Exploring patterns in pediatric type 1 diabetes care and the impact of socioeconomic status

Abstract

Background: Managing pediatric type 1 diabetes is complex and requires substantial parental involvement. Adherence to clinical guidelines is often inconsistent, and lower parental socioeconomic status is associated with worse outcomes in affected children. However, few studies have examined these children's care pathways multidimensionally over time. This study aims to identify latent clusters in the care pathways of pediatric patients with type 1 diabetes mellitus, evaluate guideline adherence and disease management within these clusters, and assess the influence of socioeconomic status on cluster membership.

Methods: We analyzed care pathways for pediatric patients with type 1 diabetes from 2017 to 2019 in the German health system, which provides universal coverage. Using state sequence analysis and clustering algorithms from the TraMineR R package, we identified patient clusters based on healthcare utilization patterns. To assess care quality within these clusters, we compared observed care patterns to clinical guideline recommendations. Our analysis was based on health insurance claims data from Techniker Krankenkasse, a statutory health insurer. From the dataset, which encompassed more than three million patients under the age of 25 years, we derived an age-homogeneous cohort of continuously insured children aged 11 to 14 years with type 1 diabetes in 2017 and extracted relevant healthcare events over a 3-year period.

Results: Based on care patterns, we identified two clusters of children, which we designated as the "guideline-adherent" and "care-with-gaps" clusters. Roughly 25% of our cohort (n = 890) fell into the latter cluster, consistently receiving care that fell short of guideline recommendations. For example, these patients had less than half as many quarters with hemoglobin A1c measurement. Lower parental educational attainment and unemployment were predictors of this suboptimal care. We also found that the average number of hospitalizations per child was almost 40% higher in the cluster with less guideline-adherent care.

Conclusions: Despite universal health coverage and frequent contact with the outpatient healthcare system, a substantial proportion of pediatric type 1 diabetes patients in Germany experience suboptimal care, particularly in glycemic diagnostics and screening for complications, leading to worse health outcomes. Higher socioeconomic status is associated with care that more closely adheres to clinical guidelines.

Keywords: Care pathways; Clustering algorithms; Insurance claims data; Pediatric health data; Socioeconomic status; State sequence analysis; Type 1 diabetes mellitus.

Fig. 1

Visualization of states and state sequences per dimension. Note: We use state distribution plots for the visualization of states and top 10 most frequent sequences for the visualization of sequences per dimension

Fig. 2

Visualization of states and state sequences per dimension and cluster. Note: We use state distribution plots for the visualization of states and top 10 most frequent sequences for the visualization of sequences per dimension and cluster