Health insurance and the financial impact of IDDM in families with a child with IDDM

Chronic Illness in Children and Foregone Care Among Household Adults in the United States: A National Study

BACKGROUND

Childhood chronic illness imposes financial burdens that may affect the entire family.

OBJECTIVE

The aim was to assess whether adults living with children with 2 childhood chronic illnesses-asthma and diabetes-are more likely to forego their own medical care, and experience financial strain, relative to those living with children without these illnesses.

RESEARCH DESIGN

2009-2018 National Health Interview Survey.

SUBJECTS

Adult-child dyads, consisting of one randomly sampled child and adult in each family.

MEASURES

The main exposure was a diagnosis of asthma or diabetes in the child. The outcomes were delayed/foregone medical care for the adult as well as family financial strain; the authors evaluated their association with the child's illness using multivariable logistic regressions adjusted for potential confounders.

RESULTS

The authors identified 93,264 adult-child dyads; 8499 included a child with asthma, and 179 a child with diabetes. Families with children with either illness had more medical bill problems, food insecurity, and medical expenses. Adults living with children with each illness reported more health care access problems. For instance, relative to other adults, those living with a child with asthma were more likely to forego/delay care (14.7% vs. 10.2%, adjusted odds ratio: 1.27; 95% CI: 1.16-1.39) and were more likely to forego medications, specialist, mental health, and dental care. Adults living with a child with diabetes were also more likely to forego/delay care (adjusted odds ratio: 1.76; 95% CI: 1.18-2.64).

CONCLUSIONS

Adults living with children with chronic illnesses may sacrifice their own care because of cost concerns. Reducing out-of-pocket health care costs, improving health coverage, and expanding social supports for families with children with chronic conditions might mitigate such impacts.

Barriers to Continuous Glucose Monitoring in People With Type 1 Diabetes: Clinician Perspectives

The purpose of this study was to determine clinician attitudes about the distinct barriers to uptake of continuous glucose monitoring (CGM) among people with diabetes. Survey data were collected measuring individual barriers, prerequisites to CGM, confidence in addressing barriers, and clinic staff resources. Results show that clinicians commonly report barriers to using CGM among people with diabetes in their clinic. Furthermore, clinicians who report a high number of barriers do not feel confident in overcoming the barriers to CGM. Interventions that attempt to empower clinicians to address concerns about CGM among people with diabetes may be warranted because low uptake does not appear to be directly related to available resources or prerequisites to starting CGM.

Health care access and glycemic control in youth and young adults with type 1 and type 2 diabetes in South Carolina

Affordability and geographic accessibility are key health care access characteristics. We used data from 481 youth and young adults (YYA) with diabetes (389 type 1, 92 type 2) to understand the association between health care access and glycemic control as measured by HbA1c values. In multivariate models, YYA with state or federal health insurance had HbA1c percentage values 0.68 higher (P = 0.0025) than the privately insured, and those without insurance 1.34 higher (P < 0.0001). Not having a routine diabetes care provider was associated with a 0.51 higher HbA1c (P = 0.048) compared to having specialist care, but HbA1c did not differ significantly (P = 0.069) between primary vs specialty care. Distance to utilized provider was not associated with HbA1c among YYA with a provider (P = 0.11). These findings underscore the central role of health insurance and indicate a need to better understand the root causes of poorer glycemic control in YYA with state/federal insurance.

How Much Time Do Families Spend on the Health Care of Children with Diabetes?

INTRODUCTION

Family time caring for children with diabetes is an overlooked component of the overall burden of the condition. We document and analyze risk factors for time family members spend providing health care at home and arranging/coordinating health care for children with diabetes.

METHODS

Data for 755 diabetic children and 16,161 non-diabetic children whose chronic conditions required only prescription (Rx) medication were from the 2009-2010 United States National Survey of Children with Special Health Care Needs (NS-CSHCN). We used generalized ordered logistic regressions to estimate adjusted odds ratios (AORs) of time burden by diabetes, insulin use, and stability of the child's health care needs, controlling for health and socioeconomic status.

RESULTS

Nearly one-quarter of diabetic children had family members who spent 11+ h/week providing health care at home, and 8% spent 11+ h/week arranging/coordinating care, compared with 3.3% and 1.9%, respectively, of non-diabetic Rx-only children. Time providing care at home for insulin-using children was concentrated in the higher time categories: AORs for insulin-using diabetic compared to non-diabetic Rx-only children were 4.4 for 1+ h/week compared with <1 h/week, 9.7 for 6+ vs. <6 h, and 12.4 for 11+ vs. <11 h (all P < 0.05); the pattern was less pronounced for non-insulin-using children. AORs for arranging/coordinating care did not vary by time contrast: AOR = 4.2 for insulin-using, 3.0 for non-insulin-using children.

CONCLUSION

Health care providers, school personnel, and policymakers need to work with family members to improve care coordination and identify other ways to reduce family time burdens caring for children with diabetes.

Characteristics of children with type 1 diabetes and persistent suboptimal glycemic control

OBJECTIVE

This study aims to determine the relationship between the duration of persistent poor glycemic control in type 1 diabetes mellitus (T1DM) children and the likelihood of subsequent improvement.

METHODS

A retrospective cohort study was conducted on T1DM patients aged 6-18 years, followed for at least six visits at Children's National Medical Center (Washington, DC) with at least one hemoglobin A1c (HbA1c) ≥ 10% after the first year since the initial visit (n=151). Medical records of patients with subsequently improved glycemic control were reviewed (n=39).

RESULTS

Patients aged 12-18 years, females, and Medicaid patients were twice as likely to be in persistently poor control as patients aged 6-11 years, males, and privately insured patients, respectively. Each additional visit with HbA1c ≥ 10% and one percentage point increase in the mean HbA1c reduced the likelihood of subsequent improvement by 20% and 50%, respectively. Of the 39 patients with improved control, only 5 (13%) sustained their improvement for ≥ 2 years. Multiple contributing factors for improved control were identified, but no one factor explained improved control in > 25% of patients.

CONCLUSION

This study suggests that the longer the duration of poor control, the more difficult it is to reverse the underlying factors of poor diabetes management. Strategies to improve regular clinic attendance along with reinforcement of changes which resulted in improved control are critical. Adolescents, females, and Medicaid patients in particular should be targeted for sustained intervention.

Impact of type 1 diabetes mellitus on the family is reduced with the medical home, care coordination, and family-centered care

OBJECTIVES

To examine whether the medical home, care coordination, or family-centered care was associated with less impact of type 1 diabetes mellitus (T1D) on families' work, finances, time, and school attendance.

STUDY DESIGN

With the 2005 to 2006 National Survey of Children with Special Health Care Needs, we compared impact in children with T1D (n = 583) with that in children with other special health care needs (n = 39 944) and children without special health care needs (n = 4945). We modeled the associations of the medical home, care coordination, and family-centered care with family impact in T1D.

RESULTS

Seventy-five percent of families of children with T1D reported a major impact compared with 45% of families of children with special health care needs (P < .0001) and 17% of families of children without special health care needs (P < .0001). In families of children with T1D, 35% reported restricting work, 38% reported financial impact, 41% reported medical expenses >$1000/year, 24% reported spending ≥11 hours/week caring or coordination care, and 20% reported ≥11 school absences/year. The medical home, care coordination, and family-centered care were associated with less work and financial impact.

CONCLUSIONS

In childhood T1D, most families experience major impact. Better systems of health care delivery may help families reduce some of this impact.

Measuring resource utilization in patient-oriented comparative effectiveness research: a psychometric study of the Resource Utilization Questionnaire

In the United States, rising health care costs have led to discussion about bending the cost curve. To understand the true burden of disease and its treatment, costs of care, including those incurred by patients and their families, must be comprehensively assessed using psychometrically sound instruments. The Resource Utilization Questionnaire (RUQ) is a 21-item self-report questionnaire first developed to measure the costs incurred by families of infants who had required intensive care during the newborn period. The purpose of this article is to describe the conceptualization of resource utilization and costs and other methodological issues in conducting economic analyses, the process of adapting the RUQ for use in children and families with Type 1 diabetes mellitus (T1DM), and the psychometric evaluation to establish content and criterion validity of the instrument. The finalized modified RUQ for T1DM (mRUQ-T1DM) contained 25 items reflecting direct (5 items) and nondirect (3 items) health care, patient/family time (8 items), and patient/family productivity (9 items) costs using a 3-month recall. The mRUQ-T1DM validly measures cost incurred by children and families with T1DM and is easily completed by parents. Furthermore, the mRUQ-T1DM may be adapted for use in other populations using a similar process.

Diabetic subjects diagnosed through the Diabetes Prevention Trial-Type 1 (DPT-1) are often asymptomatic with normal A1C at diabetes onset

OBJECTIVE

Upon diagnosis of type 1 diabetes, patients are usually symptomatic, and many have ketoacidosis. Screening for islet autoantibodies (IAs) has been shown to decrease A1C level and rate of hospitalization at diabetes onset. Metabolic tests and the presence of symptoms were described at diabetes onset during the Diabetes Prevention Trial-Type 1 (DPT-1).

RESEARCH DESIGN AND METHODS

The DPT-1 screened relatives of patients with type 1 diabetes for islet cell autoantiobodies (ICAs). Those with positive ICAs had intravenous and oral glucose tolerance tests (IVGTTs and OGTTs) and were randomized into one of two prevention trials. Throughout the DPT-1 parenteral and oral insulin study, 246 people were diagnosed with type 1 diabetes.

RESULTS

Of the 246 subjects diagnosed with diabetes, 218 had data regarding the presence of symptoms, and 138 (63.3%) reported no symptoms suggestive of diabetes. Eight subjects (3.67%) presented with ketosis. Subjects presented with a mean +/- SD A1C of 6.41 +/- 1.15%. At diagnosis, 90 subjects (50.8%) had A1C in the normal range (<6.2%). OGTT data at the time of diagnosis indicate that 35.4% had a glucose result of <100 mg/dl at 0 min.

CONCLUSIONS

The majority of subjects diagnosed with type 1 diabetes through the DPT-1 were asymptomatic at onset and had normal fasting glucose and A1C levels. This suggests that intermittent screening (IA followed by OGTT) may allow diagnosis of diabetes before severe metabolic decompensation. Screening with A1C will miss identifying many of the subjects with newly diagnosed type 1 diabetes in this cohort.

Custo do tratamento do diabetes mellitus tipo 1: dificuldades das famílias

OBJETIVOS: Conhecer a renda familiar dos pacientes diabéticos e os locais de aquisição das seringas e analisar o custo do tratamento da doença no domicílio e as conseqüências desses custos. MÉTODOS: Estudo descritivo, analítico, transversal. Entrevistados 199 pacientes atendidos em ambulatório de hospital escola, pediátrico de grande porte em São Paulo durante o ano 2004. RESULTADOS: A renda familiar predominante foi de um a dois salários mínimos (48,8%). A aquisição dos materiais para aplicar insulina era feita na farmácia (65,3%) e nas Unidades Básicas de Saúde (25,1%). A população gastava de R$ 20,00 a R$ 79,00 mensais com a compra de seringas (US$ 8 a US$ 27). CONCLUSÃO: Para minimizar os gastos com a doença, pacientes e responsáveis eram obrigados a reutilizar as seringas em (76,8%), constituindo uma prática comum no tratamento do diabetes.

Increasing expenditure on health care incurred by diabetic subjects in a developing country: a study from India

OBJECTIVE

This study aimed to assess the direct cost incurred by diabetic subjects who were in different income groups in urban and rural India, as well as to examine the changing trends of costs in the urban setting from 1998 to 2005.

RESEARCH DESIGN AND METHODS

A total of 556 diabetic subjects from various urban and rural regions of seven Indian states were enrolled. A brief uniform coded questionnaire (24 items) on direct cost was used.

RESULTS

Annual family income was higher in urban subjects (rupees [Rs] 100,000 or $2,273) than in the rural subjects (Rs 36,000 or $818) (P < 0.001). Total median expenditure on health care was Rs 10,000 ($227) in urban and Rs 6,260 ($142) in rural (P < 0.001) subjects. Treatment costs increased with duration of diabetes, presence of complications, hospitalization, surgery, insulin therapy, and urban setting. Lower-income groups spent a higher proportion of their income on diabetes care (urban poor 34% and rural poor 27%). After accounting for inflation, a secular increase of 113% was observed in the total expenses between 1998 and 2005 in the urban population. The highest increase in percentage of household income devoted to diabetes care was in the lowest economic group (34% of income in 1998 vs. 24.5% in 2005) (P < 0.01). There was a significant improvement in urban subjects in medical reimbursement from 2% (1998) to 21.3% (2005).

CONCLUSIONS

Urban and rural diabetic subjects spend a large percentage of income on diabetes management. The economic burden on urban families in developing countries is rising, and the total direct cost has doubled from 1998 to 2005.

Photocoagulation for diabetic retinopathy: determinants of patient satisfaction and the patient−provider relationship

PURPOSE

To assess satisfaction with photocoagulation treatment in diabetes patients and to investigate how it relates to patient-related characteristics and patients' visual ability. Further, to observe the interaction between physician and patient and suggest ways to improve the patient-provider relationship and, thereby, treatment satisfaction.

METHODS

This open longitudinal study included 123 diabetes patients undergoing first photocoagulation treatment for diabetic maculopathy or proliferative retinopathy. The Diabetes Treatment Satisfaction Questionnaire (DTSQ) was completed by all patients. Communication, scheduling and adherence scores were defined for each physician-patient pair. Outcome measures were: the patient's overall satisfaction with laser treatment; the patient's degree of satisfaction in relation to visual results; communication, scheduling and adherence scores, and visual acuity results.

RESULTS

The level of satisfaction after initial photocoagulation treatment was high; 46.4% of patients with proliferative retinopathy and 53.1% with maculopathy scored 31 or higher. Although 69.5% of all patients reported that their expectations of treatment corresponded to their final 9-month visual results, only 8.7% of these patients reported an improvement in visual acuity after 9 months. The number of unwanted actions performed by the patients during treatment were significantly related to the number of unclear instructions given by the physician (Fisher's exact test P < 0.01).

CONCLUSIONS

A high level of satisfaction was observed, despite the minimal improvements in visual acuity. Attempts to further improve patient satisfaction might focus on improved education of patients on the possible benefits of laser treatment, greater care in communicating information during treatment, additional nursing support, and additional clerical time to communicate with patients before each appointment.

Predictors of glucose control in children and adolescents with type 1 diabetes mellitus

AIMS

To evaluate the glucose control [(as measured by hemoglobin A1c (HbA1c)], the factors associated with glycemic control, and possible explanations for these associations in a sample of children and adolescents with type 1 diabetes.

METHODS

Data were collected on 155 children and adolescents, with type 1 diabetes mellitus, attending a multidisciplinary diabetes clinic in Portland, OR. Patients' hospital charts were reviewed to determine demographic factors, disease-related characteristics, and HbA1c level.

RESULTS

Mean percent HbA1c was 9.3. Adolescents between the ages of 14 and 18 yr were in poorer metabolic control (adjusted mean percent HbA1c 0.56 higher than children 2-8 yr). Children who attended the clinic three to four times in the previous year were in better control (adjusted mean percent HbA1c 0.46 lower than those who visited two or fewer times and 1.11 lower than those who attended five or more times). Children with married parents were in better glycemic control than those of single, separated, or divorced parents (adjusted mean percent HbA1c 0.47 lower for children of married parents). This effect appeared to be mediated, in part, by the number of glucose checks performed per day.

CONCLUSIONS

This study suggests that adolescents should be targeted for improved metabolic control. Diabetes team members need to be aware of changing family situations and provide extra support during stressful times. Regular clinic attendance is an important component of intensive diabetes management. Strategies must be developed to improve accessibility to the clinic and to identify patients who frequently miss appointments.

Clinical characteristics of children diagnosed with type 1 diabetes through intensive screening and follow-up

OBJECTIVE

The objective of this study was to determine whether earlier diagnosis of diabetes in prospectively followed autoantibody-positive children lowered onset morbidity and improved the clinical course after diagnosis.

RESEARCH DESIGN AND METHODS

The Diabetes Autoimmunity Study in the Young (DAISY) follows genetically at-risk children for the development of diabetes. Increased genetic risk is identified by family history of type 1 diabetes or expression of diabetes-associated HLA genotypes. Of the 2,140 prospectively followed children, 112 have developed islet autoantibodies and 30 have progressed to diabetes. Diabetes onset characteristics and early clinical course of these 30 children followed to diabetes were compared with those of 101 age- and sex-matched children concurrently diagnosed with diabetes in the community.

RESULTS

Pre-diabetic children followed to diabetes were less often hospitalized than the community cases (3.3 vs. 44%; P < 0.0001). They had a lower mean HbA(1c) at onset (7.2 vs. 10.9%; P < 0.0001) and 1 month after diagnosis (6.9 vs. 8.6%; P < 0.0001) but not after 6 months of diabetes. The mean insulin dose was lower in the DAISY group at 1 (0.30 vs. 0.51 U. kg(-1). day(-1); P = 0.003), 6 (0.37 vs. 0.58; P = 0.001), and 12 months (0.57 vs. 0.72; P = 0.03). There was no difference in growth parameters between the two groups. Comparisons limited to children with a family history of type 1 diabetes in both groups showed a similar pattern.

CONCLUSIONS

Childhood type 1 diabetes diagnosed through a screening and follow-up program has a less severe onset and a milder clinical course in the first year after diagnosis.

Global policy: aspects of diabetes in India

Diabetes has already been described as an epidemic, but predictions for future increases in prevalence, especially in developing countries, point to a major healthcare crisis for the future. Very little is known about the economic impact of diabetes in the developing world where predicted increases in prevalence are greatest. This paper discusses the implications of a recent study of the economic aspects of diabetes in India. The study aims were to estimate the costs of diabetes care and to assess the awareness of patients and healthcare professionals about the prevention and treatment of diabetes. The findings confirm reports from earlier studies of the high costs of treatment amongst all socio-economic patient groups resulting in a serious burden on both patients and state resources alike. Both patients and medical practitioners displayed a lack of comprehension of the need for constant disease monitoring and consistent approaches to tight glycaemic control. The long term economic implications are worrying. With the Indian diabetic population predicted to rise to >80.9 million by the year 2030, immediate health policy restructuring and investment will be needed if the best use is to be made of the scarce healthcare resources.

Sicker and poorer--the consequences of being uninsured: a review of the research on the relationship between health insurance, medical care use, health, work, and income

Health services research conducted over the past 25 years makes a compelling case that having health insurance or using more medical care would improve the health of the uninsured. The literature's broad range of conditions, populations, and methods makes it difficult to derive a precise quantitative estimate of the effect of having health insurance on the uninsured's health. Some mortality studies imply that a 4% to 5% reduction in the uninsured's mortality is a lower bound; other studies suggest that the reductions could be as high as 20% to 25%. Although all of the studies reviewed suffer from methodological flaws of varying degrees, there is substantial qualitative consistency across studies of different medical conditions conducted at different times and using different data sets and statistical methods. Corroborating process studies find that the uninsured receive fewer preventive and diagnostic services, tend to be more severely ill when diagnosed, and receive less therapeutic care. Other literature suggests that improving health status from fair or poor to very good or excellent would increase both work effort and annual earnings by approximately 15% to 20%.

Social factors associated with prolonged hospitalization among diabetic children

OBJECTIVE

To determine social factors associated with increased risk of hospital admission from diabetic ketoacidosis (DKA) or diabetic coma as well as risk of prolonged hospital stay.

METHODS

A cohort of all children (</=21 years) with type 1 diabetes mellitus (DM) in the National Inpatient Sample admitted for DKA or diabetic coma during 1996 or 1997 was conducted. Patients' age, race, gender, and insurance coverage were identified. Length of stay and charges were examined; prolonged length of stay was defined as >/=7 days.

RESULTS

A total of 8443 children with a primary hospital diagnosis of DKA and 123 children with type 1 DM and coma were identified; 55% of the children were girls, 32% were nonwhite, 29% received Medicaid insurance, and 33% resided in areas of poverty. Children with prolonged hospital stay were significantly more likely to be of nonwhite race (odds ratio [OR]: 2.0; 95% confidence interval [CI]: 1.6-2.5), to receive Medicaid insurance (OR: 1.4; 95% CI: 1.1-1.7), to live in areas of poverty (OR: 1.3; 95% CI: 1.1-1.7), and to be of younger age.

CONCLUSIONS

When compared with state census data, nonwhite and poor children were more likely to be admitted with complications of DM and to have significantly prolonged and expensive hospital stays. These children should be targeted for intensive diabetes education and outpatient medical support both to improve their health and potentially to decrease total health care costs.

Marriage rate and number of children among young adults with insulin-dependent diabetes mellitus in Japan

The main purpose of our study was to identify the social circumstances and lifestyle of IDDM patients in Japan. The present study focused on the marriage status of both men and women with IDDM as well as the number of children of women with IDDM. A questionnaire was sent to hospitals across the country. Doctors handed it or mailed it to IDDM patients aged 18 years or older. Unsigned answer sheets were returned directly by the patients. Data on the marriage rate and number of children were obtained, and possible factors affecting these indices were assessed. One thousand and thirteen patients (354 men and 659 women) answered the questionnaire. Both men and women with IDDM were less likely to be married in comparison with age-matched Japanese. The number of children of married IDDM women in various age groups was also lower in comparison with the general Japanese female population. Several factors other than diabetes complications including job discrimination, high medical costs, and psychological pressures, were thought to be responsible for these results.