663 - Endocrinology specialist care and acute care among Medicaid-insured children with type 1 diabetes in a rural state

Publication Number: 4649.663

James Bohnhoff, The Barbara Bush Children's Hospital at Maine Medical Center, Yarmouth, ME, United States; Anya Cutler, The Barbara Bush Children's Hospital at Maine Medical Center, Portland, ME, United States; Chelsea Bodnar, University of Montana, Missoula, MT, United States; Christine A. March, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States

Background: The American Diabetes Association (ADA) recommends that children and adolescents with type 1 diabetes (T1D) receive care from endocrinology specialists every three months, yet many children do not receive care at this frequency, which may increase their risk of adverse outcomes including episodes of diabetic ketoacidosis (DKA). Children living in rural areas and American Indian (AI) children are located farther from specialists, yet little data has assessed whether their increased travel burdens impact these populations' rates of endocrinology specialist care or adverse diabetes outcomes.

Objective: To describe the rate of endocrinology specialist visits and DKA events among all children with T1D in the rural state of Montana and determine whether these events occurred at different rates among rural and AI children.

Design/Methods: Using 2016-2021 Montana Medicaid claims from children aged 0-18 with a diagnosis of T1D, we calculated the rate of endocrinology specialist visits and DKA-related hospitalizations and the distribution of specialists providing endocrinology specialist visits. We created regressions with offsets for children's eligibility months to determine whether rurality (metropolitan vs micropolitan/small town/rural Rural-Urban Commuting Area codes) or AI (vs other) race were associated with specialist visits (Poisson regression) and any DKA event (logistic regression).

Results: Of 625 children with T1D, 64% lived outside of metropolitan areas and 16% were AI (Table 1). Children experienced a median 2.0 (IQR 0.5-3.2) endocrinology specialist visits per year, provided by a combination of advanced practice providers (43%) pediatric endocrinologists (37%), and adult endocrinologists (21%). 18% of children experienced at least one DKA event (Table 2). Children living outside metropolitan areas attended fewer endocrinology specialist visits (p < 0.0001) but did not have significantly different odds of DKA (p=0.283). AI children attended more endocrinology visits (p < 0.0001) but did not have significantly different odds of DKA (p=0.0559, Table 3).

Conclusion(s): Children with T1D living in the rural state of Montana received endocrinology specialist care at rates below ADA recommendations. Although rural children received less care from endocrinology specialists, these groups did not experience significantly different rates of DKA compared to other children. Future work should explore why rural children less frequently access specialist care and whether specialist care is associated with more sensitive health outcomes such as glucose time in range or hemoglobin A1C.

Table 1: Characteristics of children with type 1 diabetes (n=625)
IQR, interquartile range

Table 2: Healthcare utilization among children with type 1 diabetes (n=625)
DKA, diabetic ketoacidosis; IQR, interquartile range; SD, standard deviation

Table 3: Patient characteristics and healthcare utilization among children with type 1 diabetes (n=625)
1Poisson regression with offset for log eligibility months; 2Logistic regression with weights for log eligibility months; DKA, diabetic ketoacidosis; Metropolitan refers to Rural Urban Commuting Area Codes 1-3; Micropolitan/Small town/Rural refers to Rural-Urban Commuting Area codes 4-10