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Area Deprivation and Regional Disparities in Treatment And Diabetes Care Volume 41, December 2018 2517 Marie Auzanneau,1,2 Stefanie Lanzinger,1,2 Area Deprivation and Regional Barbara Bohn,1,2 Peter Kroschwald,3 Ursula Kuhnle-Krahl,4 Disparities in Treatment and Paul Martin Holterhus,5 Kerstin Placzek,6 Johannes Hamann,7 Rainer Bachran,8 Outcome Quality of 29,284 Joachim Rosenbauer,2,9 and Werner Maier,2,10 on behalf of the Pediatric Patients With Type 1 DPV Initiative Diabetes in Germany: A Cross- sectional Multicenter DPV EPIDEMIOLOGY/HEALTH SERVICES RESEARCH Analysis Diabetes Care 2018;41:2517–2525 | https://doi.org/10.2337/dc18-0724 1Institute of Epidemiology and Medical Biome- try, ZIBMT, University of Ulm, Ulm, Germany 2German Center for Diabetes Research (DZD), Neuherberg, Germany 3Children’s Hospital, Ruppiner Kliniken GmbH, OBJECTIVE Hochschulklinikum der Medizinischen Hochschule This study analyzed whether area deprivation is associated with disparities in health Brandenburg, Neuruppin, Germany 4 care of pediatric type 1 diabetes in Germany. Practice for Pediatric Endocrinology and Dia- betology, Gauting, Germany 5 RESEARCH DESIGN AND METHODS Division of Pediatric Endocrinology and Diabe- tes, Department of Pediatrics, University Hospital We selected patients <20 years of age with type 1 diabetes and German residence of Schleswig-Holstein, Campus Kiel/Christian- documented in the “diabetes patient follow-up” (Diabetes-Patienten-Verlaufsdo- Albrechts University of Kiel, Kiel, Germany 6 kumentation [DPV]) registry for 2015/2016. Area deprivation was assessed by Pediatric and Adolescent Medicine, University Hospital, Martin-Luther University, Halle, Germany quintiles of the German Index of MultipleDeprivation (GIMD 2010) at the district level 7Department of Pediatrics, St. Marien Hospital and was assigned to patients. To investigate associations between GIMD 2010 and Landshut, Landshut, Germany indicators of diabetes care, we used multivariable regression models (linear, 8Pediatric Practice, Oberhausen, Germany 9 logistic, and Poisson) adjusting for sex, age, migration background, diabe- Institute for Biometrics and Epidemiology, Ger- man Diabetes Center, Leibniz Center for Diabe- tes duration, and German federal state. tes Research at Heinrich Heine University, Dusseldorf,¨ Germany RESULTS 10Institute of Health Economics and Health Care We analyzed data from 29,284 patients. From the least to the most deprived Management, Helmholtz Zentrum Munchen,¨ quintile, use of continuous glucose monitoring systems (CGMS) decreased from German Research Center for Environmental Health (GmbH), Neuherberg, Germany 6.3 to 3.4% and use of long-acting insulin analogs from 80.8 to 64.3%, whereas Corresponding author: Marie Auzanneau, marie. use of rapid-acting insulin analogs increased from 74.7 to 79.0%; average HbA1c [email protected]. increasedfrom7.84to8.07%(62to65mmol/mol),andtheprevalenceofoverweight Received 3 April 2018 and accepted 12 Septem- from 11.8 to 15.5%, but the rate of severe hypoglycemia decreased from 12.1 to ber 2018. 6.9 events/100 patient-years. Associations with other parameters showed a more This article contains Supplementary Data online complex pattern (use of continuous subcutaneous insulin infusion [CSII]) or were at http://care.diabetesjournals.org/lookup/suppl/ not significant. doi:10.2337/dc18-0724/-/DC1. J.R. and W.M. share last authorship. CONCLUSIONS © 2018 by the American Diabetes Association. Area deprivation was associated not only with key outcomes in pediatric type 1 Readers may use this article as long as the work diabetes but also with treatment modalities. Our results show, in particular, that is properly cited, the use is educational and not for profit, and the work is not altered. More infor- the access to CGMS and CSII could be improved in the most deprived regions in mation is available at http://www.diabetesjournals Germany. .org/content/license. 2518 Area Deprivation and Type 1 Diabetes Diabetes Care Volume 41, December 2018 Despite considerable advances in the statutory health insurance (covering ;90% and German residence documented in management of pediatric type 1 diabetes of the population) if poor glycemic con- the DPV for 2015 and 2016. The definition over the last two decades, major geo- trol persists despite intensified conven- of type 1 diabetes in the DPV database is graphic variations in metabolic control tional insulin treatment (14). Patients based on a physician’s diagnosis accord- and diabetes-related complications have and diabetologists have to apply to ing to the international guidelines (17) persisted between countries around the health insurance company for reim- and can be revised based on the course the world (1). Treatment and outcome bursement by providing comprehensive of the disease. For each patient, we quality of patients with type 1 diabetes documentation of the blood glucose aggregated clinical data for the years also vary within countries. In Brazil, levels and insulin therapy over the last 2015 and 2016 as median, percentage, large discrepancies were found in clinical 3 months. Exigent documentation and or rate per 1 or 100 patient-years (PYs) care across different regions (2). In Ger- uncertainty of reimbursement may dis- for continuous, categorical, and event many, significant disparities in the use of courage some families in socioeconom- variables, respectively. insulin pumps and rapid-acting or long- ically disadvantaged areas. Application Area Deprivation acting analogs, HbA levels, the preva- for reimbursement of real-time CGM by 1c Area deprivation was assessed using the lence of overweight, and the rate of statutory health insurance is also neces- German Index of Multiple Deprivation severe hypoglycemia have been reported sary and only possible since 2016. For from 2010 (GIMD 2010). This index was between the federal states (3). However, patients covered by private health in- developed by Maier et al. (18,19) and is a regional variations in treatment and surance (;10% of the population), re- validated measure of area deprivation for outcome quality of care of patients imbursement depends on specifications Germany (5,8,19,20). The GIMD includes with type 1 diabetes are not completely in the insurance contract. Different seven domains of deprivation with dif- explained. proportions of patients with private ferent weighting: income (25%), employ- Relative material and social depriva- versus statutory health insurance be- ment (25%), education (15%), municipal/ tion (i.e., the lack of resources for people tweenareasinGermanycouldalso district revenue (15%), social capital compared with the societies to which lead to regional variation in diabetes (10%), environment (5%), and security they belong) show significant area-level treatment (15). (5%) (18,19). The GIMD 2010 was gen- disparities associated with health (4). The objective of our study was there- erated for all 412 districts of Germany Therefore, indices of multiple depriva- fore to analyze whether area deprivation (boundaries at 31 December 2010). Dis- tion have been used increasingly since is associated with regional disparities in tricts were categorized into deprivation 2000 to assess area deprivation, notonly the treatment and outcome quality of quintiles, with quintile 1 (Q1) represent- for epidemiological research but also for pediatric patients with type 1 diabetes in ing the least deprived and quintile 5 (Q5) public health policy (5). According to Germany. the most deprived districts. We used the Noble et al. (6), area deprivation refers five-digit postal code of the patient’s not merely to the proportion of deprived RESEARCH DESIGN AND METHODS residence to assign the district of resi- people in an area but also to an “area Study Population dence. The postal code of residence was effect” and to the negative consequences We used data from the multicenter not available for 2.6% of the patients (n = of “the lack of facilities in that area.” “diabetes patient follow-up” registry 766), so we used the postal code of the Correspondingly, indices of multiple dep- (Diabetes-Patienten-Verlaufsdokumentation treating diabetes center as proxy. rivation provide multidimensional in- [DPV]). Currently, 459 diabetes care formation on living conditions at the centers, mainly in Germany (n = 416) and Indicators of Diabetes Care regional level. Austria (n = 40), participate in the DPV Indicators of medical treatment in our Concerning type 2 diabetes, a notable initiative and prospectively document analysis were use of insulin pump ther- number of studies have shown that area demographic and clinical data on treat- apy (CSII), use of CGMS, frequency of self- deprivation is associated with worse ment and outcome quality. Twice a year, monitoring of blood glucose (SMBG), use indicators of outcome quality, such as centers transmit locally collected and of rapid-acting insulin analogs and use of BMI, HbA1c, lipid profile, and short-term anonymized data to the University of long-acting insulin analogs in patients on or long-term diabetes-related complica- Ulm, Germany, for central analysis and injection therapy, and participation in tions (7,8). However, evidence is weaker quality assurance (16). Inconsistent or diabetes education programs. CGMS with regard to type 1 diabetes (9–13). implausible data are reported back to includes real-time CGM and CGM with Moreover, to date, studies on type 1 centers for verification or correction. intermittent scanning, also called “flash diabetes focused on associations be- Data collection and analysis of anony- glucose monitoring.” Diabetes
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