The Impact of Neighborhood Deprivation on Glycemic Control for Patients with Type 2 Diabetes During Pregnancy

Implementing point-of-care hemoglobin A1C testing in an obstetrics outpatient clinic

BACKGROUND

A1C ≥6.0% is associated with increased risk of adverse outcomes in pregnant diabetic patients. A1C testing is recommended by the American Diabetes Association as a secondary measure of glycemic control in pregnant patients.

OBJECTIVE

To determine the utility of A1C point-of-care testing (POCT) during pregnancy to facilitate rapid counseling and diabetes care, particularly in relatively low-income transient patient populations.

METHODS

We performed a single-center, retrospective analysis of patients presenting to an outpatient obstetrics office with routine, in-laboratory A1C testing, before and after the implementation of POCT for A1C (n = 70 and n = 75, respectively). Demographics, results, physician referral to a nutritionist, counseling, and outcomes were retrieved from patient electronic medical records.

RESULTS

In total, 9% and 23% of the in-laboratory and POCT groups, respectively, were referred for nutrition services (P = .02). Of these, 22% of the in-laboratory group and 42% of the POCT group received immediate counseling (P < .01). An inverse correlation was observed between A1C level at study entry and gestational weeks at delivery, with a Pearson r value of -0.39 (-0.58 to -0.16) for the in-laboratory group and -0.38 (-0.57 to -0.14) for the POCT group. No statistically significant difference in pregnancy outcomes was observed.

CONCLUSION

Implementation of A1C POCT was associated with immediate counseling and management of the health of pregnant patients, but was not associated with improved outcomes, in a low-resource patient population.

An Integrative Review of Social Determinants of Glycemic Targets Achievement in Adults with Type 2 Diabetes in the United States

Several individual social determinants of health have been identified as significant factors contributing to achieving glycemic targets (glycated hemoglobin < 7). However, it remains unclear how these social variables individually or collectively contribute to glycemic targets among adults with type 2 diabetes (T2D) in the United States (U.S.) The purpose of the current integrative review (IR) was to describe and synthesize findings from studies on social determinants of glycemic target achievement in adults with T2D in the U.S. and integrate them into the United States Department of Health and Human Services Conceptual Framework. The databases searched included PubMed, CINAHL Plus with Full Text, Medline with Full Text [EBSCO], Google Scholar, bibliography, and hand searching. A total of 948 records were identified. After excluding duplicates and irrelevant studies based on inclusion and exclusion criteria through title, abstract, and full-text screening, 13 studies were finally included in this IR. The results revealed that race/ethnicity, economic access and stability, educational access and quality, healthcare access and quality, neighborhood and built environment, and social and community context contribute to glycemic target achievement among adult patients with T2D in the U.S. Integrating findings from key studies on social determinants of glycemic health may contribute to developing interventions aimed at reducing and eventually eradicating health disparities for individuals with and at risk for T2D in the U.S.

The Childhood Opportunity Index's Association with Adverse Pregnancy and Newborn Outcomes in Nulliparous Persons

OBJECTIVE

 The objective of the study was to determine if using a novel measure of social determinants of health, the Childhood Opportunity Index (COI), at the time of delivery was associated with development of adverse pregnancy outcomes (APO) in nulliparous pregnant persons.

STUDY DESIGN

 Data were extracted from the 779 participants from a single nuMoM2b (Nulliparous Pregnancy Outcomes Study: monitoring mothers-to-be) study site, a prospective cohort study designed to identify contributors to APOs. Residential address information at delivery was linked to the location's COI. The overall composite and component scores in education, health and environmental, and socioeconomic indices were recorded. APOs of interest included preterm birth, hypertensive disorders of pregnancy, small for gestational age at birth, stillbirth, and gestational diabetes. Participant characteristics were compared by COI category and the association of COI with APOs was analyzed by logistic regression, controlling for age and self-reported race/ethnicity.

RESULTS

 The overall COI distribution was very low (45%), low (17%), moderate (10%), high (15%), and very high (13%). A total of 329 (43.5%) participants experienced at least one APO. Overall COI was associated with developing an APO (p = 0.02). Each component score was also associated with developing APOs and with race/ethnicity (p < 0.05). Compared with higher COI categories, an overall low or very low categorized location was independently associated with developing an APO (odds ratio: 1.636, 95% confidence interval: 1.16-2.31). Adjusting for gestational age at birth, those in lower COI areas had newborns with lower birth weight, birth length, and head circumference (estimate [95% confidence interval] birth weight: -0.0005 g [-0.0008 to -0.0001]; length: -0.065 cm [-0.124 to -0.0091]; head circumference: -0.123 cm [-0.208 to -0.045]). COI was not associated with other newborn outcomes.

CONCLUSION

 COI, a marker for social determinants of health, is independently associated with APOs. The COI may be a tool for risk stratification for pregnant people to help with APO-reducing strategies.

KEY POINTS

· The COI is a neighborhood-level marker for social determinants of health.. · The COI at time of delivery is associated with APO and newborn birth weight, length, and head circumference.. · The COI may be usable in pregnancy clinics to help identify resource needs to optimize outcomes for pregnant individuals and newborns..

Community-level social determinants of health and pregestational and gestational diabetes

BACKGROUND

Individual adverse social determinants of health are associated with increased risk of diabetes in pregnancy, but the relative influence of neighborhood or community-level social determinants of health is unknown.

OBJECTIVE

This study aimed to determine whether living in neighborhoods with greater socioeconomic disadvantage, food deserts, or less walkability was associated with having pregestational diabetes and developing gestational diabetes.

STUDY DESIGN

We conducted a secondary analysis of the prospective Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-To-Be. Home addresses in the first trimester were geocoded at the census tract level. The exposures (modeled separately) were the following 3 neighborhood-level measures of adverse social determinants of health: (1) socioeconomic disadvantage, defined by the Area Deprivation Index and measured in tertiles from the lowest tertile (ie, least disadvantage [T1]) to the highest (ie, most disadvantage [T3]); (2) food desert, defined by the United States Department of Agriculture Food Access Research Atlas (yes/no by low income and low access criteria); and (3) less walkability, defined by the Environmental Protection Agency National Walkability Index (most walkable score [15.26-20.0] vs less walkable score [<15.26]). Multinomial logistic regression was used to model the odds of gestational diabetes or pregestational diabetes relative to no diabetes as the reference, adjusted for age at delivery, chronic hypertension, Medicaid insurance status, and low household income (<130% of the US poverty level).

RESULTS

Among the 9155 assessed individuals, the mean Area Deprivation Index score was 39.0 (interquartile range, 19.0-71.0), 37.0% lived in a food desert, and 41.0% lived in a less walkable neighborhood. The frequency of pregestational and gestational diabetes diagnosis was 1.5% and 4.2%, respectively. Individuals living in a community in the highest tertile of socioeconomic disadvantage had increased odds of entering pregnancy with pregestational diabetes compared with those in the lowest tertile (T3 vs T1: 2.6% vs 0.8%; adjusted odds ratio, 2.52; 95% confidence interval, 1.41-4.48). Individuals living in a food desert (4.8% vs 4.0%; adjusted odds ratio, 1.37; 95% confidence interval, 1.06-1.77) and in a less walkable neighborhood (4.4% vs 3.8%; adjusted odds ratio, 1.33; 95% confidence interval, 1.04-1.71) had increased odds of gestational diabetes. There was no significant association between living in a food desert or a less walkable neighborhood and pregestational diabetes, or between socioeconomic disadvantage and gestational diabetes.

CONCLUSION

Nulliparous individuals living in a neighborhood with higher socioeconomic disadvantage were at increased odds of entering pregnancy with pregestational diabetes, and those living in a food desert or a less walkable neighborhood were at increased odds of developing gestational diabetes, after controlling for known covariates.

Area Deprivation Index Predicts Mortality for Critically Ill Surgical Patients With Sepsis

Background: The impact of socioeconomic status on outcomes after sepsis has been challenging to define, and no polysocial metric has been shown to predict mortality in sepsis. The primary objective of this study was to evaluate the association between the Area Deprivation Index (ADI) and mortality in patients admitted to the surgical intensive care unit (SICU) with sepsis. Patients and Methods: All patients admitted to the SICU with sepsis (Sequential Organ Failure Assessment [SOFA] score ≥2) were retrospectively reviewed. The ADI scores were obtained and classified as "high ADI" (≥85th percentile, n = 400, representative of high socioeconomic deprivation) and "control ADI" (ADI <85th percentile, n = 976). Baseline demographic and clinical characteristics were compared between groups. The primary outcome was 90-day mortality. Results: High ADI patients were younger (mean age 58.5 vs. 60.8; p = 0.01) and more likely to be non-white (23.7% vs. 10.0%; p < 0.0005) and to present with chronic obstructive pulmonary disease (26.5% vs. 19.0%; p = 0.002). High ADI patients had increased in-hospital (27.3% vs. 21.6%; p = 0.025) and 90-day mortality (35.0% vs. 28.9%; p = 0.03). High ADI patients also had increased rates of renal failure (20.3% vs. 15.3%; p = 0.02). Both cohorts had similar intensive care unit (ICU) lengths of stay and median hospital stay, Charlson comorbidity index, and rate of discharge to home. High ADI is an independent risk factor for 90-day mortality after admission for surgical sepsis (odds ratio [OR], 1.39 ± 0.24; p = 0.014). Conclusions: High ADI is an independent predictor of 90-day mortality in patients with surgical sepsis. Targeted community interventions are needed to reduce sepsis mortality for these at-risk patients.