Research Article: Behavioral health conditions and potentially preventable diabetes-related hospitalizations in the United States: Findings from a national sample of commercial claims data

Date Published: February 28, 2019

Publisher: Public Library of Science

Author(s): Erica L. Stockbridge, Shlesma Chhetri, Leah E. Polcar, Abiah D. Loethen, Caroline P. Carney, Giuseppe Carrà.


To characterize the relationship between potentially preventable hospitalizations (PPHs) for diabetes and behavioral health conditions in commercially insured working-age persons with diabetes in the United States.

We retrospectively analyzed medical and pharmacy claims from services rendered between 2011 and 2013 for 229,039 adults with diabetes. Diabetes PPHs were identified using the Agency for Healthcare Research and Quality’s Prevention Quality Indicators v6.0 logic. We used negative binomial-logit hurdle regression models to explore the adjusted relationships between diabetes PPHs and schizophrenia, bipolar, depression, anxiety, adjustment disorder, alcohol use disorder, and drug use disorder.

A total of 4,521 diabetes PPHs were experienced by 3,246 of the persons in the sample. The 20.83% of persons with one or more behavioral health conditions experienced 43.62% (1,972/4,521; 95% CI 42.18%-45.07%) of all diabetes PPHs, and the 7.14% of persons with more than one diagnosed behavioral health condition experienced 24.77% (1,120/4,521; 95% CI 23.54%-26.05%) of all diabetes PPHs. After adjusting for sociodemographic and physical health covariates, patients with depression, schizophrenia, drug or alcohol use disorders, or multiple behavioral health conditions were at significantly increased risk of experiencing at least one diabetes PPH, while patients with depression, drug use disorder, or multiple behavioral health conditions were at significantly increased risk of experiencing recurring diabetes PPHs over time.

A number of behavioral health conditions are associated with diabetes PPHs, which are often preventable with timely, high-quality outpatient care. The results of this study will enable clinicians, payers, and policy-makers to better focus outpatient care interventions and resources within the population of persons with diabetes.

Partial Text

An estimated 30.3 million people in the United States (US) are living with diabetes [1], a complex chronic disease that is a leading cause of death [2], negatively affects quality of life [3], and is associated with high levels of healthcare utilization [4]. In 2017 in the US, an estimated $237 billion in direct medical expenditures was attributable to diabetes [4]. Persons diagnosed with diabetes have medical costs that are approximately 2.3 times that of persons without diabetes [4], and complications of diabetes represent a significant driver of healthcare costs and utilization in persons with diabetes [5].

The North Texas Regional Institutional Review Board at the University of North Texas Health Science Center reviewed and approved this project as exempt category research.

Of the 4 million people in the available Optum Clinformatics data, 229,179 were adults ages 20 to 64 with diabetes. We excluded 140 of those individuals due to missing socio-demographic information. Thus, 229,039 individuals met inclusion criteria for the study. A total of 4,521 diabetes PPHs were experienced by 3,246 of these persons (3,246/229,039; 1.42%; 95% Confidence Interval [CI] 1.37–1.47%). In addition, 623 individuals (623/229,039; 0.27% CI 0.25%-0.29%) experienced more than one diabetes PPH. Further, 47,701 (20.83%; CI 20.66%-20.99%) of persons in the study had at least one behavioral health condition; 34.30% (16,361/47,701; CI 33.88%-34.73%) of those persons had more than one behavioral health condition.

PPHs for diabetes were disproportionately concentrated in individuals with co-occurring behavioral health conditions. While 20.8% of persons with diabetes had a comorbid behavioral health condition, this group experienced 43.6% of all diabetes PPHs. These findings suggest that the outpatient care of individuals who have both diabetes and behavioral health conditions may be suboptimal, and this suboptimal care results in measurably poorer health outcomes.




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