Psychosocial issues act as barriers to self management of type 1 diabetes and have to be tackled in order to help reduce admissions for diabetic ketoacidosis (DKA), Victorian researchers say.
According to a retrospective study at the Alfred Hospital, people hospitalised with DKA, and especially those with more than one admission, had relatively high rates of drug and alcohol use, psychiatric illness and social disadvantage.
The study of 154 DKA admissions, from 128 people with diabetes, found insulin omission was the main contributing factor (54%), followed by concomitant acute illness such as infection (40%), alcohol excess (26%), new onset diabetes (16%) and illicit substance use (9%).
Inappropriate sick day management was the most common reason for the insulin omission – “suggesting a lack of diabetes self-management education or an inability to to apply such knowledge”.
When comparing patients with a single admission for DKA and those with recurrent DKA admissions, the study identified statistically different rates of smoking (27% v 69%), unemployment (11% v 31%) and illicit substance use (17% v 44%).
Depression, other psychiatric diagnoses, and homelessness were also more common in people with more than one DKA admission but not statistically different from those with only a single admission.
Clinical factors such as diabetes duration, HbA1c, and microvascular or macrovascular complication rates were not different between the two groups of patients.
“Reducing the incidence of DKA is likely to require innovative multidisciplinary models of care that address psychological wellbeing and social disadvantage, while empowering people with the ability to self-manage their diabetes,” the study said.
Lead author and endocrinologist Dr Matthew Hare told the limbic diabetes services had to be more creative in providing the necessary care and that the integration of services was critical.
“The issues are not complicated medical decisions but adherence to medication and understanding of their condition, and having the ability to self-manage when their life has so many other dramas going on.”
“I think clinicians who work at public hospitals and see this realise the challenge and that the kind of care we provide e.g six-monthly outpatient visits for people with diabetes is not what they need.”
“Integrating a multidisciplinary service that has access to social workers and psychologists etc within the care team is probably what’s needed with early referral pathways and funding for those services.”
He said he suspected that the psychosocial factors would be found to be even more common if the study was repeated with prospective assessment of psychological and sociodemographic factors using validated tools.
“DKA should be largely preventable in type 1 diabetes if people have access to the supports they need. When it keeps on happening, clearly there are other barriers which are largely psychosocial.”