Socioeconomic Deprivation, Household Education, and Employment are Associated With Increased Hospital Admissions and Poor Glycemic Control in Children With Type 1 Diabetes Mellitus

Association between glucose levels of children with type 1 diabetes and parental economic status in mobile health application

BACKGROUND

The glycemic control of children with type 1 diabetes (T1D) may be influenced by the economic status of their parents.

AIM

To investigate the association between parental economic status and blood glucose levels of children with T1D using a mobile health application.

METHODS

Data from children with T1D in China's largest T1D online community, Tang-TangQuan^®. Blood glucose levels were uploaded every three months and parental economic status was evaluated based on annual household income. Children were divided into three groups: Low-income (< 30000 Yuan), middle-income (30000-100000 Yuan), and high-income (> 100000 yuan) (1 Yuan = 0.145 United States Dollar approximately). Blood glucose levels were compared among the groups and associations were explored using Spearman’s correlation analysis and multivariable logistic regression.

RESULTS

From September 2015 to August 2022, 1406 eligible children with T1D were included (779 female, 55.4%). Median age was 8.1 years (Q1-Q3: 4.6-11.6) and duration of T1D was 0.06 years (0.02-0.44). Participants were divided into three groups: Low-income (n = 320), middle-income (n = 724), and high-income (n = 362). Baseline hemoglobin A1c (HbA1c) levels were comparable among the three groups (P = 0.072). However, at month 36, the low-income group had the highest HbA1c levels (P = 0.036). Within three years after registration, glucose levels increased significantly in the low-income group but not in the middle-income and high-income groups. Parental economic status was negatively correlated with pre-dinner glucose (r = -0.272, P = 0.012). After adjustment for confounders, parental economic status remained a significant factor related to pre-dinner glucose levels (odds ratio = 13.02, 95%CI: 1.99 to 126.05, P = 0.002).

CONCLUSION

The blood glucose levels of children with T1D were negatively associated with parental economic status. It is suggested that parental economic status should be taken into consideration in the management of T1D for children.

Association Between Psychosocial Acuity and Glycemic Control in a Pediatric Type 1 Diabetes Clinic

PURPOSE

The purpose of this study was to describe the frequency of psychosocial risk and its associations with glycemic levels in youth with type 1 diabetes (T1D) seen by social work staff during regular clinical care.

METHODS

A retrospective longitudinal analysis of observational clinical data was conducted. Individuals (1-26 years) with known T1D who were seen at a pediatric diabetes clinic in a US academic medical center between 2014 and 2021 were included. Variables included psychosocial acuity, A1C, and demographic characteristics. Chi-square tests, Wilcoxon rank sum tests, and mixed linear regressions were used to examine associations between demographic variables, psychosocial acuity, and A1C.

RESULTS

Of 966 patients, 513 (53.1%) were male, 76 (7.9%) were non-Hispanic Black, and 804 (83.2%) were non-Hispanic White. There was a mean of 6.9 annual social work encounters per patient, with 3 psychosocial domains measured at each visit. Results showed that as psychosocial acuity level increased, glycemic control decreased. There were significant differences in A1C according to race/ethnicity, insurance, age, and psychosocial acuity.

CONCLUSIONS

In a real-world clinical population, psychosocial acuity was associated with glycemic control. Presenting for psychosocial issues in their diabetes clinic was associated with reduced glycemic control among youth with T1D. There is an opportunity to connect pediatric patients with appropriate mental health services and psychosocial supports.

Social Determinants of Health Screening in Type 1 Diabetes Management

Type 1 diabetes management is intricately influenced by social determinants of health. Economic status impacts access to vital resources like insulin and diabetes technology. Racism, social injustice, and implicit biases affect equitable delivery of care. Education levels affect understanding of self-care, leading to disparities in glycemic outcomes. Geographic location can limit access to health care facilities. Stressors from discrimination or financial strain can disrupt disease management. Addressing these social factors is crucial for equitable diabetes care, emphasizing the need for comprehensive strategies that go beyond medical interventions to ensure optimal health outcomes for all individuals with type 1 diabetes.

Pancreas transplantation improves the quality of life of Japanese type 1 diabetes patients with diabetic kidney disease

OBJECTIVES

Type 1 diabetes mellitus (T1DM) patients with diabetic kidney disease-induced kidney failure have a significantly impaired quality of life (QOL), resulting in a high level of physical, mental, and social anxiety. In this study, we evaluated the QOL of T1DM patients on the list for pancreas transplantation (PTx) at their registration, and determined whether PTx improved their QOL.

METHODS

There were 58 patients (men/women, 22/36; mean age, 42.8±8.0 years) with T1DM and who were registered on the waiting list for PTx. Quantitative QOL assessment was performed using the Medical Health Survey Short Form (SF-36) version 2. Changes in the QOL before and after PTx were also examined in 24 of these patients.

RESULTS

The mean value of each endpoint and the summary score of the SF-36 physical (PCS), mental (MCS), and role (RCS) components were all below the national normal level at PTx registration. No significant difference in QOL scores was observed in the intergroup comparison of 35 patients on dialysis, 13 patients without dialysis, and ten patients after kidney transplantation. The 24 patients who underwent PTx showed improvement in PCS, MCS, and most SF-36 scores.

CONCLUSION

T1DM patients waiting for PTx had a decreased QOL, regardless of dialysis, and PTx improved their QOL.

Inequalities in Glycemic Control in Youth with Type 1 Diabetes Over Time: Intersectionality Between Socioeconomic Position and Race and Ethnicity

BACKGROUND

Racial/ethnic health inequities have been well-documented among youth and young adults with type 1 diabetes (T1D), yet little is known about how socioeconomic position (SEP) intersects with the risk marker of race/ethnicity to predict inequities in longitudinal glycemic control.

PURPOSE

To identify patterns of SEP, race/ethnicity, and clinical characteristics that differentiate hemoglobin A1c (HbA1c) trajectories among youth and young adults after T1D diagnosis.

METHODS

The SEARCH for Diabetes in Youth cohort includes youth with diabetes diagnosed from 2002 to 2006 and 2008 who were followed through 2015. We analyzed data from 1,313 youth and young adults with T1D with ≥3 HbA1c measures. Classification tree analysis identified patterns of baseline demographic, SEP, and clinical characteristic that best predicted HbA1c trajectories over an average of 8.3 years using group-based trajectory modeling.

RESULTS

Two HbA1c trajectories were identified: Trajectory 1 (77%) with lower baseline HbA1c and mild increases (from mean 7.4% to 8.4%) and Trajectory 2 (23%) with higher baseline HbA1c and major increases (from 8.5% to 11.2%). Race/ethnicity intersected with different SEP characteristics among non-Hispanic white (NHW) than in non-whites. Public health insurance predicted high-risk Trajectory 2 membership in non-whites, whereas parental education, household structure, diagnosis age and glucose checking frequency predicted membership for NHW youth and young adults. Two characteristics, race/ethnicity and parental education alone identified 80% of the Trajectory 2 members.

CONCLUSIONS

Race/ethnicity intersects with multiple SEP and clinical characteristics among youth and young adults with T1D, which is associated with particularly high risk of poor long-term glycemic control.

Association of Area-Level Socioeconomic Deprivation With Hypoglycemic and Hyperglycemic Crises in US Adults With Diabetes

IMPORTANCE

Social determinants of health play a role in diabetes management and outcomes, including potentially life-threatening complications of severe hypoglycemia and diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar state (HHS). Although several person-level socioeconomic factors have been associated with these complications, the implications of area-level socioeconomic deprivation are unknown.

OBJECTIVE

To examine the association between area-level deprivation and the risks of experiencing emergency department visits or hospitalizations for hypoglycemic and hyperglycemic crises (ie, DKA or HHS).

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used deidentified administrative claims data for privately insured individuals and Medicare Advantage beneficiaries across the US. The analysis included adults with diabetes who met the claims criteria for diabetes between January 1, 2016, and December 31, 2017. Data analyses were performed from November 17, 2020, to November 11, 2021.

EXPOSURES

Area deprivation index (ADI) was derived for each county for 2016 and 2017 using 17 county-level indicators from the American Community Survey. ADI values were applied to patients who were living in each county based on their index dates and were categorized according to county-level ADI quintile (with quintile 1 having the least deprivation and quintile 5 having the most deprivation).

MAIN OUTCOMES AND MEASURES

The numbers of emergency department visits or hospitalizations related to the primary diagnoses of hypoglycemia and DKA or HHS (ascertained using validated diagnosis codes in the first or primary position of emergency department or hospital claims) between 2016 and 2019 were calculated for each ADI quintile using negative binomial regression models and adjusted for patient age, sex, health plan type, comorbidities, glucose-lowering medication type, and percentage of White residents in the county.

RESULTS

The study population included 1 116 361 individuals (563 943 women [50.5%]), with a mean (SD) age of 64.9 (13.2) years. Of these patients, 343 726 (30.8%) resided in counties with the least deprivation (quintile 1) and 121 810 (10.9%) lived in counties with the most deprivation (quintile 5). Adjusted rates of severe hypoglycemia increased from 13.54 (95% CI, 12.91-14.17) per 1000 person-years in quintile 1 counties to 19.13 (95% CI, 17.62-20.63) per 1000 person-years in quintile 5 counties, corresponding to an incidence rate ratio of 1.41 (95% CI, 1.29-1.54; P < .001). Adjusted rates of DKA or HHS increased from 7.49 (95% CI, 6.96-8.02) per 1000 person-years in quintile 1 counties to 8.37 (95% CI, 7.50-9.23) per 1000 person-years in quintile 5 counties, corresponding to an incidence rate ratio of 1.12 (95% CI, 1.00-1.25; P = .049).

CONCLUSIONS AND RELEVANCE

This study found that living in counties with a high area-level deprivation was associated with an increased risk of severe hypoglycemia and DKA or HHS. The concentration of these preventable events in areas of high deprivation signals the need for interventions that target the structural barriers to optimal diabetes management and health.

Deterioration in glycemic control on schooldays among children and adolescents with type 1 diabetes: A continuous glucose monitoring-based study

BACKGROUND

To investigate the effect of school life by comparing the glycemic control between holidays and schooldays in children and adolescents with type 1 diabetes (T1D).

METHODS

This observational study enrolled school-aged students with T1D (aged 6-19) from September 2019 to July 2021. Continuous glucose monitoring (CGM) records were processed and divided into holidays and schooldays. Other information was collected via questionnaires. We compared the results using paired T-test, Wilcoxon paired test and logistic regression analysis.

RESULTS

78 paticipants were included (40 boys, mean age 9.95 years). A total of 142,945 h of CGM data were analyzed. Overall, TIR (3.9-7.8 mmol/L) during holidays was better than schooldays [56.97 (SD 15.03) vs. 55.87 (15.06), %, p = 0.039]. On nocturnal (0-6 am) glycemic fluctuation, TIR was longer in children aged 6-10 [60.54 (17.40) vs. 56.98 (SD 16.32), %, p = 0.012] during holiday and TAR (7.8 mmol/L) was shorter [31.54 (17.54) vs. 35.54 (16.95), %, p = 0.013], compared with schooldays. In adolescents aged 10-19 years, TAR was also significantly shorter during holidays. Stratified analysis showed that girls, patients with longer duration, and insulin pump users had more pronounced worsening of nighttime glycemia on schooldays. Logistic regression analysis showed that girls had higher risk of worse nocturnal glycemic control [3.26, 95% CI: (1.17, 9.72), p = 0.027] and nocturnal hyperglycemia [OR = 2.95, 95% CI: (1.08, 8.56), p = 0.039], compared to boys.

CONCLUSIONS

Children and adolescents with T1D were found to have worse glycemic control in nighttime during schooldays.

Feasibility of Electronic Health Record Assessment of 6 Pediatric Type 1 Diabetes Self-management Habits and Their Association With Glycemic Outcomes

IMPORTANCE

A low-burden electronic health record (EHR) workflow has been devised to systematize the collection and validation of 6 key diabetes self-management habits: (1) checks glucose at least 4 times/day or uses continuous glucose monitor (CGM); (2) gives at least 3 rapid-acting insulin boluses per day; (3) uses insulin pump; (4) delivers boluses before meals; (5) reviewed glucose data since last clinic visit, and (6) has changed insulin doses since the last clinic visit.

OBJECTIVE

To describe the performance of these habits and examine their association with hemoglobin A1c (HbA1c) levels and time in range (TIR).

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study included individuals with known type 1 diabetes who were seen in a US pediatric diabetes clinic in 2019.

MAIN OUTCOMES AND MEASURES

Habit performance, total habit score (sum of 6 habits per person), HbA1c levels, and TIR.

RESULTS

Of 1344 patients, 1212 (609 [50.2%] males; 66 [5.4%] non-Hispanic Black; 1030 [85.0%] non-Hispanic White; mean [SD] age, 15.5 [4.5] years) were included, of whom 654 (54.0%) were using CGM and had a TIR. Only 105 patients (8.7%) performed all 6 habits. Habit performance was lower among older vs younger patients (age ≥18 years vs ≤12 years: 17 of 411 [4.1%] vs 57 of 330 [17.3%]; P < .001), Black vs White patients (3 [4.5%] vs 95 [9.2%]; P < .001), those with public vs private insurance (14 of 271 [5.2%] vs 91 of 941 [9.7%]; P < .001), and those with lower vs higher parental education levels (<college degree vs ≥college degree: 35 of 443 [7.9%] vs 66 of 574 [11.5%]; P < .001). After adjustment for demographic characteristics and disease duration, for every 1-unit increase in total habit score, we found a mean (SE) 0.6% (0.05) decrease in HbA1c among all participants and a mean (SE) 2.86% (0.71) increase in TIR among those who used CGMs. Multiple regression models revealed that performing each habit was associated with a significantly lower HbA1c level (habit 1: -0.16% [95% CI, -1.91% to -1.37%]; habit 2: -1.01% [-1.34% to -0.69%]; habit 3: -0.71% [95% CI, -0.93% to -0.49%]; habit 4: -0.97% [95% CI, -1.21% to -0.73%]; habit 5: -0.44% [95% CI, -0.71% to -0.17%]; habit 6: -0.75% [95% CI, -0.96% to -0.53%]; all P < .001). There were differences in HbA1c according to race, insurance, and parental education, but these associations were attenuated with the inclusion of the 6 habits, which had more robust associations with HbA1c levels than the demographic characteristics.

CONCLUSIONS AND RELEVANCE

These findings suggest that a focus on increasing adherence to the 6 habits could be critical for improving disparities in glycemic outcomes; these metrics have been adopted by the Type 1 Diabetes Exchange Quality Improvement Collaborative for continuous quality improvement.

Demographic and socioeconomic patterns in the risk of alcohol-related hospital admission in children and young adults with childhood onset type-1 diabetes from a record-linked longitudinal population cohort study in Wales

BACKGROUND

Little is known about alcohol-related harm in children and young adults with type 1 diabetes (T1D). Education on managing alcohol intake is provided to teenagers with T1D in paediatric clinics in Wales, but its effectiveness is unknown. We compared the patterns in risk of alcohol-related hospital admissions (ARHA) between individuals with and without childhood-onset T1D.

METHODS

We extracted data for 1 791 577 individuals born during 1979 to 2014 with a general practitioner registration in Wales, and record-linked the demographic data to ARHA between 1998 and June 2016 within the Secure Anonymised Information Linkage Databank (SAIL). Linkage to a national T1D register (Brecon Cohort) identified 3575 children diagnosed aged <15 years since 1995. We estimated hazard ratios (HRs) with 95% confidence intervals (95% CIs) for the risk of ARHA using recurrent-event models, including interaction terms.

RESULTS

Individuals with T1D had a higher riskof ARHA (HR: 1.78; 95% CI: 1.60-1.98), adjusted for age group, sex, and deprivation. The risk in people with diabetes was highest aged 14 to 17 years, around three times higher than the peak in non-T1D aged 18 to 22. Females with diabetes had a lower risk generally. The association between deprivation and ARHA was weaker in the T1D group.

CONCLUSION

Young people with T1D had increased risks of ARHA, particularly at school age, and smaller socioeconomic inequalities in ARHA. A review of interventions to reduce alcohol-related harm in T1D is needed, perhaps including modification of current education and guidance for teenagers on managing alcohol consumption and reviewing criteria for hospital admission.

Enhancing Care Coordination for Students with Type 1 Diabetes

BACKGROUND

Care coordination for chronic health conditions is critical to academic success, yet concrete strategies on its operationalization in schools are not well reported in the literature. Type 1 diabetes (T1D) is one such condition that requires a team-based approach to care coordination. The purpose of this study was to gain a deeper understanding of how care coordination for T1D currently operates and identify strategies for its support and facilitation in schools.

METHODS

Focus groups were conducted with school nurses, parents of T1D children, and providers in each of the 9 Educational Service Districts in Washington State. Recorded notes were analyzed using content analytic techniques.

RESULTS

Five major themes emerged from the data, each with 3 to 4 second-order themes. Care coordination depended on family, school, and child developmental contexts, knowledge/experience about T1D among school nurses, teachers, parents, and providers, access and availability of team members, communication, and relationships.

CONCLUSIONS

Findings highlight the importance of a contextualized and holistic perspective of facilitators and barriers to care coordination in schools. Promoting the development of supportive relationships and effective team-based approaches provides a foundation and informs intersectional care coordination for all children with chronic conditions.

Hospitalization in Pediatric Diabetes: A Nationwide Analysis of all Admission Causes for Germany in 2015

INTRODUCTION

Regarding pediatric diabetes, hospital admission for acute complications of type 1 diabetes (T1D) has often been investigated, but little is known about other causes of hospitalization. This study aimed to explore the total burden of hospitalization in individuals with diabetes<20 years of age in Germany.

METHODS

Using the German Diagnosis-Related Groups data for 2015, we examined the frequencies of hospitalization with diabetes (20 251 inpatient cases), stratified by diabetes type [T1D, type 2 diabetes (T2D), other specified diabetes types (T3D), and unclear diabetes], and without diabetes (1 269 631 inpatient cases). Using estimates of the population at risk with T1D, T2D, and without diabetes, we evaluated hospitalization rates (per patient-year) by Poisson regression. For T1D, T2D, and T3D, we investigated the most frequent diagnoses and the median length of stay. Most analyses were stratified by sex, age-group and east/west residence.

RESULTS

Children and adolescents with diabetes had a 6 to 9 times higher hospitalization risk than peers without diabetes (hospitalization rate 0.09). The hospitalization rate was higher for T2D compared with T1D (0.84 vs. 0.53, P<0.001). In T2D, two-third of inpatient cases were not directly related to diabetes, and stay was shorter compared with T1D and T3D (3 vs. 4 and 5 days, respectively). In T1D, hospitalization was more frequent among girls than boys (0.58 vs. 0.49, P<0.001), and mostly due to "diabetes without complications" (65.7%). Hospitalization tended to be more frequent and longer in the youngest patients, and in those with east residence.

CONCLUSION

Hospitalization rate in pediatric diabetes in Germany remained high, especially for T2D patients, girls with T1D, and young children.

Food insecurity is associated with high risk glycemic control and higher health care utilization among youth and young adults with type 1 diabetes

AIMS

Household food insecurity (FI), i.e., limited availability of nutritionally adequate foods, is associated with poor glycemic control among adults with type 2 diabetes. We evaluated the association of FI among youth and young adults (YYA) with type 1 diabetes to inform recent clinical recommendations from the American Diabetes Association for providers to screen all patients with diabetes for FI.

METHODS

Using data from the Washington and South Carolina SEARCH for Diabetes in Youth Study sites, we conducted an observational, cross-sectional evaluation of associations between FI and glycemic control, hospitalizations, and emergency department (ED) visits among YYA with type 1 diabetes. FI was assessed using the Household Food Security Survey Module, which queries conditions and behaviors typical of households unable to meet basic food needs. Participants' HbA1c were measured from blood drawn at the research visit; socio-demographics and medical history were collected by survey.

RESULTS

The prevalence of FI was 19.5%. In adjusted logistic regression analysis, YYAs from food-insecure households had 2.37 higher odds (95% CI: 1.10, 5.09) of high risk glycemic control, i.e., HbA1c >9.0%, vs. peers from food-secure households. In adjusted binomial regression analysis for ED visits, YYAs from food-insecure households had an adjusted prevalence rate that was 2.95 times (95% CI [1.17, 7.45]) as great as those from food secure households.

CONCLUSIONS

FI was associated with high risk glycemic control and more ED visits. Targeted efforts should be developed and tested to alleviate FI among YYA with type 1 diabetes.