Specialty Care Access Not Equal Among Teens With Diabetes

Commercially insured youths with type 2 diabetes were less likely to see specialists compared with their counterparts with type 1 diabetes, a cross-sectional study of claims data indicated.

In propensity score-weighted analyses, the incidence of ambulatory claims from an endocrine and/or diabetes clinician was 39% lower among patients with type 2 diabetes versus those with type 1 diabetes (incidence rate ratio [IRR] 0.61, 95% CI 0.52-0.72, P<0.001), reported researchers led by Christine March, MD, MS, of UPMC Children’s Hospital of Pittsburgh.

On average, the group with type 2 diabetes had 2.3 visits with a diabetes physician or advanced practice clinician during the 13-month study period, as compared with 4.0 visits for the type 1 diabetes group. And 23% and 60% of the two groups, respectively, had four or more of these specialist visits, according to the findings in JAMA Network Open.

“Though all participants in our study had commercial insurance, this finding emphasizes that these youth [with type 2 diabetes] continue to experience barriers to receiving care despite theoretically having access,” March told MedPage Today, calling the findings “surprising, though not unexpected.”

“This finding is consistent with our anecdotal experience and some small, prior studies which have reported that many youths with type 2 diabetes are lost to follow-up within a few years of diagnosis,” she said.

But patients with youth-onset type 2 diabetes shouldn’t fall through the cracks, said March, as it seems to be “a more aggressive disease” than adult-onset type 2 diabetes.

In the study, the kids with type 2 diabetes were more likely than those with type 1 diabetes to have at least one comorbidity and to have diagnoses in multiple Pediatric Complex Chronic Condition Classification categories, “suggesting higher medical complexity,” according to the researchers. Having a comorbidity was tied with a 7% (IRR 1.07, 95% CI 1.03-1.10) higher incidence of a specialist claim among the type 1 diabetes group but a 23% (IRR 0.77, 95% CI 0.67-0.87) lower incidence among the type 2 diabetes group.

“These adolescents are at a very high risk for complications early, and comorbidities are frequent,” explained March. “Current guidelines recommend that these youth be managed by a diabetes specialist, if able. Infrequent appointments with a specialist may translate into missed opportunities to fine-tune treatment and help this vulnerable population achieve durable glycemic control and promote their overall well-being.”

Clinicians may be able to boost specialty care for youths with type 2 diabetes by combining appointments with other specialists they need to see for their comorbidities in order to reduce some of the burden of frequent appointments. March also suggested partnering with community supports to deliver care in “new ways,” like engaging with local centers, community health workers, and school systems.

Researchers used Optum Clinformatics Data Mart commercial claims data on youths under 19 years with type 1 or type 2 diabetes and at least 80% enrollment in a commercial health plan from December 2018 to December 2019. This included 4,300 kids with type 1 diabetes and 472 with type 2 diabetes. The average age was about 14 years, 52% were male, and 71% were white. Those with over 12 ambulatory claims were excluded.

Youth with type 1 diabetes were significantly more likely to be white, have a longer duration of diabetes (2.5 vs 1.6 years), and use a continuous glucose monitor (60.3% vs 4.9%). They were also more likely to come from a household with a higher income.

When type 1 and type 2 diagnoses were pooled and adjusted for confounders, each additional specialist claim was linked with a higher chance of having a claim with one of the following:

• Diabetes care and education specialist (OR 1.31, 95% CI 1.25-1.36)
• Dietitian (OR 1.14, 95% CI 1.09-1.19)
• Behavioral health clinician (OR 1.16, 95% CI 1.12-1.20)

“This means that if you don’t see your diabetes specialist, you may be less likely to receive help from other essential people on the diabetes care team,” March pointed out.

As for acute care claims, every additional specialist claim was tied with higher odds of admission (OR 1.17, 95% CI 1.11-1.24) and diabetic ketoacidosis (OR 1.16, 95% CI 1.08-1.25), but no difference in claims for emergency care.

“Having few or very frequent encounters with a specialist was associated with a higher likelihood of admission. This last finding was surprising,” said March. “Prior studies have correlated infrequent appointment attendance with a diabetes specialist with a higher risk for acute care utilization. Our results suggest that some centers may see patients with poorly controlled diabetes more frequently to help with their management. This may only be so helpful in preventing acute care utilization.”

“Future research needs to consider how we appropriately tailor care to best support our patients,” she said.

Some limitations to the study included a reliance on billing diagnosis codes to identify cases and lack of lab data like HbA1c. Publicly insured youth were also excluded from the analysis. As many teens with type 2 diabetes have Medicaid, this may limit the generalizability of the findings.

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