Factors influencing preference of insulin regimen in people with type 1 (insulin-dependent) diabetes

Socio-economic status and mortality in people with type 1 diabetes in Scotland 2006-2015: a retrospective cohort study

AIMS

To describe the association between socio-economic status and mortality in a nation-wide cohort of people with type 1 diabetes in Scotland and to compare patterns over time and with the general population.

METHODS

A retrospective cohort study was performed using data for people with type 1 diabetes from a population-based register linked to mortality records. Socio-economic status was derived from quintiles of an area-based measure: the Scottish Index of Multiple Deprivation. Sex-specific directly age-standardized mortality rates for each Scottish Index of Multiple Deprivation quintile and rate ratios comparing the most vs least deprived quintile were calculated for two time periods: 2006-2010 and 2011-2015. Data for the population without type 1 diabetes between 2011 and 2015 were available for comparison.

RESULTS

Data for 3802 deaths among 33 547 people with type 1 diabetes were available. The age-standardized mortality rate per 1000 person-years decreased over time (from 2006-2010 to 2011-2015) for men and women with type 1 diabetes: 24.8 to 20.2 and 22.5 to 17.6, respectively. Mortality in populations with and without type 1 diabetes was generally higher for men than women and was inversely associated with socio-economic status. Rate ratios for the most vs least deprived groups increased over time among people with type 1 diabetes (men: 2.49 to 2.81; women: 1.92 to 2.86) and were higher than among populations without type 1 diabetes in 2011-2015 (men: 2.06; women: 1.66).

CONCLUSIONS

Socio-economic deprivation was associated with a steeper mortality gradient in people with type 1 diabetes than in the population without type 1 diabetes in Scotland. Age-standardized mortality has decreased over time but socio-economic inequalities may be increasing.

Socioeconomic inequalities in mortality, morbidity and diabetes management for adults with type 1 diabetes: A systematic review

Aims

To systematically review the evidence of socioeconomic inequalities for adults with type 1 diabetes in relation to mortality, morbidity and diabetes management.

Methods

We carried out a systematic search across six relevant databases and included all studies reporting associations between socioeconomic indicators and mortality, morbidity, or diabetes management for adults with type 1 diabetes. Data extraction and quality assessment was undertaken for all included studies. A narrative synthesis was conducted.

Results

A total of 33 studies were identified. Twelve cohort, 19 cross sectional and 2 case control studies met the inclusion criteria. Regardless of healthcare system, low socioeconomic status was associated with poorer outcomes. Following adjustments for other risk factors, socioeconomic status was a statistically significant independent predictor of mortality in 9/10 studies and morbidity in 8/10 studies for adults with type 1 diabetes. There appeared to be an association between low socioeconomic status and some aspects of diabetes management. Although only 3 of 16 studies made adjustments for confounders and other risk factors, poor diabetes management was associated with lower socioeconomic status in 3/3 of these studies.

Conclusions

Low socioeconomic status is associated with higher levels of mortality and morbidity for adults with type 1 diabetes even amongst those with access to a universal healthcare system. The association between low socioeconomic status and diabetes management requires further research given the paucity of evidence and the potential for diabetes management to mitigate the adverse effects of low socioeconomic status.

Obedience and motivation as mechanisms for adherence to medication: a study in obese type 2 diabetic patients

OBJECTIVE

To clarify the mechanisms of adherence.

METHODS

A cross-sectional, multicenter French study using a self-questionnaire administered by 116 general practitioners to 782 obese type 2 diabetic patients.

RESULTS

The analysis of 670 completed questionnaires revealed a strong association between the adherence to medication and the behavior of fastening the seatbelt when seated in the rear of a car. Multivariate analysis indicated that this behavior was an independent determinant of adherence to medication (odds ratio [OR] 2.3, 95% confidence interval [CI] 1.4-3.6, P < 0.001) with the same OR as the motivation to adhere to medical prescriptions (OR 2.2, 95% CI 1.3-3.6, P = 0.003) in a model with good accuracy (area under the receiver operating characteristic curve 0.774). A multiple correspondence analysis suggested that adherence to medication and seatbelt behavior are "homologous" behaviors, with homology between phenomena defined by the fact that they share a common etiology.

CONCLUSION

ADHERENCE MAY HAVE TWO DIMENSIONS: passive (obedience, the main determinant of seatbelt behavior) and active (motivation). This conclusion has theoretical and practical implications. Firstly, empowerment through patient education can be defined as a process that replaces the passive mechanism of adherence in patients' minds with an active, conscious choice. Secondly, recognizing these two dimensions may help to establish a tailored patient-physician relationship to prevent nonadherence.

Is there an impatience genotype leading to non-adherence to long-term therapies?

In chronic diseases such as diabetes, adherence to therapy aims to preserve health, which is a long-term objective, whereas non-adherence tends to present an immediate 'reward'. We propose that non-adherence, like addiction, is at least in part due to the fact that, for physiological, and maybe genetic reasons described in a new field, neuroeconomics, a number of people have a taste for the present rather than the future. Thus, for 'impatient patients' it is natural not to adhere to therapeutic prescriptions that share the characteristic of being future-oriented. This hypothesis may apply to any disease requiring long-term therapy.