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Associations Between Socioeconomic Status and Patient Experience With Type 1 Diabetes Management and Complications: Cross-sectional Analysis of a Cohort From Québec, Canada

Published:March 03, 2022DOI:https://doi.org/10.1016/j.jcjd.2022.02.008

      Abstract

      Background

      Low socioeconomic status (SES) may add to the challenges of type 1 diabetes (T1D) management and be an independent risk factor for chronic and acute diabetes complications. Our aim in this study was to evaluate the association between SES and TID management and risk of complications in a universal health-care system using data from a registry of people living with T1D (PWT1D) in Québec, Canada (the BETTER registry).

      Methods

      This study was a cross-sectional analysis describing the association between SES factors (education, income, employment and insurance coverage) and T1D outcomes (glycated hemoglobin [A1C], acute and chronic complications and comorbidities), using chi-square tests and regression analyses (adjusted for diabetes duration, sex, ethnicity and diabetes technology use).

      Results

      In a sample of 1,333 PWT1D, lower education level was associated with cardiovascular disease (odds ratio [OR], 2.44; p=0.002), depression (OR, 1.56; p=0.020), nephropathy (OR, 2.10; p=0.001) and higher A1C (OR, 1.79; p<0.001). Low-income groups were more likely to report higher A1C (OR, 2.16; p=0.001), retinopathy (OR, 1.84; p=0.038), neuropathy (OR, 1.89; p=0.043), nephropathy (OR, 2.23; p=0.024), severe hypoglycemia (OR, 1.87; p=0.022) and depression (OR, 1.87; p=0.012). Unemployment was associated with retinopathy (OR, 2.37; p=0.009) and neuropathy (OR, 1.96; p=0.035). Diabetic ketoacidosis (OR, 2.81; p=0.001) and neuropathy (OR, 1.67; p=0.020) were more likely to be reported by participants with public insurance.

      Conclusions

      PWT1D from lower SES, particularly those with low income and low education, were more likely to report T1D-related complications and comorbidities. Further longitudinal investigations are needed to better understand the nature and directionality of these associations.

      Résumé

      Introduction

      Un faible statut socioéconomique (SSE) peut accroître la complexité de la prise en charge du diabète de type 1 (DT1) et constituer un facteur de risque indépendant des complications à court et à long terme du diabète. Dans la présente étude, notre objectif était d’évaluer l’association entre le SSE et la prise en charge du DT1, et le risque de complications dans le cadre d’un système de soins de santé universel à partir des données d’un registre de personnes vivant avec le diabéte de type 1 (PDT1) du Québec, au Canada (le registre BETTER).

      Méthodes

      Cette étude constituait une analyse transversale qui décrivait l’association entre les facteurs du SSE (scolarité, revenu, emploi et couverture d’assurance) et les issues du DT1 (l’hémoglobine glyquée [A1c], les complications à court et à long terme et les maladies associées) au moyen de tests du chi carré et d’analyses de régression (ajustées à la durée du diabète, au sexe, à l’origine ethnique et à l’utilisation de la technologie du diabète).

      Résultats

      Dans un échantillon de 1333 PDT1, le faible niveau de scolarité était associé aux maladies cardiovasculaires (rapport de cotes [RC], 2,44; p = 0,002), à la dépression (RC, 1,56; p = 0,020), à la néphropathie (RC, 2,10; p = 0,001) et à l’A1c plus élevée (RC, 1,79; p < 0,001). Les groupes de faible revenu étaient plus susceptibles de déclarer une A1c plus élevée (RC, 2,16; p = 0,001), une rétinopathie (RC, 1,84; p = 0,038), une neuropathie (RC, 1,89; p = 0,043), une néphropathie (RC, 2,23; p = 0,024), une hypoglycémie grave (RC, 1,87; p = 0,022) et une dépression (RC, 1,87; p = 0,012). Le chômage était associé à la néphropathie (RC, 2,37; p = 0,009) et à la neuropathie (RC, 1,96; p = 0,035). Les participants qui avaient une assurance publique étaient plus susceptibles de déclarer une acidocétose diabétique (RC, 2,81; p = 0,001) et une neuropathie (RC, 1,67; p = 0,020).

      Conclusions

      Les PDT1 de plus faible SSE, particulièrement ceux qui avaient un faible revenu et une faible scolarité, étaient plus susceptibles de déclarer des complications liées au diabète et des maladies associées. D’autres études longitudinales sont nécessaires pour mieux comprendre la nature et la directionnalité de ces associations.

      Keywords

      Mots clés

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      References

        • Imran S.A.
        • Agarwal G.
        • Bajaj H.S.
        • Ross S.
        Targets for glycemic control.
        Can J Diabetes. 2018; 42: S42-S46
        • Foster N.C.
        • Beck R.W.
        • Miller K.M.
        • et al.
        State of type 1 diabetes management and outcomes from the T1D Exchange in 2016-2018.
        Diabetes Technol Ther. 2019; 21: 66-72
        • McGibbon A.
        • Adams L.
        • Ingersoll K.
        • et al.
        Glycemic management in adults with type 1 diabetes.
        Can J Diabetes. 2018; 42: S80-S87
        • Secrest A.M.
        • Costacou T.
        • Gutelius B.
        • Miller R.G.
        • Songer T.J.
        • Orchard T.J.
        Associations between socioeconomic status and major complications in type 1 diabetes: The Pittsburgh Epidemiology of Diabetes Complication (EDC) Study.
        Ann Epidemiol. 2011; 21: 374-381
        • Agborsangaya C.B.
        • Lau D.
        • Lahtinen M.
        • Cooke T.
        • Johnson J.A.
        Multimorbidity prevalence and patterns across socioeconomic determinants: A cross-sectional survey.
        BMC Public Health. 2012; 12: 201
        • Yaghoubi M.
        • Mansell K.
        • Vatanparast H.
        • Steeves M.
        • Zeng W.
        • Farag M.
        Prevalence of type 1 and type 2 diabetes–related complications and their association with determinants identified in Canada's survey on living with chronic diseases–diabetes component.
        Can J Diabetes. 2020; 44: 304-311.e3
        • Sawka A.M.
        • Boulos P.
        • Talib A.S.
        • et al.
        Low socioeconomic status and increased risk of severe hypoglycemia in type 1 diabetes: A systematic literature review.
        Can J Diabetes. 2007; 31: 233-241
        • Rawshani A.
        • Svensson A.M.
        • Rosengren A.
        • Eliasson B.
        • Gudbjornsdottir S.
        Impact of socioeconomic status on cardiovascular disease and mortality in 24,947 individuals with type 1 diabetes.
        Diabetes Care. 2015; 38: 1518-1527
        • Barua B.
        • Hasan S.
        • Timmermans I.
        Comparing performance of universal health care countries.
        The Fraser Institute, 2017
        • Willner S.
        • Whittemore R.
        • Keene D.
        "Life or death": Experiences of insulin insecurity among adults with type 1 diabetes in the United States.
        SSM Popul Health. 2020; 11100624
      1. Statistics Canada. Table 13-10-0096-01. Health characteristics, annual estimates. http://doi.org/10.25318/1310009601-eng [cited 2022 January 03]. https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1310009601

        • Institut national de santé publique du Québec
        Deprivation.
        https://www.inspq.qc.ca/en/deprivation
        Date accessed: October 21, 2021
        • Gamache P.
        • Hamel D.
        • Blaser C.
        Bureau d’information et d’études en santé des populations. Material and social deprivation index: A summary. 2019.
        • Gold A.E.
        • MacLeod K.M.
        • Frier B.M.
        Frequency of severe hypoglycemia in patients with type I diabetes with impaired awareness of hypoglycemia.
        Diabetes Care. 1994; 17: 697-703
        • Fox J.
        • Monette G.
        Generalized collinearity diagnostics.
        J Am Stat Assoc. 1992; 87: 178-183
        • Guerrero V.M.
        Use of the Box-Cox transformation with binary response models.
        Biometrika. 1982; 69: 309-314
        • Dong Y.
        • Peng C.Y.
        Principled missing data methods for researchers.
        SpringerPlus. 2013; 2: 222
        • Yeung C.W.
        • Thomas S.
        Income Imputation for the Canadian Community Health Survey: Statistics Canada. 2013.
        • Wang J.
        • Geng L.
        Effects of socioeconomic status on physical and psychological health: Lifestyle as a mediator.
        Int J Environ Res Public Health. 2019; 16: 281
        • Paquet G.
        Santé et inégalités sociales: Un problème de distance culturelle.
        Institut Québécois de Recherche sur La Culture, 1989
        • Dostie M.
        Les corps investis.
        De Boeck, Brussels1989
        • Jetha A.
        • Chen C.
        • Mustard C.
        • et al.
        Longitudinal examination of temporality in the association between chronic disease diagnosis and changes in work status and hours worked.
        Occup Environ Med. 2017; 74: 184-191
        • Kraut A.
        • Walld R.
        • Tate R.
        • Mustard C.
        Impact of Diabetes on Employment and Income in Manitoba, Canada.
        Diabetes Care. 2001; 24: 64-68
        • Foos V.
        • Varol N.
        • Curtis B.H.
        • et al.
        Economic impact of severe and non-severe hypoglycemia in patients with Type 1 and Type 2 diabetes in the United States.
        J Med Econ. 2015; 18: 420-432
        • Gouvernement du Québec
        Insulin pump access program.
        • Janež A.
        • Guja C.
        • Mitrakou A.
        • et al.
        Insulin therapy in adults with type 1 diabetes mellitus: A narrative review.
        Diabetes Ther. 2020; 11: 387-409
        • Thomas N.J.
        • Jones S.E.
        • Weedon M.N.
        • Shields B.M.
        • Oram R.A.
        • Hattersley A.T.
        Frequency and phenotype of type 1 diabetes in the first six decades of life: A cross-sectional, genetically stratified survival analysis from UK Biobank.
        Lancet Diabetes Endocrinol. 2018; 6: 122-129
        • Leslie R.D.
        • Evans-Molina C.
        • Freund-Brown J.
        • et al.
        Adult-onset type 1 diabetes: Current understanding and challenges.
        Diabetes Care. 2021; 44: 244956
        • Régie de l'assurance maladie du Québec
        List of medications.
        https://www.ramq.gouv.qc.ca/en/media/12666
        Date accessed: January 6, 2022
        • Diabetes Canada
        Coverage of insulin pumps across Canada.
        • Ke C.
        • Kim S.J.
        • Shah B.R.
        • et al.
        Impact of socioeconomic status on incidence of end-stage renal disease and mortality after dialysis in adults with diabetes.
        Can J Diabetes. 2019; 43: 483-489.e4
        • Everett E.
        • Mathioudakis N.N.
        Association of socioeconomic status and DKA readmission in adults with type 1 diabetes: Analysis of the US National Readmission Database.
        BMJ Open Diabetes Res Care. 2019; 7e000621
        • Weinstock R.S.
        • Xing D.
        • Maahs D.M.
        • et al.
        Severe hypoglycemia and diabetic ketoacidosis in adults with type 1 diabetes: Results from the T1D Exchange clinic registry.
        J Clin Endocrinol Metab. 2013; 98: 3411-3419
        • Scott A.
        • Chambers D.
        • Goyder E.
        • O'Cathain A.
        Socioeconomic inequalities in mortality, morbidity and diabetes management for adults with type 1 diabetes: A systematic review.
        PLoS One. 2017; 12e0177210
        • Statistics Canada
        Quebec [Province] and Canada [Country] (table). Census profile. 2016 Census. 2017 Catalogue No. 98-316-X2016001.
        • Xu G.
        • Liu B.
        • Sun Y.
        • et al.
        Prevalence of diagnosed type 1 and type 2 diabetes among US adults in 2016 and 2017: Population based study.
        BMJ. 2018; 362: k1497
        • Lanting L.C.
        • Joung I.M.
        • Mackenbach J.P.
        • Lamberts S.W.
        • Bootsma A.H.
        Ethnic differences in mortality, end-stage complications, and quality of care among diabetic patients: A review.
        Diabetes Care. 2005; 28: 2280-2288
        • Pampalon R.
        • Hamel D.
        • Gamache P.
        A comparison of individual and area-based socio-economic data for monitoring social inequalities in health.
        Health Rep. 2009; 20: 85-94
        • Wu Z.
        • Rabasa-Lhoret R.
        • Messier V.
        • et al.
        Self-reported haemoglobin A1c highly agrees with laboratory-measured haemoglobin A1c among adults living with type 1 diabetes: A BETTER registry study.
        Diabetes Metab. 2021; 101277