban areas due to fewer DSME centers and limited accessibility to DSME program. The DSME program was developed to educate diabetes patients on disease management and reduce diabetes-related complications and ED visit rates ( Powers et al., 2015 ). However, lack of health insurance coverage among populations in northern Florida might have prevented access to DSME programs, lowered DSME participation rates, and, therefore, resulted in higher ED visit rates.

Another reason of the high non-gestational diabetes-related ED visit rates in northern Florida could be the high percentages of non-Hispanic Black populations in those areas. The findings of this study showed that counties with high percentages of non-Hispanic Black populations tended to have significantly high ED visit rates, which is consistent with the findings of previous studies ( Taylor et al., 2017 ; Uppal et al., 2022 ). A study by Uppal et al. (2022) reported that diabetes-specific ED use among non-Hispanic Black patients was approximately 3 times higher than among non-Hispanic White patients. This difference was the result of non-Hispanic Black patients having higher risks of diabetes-related complications such as albuminuria, retinopathy, lower extremity amputation, end-stage renal disease (ESRD), and worse glycemic control than their non-Hispanic White counterparts ( Osborn, De Groot & Wagner, 2013 ; Canedo et al., 2018 ). Moreover, minority groups, such as Black and Hispanic populations, are less likely to receive recommended diabetes preventive care ( Taylor et al., 2017 ) and have low participation in DSME programs ( Khan et al., 2021 ).

The significant low county-level non-gestational diabetes-related ED visit rates among the percentage of married people identified in this study suggests that social support from marriage relationships may be beneficial for diabetes patients. Previous studies reported lower diabetes morbidity and mortality among married persons compared to their unmarried counterparts ( Kposowa, Ezzat & Breault, 2021 ). This relationship is explained by the fact that married people are more likely to get better social and mental support ( Umberson, 1992 ), lead healthy lifestyles ( Eng et al., 2005 ), and have better medication adherence and diabetes management ( Gelaw et al., 2014 ; Ahmed, Abugalambo & Almethen, 2017 ).

The finding that counties with high percentages of current smokers had higher non-gestational diabetes-related ED visit rates is consistent with reports from previous studies ( U.S. Department of Health and Human Services, 2010 , 2014 ). According to a report published by the Centers for Disease Control and Prevention (CDC), people who smoke and have diabetes are more likely to develop serious health problems from diabetes such as heart disease, kidney disease, retinopathy, peripheral neuropathy, and lower leg amputations ( U.S. Department of Health and Human Services, 2010 ; Centers for Disease Control and Prevention, 2022 ). Moreover, these people tend to have trouble with insulin dosing and managing diabetes ( U.S. Department of Health and Human Services, 2010 , 2014 ).