“This study is the first, to our knowledge, to compare longitudinal severity of multiple diabetes complications simultaneously among patients with newly diagnosed diabetes who do and do not have MH or SU disorders,” write Eric M. Schmidt (Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System) and colleagues.
Health care approaches may reduce diabetes complication severity
The prevalence of diabetes worldwide is extensive and increasing and the duration of the disease is also increasing, which extends the window of time over which complications can arise.To manage populations at risk for chronic diseases such as diabetes, it is important to identify and implement health care practices that reduce the costly and health-limiting complications that patients may develop over the long-term.
Among individuals with diabetes, co-occurring mental health or substance abuse disorders increase the risk of medical complications, morbidity, and mortality.
Research has already suggested that among people with these disorders, healthcare approaches that integrate medical and behavioral care can minimize the risk for diabetes and can also help reduce the risk for complications among people who do develop the condition.
“However, to our knowledge, no previous analyses have examined whether health care received before the onset of diabetes is associated with long-term severity of complications among patients with MH or SU disorders,” write Schmidt and team.
Understanding more about this association could help to guide the design of healthcare delivery models that would promote initiatives to improve health outcomes:
Knowing more about how health care accessed before the onset of diabetes is associated with health benefits after the onset of diabetes could inform treatment planning and population health management.”
Schmidt and team examined the association
As reported in the journal JAMA Network Open, Schmidt and colleagues investigated whether the severity of complications among people with newly diagnosed diabetes progresses differently between people with and without a pre-existing mental health or substance use disorder.They also asked whether engagement in primary care before a diagnosis is associated with the long-term severity of diabetes complications.
For the study, the team analyzed medical record data from the US Department of Veteran Affairs health care systems for 122,992 patients who had been newly diagnosed with diabetes in 2008 and who were aged between 18 and 85 years at the time of diagnosis.
Mixed effect regression analyses were used to test the associations between prediabetes patient or healthcare factors and the progression of diabetes complication severity between 2006 and 2015.
Patients were divided into those with a mental health disorder only, a substance use disorder only, those with both of the disorders and those with neither disorder before diabetes was diagnosed. They were also divided based on the amount of primary health care they had engaged in prior to diagnosis.
Nine-year trajectories of a measure called the Diabetes Complication Severity Index score were used to assess the main outcome.
Patients with mental health or substance use disorders experienced fewer complications
The analysis showed that more than 90% of patients with mental health or substance use disorders attended primary care visits prior to being diagnosed with diabetes, compared with 58% of those who did not have the disorders.Patients with the disorders had significantly lower diabetes complication scores for seven years following their diabetes diagnosis, compared with patients without the disorders, even after adjusting for potential confounders such as sociodemographic characteristics and medical comorbidities.
Among patients with MH [mental health] or SU [substance use] disorders, receiving more medical and mental health care from an integrated healthcare system before the onset of diabetes is associated with modest, albeit impermanent, health benefits after the onset of diabetes."
The authors say that although no causal connections can be drawn based on the current study, the reduced diabetes complication severity among patients with the mental health or substance use disorders may be due to the possibility that they were already being treated for other conditions such as hypertension before diabetes was diagnosed:
“Hypertension was diagnosed twice as often in patients with than in those without MH or SU disorders before the onset of diabetes, but hypertension rates were similar across groups the subsequent year.”
The authors say this suggests that more patients with the disorders were probably already having their blood pressure managed at the onset of diabetes, even though a similar number of patients without the disorders may have benefited from blood pressure management before diabetes onset:
“Perhaps patients with MH or SU disorders had more clinical momentum to implement recommended complication prevention practices into their medical care plans at the time of the onset of diabetes.”
Future research
The team suggests that future studies should focus on the effects that health care provided before the onset of diabetes might have on long term health benefits.The researchers say it appears worthwhile to investigate the plausibility of clinical momentum to reduce complication risks in patients with mental health or substance use disorders:
How disease control (eg, glycated hemoglobin level) or medication adherence mediate complication trajectories after the onset of diabetes should be examined."
The team concludes that future studies should explore whether the current findings apply equally to all diabetes complications and mental health or substance use disorders diagnoses.
Journal reference:
Schmidt, E., M., et al. (2019). Patient and Health Care Factors Associated With Long-term Diabetes Complications Among Adults With and Without Mental Health and Substance Use Disorders. JAMA Network Open.
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