Universal drug coverage and income-related disparities in glycaemic control

Small Steps Towards an Inclusive Diabetes Prevention Program: How Small Steps for Big Changes is Improving Program Equity and Inclusion

Social determinants of health, the effects of colonialism, and systemic injustices result in some groups being at disproportionately higher risk for developing type 2 diabetes (T2D). Many T2D prevention programs have not been designed to provide equitable and inclusive care to everyone. This paper presents an example of the steps taken in an evidence-based community T2D prevention program, Small Steps for Big Changes (SSBC), to improve equitable access and inclusivity based on input from a stakeholder advisory group and the ConNECT Framework. To improve reach to those most at risk for T2D, SSBC has changed both eligibility criteria and program delivery. To ensure that all testing is done in an inclusive manner, changes have been made to measurements, and to training for those delivering the program. This paper also provides actionable recommendations for other researchers to incorporate into their own health programs to promote inclusivity and ensure that they reach those most at risk of T2D.

Expanding the use of patient-reported outcomes (PROs): Screening youth with type 1 diabetes from underrepresented populations

AIM

Youth from lower socioeconomic status (SES) have suboptimal type 1 diabetes (T1D) outcomes. Patient reported outcomes (PROs) measure psychosocial states and are associated with T1D outcomes, however are understudied in low SES youth. We aimed to evaluate associations between PROs and public insurance status, a proxy for low SES.

METHODS

We analyzed survey data from 129 youth with T1D (age 15.7 ± 2.3 years, 33 % publicly insured) screened with PROMIS Global Health (PGH, measuring global health) and Patient Health Questionnaire (PHQ-9, measuring depressive symptoms) during diabetes appointments. Correlation and regression analyses evaluated differences in PGH and PHQ-9 by insurance status.

RESULTS

For youth with public insurance, lower global health correlated with lower self-monitoring blood glucose (SMBG; r = 0.38,p = 0.033) and older age (r = -0.45,p = 0.005). In youth with private insurance, lower global health correlated with lower SMBG (r = 0.27,p = 0.018) and female sex (rho = 0.26,p = 0.015). For youth with private insurance, higher depressive symptoms correlated with higher body mass index (r = 0.22,p = 0.03) and fewer SMBG (r = -0.35,p = 0.04). In multivariate regression analyses, public insurance was inversely associated with global health (p = 0.027).

CONCLUSION

PGH is a particularly salient PRO in youth with public insurance. Global health may be an important psychosocial factor to assess in youth with T1D from low SES backgrounds.

Household Income Is Related to Dietary Fiber Intake and Dietary Acid Load in People with Type 2 Diabetes: A Cross-Sectional Study

Household income was related to habitual dietary intake in general Japanese people. This cross-sectional study investigated the relationship between household income and habitual dietary intake in people with type 2 diabetes mellitus (T2DM). Household income was evaluated using a self-reported questionnaire and categorized into high and low household income. Nutritional status was assessed using a brief-type self-administered diet history questionnaire. Among 128 men and 73 women, the proportions of participants with low household income were 67.2% (n = 86/128) in men and 83.6% (n = 61/73) in women. Dietary fiber intake (11.3 ± 4.2 vs. 13.8 ± 6.0 g/day, p = 0.006) was lower, and dietary acid load, net endogenous aid production score (NEAP) (51.7 ± 10.5 vs. 46.8 ± 10.4 mEq/day, p = 0.014) and potential renal acid load score (PRAL) (9.5 ± 10.7 vs. 3.7 ± 14.1 mEq/day, p = 0.011) were higher in men with low household income than in those without. Multivariable linear regression analyses demonstrated that log (dietary fiber intake) in men with low household income was lower than that in those with high household income after adjusting for covariates (2.35 [2.26−2.44] vs. 2.52 [2.41−2.62], p = 0.010). Furthermore, NEAP (54.6 [51.7−57.4] vs. 45.8 [42.5−49.2], p <0.001) in men with low household income were higher than in those with high household income after adjusting for covariates. Contrastingly, household income was not related to diet quality in women. This study showed that household income was related to dietary fiber intake and dietary acid load in men but not in women.

Introduction of publicly funded pharmacare and socioeconomic disparities in glycemic management in children and youth with type 1 diabetes in Ontario, Canada: a population-based trend analysis

BACKGROUND

We evaluated the impact of publicly funded pharmacare (Ontario Health Insurance Plan [OHIP]+), which was introduced in Ontario on Jan. 1, 2018, for youth less than 25 years of age, on temporal trends in hemoglobin A_1c (HbA_1c, a measure of glycemic management) and the differential effect on the change in temporal trends in HbA_1c according to socioeconomic status (SES).

METHODS

We conducted a trend analysis using administrative data sets. We included youth aged 21 years, 9 months or younger, residing in Ontario on Jan. 1, 2016, with diabetes diagnosed before age 15 years and before Jan. 1, 2015. We used claims for insulin to measure pharmacare use. We evaluated the change in HbA_1c (%) per 90 days before (Jan. 1, 2016, to Dec. 31, 2017) the introduction of and during (Apr. 1, 2018, to Mar. 31, 2019) OHIP+ coverage, and the difference in the change in HbA_1c according to SES, using segmented regression analysis.

RESULTS

Of 9641 patients, 7041 (73.0%) made an insulin claim. We found a negligible difference in the temporal change in HbA_1c during compared with before OHIP+ coverage that was not statistically significant (β estimate -0.0002, 95% confidence interval [CI] -0.0004 to 0.0000). The size of the effect was slightly greater in those individuals with the lowest SES than in those with the highest SES (β estimate -0.0008, 95% CI -0.0015 to -0.0001).

INTERPRETATION

We found that the effect of OHIP+ on the change in HbA_1c was slightly greater for youth in the lowest SES than for those in the highest SES. Our findings suggest that publicly funded pharmacare may be an effective policy tool to combat worsening socioeconomic disparities in diabetes care and outcomes.

Universal Drug Coverage and Socioeconomic Disparities in Health Care Costs Among Persons With Diabetes

OBJECTIVE

To examine whether neighborhood socioeconomic status (SES) is a predictor of non-drug-related health care costs among Canadian adults with diabetes and, if so, whether SES disparities in costs are reduced after age 65 years, when universal drug coverage commences as an insurable benefit.

RESEARCH DESIGN AND METHODS

Administrative health databases were used to examine publicly funded health care expenditures among 698,113 younger (20-64 years) and older (≥65 years) adults with diabetes in Ontario from April 2004 to March 2014. Generalized linear models were constructed to examine relative and absolute differences in health care costs (total and non-drug-related costs) across neighborhood SES quintiles, by age, with adjustment for differences in age, sex, diabetes duration, and comorbidity.

RESULTS

Unadjusted costs per person-year in the lowest SES quintile (Q1) versus the highest (Q5) were 39% higher among younger adults ($5,954 vs. $4,270 [Canadian dollars]) but only 9% higher among older adults ($10,917 vs. $9,993). Adjusted non-drug costs (primarily for hospitalizations and physician visits) were $1,569 per person-year higher among younger adults in Q1 vs. Q5 (modeled relative cost difference: 35.7% higher) and $139.3 million per year among all individuals in Q1. Scenarios in which these excess costs per person-year were decreased by ≥10% or matched the relative difference among seniors suggested a potential for savings in the range of $26.0-$128.2 million per year among all lower-SES adults under age 65 years (Q1-Q4).

CONCLUSIONS

SES is a predictor of diabetes-related health care costs in our setting, more so among adults under age 65 years, a group that lacks universal drug coverage under Ontario's health care system. Non-drug-related health care costs were more than one-third higher in younger, lower-SES adults, translating to >$1 billion more in health care expenditures over 10 years.