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- Title
Patient and Health Care Factors Associated With Long-term Diabetes Complications Among Adults With and Without Mental Health and Substance Use Disorders.
- Authors
Schmidt, Eric M.; Barnes, James; Chen, Cheng; Trafton, Jodie; Frayne, Susan; Harris, Alex H. S.
- Abstract
Key Points: Question: Among patients with newly diagnosed diabetes, are preexisting mental health (MH) or substance use (SU) disorders and primary care utilization before a new diabetes diagnosis associated with the long-term severity of diabetes complications? Findings: In this cohort study of 122 992 patients in the US Department of Veterans Affairs health system, more than 90% of patients with MH or SU disorders had primary care visits before diabetes was newly diagnosed, compared with approximately 58% of patients without MH or SU disorders. Patients with MH or SU disorders experienced significantly lower severity of diabetes complications for 7 years thereafter, compared with patients without preexisting MH or SU disorders, even after controlling for sociodemographic characteristics and medical comorbidities. Meaning: Among patients with MH or SU disorders, receiving more medical and mental health care from an integrated health care system before the onset of diabetes is associated with modest, albeit impermanent, health benefits after the onset of diabetes. This cohort study uses data from the US Veterans Affairs health care systems to examine whether preexisting mental health or substance use disorders and primary care utilization before a new diabetes diagnosis are associated with the long-term severity of diabetes complications. Importance: Among people with diabetes, co-occurring mental health (MH) or substance use (SU) disorders increase the risk of medical complications. Identifying how to effectively promote long-term medical benefits for at-risk populations, such as people with MH or SU disorders, is essential. Knowing more about how health care accessed before the onset of diabetes is associated with health benefits after the onset of diabetes could inform treatment planning and population health management. Objective: To analyze how preexisting MH or SU disorders and primary care utilization before a new diabetes diagnosis are associated with the long-term severity of diabetes complications. Design, Setting, and Participants: This cohort study analyzed medical record data from US Department of Veterans Affairs health care systems nationwide and used mixed-effects regressions to test associations between prediabetes patient or health care factors and longitudinal progression of diabetes complication severity from 2006 to 2015. Participants included patients who received a new diabetes diagnosis in 2008 and who were aged 18 to 85 years at the time of their diagnosis. Data analysis was conducted from March to August 2017. Exposures: Patients were assigned to groups on the basis of a 2-year look-back period for MH or SU disorders status (MH disorder only, SU disorder only, MH and SU disorder, or no MH or SU disorder diagnoses) and on the basis of the amount of primary care utilization before diabetes was diagnosed. Main Outcomes and Measures: Nine-year trajectories of Diabetes Complication Severity Index (DCSI) scores. Results: Among 122 992 patients with newly diagnosed diabetes, the mean (SD) age was 62.3 (11.1) years, 118 810 (96.6%) were male, and 28 633 (23.3%) had preexisting MH or SU disorders diagnoses. From the onset of diabetes to 7 years later, patients' mean estimated DCSI scores increased from 0.84 (95% CI, 0.82-0.87) to 1.42 (95% CI, 1.36-1.47). Controlling for sociodemographic characteristics and medical comorbidities, SU disorders only (decrease in DCSI score, −0.09; 95% CI, −0.13 to −0.04; P <.001) or both MH and SU disorders (decrease in DCSI score, −0.13; 95% CI, −0.16 to −0.09; P <.001), but not MH disorders only, were associated with lower DCSI scores at the time of the onset of diabetes compared with no MH or SU disorders. More than 90% of patients with MH or SU disorders had primary care visits before diabetes was newly diagnosed, compared with approximately 58% of patients without MH or SU disorders. Patients who had primary care visits before the onset of diabetes had lower baseline DCSI scores, compared with patients who did not have primary care visits (decrease in DCSI score, −0.41 [95% CI, −0.43 to −0.39] for 1-2 visits, −0.50 [95% CI, −0.52 to −0.48] for 3-4 visits, −0.39 [95% CI, −0.41 to −0.37] for 5-8 visits, and −0.15 [95% CI, −0.17 to −0.12] for ≥9 visits; P <.001 for all). Patients with MH or SU disorders had lower overall, but more rapidly progressing, mean DCSI scores through year 7 after the onset of diabetes (MH disorder only, 0.006 [95% CI, 0.005-0.008], P <.001; SU disorder only, 0.005 [95% CI, 0.001-0.008], P =.004; or both MH and SU disorders, 0.008 [95% CI, 0.006-0.011], P <.001), compared with patients without MH or SU disorders. Conclusions and Relevance: Access to and engagement in integrated health care may be associated with modest, albeit impermanent, long-term health benefits for patients with MH and/or SU disorders with newly diagnosed diabetes.
- Subjects
DIABETES complications; PSYCHIATRIC diagnosis; SUBSTANCE abuse diagnosis; MORTALITY risk factors; CARDIOVASCULAR diseases; CEREBROVASCULAR disease; CLUSTER analysis (Statistics); COMPARATIVE studies; CONFIDENCE intervals; DIABETIC nephropathies; DIABETIC neuropathies; DIABETIC retinopathy; HEALTH care teams; HOSPITAL care; HYPERTENSION; INTEGRATED health care delivery; LONGITUDINAL method; MEDICAL care use; METABOLIC disorders; PERIPHERAL vascular diseases; PRIMARY health care; REGRESSION analysis; UNITED States. Dept. of Veterans Affairs; COMORBIDITY; TREATMENT effectiveness; DISEASE duration; DATA analysis software; DESCRIPTIVE statistics; DISEASE complications
- Publication
JAMA Network Open, 2019, Vol 2, Issue 9, pe1912060
- ISSN
2574-3805
- Publication type
Article
- DOI
10.1001/jamanetworkopen.2019.12060