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Health care utilization trends across the transition period in a national cohort of adolescents and young adults with type 1 diabetes

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Garvey, Katharine C., Finkelstein, Jonathan A., Zhang, Fang, LeCates, Robert, Laffel, Lori, Wharam, James F.·2022·Diabetes Care
DOI 10.2337/dc22-0152PMC PMC9679267
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Abstract

OBJECTIVE: Lack of effective transition from pediatric to adult care may contribute to adverse outcomes in young adults with type 1 diabetes. The understanding of outpatient and acute care utilization patterns across the adolescent to young adult transition age in type 1 diabetes populations is suboptimal in the U.S. RESEARCH DESIGN AND METHODS: We studied claims data from 14,616 individuals diagnosed with type 1 diabetes, aged 16–24 years, and enrolled in a large national health plan for ≥1 year from 2005 to 2012. Annual outpatient and emergency department visits and hospitalization rates were calculated at each age. Generalized estimating equations were used to assess the association of age-group (adolescents [age 16–18 years] vs. young adults [age 19–24 years]), outpatient visits, and sociodemographic variables with emergency department visit and hospitalization rates. RESULTS: Endocrinologist visits declined from 2.3 per year at age 16 years to 1.5 per year by age 22. Emergency department rates increased per year from 45 per 100 at age 16 to 63 per 100 at age 20, then decreased to 60 per 100 by age 24. Hospitalizations per year climbed from 14 per 100 at age 16 to 21 per 100 at age 19, then decreased to 17 per 100 by age 24. In statistical models, young adults experienced higher rates of emergency department visits (incidence rate ratio [IRR] 1.24 [95% CI 1.18, 1.31]) and hospitalizations (IRR 1.25 [95% CI 1.15, 1.36]) than adolescents. Additional significant predictors of emergency department visits and hospitalizations included female sex and Black race. Individuals with two or more endocrinologist visits per year were less likely to have emergency department visits and hospitalizations; higher income was also protective. CONCLUSIONS: Results highlight concerning increases in acute care utilization for young adults with type 1 diabetes who are less engaged with outpatient diabetes care and highlight socioeconomic risk factors that warrant further study.

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  • Young people with established diabetes in the pediatric age-group, especially during adolescence, experience greater rates of DKA than adults with diabetes.

    “Young people with established diabetes in the pediatric age-group, especially during adolescence, experience greater rates of DKA than adults with diabetes (186).”

    From 6. Glycemic Goals, Hypoglycemia, and Hyperglycemic Crises: Standards of Care in Diabetes-2026. (2026) · cites this paper as [186]

    The paper’s background passage (page unavailable) reports high DKA rates in young adults relative to both older adults and younger adolescents—the reverse of the claimed adolescent-versus-adult pattern. Its Results also show higher overall emergency-department and hospitalization rates in young adults than adolescents, though those measures are not DKA-specific. (LLM, conf=0.87)

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  • DKA is often associated with psychosocial challenges, such as disordered eating behaviors, and with periods of transition, such as from pediatric to adult health care when there may be gaps in ambulatory care.

    “Notably, the majority of DKA cases occur in those with established diabetes compared with those with newly diagnosed diabetes, often in association with psychosocial challenges, such as disordered eating behaviors, and during periods of transition, such as from pediatric to adult health care when there may be gaps in ambulatory care (186)(187)(188).”

    From 6. Glycemic Goals, Hypoglycemia, and Hyperglycemic Crises: Standards of Care in Diabetes-2026. (2026) · cites this paper as [186]

    The Abstract describes gaps between pediatric and adult diabetes care and identifies DKA as a risk for young adults with type 1 diabetes. The Conclusions link irregular endocrinology follow-up with DKA admission. Our copy does not link DKA to psychosocial challenges or disordered eating behaviors. (LLM, conf=0.86)

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  • Other factors associated with DKA include age 10-14 years, public insurance, and prior episodes of DKA.

    “Other factors associated with DKA include age 10-14 years, public insurance, and prior episodes of DKA; use of insulin pump therapy does not appear to be associated with increased DKA occurrence in the current era.”

    From 6. Glycemic Goals, Hypoglycemia, and Hyperglycemic Crises: Standards of Care in Diabetes-2026. (2026) · cites this paper as [186]

    The Methods/Abstract describe a cohort aged 16–24, and the Conclusions state that publicly insured populations were not included. Our copy does not address whether age 10–14, public insurance, or prior DKA episodes are associated with DKA (searched those terms and variants). (LLM, conf=0.76)

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  • The majority of DKA cases occur in those with established diabetes compared with those with newly diagnosed diabetes.

    “Notably, the majority of DKA cases occur in those with established diabetes compared with those with newly diagnosed diabetes, often in association with psychosocial challenges, such as disordered eating behaviors, and during periods of transition, such as from pediatric to adult health care when there may be gaps in ambulatory care (186)(187)(188).”

    From 6. Glycemic Goals, Hypoglycemia, and Hyperglycemic Crises: Standards of Care in Diabetes-2026. (2026) · cites this paper as [186]

    The Conclusions discuss DKA risk in young adults and associations with gaps in endocrinology follow-up, but do not compare DKA cases in established versus newly diagnosed diabetes. Searches for that distinction and for DKA at diagnosis found no passage addressing which group accounts for the majority of cases. (LLM, conf=0.75)

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Cites

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Research works printed but not linked: 1

  1. [7]7. Pacaud D, Yale J, Stephure D, Dele-Davies H. Problems in transition from pediatric to adult care in individuals with diabetes. Can J Diabetes 2005;40:29-35

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Authors
Garvey, K. C., Finkelstein, J. A., Zhang, F., LeCates, R., Laffel, L., & Wharam, J. F.
Affiliations
  • Boston Children's Hospital (US)
  • Harvard Pilgrim Health Care (US)
  • Duke University (US)
Corresponding author
Garvey, Katharine C.
ORCID
Venue
Diabetes Care
Publisher
American Diabetes Association
Published
2022-08-24
Volume
45
Issue
11
Pages
2509-2517
ISSN
  • 0149-5992 (ISSN-L)
  • 1935-5548
DOI
10.2337/dc22-0152
PMC
PMC9679267
OpenAlex
W4293105723
Semantic Scholar
8d383d641a664aec8813003a53f4689e4d97869c
Cited by
34
References
48
Citations by year
2026: 15 · 2025: 9 · 2024: 5 · 2023: 4 · 2022: 1
FWCI
5.98
Type
journal article
Language
en
Open access
Licence
www.diabetesjournals.org/journals/pages/license (vor)
Locations
  • Diabetes Care (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
Funders
National Institute of Diabetes and Digestive and Kidney Diseases (K23DK102655)
Topics
  • Health Sciences › Health Professions › Speech and Hearing › Adolescent and Pediatric Healthcare
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Education
Keywords
type 1 diabetes, adolescents, young adults, transition to adult care, health care utilization, emergency department visits, hospitalization, outpatient visits, socioeconomic disparities, sex differences, racial disparities, income
MeSH terms
Adolescent, Adult, Child, Diabetes Mellitus, Type 1, Emergency Service, Hospital, Female, Hospitalization, Humans, Middle Aged, Patient Acceptance of Health Care, Young Adult, Transition to Adult Care

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