Socioeconomic and Racial Disparities in Diabetic Ketoacidosis Admissions in Youth With Type 1 Diabetes

Abstract

OBJECTIVE: We sought to determine whether census tract poverty, race, and insurance status were associated with the likelihood and severity of diabetic ketoacidosis (DKA) hospitalization among youth with type 1 diabetes (T1D). METHODS: We conducted a retrospective population-based cohort study using Cincinnati Children’s Hospital electronic medical record (EMR) data from January 1, 2011, to December 31, 2017, for T1D patients ≤18 years old. The primary outcome was admission for DKA. Secondary outcomes included DKA severity, defined by initial pH and bicarbonate, and length of stay. Exposures were the poverty rate for the youth’s home census tract, parent-reported race, and insurance status. We used multivariable logistic regression to analyze effects on odds of admission. RESULTS: We identified 439 patients with T1D; 152 were hospitalized. The cohort was 48% female, 25% Black, and 36% publicly insured; the median age was 14 years. For every 10% increase in a youth’s census tract poverty rate, the adjusted odds of admission increased by 22% (95% CI, 1.03-1.47). Public insurance status was associated with DKA admission (adjusted odds ratio [AOR], 2.71, 95% CI, 1.62-4.55) while race was not. There were no clinically meaningful differences in pH or bicarbonate by census tract poverty, race, or insurance status; however, Black patients experienced differences in care (eg, longer length of stay). CONCLUSION: Youth with T1D living in high poverty areas and on public insurance were significantly more likely to be admitted for DKA. Severity upon presentation was similar across exposures. Understanding contextual mechanisms by which disparities emerge will inform changes aimed at equitably improving care.

Association of Neighborhood Resources and Race and Ethnicity With Readmissions for Diabetic Ketoacidosis at US Children’s Hospitals

“… 9 However, this study was limited in that the number of readmissions was low, with only 42 children (10%) being readmitted during the study period. 9 …”

“…In another study using insurance status, and greater Census tract poverty were significantly associated with readmission. 9 However, this study was limited in that the number of readmissions was low, with only 42 children (10%) being readmitted during the study period. 9 Several studies [14][15][16] have begun to explore the association among neighborhood opportunity, acute care use, and hospitalizations.…”

“…9 However, this study was limited in that the number of readmissions was low, with only 42 children (10%) being readmitted during the study period. 9 Several studies [14][15][16] have begun to explore the association among neighborhood opportunity, acute care use, and hospitalizations. One study found that residing in an area in the very low COI category was associated with significantly greater odds of having multiple acute care visits for conditions amenable to outpatient care compared with children who live in areas in the very high COI category.…”

“…A total of 83 445 DKA encounters were identified, of which 72 726 were included in our analysis (median age, 13 [IQR, [9][10][11][12][13][14][15] a Unless otherwise indicated, data are expressed as number (%) of encounters.…”

“…Further, White children are less likely to require hospitalization for DKA compared with children of other races and ethnicities. 2 , 4 Although socioeconomic factors—including lack of health insurance or public insurance, 2 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 lower income or living in areas of poverty, 2 , 4 , 9 , 10 , 12 and lower parental educational achievement 10 —have been associated with higher risk and severity of DKA, other community attributes may influence health outcomes.…”