Diabetes-related hospital mortality affected by geography

Diabetes treatments are more advanced than ever, yet according to the American Diabetes Association, this medical condition is still the seventh-leading cause of death in the United States and was responsible for direct medical costs and lost productivity of more than $300 billion in 2017.

The burden of diabetes is not distributed equally among the American population. Studies have found that low income patients and those living in rural areas or in the South are just a few groups that have higher rates of diabetes diagnosis or face challenges in obtaining necessary medical care due to high costs and provider shortages. However, not as much is known about how diabetes-related mortality varies regionally and the extent to which different individual and geographic variations such as income and rurality are associated with mortality in hospitals.

To gain a better understanding of these, a research team led by Alva O. Ferdinand, DrPH, JD, assistant professor and deputy director of the Southwest Rural Health Center at the Texas A&M School of Public Health, analyzed data on diabetes-related mortality in hospitals across the United States between 2009 and 2015.

The goal of this study, published in Journal of Diabetes and Its Complications, was to examine geographic and individual-level factors associated with higher mortality risk to better identify groups that face greater risk of diabetes-related hospital death.

With a clearer picture of these factors, health care providers and policymakers will be better equipped to tailor interventions to meet the need of at-risk populations and further improve diabetes care in the United States.

Ferdinand and colleagues examined diagnosis codes in the data and identified hospitalizations that were primarily driven by a diabetes-related complication, then categorized those hospitalizations based on whether the patient died while in the hospital. They then included data on each patient’s residence (urban or rural) and census region (Northeast, Midwest, South or West) as well as social and demographic variables such as age, gender, race and payment source (Medicare, Medicaid, private insurance or uninsured).

The results of their analysis highlighted significant differences in diabetes-related hospital deaths between different regions and across the urban-rural continuum. Micropolitan and non-core residents had significantly higher odds of experiencing a diabetes-related hospital death than their counterparts in large central metropolitan areas.

These findings are consistent with previous research finding that rural diabetes patients were less likely to receive preventive care and were thus more likely to be hospitalized for more serious complications later. The findings also suggested that residents of the South and Midwest regions have greater need for improvements in preventive care, such as diabetes and nutrition education, early screening and expansion of specialized outpatient care than other regions.

“Diabetes-related hospital mortality was more common for patients covered by Medicaid than by private insurance, and the uninsured were more likely to die of diabetes-related conditions in hospitals across all regions,” Ferdinand said. “This points to a need for improved access to outpatient care, targeted diabetes management, and continuity of care for lower income and uninsured people.”

Although the authors noted a decrease in the rate of diabetes-related hospital deaths over their study period, Ferdinand and colleagues identified areas still needing improvement. These include access to care, diabetes education and self-management efforts and care coordination in less urban areas, especially in the South and Midwest.

The researchers noted that future studies are needed to investigate possible solutions to fill these gaps and to further explore cultural factors such as food preferences and attitudes toward physicians correlate with diabetes-related hospital deaths and whether controlling for these factors still reveal disparities.

“A better understanding of variations in diabetes-related mortality will help policymakers and other advocates more effectively put medical and allocative interventions in place that will potentially yield significant improvements in diabetes outcomes in the United States,” Ferdinand said.