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Simba S, Von Oettingen JE, Rahme E, Ladd JM, Nakhla M, Li P. Socioeconomic Disparities in Glycemic Management in Children and Youth With Type 1 Diabetes: A Retrospective Cohort Study. Can J Diabetes 2023; 47:658-664.e2. [PMID: 37481125 DOI: 10.1016/j.jcjd.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 07/12/2023] [Accepted: 07/12/2023] [Indexed: 07/24/2023]
Abstract
OBJECTIVE In Canada, few studies have addressed health inequalities in type 1 diabetes (T1D) outcomes. In this study, we examined the relationship between socioeconomic status (SES) and glycemic management in children with T1D and determine whether technology use (insulin pumps or continuous glucose monitoring [CGM]), diabetes-related physician visits, and depressive symptoms modified the association. METHODS This work was a retrospective cohort study using the Montréal Children's Hospital Pediatric Diabetes Database of children 0 to 18 years old, diagnosed with T1D for ≥1 year, and with a hospital visit between November 2019 and October 2020. Main exposure was SES measured by the Material and Social Deprivation Index (least, moderately, or most deprived). We determined the association between SES and mean glycated hemoglobin (A1C; main outcome) in the year after the index visit using multivariable linear regression, adjusting for age, sex, diabetes duration, technology use, diabetes-related physician visits, and depressive symptoms (subgroup). We examined interaction terms for technology use, diabetes-related physician visits, and depressive symptoms. RESULTS The study cohort included 306 children (mean age 13.6 years, mean A1C 8.5%). Children in the most-deprived compared with least-deprived quintiles had higher mean A1C; effect modification was significant with CGM only. Children not using CGM in the most-deprived compared with least-deprived quintiles had higher mean A1C (0.52%; 95% confidence interval, 0.14% to 0.86%), whereas the association was not significant for children using CGM. CONCLUSIONS Lower SES was associated with higher A1C; these disparities were not observed among CGM users. Further research is required to determine strategies to promote CGM access among children of lower SES in the Canadian health-care context.
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Affiliation(s)
- Suzanne Simba
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Québec, Canada
| | - Julia E Von Oettingen
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Québec, Canada; Department of Pediatrics, McGill University, Montréal, Québec, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montréal, Québec, Canada
| | - Elham Rahme
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Québec, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montréal, Québec, Canada; Department of Medicine, McGill University, Montréal, Québec, Canada
| | - Jennifer M Ladd
- Division of Pediatric Endocrinology, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, United States
| | - Meranda Nakhla
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Québec, Canada; Department of Pediatrics, McGill University, Montréal, Québec, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montréal, Québec, Canada
| | - Patricia Li
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Québec, Canada; Department of Pediatrics, McGill University, Montréal, Québec, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montréal, Québec, Canada.
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Laporte R, Babe P, Jouve E, Daguzan A, Mazoue F, Minodier P, Noel G, Urbina D, Gentile S. Developing and Validating an Individual-Level Deprivation Index for Children's Health in France. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:16949. [PMID: 36554830 PMCID: PMC9816939 DOI: 10.3390/ijerph192416949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 12/01/2022] [Accepted: 12/10/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND Deprivation generates many health inequalities. This has to be taken in account to enhance appropriate access to care. This study aimed to develop and validate a pediatric individual-level index measuring deprivation, usable in clinical practice and in public health. METHODS The French Individual Child Deprivation Index (FrenChILD-Index) was designed in four phases: item generation then reduction using the literature review and expert opinions, and index derivation then validation using a cross-sectional study in two emergency departments. During these last two phases, concordance with a blinded evaluation by an expert enabled us to determine thresholds for two levels of moderate and severe deprivation. RESULTS The generation and reduction phases retained 13 items. These were administered to 986 children for the derivation and validation phases. In the validation phase, the final 12 items of the FrenChILD-Index showed for moderate deprivation (requiring single specific care for deprived children) a sensitivity of 96.0% [92.6; 98.7] and specificity of 68.3% [65.2; 71.4]. For severe deprivation (requiring a multidisciplinary level of care), the sensitivity was 96.3% [92.7; 100] and specificity was 91.1% [89.2; 92.9]. CONCLUSIONS The FrenChILD-Index is the first pediatric individual-level index of deprivation validated in Europe. It enables clinical practice to address the social determinants of health and meet public health goals.
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Affiliation(s)
- Remi Laporte
- Permanence d’Accès aux Soins de Santé Mère-Enfant, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, 13005 Marseille, France
- Equipe de Recherche EA 3279 “Santé Publique, Maladies Chroniques et Qualité de Vie”, Faculté de Médecine, Aix Marseille University, 13005 Marseille, France
- Service d’Accueil des Urgences Pédiatriques, Hôpital Nord, APHM, 13005 Marseille, France
| | - Philippe Babe
- Permanence d’Accès aux Soins de Santé Pédiatrique, Hôpitaux Pédiatriques de Nice CHU-Lenval, 06200 Nice, France
- Service d’Accueil des Urgences Pédiatriques, Hôpitaux Pédiatriques de Nice CHU-Lenval, 06200 Nice, France
| | - Elisabeth Jouve
- Service d’Evaluation Medicale, Assistance Publique-Hôpitaux de Marseille, 13005 Marseille, France
| | - Alexandre Daguzan
- Equipe de Recherche EA 3279 “Santé Publique, Maladies Chroniques et Qualité de Vie”, Faculté de Médecine, Aix Marseille University, 13005 Marseille, France
- Service d’Evaluation Medicale, Assistance Publique-Hôpitaux de Marseille, 13005 Marseille, France
| | - Franck Mazoue
- Equipe de Recherche EA 3279 “Santé Publique, Maladies Chroniques et Qualité de Vie”, Faculté de Médecine, Aix Marseille University, 13005 Marseille, France
| | - Philippe Minodier
- Service d’Accueil des Urgences Pédiatriques, Hôpital Nord, APHM, 13005 Marseille, France
| | - Guilhem Noel
- Service d’Accueil des Urgences Pédiatriques, Hôpital Nord, APHM, 13005 Marseille, France
| | - Diego Urbina
- Service d’Accueil des Urgences Pédiatriques, Hôpital Nord, APHM, 13005 Marseille, France
| | - Stephanie Gentile
- Equipe de Recherche EA 3279 “Santé Publique, Maladies Chroniques et Qualité de Vie”, Faculté de Médecine, Aix Marseille University, 13005 Marseille, France
- Service d’Evaluation Medicale, Assistance Publique-Hôpitaux de Marseille, 13005 Marseille, France
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Catherine JP, Russell MV, Peter CH. The impact of race and socioeconomic factors on paediatric diabetes. EClinicalMedicine 2021; 42:101186. [PMID: 34805811 PMCID: PMC8585622 DOI: 10.1016/j.eclinm.2021.101186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 08/12/2021] [Accepted: 10/19/2021] [Indexed: 12/16/2022] Open
Abstract
There are over 29,000 children and young people (CYP) with Type 1 diabetes mellitus (T1DM) in England and Wales and another 726 with Type 2 diabetes mellitus (T2DM). There is little effect of deprivation on the prevalence of T1DM whereas the association of deprivation on the percentage of CYP with T2DM is striking with 45% of cases drawn from the most deprived backgrounds. A number that has not changed over the last 4 years. Data from the UK and USA as well as other countries demonstrate the impact of deprivation on outcomes in diabetes mellitus with clear effects on measures of long-term control and complications. In the UK black CYP had higher glycosylated haemoglobin (HbA1c) values compared to other groups. Within the black group, CYP from a Caribbean background had a higher mean HbA1c (77.0 mmol/mol (9.2%)) than those from Africa (70.4 mmol/mol (8.6%)). Treatment regimen (multiple daily injections or insulin pump therapy) explained the largest proportion of the variability in HbA1c followed by deprivation. Those in the least deprived areas had an average HbA1c 5.88 mmol/mol (0.5%) lower than those living in the most deprived areas. The picture is complex as UK data also show that deprivation and ethnicity is associated with less use of technology that is likely to improve diabetes control. Increased usage of pump therapy and continuous glucose monitoring was associated with a younger age of patient (less than 10 years of age), living in the least deprived areas and white ethnicity. This gap between pump usage amongst CYP with T1DM living in the most and least deprived areas has widened with time. In 2014/15 the gap was 7.9% and by 2018/19 had increased to 13.5%. To attain an equitable service for CYP with diabetes mellitus we need to consider interventions at the patient, health care professional, community, and health care system levels.
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Dos Santos TJ, Donado Campos JDM, Argente J, Rodríguez-Artalejo F. Effectiveness and equity of continuous subcutaneous insulin infusions in pediatric type 1 diabetes: A systematic review and meta-analysis of the literature. Diabetes Res Clin Pract 2021; 172:108643. [PMID: 33359572 DOI: 10.1016/j.diabres.2020.108643] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 12/03/2020] [Accepted: 12/18/2020] [Indexed: 12/28/2022]
Abstract
AIMS We conducted a systematic review and meta-analysis of randomized controlled trials (RCT) and non-randomized studies (NRS) to assess the effectiveness and equity of continuous subcutaneous insulin infusions (CSII) versus multiple-daily injections (MDI) on glycemic outcomes. METHODS Searches were conducted between 2000 and 2019 in MEDLINE, CENTRAL, EMBASE and HTA. Included studies compared the CSII vs MDI in children and young people (CYP) ≤ 20 years with type 1 diabetes. Two independent reviewers screened the articles, extracted the data, assessed the risk of bias, evaluated the quality of evidence, and identified equity data. Results were pooled with a random-effects model. RESULTS Of the 578 articles screened, 16 RCT (545 CYP on CSII) and 70 NRS (73253 on CSII) were included in the meta-analysis. There was moderate-level evidence that the CSII lower HbA1c in RCT (pooled mean difference [MD]: -0.22%; 95% confidence interval [CI]: -0.33, -0.11%; I2:34%) and insufficient in NRS (pooled MD: -0.45%; 95%CI: -0.52, -0.38%; I2:99%). The pooled incidence rate ratio of severe hypoglycemia on CSII vs MDI in RCT was 0.87 (95%CI: 0.55, 1.37; I2:0%; low-level evidence), and 0.71 (95%CI: 0.63, 0.81; I2:57%, insufficient evidence) in NRS. Health-related quality of life presented insufficient evidence. Equity data were scarcely reported. CONCLUSIONS CSII modestly lower HbA1c when compared with MDI. Current literature does not provide adequate data on other glycemic outcomes. Future assessment on diabetes technology should include individual and area-level socioeconomic data. The study protocol was pre-registered in PROSPERO (CRD42018116474).
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Affiliation(s)
- Tiago Jeronimo Dos Santos
- Department of Preventive Medicine and Public Health, School of Medicine, Universidad Autónoma de Madrid/IdiPAZ, Madrid, Spain; Departments of Pediatrics & Pediatric Endocrinology, Hospital Infantil Universitario Niño Jesús, Research Institute "La Princesa", Madrid, Spain.
| | - Juan de Mata Donado Campos
- Department of Preventive Medicine and Public Health, School of Medicine, Universidad Autónoma de Madrid/IdiPAZ, Madrid, Spain; Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain
| | - Jesús Argente
- Departments of Pediatrics & Pediatric Endocrinology, Hospital Infantil Universitario Niño Jesús, Research Institute "La Princesa", Madrid, Spain; Department of Pediatrics, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain; Centro de Investigación Biomédica en Red de Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain; IMDEA Food Institute, CEIUAM+CSI, Madrid, Spain.
| | - Fernando Rodríguez-Artalejo
- Department of Preventive Medicine and Public Health, School of Medicine, Universidad Autónoma de Madrid/IdiPAZ, Madrid, Spain; Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain; IMDEA Food Institute, CEIUAM+CSI, Madrid, Spain.
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Auzanneau M, Lanzinger S, Bohn B, Kroschwald P, Kuhnle-Krahl U, Holterhus PM, Placzek K, Hamann J, Bachran R, Rosenbauer J, Maier W. Area Deprivation and Regional Disparities in Treatment and Outcome Quality of 29,284 Pediatric Patients With Type 1 Diabetes in Germany: A Cross-sectional Multicenter DPV Analysis. Diabetes Care 2018; 41:2517-2525. [PMID: 30327359 DOI: 10.2337/dc18-0724] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 09/12/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE This study analyzed whether area deprivation is associated with disparities in health care of pediatric type 1 diabetes in Germany. RESEARCH DESIGN AND METHODS We selected patients <20 years of age with type 1 diabetes and German residence documented in the "diabetes patient follow-up" (Diabetes-Patienten-Verlaufsdokumentation [DPV]) registry for 2015/2016. Area deprivation was assessed by quintiles of the German Index of Multiple Deprivation (GIMD 2010) at the district level and was assigned to patients. To investigate associations between GIMD 2010 and indicators of diabetes care, we used multivariable regression models (linear, logistic, and Poisson) adjusting for sex, age, migration background, diabetes duration, and German federal state. RESULTS We analyzed data from 29,284 patients. From the least to the most deprived quintile, use of continuous glucose monitoring systems (CGMS) decreased from 6.3 to 3.4% and use of long-acting insulin analogs from 80.8 to 64.3%, whereas use of rapid-acting insulin analogs increased from 74.7 to 79.0%; average HbA1c increased from 7.84 to 8.07% (62 to 65 mmol/mol), and the prevalence of overweight from 11.8 to 15.5%, but the rate of severe hypoglycemia decreased from 12.1 to 6.9 events/100 patient-years. Associations with other parameters showed a more complex pattern (use of continuous subcutaneous insulin infusion [CSII]) or were not significant. CONCLUSIONS Area deprivation was associated not only with key outcomes in pediatric type 1 diabetes but also with treatment modalities. Our results show, in particular, that the access to CGMS and CSII could be improved in the most deprived regions in Germany.
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Affiliation(s)
- Marie Auzanneau
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany .,German Center for Diabetes Research (DZD), Neuherberg, Germany
| | - Stefanie Lanzinger
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany.,German Center for Diabetes Research (DZD), Neuherberg, Germany
| | - Barbara Bohn
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany.,German Center for Diabetes Research (DZD), Neuherberg, Germany
| | - Peter Kroschwald
- Children's Hospital, Ruppiner Kliniken GmbH, Hochschulklinikum der Medizinischen Hochschule Brandenburg, Neuruppin, Germany
| | | | - Paul Martin Holterhus
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, University Hospital of Schleswig-Holstein, Campus Kiel/Christian-Albrechts University of Kiel, Kiel, Germany
| | - Kerstin Placzek
- Pediatric and Adolescent Medicine, University Hospital, Martin-Luther University, Halle, Germany
| | - Johannes Hamann
- Department of Pediatrics, St. Marien Hospital Landshut, Landshut, Germany
| | | | - Joachim Rosenbauer
- German Center for Diabetes Research (DZD), Neuherberg, Germany.,Institute for Biometrics and Epidemiology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University, Düsseldorf, Germany
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Mazarello Paes V, Charalampopoulos D, Edge J, Taylor-Robinson D, Stephenson T, Amin R. Predictors of glycemic control in the first year of diagnosis of childhood onset type 1 diabetes: A systematic review of quantitative evidence. Pediatr Diabetes 2018; 19:18-26. [PMID: 28488346 DOI: 10.1111/pedi.12530] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Revised: 02/28/2017] [Accepted: 03/28/2017] [Indexed: 12/14/2022] Open
Abstract
Early glycemic control is associated with reduced future vascular complications risk in type 1 diabetes (T1D). The aim of this study was to systematically review evidence on the predictors of glycemic control within 12 months of diagnosis of childhood onset T1D. Inclusion criteria for the electronic search were: interventional and observational studies that assessed and quantified an association between the predictor and glycemic control within 12 months of diagnosis of childhood onset T1D. A total of 17 915 articles were identified from 6 databases and 20 studies were finally included in the analysis. Harvest plots and narrative synthesis were used to summarize data from intervention (n = 0), prospective/retrospective cohort (n = 15), and cross-sectional (n = 5) studies. Significant predictors of poorer glycemic control 0 to 3 months after diagnosis were older age and female gender. Non-white ethnicity, diabetes autoantibody positivity, measures of deprivation, and non-private health insurance were potential predictors. Predictors of poorer glycemic control 4 to 12 months after diagnosis were: older age, non-white ethnicity, a single parent family, high hemoglobin A1c (HbA1c) levels at diagnosis, longer T1D duration, and non-intensive insulin therapy. Potential predictors included: family with health issues, clinical factors, and comorbidities at diagnosis. Most significant predictors of poor glycemic control within 12 months of diagnosis of childhood onset T1D are non-modifiable. These factors need to be recognized and addressed through individualized and multidisciplinary diabetes care. Further research is required to confirm the association of potential predictors with early glycemic control.
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Affiliation(s)
- Veena Mazarello Paes
- Children's Policy Research Unit, Great Ormond Street Institute of Child Health, University College London, London, UK.,Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Dimitrios Charalampopoulos
- Children's Policy Research Unit, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Julie Edge
- Department of Paediatric Endocrinology and Diabetes, University of Oxford, Oxford, UK
| | - David Taylor-Robinson
- Children's Policy Research Unit, Great Ormond Street Institute of Child Health, University College London, London, UK.,Department of Public Health and Policy, University of Liverpool, Liverpool, UK
| | - Terence Stephenson
- Children's Policy Research Unit, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Rakesh Amin
- Children's Policy Research Unit, Great Ormond Street Institute of Child Health, University College London, London, UK
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Clarke ABM, Daneman D, Curtis JR, Mahmud FH. Impact of neighbourhood-level inequity on paediatric diabetes care. Diabet Med 2017; 34:794-799. [PMID: 28164370 DOI: 10.1111/dme.13326] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/31/2017] [Indexed: 11/29/2022]
Abstract
AIMS To evaluate the association between neighbourhood-level inequity and glycaemic control in paediatric participants with Type 1 diabetes using the Neighbourhood Equity Index (NEI). METHODS The NEI was linked to the clinical data of 519 children with diabetes followed at the Hospital for Sick Children (Toronto, Canada). The NEI is a composite measure of inequity developed using the World Health Organization's Urban Health Equity Assessment and Response Tool (HEART), which encompasses 15 weighted indicators evaluating economic, social, environmental and lifestyle factors. The geographic distribution of participants was determined using postal codes, and the relationship between HbA1c and NEI was evaluated using regression and spatial analysis techniques. RESULTS Participants' mean HbA1c was significantly correlated with NEI (R = -0.24, P < 0.0001). Regression analysis demonstrated that NEI was a strong predictor of mean HbA1c (P < 0.0001), accounting for differences in HbA1c as large as 1.0% (11 mmol/mol) when controlled for age, sex, diabetes duration, insulin pump therapy and number of annual clinic visits. Geo-mapping using spatial scan testing revealed the presence of two clusters of low-equity neighbourhoods containing 3.22 (P = 0.001) and 2.83 (P = 0.02) times more participants with HbA1c ≥ 9.5% (80 mmol/mol) than expected. CONCLUSIONS Our findings demonstrated that NEI was a significant predictor of HbA1c in our clinic population and a useful tool for investigating spatial trends related to inequities in health, providing evidence that a composite, area-based measure of overall inequity is well suited to the study of glycaemic control in urban paediatric Type 1 diabetes populations.
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Affiliation(s)
- A B M Clarke
- Division of Endocrinology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - D Daneman
- Division of Endocrinology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - J R Curtis
- Division of Endocrinology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - F H Mahmud
- Division of Endocrinology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
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McKergow E, Parkin L, Barson DJ, Sharples KJ, Wheeler BJ. Demographic and regional disparities in insulin pump utilization in a setting of universal funding: a New Zealand nationwide study. Acta Diabetol 2017; 54:63-71. [PMID: 27650535 DOI: 10.1007/s00592-016-0912-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 09/01/2016] [Indexed: 10/21/2022]
Abstract
AIMS Insulin pumps have been publically funded in New Zealand since 2012 for patients who meet certain clinical criteria; however, the patterns of utilization have not been described. We undertook a nationwide study to estimate the annual proportions of patients with type 1 diabetes mellitus who used a pump between 2012 and 2014, overall, and according to sex, age, ethnicity, socioeconomic position, and region. METHODS We used data from the New Zealand Virtual Diabetes Register and routinely collected national demographic, health, and pharmaceutical dispensing data from the Ministry of Health to identify patients with type 1 diabetes and to calculate the overall, and subgroup, proportions using pumps. RESULTS Between 2012 and 2014, funded pump use among patients with type 1 diabetes (n = 13,727) increased from 1.8 to 9.3 % overall; however, there were differences in uptake according to demographic characteristics and region. In 2014, proportionate pump use was significantly higher in females versus males (adjusted odds ratio (OR) 2.0 [95 % confidence interval 1.8-2.3]), in those aged <20 years, and in some regions. Māori (indigenous people), Pacific, and Asian patients were significantly less likely to use pumps than New Zealand Europeans (ORs 0.30 [0.23-0.41], 0.26 [0.14-0.46], 0.22 [0.14-0.35], respectively), as were those in the most versus the least deprived socioeconomic decile (OR 0.36 [0.25-0.52]). CONCLUSIONS It is essential to explore the factors driving differential insulin pump uptake, in both New Zealand and elsewhere, if all patients are to have equal opportunity to benefit from intensive diabetes management.
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Affiliation(s)
- Erin McKergow
- Dunedin School of Medicine, University of Otago, P.O. Box 56, Dunedin, 9054, New Zealand
| | - Lianne Parkin
- Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, P.O. Box 56, Dunedin, 9054, New Zealand.
| | - David J Barson
- Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, P.O. Box 56, Dunedin, 9054, New Zealand
| | - Katrina J Sharples
- Department of Mathematics and Statistics, University of Otago, P.O. Box 56, Dunedin, 9054, New Zealand
| | - Benjamin J Wheeler
- Department of Women's and Children's Health, Dunedin School of Medicine, University of Otago, P.O. Box 56, Dunedin, 9054, New Zealand
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Khanolkar AR, Amin R, Taylor-Robinson D, Viner RM, Warner JT, Stephenson T. Young people with Type 1 diabetes of non-white ethnicity and lower socio-economic status have poorer glycaemic control in England and Wales. Diabet Med 2016; 33:1508-1515. [PMID: 26802317 DOI: 10.1111/dme.13079] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/19/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND The impact of ethnicity and socio-economic status (SES) on glycaemic control during childhood Type 1 diabetes is poorly understood in England and Wales. METHODS We studied 18 478 children with Type 1 diabetes (< 19 years) attending diabetes clinics and included in the 2012-2013 National Paediatric Diabetes Audit. Self-identified ethnicity was categorized as white, Asian, black, mixed, other and 'not-stated' (did not to divulge ethnicity). A small area measure of SES was estimated from the Index of Multiple Deprivation. Multiple linear regression was used to assess associations between ethnicity, SES and glycaemic control (mean HbA1c levels) accounting for age, gender and diabetes duration. The impact of insulin pump use on the ethnicity/SES-HbA1c associations was tested in 13 962 children. RESULTS All children from minority ethnic groups had higher mean HbA1c compared with white children, with largest differences observed in black and mixed ethnicities [8 mmol/mol (2.9%), 95% CI 5-11 and 7 mmol/mol (2.8%), 95% CI 5-9, respectively]. Lower SES was associated with higher mean HbA1c with a dose effect. The lowest SES group had a mean HbA1c that was 7 mmol/mol (2.8%) (95% CI 6-8) higher compared with the highest SES group, adjusted for ethnicity. Estimates for ethnicity were attenuated, but significant on adjustment for SES. Fewer non-white (white 20.3 vs. black 5.5%) and deprived (least deprived 21.1 vs. most deprived 13.2%) children were on insulin pump therapy. Ethnicity and SES remained significant predictors of HbA1c after accounting for insulin pump use. CONCLUSION The association between ethnicity and glycaemic control persists after adjustment for deprivation and pump use. An alternative approach to intensive insulin therapy might benefit these vulnerable children.
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Affiliation(s)
- A R Khanolkar
- Institute of Child Health, University College London (UCL), London, UK.
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
| | - R Amin
- Institute of Child Health, University College London (UCL), London, UK
| | - D Taylor-Robinson
- Institute of Child Health, University College London (UCL), London, UK
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - R M Viner
- Institute of Child Health, University College London (UCL), London, UK
| | - J T Warner
- Department of Child Health, University Hospital of Wales, Cardiff, UK
| | - T Stephenson
- Institute of Child Health, University College London (UCL), London, UK
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Inman M, Daneman D, Curtis J, Sochett E, Elia Y, Dunger DB, Deanfield J, Mahmud FH. Assessing social determinants of health in a pediatric diabetes clinical research trial: Are recruited subjects representative of the larger clinical population? Diabetes Res Clin Pract 2016; 113:41-3. [PMID: 26972960 DOI: 10.1016/j.diabres.2016.01.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 01/22/2016] [Accepted: 01/26/2016] [Indexed: 10/22/2022]
Abstract
Social determinants of health (SDH) impact clinical outcomes and are often poorly described in research trials. Using a validated tool, SDH dimensions were compared between adolescents enrolled and not enrolled into a large diabetes study. We observed that our study cohort reflected a SDH profile mirroring the eligible population.
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Affiliation(s)
- Mark Inman
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Denis Daneman
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Jacqueline Curtis
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Etienne Sochett
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Yesmino Elia
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - David B Dunger
- Department of Pediatrics, University of Cambridge, Cambridge, UK
| | - John Deanfield
- Institute of Cardiovascular Science, University College Hospital, London, UK
| | - Farid H Mahmud
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.
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Zuijdwijk CS, Cuerden M, Mahmud FH. Social determinants of health on glycemic control in pediatric type 1 diabetes. J Pediatr 2013; 162:730-5. [PMID: 23360562 DOI: 10.1016/j.jpeds.2012.12.010] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Revised: 10/29/2012] [Accepted: 12/04/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To evaluate the relationship between the social determinants of health (SDH) and glycemic control in a large pediatric type 1 diabetes (T1D) population. STUDY DESIGN Deprivation Indices (DI) were used to ascertain population-level measures of socioeconomic status, family structure, and ethnicity in patients with T1D followed at The Hospital for Sick Children August 2010-2011 (n = 854). DI quintile scores were determined for individual patients based on de-identified postal codes, and linked to mean patient A1Cs as a measure of glycemic control. We compared mean A1C between the most and least deprived DI quintiles. Associations were estimated controlling for age and sex, and repeated for insulin pump use. RESULTS The T1D population evaluated in this study was most concentrated in the least and most deprived quintiles of the Material DI. A1C levels were highest in patients with the greatest degree of deprivation (fifth vs first quintile) on the Material DI (9.2% vs 8.3%, P < .0001), Social DI (9.1% vs 8.3%, P < .0001), and Ethnic Concentration Index (8.9% vs 8.4%, P = .03). These relationships between measures of the SDH and A1C were not evident for patients on insulin pumps. On regression analysis, higher A1C was predicted by older age, female sex, not using pump therapy, and being in the most deprived quintile for Material and Social Deprivation, but not Ethnic Concentration. CONCLUSIONS Measures of the SDH comprising Material and Social Deprivation were significantly associated with suboptimal glycemic control in our pediatric T1D cohort. Use of insulin pump therapy also predicted A1C and may have a moderating effect on these relationships.
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Affiliation(s)
- Caroline S Zuijdwijk
- Division of Endocrinology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
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Thompson RJ, Agostini K, Potts L, Luscombe J, Christie D, Viner R, White B, Hindmarsh PC. Deprivation and ethnicity impact on diabetes control and use of treatment regimen. Diabet Med 2013; 30:491-4. [PMID: 22998504 DOI: 10.1111/dme.12023] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/16/2012] [Indexed: 01/29/2023]
Abstract
AIMS Deprivation and/or ethnicity impact on care delivery. We have assessed how these factors influence diabetes care in a paediatric clinic. METHODS We related access to care [type of insulin treatment regimen-twice daily, multiple daily injections and insulin pump therapy (continuous subcutaneous insulin infusion)], measures of care process (HbA(1c)) and an approximate measure of satisfaction with the service (clinic attendance rate) in 325 (170 male) children and young people with Type 1 diabetes (mean age 10.6 years, mean duration of diabetes of 4.5 years), with indices of deprivation and ethnicity. RESULTS Of the 325 children and young people, 2.7% received twice-daily insulin, 48.4% multiple daily injections and 48.9% continuous subcutaneous insulin infusion. Median clinic HbA(1c) was 62 mmol/mol (7.8%) and those receiving the insulin pump therapy had the lowest HbA(1c). Four ethnic groups were represented; White British 81.6%, Asian non-Indian 6.5%, African 8.1% and Asian Indian 3.8%. Mean deprivation score was 21.06. White British and Asian Indian groups were more likely to receive insulin pump therapy (χ(2) = 50.3; P < 0.001). Attendance rates were 94.1% and did not differ across ethnic groups. Deprivation was related to ethnicity and HbA(1c) (R(2) = 0.02; P = 0.02). There was no relationship between clinic attendance and deprivation. Insulin regimen and ethnicity were associated with HbA(1c) (R(2) = 0.096; P < 0.001). Similar findings were obtained when analysis was confined to the White British population. CONCLUSIONS These data suggest that deprivation and ethnicity influence diabetes control and how intensive insulin therapy is utilized. A better consideration of the needs of different ethnic groups is required to ensure equitable care delivery in paediatric diabetes.
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Affiliation(s)
- R J Thompson
- Children and Young People's Diabetes Service, University College London Hospitals, London, UK
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