PEDIATRICS Vol. 111 No. 1 January 2003, pp. 222-224
Social Inequality in Childhood Diabetes—A Population-Based Follow-up Study in Germany
To the Editor.—In the January 2002 issue of Pediatrics, Keenan et al1 reported a higher prevalence of ketoacidosis and more prolonged hospitalization in diabetic children and adolescents with low socioeconomic status in the United States. They suggest intensive programs for this patient group to improve their health and potentially to decrease total health care costs.
Actually, reduction of social inequality in health is one of the main targets in Europe, too. Because there is a widespread health care system with free entrance for everybody in Germany, it is often argued that social inequality should be less pronounced compared with other countries. However, for children and adolescents with diabetes, only little population-based data about the association between socioeconomic status and health outcomes is available, in Germany as well as in other countries.2–4 Therefore, we performed a study to analyze the influence of several socioeconomic variables on health care outcomes in childhood diabetes in the first course after onset.
The study was based on the population-based incidence study in North Rhine-Westphalia, Germany, part of the EURODIAB ACE network.5 In 1996–1998, a total of 1257 children and adolescents with diabetes onset before the age of 15 were registered. A total of 733 families (58%) agreed to participate in the present study and filled out a baseline questionnaire. The follow-up was completed by 616 of these families (84%). A total of 575 families with a follow-up period of 0.5 to 2 years (1.2 years in average) after diabetes onset were included in additional analyses.
Length of hospitalization at diagnosis, and post-onset hospitalization, severe hypoglycemia, and acute hyperglycemia/ketoacidosis were assessed as health care outcome variables, with parents’ school education (
10/>10 years), family situation (single parent/complete), health insurance (public/private), and nationality (German/other) as predictors. Information was taken from clinic documentation and families’ self-report. Age- and sex-adjusted relative risks for the length of hospital stay at diabetes onset were estimated as ratios of the adjusted means. Age- and sex-adjusted relative risks for the other health care outcomes were estimated using multivariate Poisson regression models, with and without adjusting for extra-Poisson variation.
Fifty-one percent of the patients were male. Mean age (standard deviation) at onset was 8.3 (3.8) years (age distribution: 0–4, 5–9, 10–14 years: 24.0, 38.3, 37.7%, respectively). In 54.1% of the families, highest parents’ school education was 10 years or less. Six and three tenths percent were single-parent-families, 84.2% had a public insurance, and 4.4% of the families were non-German.
Mean length of hospital stay at onset was 15.8 (standard deviation: 8.1) days, incidence rates (per person-year) of post-onset hospitalization, severe hypoglycemia, and acute hyperglycemia/ketoacidosis were 0.30 (95% confidence interval: 0.26–0.34), 0.09 (0.07–0.12), and 0.04 (0.03–0.06), respectively. Health care outcomes tended to be worse in lower social status (Table 1). Significant associations were observed between incidence of post-onset hospitalization and parents’ school education as well as health insurance; between number of hospital days and school education, health insurance, and nationality; between incidence of severe hypoglycemia and school education; and between incidence of ketoacidosis and school education as well as the family status. After adjustment for extra-Poisson variation, the associations between post-onset hospital days and health insurance (1.67; 0.98–3.07) and between severe hypoglycemia and parents’ education (1.75; 1.04–3.06) failed to reach significance. No significant association was found between social status and length of hospital stay at diabetes onset.
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Despite free entrance into the health care system and a lot of initiatives to improve diabetes care in Germany, various health care outcomes of diabetic children and adolescents in the first course after diabetes onset tended to be worse in families with lower socioeconomic status. Except length of hospitalization at onset, all post-onset health care outcomes were significantly associated with at least 1 indicator of the socioeconomic status. Relative risk estimates were similar to those found in the study of Keenan et al1 and in an earlier study by Palta and colleagues,6 which presented associations between socioeconomic variables and hospitalization. More efforts should be undertaken to reduce this social inequality in health. Special programs should target families with lower social status to improve diabetic children’s and adolescents’ health and potentially to reduce health care costs, particularly costs and burden resulting from hospitalization.7
ACKNOWLEDGMENTS
We thank the North Rhine-Westphalian Ministeries of Science and Health and the German Diabetes Foundation.
Andrea Icks, MD
Joachim Rosenbauer, MD
Burkhard Haastert, MD
Guido Giani, MD
Diabetes Research Institute at Heinrich-Heine-University
Department of Biometrics and Epidemiology
Auf’m Hennekamp 65
D-40225 Dusseldorf, Germany
REFERENCES
- Keenan HT, Foster CM, Bratton SL. Social factors associated with prolonged hospitalization among diabetic children.
Pediatrics.2002; 109
:40
–44
[Abstract/Free Full Text] - Hecker W, Bartus B, Heinze E, Holl RW. Stoffwechseleinstellung des Diabetes mellitus bei Kindern und Jugendlichen deutscher und ausländischer Nationalität. Diabetes und Stoffwechsel.1998; 7 :177 –180
- Icks A, Rosenbauer J, Holl RW, Grabert M, Giani G. Hospitalization among diabetic children and adolescents and in the general population in Germany.
Diabetes Care.2001; 24
:435
–440
[Abstract/Free Full Text] - Rosenbauer J, Icks A, Giani G. Clinical characteristics and predictors of severe ketoacidosis at onset of childhood type 1 diabetes in a North-Rhine-Westphalian region, Germany. J Pediatr Endocrinol Metab.2002 . In press
- Rosenbauer J, Icks A, Giani G. Five-year-incidence registration of type 1 diabetes in childhood in Northrhine-Westfalia. Diabetologia.2001; 44(suppl) :A98
- Palta M, LeCaire T, Daniels K, Shen G, Allen C, D’Alessio D, for the Wisconsin Diabetes Registry. Risk factors for hospitalization in a cohort with type 1 diabetes.
Am J Epidemiol.1997; 146
:627
–636
[Abstract/Free Full Text] - Icks A, Rosenbauer J, Haastert B, Giani G. Hospitalization among diabetic children and adolescents and in non-diabetic control subjects: a prospective population-based study. Diabetologia.2001; 44(suppl3) :B87 –B92
In Reply.—
We would like to thank Dr Icks and colleagues for their interest in our article and for the data they provide from their follow-up study of diabetic children in Germany. It is very interesting that in a country with free access to health care, socioeconomic status remains a determinant of relative risk of hyperglycemia with ketoacidosis in a population of diabetic children. Their findings support the idea that in the United States medical insurance is a marker for many social factors that influence health care other than simply access to a provider. These factors may include poverty, education, cultural and language barriers, access to transportation, and ability to see a consistent provider. In a recent article by Rewers et al,1 the majority of acute complications in diabetic children were seen in a very small percentage of children (60% of all ketoacidosis episodes were in 5% of children with 
2 episodes). Children with complications were more likely to be underinsured or have psychiatric disorders.
If underinsurance is a marker for multiple social factors, providing insurance alone will not solve the problem of unequal health in the United States. Intensive programs that target those children at higher risk for repeat admissions for chronic illnesses and which incorporate social workers, nutritionists, psychologists, as well as physicians and nurses, will have the best chance of improving health in this population. Intensive glucose control delays or prevents the often-devastating long-term health consequences of uncontrolled diabetes2,3 that may both increase cost savings in the health care system and, more importantly, provide an improved quality of life for this group of children.
Heather Keenan, MDCM, MPH
Department of Social Medicine
CB #7220, Wing D, School of Medicine
University of North Carolina
Chapel Hill, NC 27599, USA
Susan L. Bratton, MD, MPH
Department of Pediatrics
University of Michigan Health System
Ann Arbor, MI 48109-0243, USA
REFERENCES
- Rewers A, Chase HP, Mackenzie T, et al. Predictors of acute complications in children with type 1 diabetes.
JAMA.2002; 287
:2511
–2518
[Abstract/Free Full Text] - Wagner EH, Sandhu N, Newton KM, et al. Effect of improved glycemic control on health care costs and utilization.
JAMA.2001; 285
:182
–189
[Abstract/Free Full Text] - The Writing Team for the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Research Group. Effect of intensive therapy on the microvascular complications of type 1 diabetes mellitus.
JAMA.2002; 287
:2563
–2569
[Abstract/Free Full Text]
PEDIATRICS (ISSN 1098-4275). ©2003 by the American Academy of Pediatrics
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