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- Title
Association of Area-Level Socioeconomic Deprivation With Hypoglycemic and Hyperglycemic Crises in US Adults With Diabetes.
- Authors
Kurani, Shaheen Shiraz; Heien, Herbert C.; Sangaralingham, Lindsey R.; Inselman, Jonathan W.; Shah, Nilay D.; Golden, Sherita Hill; McCoy, Rozalina G.
- Abstract
This cohort study examines the geographically based risk factors for emergency department visits and hospitalizations associated with severe hypoglycemia and diabetic ketoacidosis or hyperglycemic hyperosmolar state in insured individuals with diabetes. Key Points: Question: Is there an association between county-level deprivation and hypoglycemic and hyperglycemic crises among adults with diabetes? Findings: In this cohort study of 1 116 361 adults with diabetes, patients who lived in areas of increasing socioeconomic deprivation experienced significantly higher rates of emergency department visits and hospitalizations for severe hypoglycemia and diabetic ketoacidosis or hyperglycemic hyperosmolar state after adjustment for other patient-level risk factors. Meaning: The findings of this study suggest that county-level socioeconomic deprivation is an independent risk factor for hypoglycemic and hyperglycemic crises, calling for interventions that target the structural barriers to optimal diabetes management and health. 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.
- Subjects
UNITED States; HYPERGLYCEMIA; HOSPITAL emergency services; SOCIAL determinants of health; CONFIDENCE intervals; DIABETES; RETROSPECTIVE studies; SOCIOECONOMIC factors; RISK assessment; HYPOGLYCEMIA; HOSPITAL care; DESCRIPTIVE statistics; CHI-squared test; RESIDENTIAL patterns; MEDICAL appointments; DATA analysis software; LONGITUDINAL method
- Publication
JAMA Network Open, 2022, Vol 5, Issue 1, pe2143597
- ISSN
2574-3805
- Publication type
Article
- DOI
10.1001/jamanetworkopen.2021.43597