April 10, 2019 | Erin Bluvas, bluvase@sc.edu
Recent research led by professor of epidemiology Angela Liese has shed light on factors that influence optimal glycemic control for youth and young adults with type 1 and type 2 diabetes. The study, which was published in Pediatric Diabetes, found that having health insurance coverage, the type of coverage, and having a healthcare provider were all factors associated with hemoglobin A1c (HbA1c)—a measure that reveals the average level of blood sugar for the past two to three months and helps predict risk of future complications. The authors* did not find an association between HbA1c and type of or distance to healthcare provider among participants with a healthcare provider.
“Regular interactions with healthcare providers are necessary components of lifelong disease self-management for individuals diagnosed with type 1 or type 2 diabetes,” says Liese. “Previous studies have demonstrated the need for both patient-initiated and provider-initiated interactions in order to achieve optimal glycemic control—which is the hallmark of diabetes management and the key to reducing the risk of chronic complications, such as kidney disease, neuropathy, retinopathy and cardiovascular disease, and preventing premature mortality.”
Diabetes self-management includes regular healthcare visits and frequent blood testing for HbA1c levels. Prescriptions for insulin and oral diabetes medications as well as glucose monitoring supplies add to the costs faced by patients and their families.
Data from 2001 to 2005 indicates that 55.6 percent of youth and young adults with type 1 diabetes and 46 percent of those with type 2 diabetes did not achieve optimal glycemic control. Minority groups are particularly at risk, with 65 percent of non-Hispanic black and 61 percent of Hispanic youth and young adults with type 1 diabetes (41 percent and 49 percent, respectively for type 2 diabetes) not achieving optimal glycemic control compared to 53 percent (29 percent for type 2 diabetes) of non-Hispanic whites. Inadequate glycemic control continues to persist, according to recent data, despite the increasing availability of new technologies (e.g., insulin pumps, continuous glucose monitoring).
“This raises the question as to what individual, social, environmental, and healthcare systems factors may present barriers to good glycemic control, particularly in the domain of healthcare access,” Liese explains.
With geographic access to endocrinologists concentrated in urban areas and highly variable across the United States, Liese and her team examined how access—both affordability and geographic—impacts glycemic control among youth and young adults with diabetes. As a largely rural state with access to endocrinologists within 20 miles at only 54.6 percent for children (84.9 percent for adults), the researchers focused their study on South Carolina. Further, the Southern U.S. has a particularly unfavorable ratio of children with diabetes to pediatric endocrinologists (355:1) compared to the national average (290:1).
“Unfortunately, having geographic access does not guarantee access to a provider, because in the U.S., health insurance type is another determinant of access to care,” says Liease, who notes that although some federal programs offer coverage specifically for children with disabilities or in low-income households, youth with diabetes in the U.S. are largely dependent on their parents’ or guardians’ health insurance access. “South Carolina’s decision to not take advantage of Medicaid expansion and very low eligibility levels compared to national averages perpetuates our long-standing trends of having higher than national rates of uninsured individuals, including children. This makes the situation particularly troublesome for youth and young adults with diabetes, especially as they age out of their parents’ health insurance plans.”
In this study, the researchers collected data via the SEARCH for Diabetes Study, a multi-center project that began as a surveillance effort aimed at identifying existing and new cases of diabetes. It has evolved to help find answers to questions about the types and complications of diabetes as well has how it affects the lives of youth and young adults (learn about Liese’s recently funded SEARCH project to study the impact of disparities in food security).
Nearly 500 individuals, ages 6 to 30, participated in the present study as a part of the South Carolina cohort of the overarching SEARCH project. After analyzing data on these participants, the researchers found a 1.34 higher HbA1c value among uninsured participants than among those with private insurance and a more than six-fold higher odds of having very poor, i.e. high risk glycemic control. They also found that youth and young adults with diabetes who had state or federal insurance had 0.68 higher HbA1c levels compared to those with private insurance. Further, within the confines of the models used in this analysis, they noted that minority race/ethnicity was a significant predictor of higher HbA1c and poorer glycemic control.
“There is an urgent need to identify ways to improve glycemic control and metabolic health in youth and young adults with diabetes given the low rates of glycemic control overall, and the rising number of this population with diabetes,” says Liese. “Our study of healthcare access characteristics suggests a significant and clinically meaningful relationship between lack of health insurance, type of health insurance, having a regular provider and poor glycemic control. This work further underscores the importance of social determinants of health on diabetes management outcomes in youth and young adults.”
*Co-authors include Xiaonan Ma, Lauren Reid, Melanie Sutherland, Bethany Bell, Jan Eberth, Janice Probst, Christine Turley, and Elizabeth Mayer-Davis.
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