US 'Emerging Adults' With Type 1 Diabetes Face DKA Danger

In contrast to youth with type 1 diabetes in Canada, those in the United States are vulnerable to lapses in care at the time of transition from adolescence to adulthood, placing them at risk for the serious complication of diabetic ketoacidosis (DKA) and other adverse outcomes, new research suggests.

Indeed, the study found that as teens became young adults in the United States, hospitalization rates for DKA soared by 90%, compared with a 23% rise for the same age group in Canada.

"The US healthcare system is failing far too many patients, including those with diabetes," said lead author Adam Gaffney, MD, a pulmonary and critical care physician at the Cambridge Health Alliance and Harvard Medical School, Massachusetts, in a press release by the US Physicians for a National Health Program (PNHP).

Gaffney and colleagues published their findings online May 8 in the Journal of General Internal Medicine.

"In America, 29 million are uninsured, while far more face unaffordable deductibles or sky-high drug costs — including for insulin. The consequences can be deadly," Gaffney outlined.

He told Medscape Medical News in an interview, "I think as clinicians we should really advocate for our patients for systemic change...We see the harm that the health system does to our patients. So we should really speak up for systems that would cover people, and provide universal coverage, and seamless coverage over the lifespan."

"Churn" Leads to Disruptions to Healthcare in the United States

The authors explain in their article that the prevalence of DKA rose at the time of transition from adolescence to young adulthood in both countries, but the increase was considerably higher in the United States than Canada.

While US youth are at risk for disruptions in health coverage at that age, Canada's single-payer system, with family physicians as primary care providers, offers universal, seamless coverage across a patient's lifespan.

Most of the current study's results predate the launch of the US Affordable Care Act (Obamacare), which raised the upper age cut-off for which private family insurance plans could cover children from 18 to 26 years.

However, Gaffney points out, many families don't have private insurance and some youth who were previously eligible for Medicaid as children may not be as adults.

Moreover, the Affordable Care Act didn't prevent the "churn" that often accompanies the youth-to-adult care transition, Gaffney told Medscape Medical News.

"Certainly the law made a difference and improved the lives of people with chronic diseases, but there's still a long way to go."

"We have to be aware of 'churn,' the dynamic that people are constantly changing insurance plans, whether because their boss changed it for them or because they lost their job. Churn can also lead to disruptions in coverage, their ability to see a doctor, or to obtain the same insulin they used to take."

As clinicians, he said, "we have to be aware of the sorts of financial barriers that our patients are facing, whether in terms of the co-pays they need to pay to see us or the sizable deductibles they may need to cover just to get their insulin."

And although Canada's health system does not uniformly cover drugs, they’re typically far less expensive than in the United States, he emphasizes.

"I think as clinicians we should really advocate for our patients for systemic change."

"We see the harm that the health system does to our patients. So we should really speak up for systems that would cover people, and provide universal coverage, and seamless coverage over the lifespan," Gaffney stressed.

Almost a Third of 23 Year Olds in the United States Were Uninsured

In the cross-sectional analysis of inpatient administrative databases in the United States in 1998-2014 and in Manitoba, Canada, in 2003-2013, a total of 168,946 patients aged 12-30 years were hospitalized for DKA in the United States and 1278 in Canada.

In the United States, 41.7% were nonwhite, 52.5% were female, and 20% were uninsured. In Manitoba, 52.3% were female (information on ethnicity/race not provided).

In both the US and Canadian populations, those admitted with DKA were more likely to be residents of low-income areas.

In the United States, the DKA hospitalization rate rose from 4.2/10,000 population at age 15 years to a peak of 9.7/10,000 at age 19. In Manitoba, the rate remained below 4.0/10,000 until age 17, peaking at just 5.4/10,000 at age 24 years.

The increase in DKA hospitalizations from ages 15-17 years to 19-21 years was almost doubled in the United States, compared with a 23% rise in Canada.

In the United States, the rise among those in the highest income zip codes was 84.4%, compared with 117.7% in the lowest income zip codes.

In Manitoba, lower income also predicted higher DKA hospitalization rates: 2.0/10,000 in the highest income quintile versus 5.4/10,000 in the lowest.

In the overall US population, uninsurance rates rose from 12.8% at age 17 to 23.6% at age 19 and 31.7% at age 23. In contrast, close to 100% were insured in Canada regardless of age.

While DKA hospitalizations increased from 5.1/10,000 in 1998 to 8.9/10,000 in 2014 in the United States, those rates declined in Manitoba from 2003 to 2013.

The cost of a DKA hospitalization averaged $21,445 in the United States in 2014.

"Our findings suggest that the US healthcare system fails many emerging adults with diabetes and that improving the pediatric-to-adult medical transition is imperative," the authors conclude.

The study was funded by the Manitoba Health Research Council Chair in Primary Prevention, Manitoba government, an Institutional National Research Service Award, and the Ryoichi Sasakawa Fellowship Fund. Gaffney is president of PNHP.

J Gen Intern Med. Published online May 8, 2019. Abstract

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