Mental health visits and low socio-economic status in adolescence are associated with complications of Type 1 diabetes in early adulthood: a population-based cohort study

Measuring Health Equity in Emergency Care Using Routinely Collected Data: A Systematic Review

Introduction: Achieving equity in health care remains a challenge for health care systems worldwide and marked inequities in access and quality of care persist. Identifying health care equity indicators is an important first step in integrating the concept of equity into assessments of health care system performance, particularly in emergency care.

Methods: We conducted a systematic review of administrative data-derived health care equity indicators and their association with socioeconomic determinants of health (SEDH) in emergency care settings. Following PRISMA-Equity reporting guidelines, Ovid MEDLINE, EMBASE, PubMed, and Web of Science were searched for relevant studies. The outcomes of interest were indicators of health care equity and the associated SEDH they examine.

Results: Among 29 studies identified, 14 equity indicators were identified and grouped into four categories that reflect the patient emergency care pathway. Total emergency department (ED) visits and ambulatory care-sensitive condition-related ED visits were the two most frequently used equity indicators. The studies analyzed equity based on seven SEDH: social deprivation, income, education level, social class, insurance coverage, health literacy, and financial and nonfinancial barriers. Despite some conflicting results, all identified SEDH are associated with inequalities in access to and use of emergency care.

Conclusion: The use of administrative data-derived indicators in combination with identified SEDH could improve the measurement of health care equity in emergency care settings across health care systems worldwide. Using a combination of indicators is likely to lead to a more comprehensive, well-rounded measurement of health care equity than using any one indicator in isolation. Although studies analyzed focused on emergency care settings, it seems possible to extrapolate these indicators to measure equity in other areas of the health care system. Further studies elucidating root causes of health inequities in and outside the health care system are needed.

Tryptophan, kynurenine pathway, and diabetic ketoacidosis in type 1 diabetes

Diabetic ketoacidosis (DKA) is a serious complication of complete insulin deficiency and insulin resistance in Type 1 diabetes (T1D). This results in the body producing high levels of serum ketones in an attempt to compensate for the insulin deficiency and decreased glucose utilization. DKA's metabolic and immunologic dysregulation results in gradual increase of systemic and cerebral oxidative stress, along with low grade systemic and cerebral inflammation and the development of pretreatment subclinical BE. During treatment the early progression of oxidative stress and inflammation is hypothesized to advance the possibility of occurrence of crisis of clinical brain edema (BE), which is the most important cause of morbidity and mortality in pediatric DKA. Longitudinal neurocognitive studies after DKA treatment show progressive and latent deficits of cognition and emphasize the need for more effective DKA treatment of this long-standing conundrum of clinical BE, in the presence of systemic osmotic dehydration, metabolic acidosis and immune dysregulation. Candidate biomarkers of several systemic and neuroinflammatory pathways prior to treatment also progress during treatment, such as the neurotoxic and neuroprotective molecules in the well-recognized tryptophan (TRP)/kynurenine pathway (KP) that have not been investigated in DKA. We used LC-MS/MS targeted mass spectrometry analysis to determine the presence and initiation of the TRP/KP at three time points: A) 6-12 hours after initiation of treatment; B) 2 weeks; and C) 3 months following DKA treatment to determine if they might be involved in the pathogenesis of the acute vasogenic complication of DKA/BE. The Trp/KP metabolites TRP, KYN, quinolinic acid (QA), xanthurnenic acid (XA), and picolinic acid (PA) followed a similar pattern of lower levels in early treatment, with subsequent increases. Time point A compared to Time points B and C were similar to the pattern of sRAGE, lactate and pyruvic acid. The serotonin/melatonin metabolites also followed a similar pattern of lower quantities at the early stages of treatment compared to 3 months after treatment. In addition, glutamate, n-acetylglutamate, glutamine, and taurine were all lower at early treatment compared to 3 months, while the ketones 3-hydroxybutaric acid and acetoacetate were significantly higher in the early treatment compared to 3 months. The two major fat metabolites, L-carnitine and acetyl-L-carnitine (ALC) changed inversely, with ALC significantly decreasing at 2 weeks and 3 months compared to the early stages of treatment. Both anthranilic acid (AA) and 3-OH-anthranilic acid (3OH-AA) had overall higher levels in the early stages of treatment (A) compared to Time points (B and C). Interestingly, the levels of AA and 3OH-AA early in treatment were higher in Caucasian females compared to African American females. There were also differences in the metabolite levels of QA and kynurenic acid (KA) between genders and between races that may be important for further development of custom targeted treatments. We hypothesize that the TRP/KP, along with the other inflammatory pathways, is an active participant in the metabolic and immunologic pathogenesis of DKA's acute and chronic insults.

The psychopathology of recurrent diabetic ketoacidosis: A case-control study

BACKGROUND

Despite its poor prognosis, the psychological factors associated with recurrent diabetic ketoacidosis are poorly understood. In people with type 1 diabetes, we assessed for psychopathology in those with and without recurrent diabetic ketoacidosis (DKA).

METHOD

The design was a case-control study. Cases were defined as people with two or more DKA episodes in a 12-month period (recurrent DKA). Cases and controls were matched for gender and age. We compared groups for scores on Beck's Anxiety Inventory (BAI), Beck's Depression Inventory II, Difficulty in Emotion Regulation Scale (DERS), Experiences in Close Relationships-Revised, Standardised Assessment of Personality-Abbreviated Scale (SAPAS), Interpersonal Problem Inventory, Eating Disorder Examination Questionnaire and Problem Areas in Diabetes (PAID) using unpaired t-tests or Mann-Whitney U tests for parametric and non-parametric data, respectively. Correction was made for multiple testing.

RESULTS

In all, 23 cases and 23 controls were recruited with mean age 31.0 (11.4) years and 65.2% were men. Cases had higher HbA_1c levels than controls (101.1 (23.2) vs. 85.7 (21.7) mmol/mol, (p = 0.02)). Compared to controls, people with recurrent DKA had higher scores on the BAI (p = 0.004), PAID (p = 0.004), DERS (p = 0.001) and SAPAS (p < 0.001). Sixteen of 23 (69.6%) cases screened positive for a personality disorder compared to 6 of 23 (26.1%) controls.

CONCLUSIONS

People with recurrent DKA have elevated levels of anxiety and diabetes distress, greater difficulty with emotion regulation and personality dysfunction compared to matched controls.

A province wide review of transition practices for young adult patients with type 1 diabetes

RATIONALE, AIMS, AND OBJECTIVES

Many studies on the transition from paediatric to adult care focus on practices within a single institution or program. We examine the transition for young adults with type 1 diabetes across an entire Canadian province with a small, mostly rural population and high rates of type 1 diabetes: Newfoundland and Labrador (NL). Our aim is to determine how transition is occurring across the jurisdiction and identify methods for improving clinical services for paediatric patients with a chronic condition during their move into adult care.

METHODS

A provincial diabetes database and hospital admission data were reviewed for a cohort of young adults with type 1 diabetes who transitioned into adult care. Semi-structured interviews were conducted with paediatric and adult diabetes providers.

RESULTS

Between 2008 and 2013, 93 patients with type 1 diabetes transitioned into adult care. Rates of diabetes-related hospitalizations increased from 15.6/100 person-years in the 3 years before their 18th birthday to 16.7/100 person-years in the three-year period after. Between 2017 and 2019, 15 interviews were conducted across the province's four regional health authorities. Various models of transition care are being employed, reflecting staff and resource availability in different centres. While no formal transition program was identified in either region, some providers, particularly in rural areas, reported being comfortable with their current transition practices. Suggested improvements included more structured processes, shared educational resources, expanding the role played by primary care physicians, and a dedicated transfer clinic.

CONCLUSIONS

We found different approaches for transitioning patients with diabetes into adult care across NL. Yet this variation may not negatively impact patient outcomes, particularly in rural areas. The approach we employed of combining reviews of administration data with a detailed analysis of current processes could be employed in other jurisdictions to identify appropriate quality improvement initiatives.

Persistent Anxiety Is Associated with Higher Glycemia Post-Transition to Adult Services in Asian Young Adults with Diabetes

BACKGROUND

There is little longitudinal information on psychological burden and metabolic outcomes in young adults with diabetes (YAD) in Asia. We aimed to evaluate the association between psychological status and glycemia at baseline and 2 years following transition in a cohort of YAD in Singapore.

METHODS

Subjects with type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM), aged 17 to 25 years, were recruited from the YAD clinic in Singapore General Hospital. The Hospital Anxiety and Depression and Problem Areas for Diabetes scales were administered at transition (baseline) and at 18 to 24 months. Glycosylated hemoglobin (HbA1c) assessed during routine visits was tracked longitudinally.

RESULTS

A total of 98 T1DM (74.8%) and 33 T2DM (25.2%) subjects were recruited between January 2011 and November 2017. At baseline, mean HbA1c was 8.6%±1.7%. Only 26.0% achieved HbA1c of ≤7.5% and 16.8% achieved HbA1c of <7%. At baseline, prevalence of anxiety was 29.8%. At 24 months, 14.1% had persistent anxiety. Those with persistent anxiety had the highest mean HbA1c, particularly at 6 months (persistently anxious vs. persistently non-anxious: 9.9%±1.2% vs. 8.2%±1.9%, P=0.009). At baseline, 9.2% of subjects had depression. This group also had poorer glycemia at baseline (HbA1c of depressed vs non-depressed: 9.6%±2.1% vs. 8.5%±1.6%, P=0.04), which persisted up to 24 months.

CONCLUSION

The majority of YAD in Singapore have suboptimal glycemia. Psychological distress is a critical harbinger of poorer metabolic outcomes.

Individual and neighbourhood socioeconomic status increase risk of avoidable hospitalizations among Canadian adults: A retrospective cohort study of linked population health data

INTRODUCTION

Avoidable hospitalizations refer to acute care use for conditions that should normally be managed in primary care settings. Lower socioeconomic status that is often measured using area-based indicators (e.g. median household income) has been shown to increase risk of avoidable hospitalizations. However, both area- and individual-level socioeconomic status can contribute to hospitalization risk, but previous data limitations have prevented separate analyses. Further, the joint effect of individual and neighbourhood socioeconomic status has not been established in the Canadian population. To address this, this study links individual-level household income and neighbourhood-level material deprivation data within a population-based Canadian cohort.

OBJECTIVES

To determine the individual and joint effect of individual-level household income and neighbourhood-level material deprivation on risk of hospitalization for a set of chronic ambulatory care sensitive conditions using linked health survey, hospital discharge, and census-derived data.

METHODS

A pooled cohort was created by linking sociodemographic and health information from eight cycles of the Canadian Community Health Survey (2000/2001 - 2010) to hospital discharge records and Canadian Marginalization Indices (2001, 2006) (N = 354,595). The primary outcome variable was risk of index hospitalization with a primary diagnosis of angina, asthma, congestive heart failure, chronic obstructive pulmonary disease, diabetes, epilepsy, or hypertension. The primary exposure variable was joint individual-level national household income quintile and neighbourhood-level material deprivation quintile. Relative risk (RR) was estimated by constructing modified Poisson regression models with robust error variance.

RESULTS

In fully adjusted models with income and deprivation considered separately, individuals in the lowest household income quintile and highest material deprivation quintile were at increased risk of hospitalization (Income RR: 1.82 (95% CI 1.56-2.13) Deprivation RR: 1.67 (1.44-1.95)). When income and deprivation were jointly considered, those with low individual income living in high deprivation neighbourhoods were at greatest risk of hospitalization (RR 1.83 (95% CI 1.63 - 2.05)).

CONCLUSION

Both individual income and neighbourhood deprivation separately and jointly increase risk of avoidable hospitalizations. Additional research is needed to understand their mechanisms of action. However, both levels should be considered when designing effective policies and interventions to reduce avoidable hospitalizations.

Socioeconomic inequalities in hospitalizations for chronic ambulatory care sensitive conditions: a systematic review of peer-reviewed literature, 1990-2018

BACKGROUND

Hospitalizations for chronic ambulatory care sensitive conditions are an important indicator of health system equity and performance. Chronic ambulatory care sensitive conditions refer to chronic diseases that can be managed in primary care settings, including angina, asthma, and diabetes, with hospitalizations for these conditions considered potentially avoidable with adequate primary care interventions. Socioeconomic inequities in the risk of hospitalization have been observed in several health systems globally. While there are multiple studies examining the association between socioeconomic status and hospitalizations for chronic ambulatory care sensitive conditions, these studies have not been systematically reviewed. The objective of this study is to systematically identify and describe socioeconomic inequalities in hospitalizations for chronic ambulatory care sensitive conditions amongst adult populations in economically developed countries reported in high-quality observational studies published in the peer-reviewed literature.

METHODS

Peer-reviewed literature was searched in six health and social science databases: MEDLINE, EMBASE, PsycInfo, CINAHL, ASSIA, and IBSS using search terms for hospitalization, socioeconomic status, and chronic ambulatory care sensitive conditions. Study titles and abstracts were first screened followed by full-text review according to the following eligibility criteria: 1) Study outcome is hospitalization for selected chronic ambulatory care sensitive conditions; 2) Primary exposure is individual- or area-level socioeconomic status; 3) Study population has a mean age ± 1 SD < 75 years of age; 4) Study setting is economically developed countries; and 5) Study type is observational. Relevant data was then extracted, and studies were critically appraised using appropriate tools from The Joanna Briggs Institute. Results were narratively synthesized according to socioeconomic constructs and type of adjustment (minimally versus fully adjusted).

RESULTS

Of the 15,857 unique peer-reviewed studies identified, 31 studies met the eligibility criteria and were of sufficient quality for inclusion. Socioeconomic constructs and hospitalization outcomes varied across studies. However, despite this heterogeneity, a robust and consistent association between lower levels of socioeconomic status and higher risk of hospitalizations for chronic ambulatory care sensitive conditions was observed.

CONCLUSIONS

This systematic review is the first to comprehensively identify and analyze literature on the relationship between SES and hospitalizations for chronic ambulatory care sensitive conditions, considering both aggregate and condition-specific outcomes that are common to several international health systems. The evidence consistently demonstrates that lower socioeconomic status is a risk factor for hospitalization across global settings. Effective health and social interventions are needed to reduce these inequities and ensure fair and adequate care across socioeconomic groups.

TRIAL REGISTRATION

PROSPERO CRD42018088727.

Risk factors and prevention strategies for diabetic ketoacidosis in people with established type 1 diabetes

Diabetic ketoacidosis (DKA) is a serious acute complication of type 1 diabetes, which is receiving more attention given the increased DKA risk associated with SGLT inhibitors. Sociodemographic and modifiable risk factors were identified with strong evidence for an increased risk of DKA, including socioeconomic disadvantage, adolescent age (13-25 years), female sex, high HbA_1c, previous DKA, and psychiatric comorbidities (eg, eating disorders and depression). Possible prevention strategies, which include the identification of people at risk based on non-modifiable sociodemographic risk factors, are proposed. As a second risk mitigation strategy, structured diabetes self-management education that addresses modifiable risk factors can be used. Evidence has found that structured education leads to reduced DKA rates. Knowledge of these risk factors and potent risk mitigation strategies are important to identify subgroups of people with an elevated DKA risk. This knowledge should also be used when adjunct therapy options with an increased DKA risk are considered. Prevention of DKA in people with type 1 diabetes is an important clinical task, which should also be addressed when SGLT inhibitors are part of therapy.

Factors associated with health psychology use in pediatric type 1 diabetes

AIMS

Identify the prevalence of health psychology use in children with type 1 diabetes (T1D) and evaluate how individual and contextual characteristics are associated with use.

METHODS

Children ages 8-16 years with T1D and their parents were recruited from two tertiary diabetes clinics. Cross-sectional data included parent and adolescent surveys and hemoglobin A1c. Parents self-reported the child's use of health psychology in the last year along with individual factors (e.g., predisposing factors including demographics, enabling factors including health insurance type, evaluated need including mental health diagnoses and perceived need including self-management barriers). Association of health psychology use with individual (e.g., demographics, enabling factors, evaluated and perceived need) and contextual (e.g., clinical site) characteristics was evaluated using logistic regression.

RESULTS

Of 363 eligible participants, 267 (74%) participated. Health psychology use was reported by only 8.2% (n = 22) of participants and was significantly associated with evaluated need factor of mental health diagnosis (OR 5.8; p < 0.001) and perceived need factor of parent-reported self-management barriers. Use was not associated with other individual or contextual factors.

CONCLUSIONS

Though infrequent, health psychology use was positively associated with mental health diagnoses and self-management barriers.

“Medical Clearance” of Psychiatric Patients in the Emergency Department

Background & goals:

The past few years have seen an increase in the number of children and adolescents presenting to emergency departments with mental health complaints, including, but not limited to, depression, suicidality, and substance use-related conditions. This places many demands on the emergency physicians ranging from evaluating medical stability (also known as medical clearance) to arranging for psychiatric are, be it inpatient or outpatient. The goals of this article are to describe the current landscape of emergency care for the pediatric patient presenting with mental health issues and to highlight gaps in the current system.

Methods:

We review the literature on the epidemiology of mental health emergency visits and guidelines for the medical clearance of pediatric and adolescent patients.

Results:

The needs of young patients with mental health difficulties exceed the resources available in emergency care. Linkage to outpatient care is often inadequate and may be reinforcing and perpetuating the current mental health crisis witnessed country-wide in the US. Guidelines are lacking to standardize care in the ED, but there is a consensus that extensive routine laboratory testing is unnecessary.

Conclusions:

Evaluation of physical stability, known as medical clearance, is a process best customized to every patient’s individual needs. However, requirements of admitting psychiatric inpatient facilities may conflict with recommendations of ancillary testing.

Acute diabetes complications across transition from pediatric to adult care in Ontario and Newfoundland and Labrador: a population-based cohort study

BACKGROUND

Transition to adult diabetes care is a high-risk period for acute complications, yet the optimal transition care model is unknown. To gain insight into the impact on health outcomes of system-level transition processes that reflect resourcing differences, we examined acute complications in youth with diabetes across transition in 2 Canadian provinces with different transition care models.

METHODS

We used linked provincial health administrative data for Ontario and Newfoundland and Labrador to create 2 parallel cohorts of youth with diabetes diagnosed before age 15 years who turned 17 between 2006 and 2011. Participants were followed until 2015 (maximum age 21 yr). We described rates of and proportion of participants with at least 1 diabetes-related hospital admission at age 15-17 years and 18-20 years, standardized according to material deprivation based on the 2006 Canadian Marginalization Index. We compared diabetes-related admissions at age 15-17 years and 18-20 years in the Ontario cohort.

RESULTS

The cohorts consisted of 2525 youth in Ontario and 93 in Newfoundland and Labrador. In Newfoundland and Labrador, 39 participants (42.0%) were in the lowest socioeconomic quintile, versus 326 (12.9%) in Ontario. The standardized rate of diabetes-related hospital admissions per 100 person-years was 13.5 (95% confidence interval [CI] 12.6-14.4) at age 15-17 years and 14.4 (95% CI 13.5-15.3) at age 18-20 years in Ontario, and 11.4 (95% CI 7.0-15.8) at age 15-17 years and 10.5 (95% CI 6.4-14.6) at age 18-20 years in Newfoundland and Labrador. In Ontario, there was no association between the rate (adjusted rate ratio 1.10, 95% CI 0.94-1.28) or occurrence (adjusted odds ratio 1.03, 95% CI 0.91-1.17) of diabetes-related admissions across transition.

INTERPRETATION

Although posttransition care is delivered differently in the 2 provinces, rates of adverse events across transition were stable in both. Coordinated support during transition is needed to help mitigate adverse events for young adults in both provinces. Delivery of other health care and social services, including primary care, may be influencing the risk of adverse events after transition to adult care.

Recurrent diabetic ketoacidosis and a brief history of brittle diabetes research: contemporary and past evidence in diabetic ketoacidosis research including mortality, mental health and prevention

Pharmacological, technological and educational approaches have advanced the treatment of Type 1 diabetes in the last four decades and yet diabetic ketoacidosis (DKA) continues to be a leading cause of admission in Type 1 diabetes. This article begins by reviewing the contemporary epidemiological evidence in DKA. It highlights a rise in DKA episodes in the last two decades, with DKA continuing to be the leading cause of death in young people with Type 1 diabetes, and that DKA episodes are a marker for subsequent all-cause mortality. It also summarizes the limited evidence base for DKA prevention and associations with psychopathology. To emphasize the importance of this group with high-risk Type 1 diabetes and the degree to which they have been overlooked in the past two decades, the article summarizes the research literature of recurrent DKA during 1976-1991 when it was extensively investigated as part of the phenomenon of 'brittle diabetes'. This period saw numerous basic science studies investigating the pathophysiology of recurrent DKA. Subsequently, research centres published their experiences of brittle diabetes research participants manipulating their treatment under research conditions. Unfortunately, the driver for this behaviour and whether it was indicative of other people with ketoacidosis was not pursued. In summary, we suggest there has been a stasis in the approach to recurrent DKA prevention, which is likely linked to historical cases of mass sabotage of brittle diabetes research. Further investigation is required to clarify possible psychological characteristics that increase the risk of DKA and thereby targets for DKA prevention.