Diabetes Care Barriers, Use, and Health Outcomes in Younger Adults With Type 1 and Type 2 Diabetes

Abstract

ImportanceTreatment challenges exist for younger adults with type 1 (T1D) and type 2 diabetes (T2D). Health care coverage, access to, and use of diabetes care are not well delineated in these high-risk populations.ObjectiveTo compare patterns of health care coverage, access to, and use of diabetes care and determine their associations with glycemia among younger adults with T1D and with T2D.Design, Setting, and ParticipantsThis cohort study analyzed data from a survey that was jointly developed by 2 large, national cohort studies: the SEARCH for Diabetes in Youth (SEARCH) study, an observational study of individuals with youth-onset T1D or T2D, and the Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) study, a randomized clinical trial (2004-2011) followed by an observational study (2012-2020). The interviewer-directed survey was administered during in-person study visits in both studies between 2017 and 2019. Data analyses were performed between May 2021 and October 2022.Main Outcomes and MeasuresSurvey questions addressed health care coverage, usual sources of diabetes care, and frequency of care use. Glycated hemoglobin (HbA1c) levels were assayed in a central laboratory. Patterns of health care factors and HbA1c levels were compared by diabetes type.ResultsThe analysis included 1371 participants (mean [range] age, 25 [18-36] years; 824 females [60.1%]), of whom 661 had T1D and 250 had T2D from the SEARCH study and 460 had T2D from the TODAY study. Participants had a mean (SD) diabetes duration of 11.8 (2.8) years. More participants with T1D than T2D in both the SEARCH and TODAY studies reported health care coverage (94.7%, 81.6%, and 86.7%), access to diabetes care (94.7%, 78.1%, and 73.4%), and use of diabetes care (88.1%, 80.5%, and 73.6%). Not having health care coverage was associated with significantly higher mean (SE) HbA1c levels in participants with T1D in the SEARCH study (no coverage, 10.8% [0.5%]; public, 9.4% [0.2%]; private, 8.7% [0.1%]; P < .001) and participants with T2D from the TODAY study (no coverage, 9.9% [0.3%]; public, 8.7% [0.2%]; private, 8.7% [0.2%]; P = .004). Medicaid expansion vs without expansion was associated with more health care coverage (participants with T1D: 95.8% vs 90.2%; participants with T2D in SEARCH: 86.1% vs 73.9%; participants with T2D in TODAY: 93.6% vs 74.2%) and lower HbA1c levels (participants with T1D: 9.2% vs 9.7%; participants with T2D in SEARCH: 8.4% vs 9.3%; participants with T2D in TODAY: 8.7% vs 9.3%). The T1D group incurred higher median (IQR) monthly out-of-pocket expenses than the T2D group ($74.50 [$10.00-$309.00] vs $10.00 [$0-$74.50]).Conclusions and RelevanceResults of this study suggested that lack of health care coverage and of an established source of diabetes care were associated with significantly higher HbA1c levels for participants with T1D, but inconsistent results were found for participants with T2D. Increased access to diabetes care (eg, through Medicaid expansion) may be associated with improved health outcomes, but additional strategies are needed, particularly for individuals with T2D.

Psychosocial Factors and Glycemic Control in Young Adults With Youth-Onset Type 2 Diabetes

“…Young adults with type 2 diabetes experience many of the developmental challenges faced by peers with type 1 diabetes, such as changes in support networks, responsibilities, and health care systems. 37 The few cross-sectional studies assessing the association of psychosocial factors with HbA 1c in young adults with type 1 diabetes reported that depression, 38 diabetes distress, 39 anxiety disorders, 40 social support, 41 and health care coverage insecurity 42 were associated with HbA 1c . However, because the management of type 1 diabetes frequently involves technologies (eg, insulin pumps and continuous glucose monitoring) that pose unique challenges, it is important to study the 2 groups separately and in longitudinal studies.…”

Unfavorable social determinants of health and risk of mortality in adults with diabetes: findings from the National Health Interview Survey

“…Similar efforts should be made to capture diabetes type in population-based survey data, given prior evidence showing that patients with type 1 versus type 2 diabetes may have different SDOH profiles, with implications for downstream mortality risk. 38 Uncovering these incompletely understood differences and the extent to which they affect the diabetes–mortality association could inform risk stratification and care pathways for adults with type 1 or type 2 diabetes.…”

Health-Care Utilization and Outcomes in Young Adults With Type 1 and Type 2 Diabetes

“…The ACA and Medicaid expansion are seen as important tools for increasing access to care and use of preventive services, and affected health-care utilization for young adults with DM. Using a large study cohort of 1371 participants from 2 large national cohorts in the SEARCH and the TODAY study (mean age 25 years [range, 18-36 years]), young adults with T2D were found to have less health-care coverage, and less access to and use of DM care compared to young adults with T1D [ 58 ]. Furthermore, less access was associated with higher HbA 1c .…”